Spinal cord compression as initial presentation of metastatic occult follicular thyroid carcinoma

To err is human; acute appendicitis a mistaken clinical identity for metastatic follicular thyroid carcinoma, a case report

INTRODUCTION AND IMPORTANCE

Thyroid cancer accounts for majority of endocrine cancers with follicular thyroid cancer the second most common. It tends to spread via hematogenous route with distant metastasis thus besides presenting as a neck mass it may also present with symptoms tallying to regions of metastasis which may misguide the diagnosis. We report a case of a 50-year-old man who presented with features of appendicitis only to discover metastatic right iliac bone follicular thyroid cancer. We describe our experience on diagnostic formulation, radiological work up, surgery, radioactive iodine therapy and follow up.

CASE PRESENTATION

50-year-old man presenting with acute abdomen and fevers with suspicion for appendicitis, worked up and found to have metastatic follicular carcinoma. Underwent total thyroidectomy and radioactive iodine therapy to achieve disease stability without progression with a 5 year follow up completed.

CLINICAL DISCUSSION

The tendency to jump to medical imaging to establish a diagnosis in a lab oriented rather than clinical oriented approach. The role of radiology to establish the underlying disease and identify the primary lesion. Successfully halting disease progression for metastatic follicular thyroid carcinoma with surgery and radioactive iodine therapy.

CONCLUSION

Right iliac fossa tenderness does not always equate to acute appendicitis hence the use of diagnostic imaging to diagnose the metastatic lesion thus simplifying the puzzle to identify the primary. We hope through sharing our experience, we encourage the use of interventional radiology in a region that tends to opt for open approach when percutaneous approaches have shown to be successful.

Translational Strategies to Target Metastatic Bone Disease

Metastatic bone disease is a common and devastating complication to cancer, confounding treatments and recovery efforts and presenting a significant barrier to de-escalating the adverse outcomes associated with disease progression. Despite significant advances in the field, bone metastases remain presently incurable and contribute heavily to cancer-associated morbidity and mortality. Mechanisms associated with metastatic bone disease perpetuation and paralleled disruption of bone remodeling are highlighted to convey how they provide the foundation for therapeutic targets to stem disease escalation. The focus of this review aims to describe the preclinical modeling and diagnostic evaluation of metastatic bone disease as well as discuss the range of therapeutic modalities used clinically and how they may impact skeletal tissue.

Factors Affecting Life Expectancy After Bone Metastasis in Adults - Results of a 5-year Prospective Study

There is a scarcity of literature available regarding the factors affecting life expectancy in bone metastasis (BM). Our objective is to evaluate the factors affecting life expectancy in adult patients with BM. In this prospective cohort study for over 5 years, 111 adults with BM were included in the analysis. The life expectancy was calculated from the time of diagnosis of BM to death. Statistical analysis was done using the SPSS statistical program. The Pearson chi-square test was used to analyze the significance and life expectancy was represented on the Kaplan Meier curve. The overall median survival time was 9 months. The patients with a primary malignancy detected along with BM had a median survival of 9 months. Those without a known primary at the time of diagnosis survived for a median period of 8 months and those with known primary for 14 months (P-value 0.01). The median survival of patients with BM from the lung, breast, and prostate was 6, 14, and 24 months, respectively (P-value 0.001). Only 22% of patients with extraskeletal metastasis in addition to BM survived more than 6 months (P-value 0.013). Patients with neurological deficits had a median survival of 2 months (P-value 0.0001). There was no statistically significant association between gender and the mode of treatment and survival. There was a significant association between life expectancy and mode of presentation, the primary site of origin, presence of extraskeletal secondary, BM with unknown primary, and symptoms on presentation in patients with BM.

Acute paraparesis as presentation of an occult follicular thyroid carcinoma: A case report

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Follicular thyroid carcinoma is usually confined to the thyroid gland, but can metastasize.

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Signs and symptoms associated with bone metastasis are rare as first clinical manifestations.

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Complementary imaging studies, as TC and MRI, are very important, especially if bone metastases are suspected.

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Surgical procedure and ablative radioactive iodine therapy in these cases are key to achieve a better outcome.

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A low suspicion threshold for thyroid neoplasms must be taken into account when investigating metastasis to the bone.

Introduction

Follicular thyroid carcinoma is the second most frequent type of well differentiated thyroid tumours. It is usually confined to the thyroid gland, however it can metastasize in a later stage of the disease. Signs and symptoms associated with bone metastasis are rare as first clinical manifestations.

Case report

An 84-year-old female complained with acute paraparesis. Magnetic resonance imaging revealed an extensive intraosseous infiltrating lesion compatible with a bone metastasis from an occult tumour. Biopsy samples were compatible with bone metastasis from a follicular thyroid carcinoma. The patient was submitted to total thyroidectomy followed by iodine ablative therapy.

Discussion

Follicular thyroid carcinoma presentation with symptoms related to bone metastasis is rare. Patients with bone lesions, such as pathological fractures or compressive symptoms should be studied since they may have clinically unapparent lesions from an unknown tumour. Patients with FTC should be submitted to total thyroidectomy. Bone lesions may be addressed to improve quality of life however this decision depends on disease extent.

Conclusion

Acute paraparesis is a rare form of presentation of thyroid carcinoma. These neoplasms must be taken into account when investigating metastasis to the bone from unknown neoplasms.

Skeletal Metastasis-an Epidemiological Study

Metastasis is the commonest bone tumors. The commonest primary metastasis to the bone are the breast, lung, prostate, kidney, and thyroid. The bone is the third common site of metastatic disease, only the lung and the liver have higher metastatic rate than skeleton. We have no epidemiological studies conducted to evaluate the various aspects of skeletal metastasis like age, sex distribution, presentation, common sites of primary and associated secondary metastases, and investigation from Indian subcontinent. Here we are presenting the first epidemiological study of skeletal metastasis from our region. We have conducted a prospective descriptive study in the Departments of Orthopedics and Radiotherapy, Government Medical College, Kozhikode, during the period of 2007 to 2009. One hundred eleven patients were included in the study above the age of 30 years. Clinical examination and investigation were done on these patients. Skeletal metastasis commonly occurs in the fifth decade of life with modest male preponderance. In most of the cases, the primary site of malignancy was undetected at the time of presentation. Pain was the commonest presented complaint of the patient. The spine is the commonest site affected and the lung was the common site of primary metastasis. Most of the cases were detected by radiogram and confirmation was obtained by minimally invasive technique like FNAC or CNB.

Follicular Thyroid Carcinoma Presenting as Large Solitary Vertebral Metastasis: Report of Two Unusual Cases Treated with Radiotherapy

Solitary spinal metastasis with cord compression as the presenting feature of follicular thyroid carcinoma (FTC) is extremely unusual with <10 cases reported in world literature. We hereby present two such cases in a 39-year-old male with lytic lesion left sacral bone with biopsy showing metastatic carcinoma with morphology and immunophenotype of thyroid gland and a 35-year-old female with thoracic vertebral lesions suggestive of metastatic deposit of FTC. Subsequently, both patients were found to have a solitary nodule in the thyroid lobe. They were treated with local radiotherapy (RT) with significant symptomatic relief. The present cases highlight the rarity of FTC to present as upfront solitary vertebral metastases with significant morbidity in young individuals although a slow indolent course with metastases in late stages of disease is more common, debilitating the effect of metastatic lesion requiring RT for pain palliation and the role of supportive nursing care for patient rehabilitation.

Isolated Spinal Metastasis with Spinal Cord Compression Leads to a Diagnosis of a Follicular Thyroid Carcinoma

Introduction: Thyroid carcinoma initially presents with clinical symptoms due to metastatic lesions in less than 5% of cases. Spinal cord compression from an epidural metastatic lesion as a first symptom is extremely rare. One would expect such a presentation to occur much later in the course of the disease.

Methods: We are presenting a case report of a follicular thyroid carcinoma that presented with spinal cord compression from a thoracic epidural metastatic lesion in a previously healthy 55-year-old male. A single metastasis of follicular thyroid carcinoma presenting with posterior spinal cord compression is rare. In this particular case, our management included a mid-thoracic laminectomy, followed by resection of the epidural lesion. Once the surgical pathology confirmed the diagnosis of a follicular thyroid carcinoma, the general surgery team performed a near total thyroidectomy, after which he received radioactive iodine therapy. The patient is symptom-free at his three-year follow-up.

Conclusion: Initial presentation of follicular thyroid carcinoma with symptomatic thoracic myelopathy from an epidural metastasis is very uncommon. An early diagnosis and prompt surgical intervention provided an excellent outcome.

Bone metastases of unknown origin: epidemiology and principles of management

Metastases are the most common malignancies involving bone; breast, prostate, lung and thyroid are the main sites of primary cancer. However, up to 30 % of patients present with bone metastases of unknown origin, where the site of the primary neoplasm cannot be identified at the time of diagnosis despite a thorough history, physical examination, appropriate laboratory testing and modern imaging technology (CT, MRI, PET). Sometimes only extensive histopathological investigations on bone specimens from biopsy can suggest the primary malignancy. At other times, a bone lesion can have such a highly undifferentiated histological appearance that a precise pathological classification on routine hematoxylin-eosin-stained section is not possible. The authors reviewed the relevant literature in an attempt to investigate the epidemiology of the histological primaries finally identified in patients with bone metastases from occult cancer, and a strategy of management and treatment of bone metastases from occult carcinomas is suggested. Lung, liver, pancreas and gastrointestinal tract are common sites for primary occult tumors. Adenocarcinoma is the main histological type, accounting for 70 % of all cases, while undifferentiated cancer accounts for 20 %. Over the past 30 years, lung cancer is the main causative occult primary for bone metastases and has a poor prognosis with an average survival of 4-8 months. Most relevant literature focuses on the need for standardized diagnostic workup, as surgery for bone lesions should be aggressive only when they are solitary and/or the occult primaries have a good prognosis; in these cases, identification of the primary tumor may be important and warrants special diagnostic efforts. However, in most cases, the primary site remains unknown, even after autopsy. Thus, orthopedic surgery has a mainly palliative role in preventing or stabilizing pathological fractures, relieving pain and facilitating the care of the patient in an attempt to provide the most appropriate therapy for the primary tumor as soon as possible.

LEVEL OF EVIDENCE

5.