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Table of Contents
CASE REPORTS
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 12-15

Thyroid carcinoma as a dural mass: A rare mode of presentation


Department of Pathology, Medical College, Baroda, India

Date of Submission28-Aug-2020
Date of Acceptance20-May-2021
Date of Web Publication12-Apr-2022

Correspondence Address:
Dr. Sivaranjini Narayanan
TC40/733, Thoppu Lane, Sreevaraham, Manacaud, Trivandrum 695009.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJNO.IJNO_21_20

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  Abstract 

Context: Distant metastasis is a rare, primary manifestation of follicular carcinoma of the thyroid. Case Report: We report a case of a 72-year-old woman presenting with a solid mass located in the left parieto-occipital region. The 3D computed tomography (CT) showed a large solid mass supplied by branches of the external carotid artery. After magnetic resonance imaging, a probable diagnosis of meningioma was made. The patient underwent surgery where a soft mass invading the superior sagittal sinus was encountered and resected. Histological examination revealed a thyroid follicular neoplasm with positive staining for thyroglobulin and thyroid transcription factor I on immunohistochemical analysis. Postoperatively, levels of thyroid hormones were normal. Subsequent ultrasonogram revealed a nodule in the thyroid gland, which on fine needle aspiration cytology was diagnosed as a follicular neoplasm. Treatment was planned for the thyroid gland, the patient receiving chemotherapy including sorafenib. Conclusions: The present case emphasizes that although they are uncommon, dural metastasis can be mistaken for meningiomas. Confirmation of diagnosis as meningioma should be established only after the histopathological analysis. Thyroid follicular carcinoma should be included in the differential diagnosis in cases of extrinsic tumoral lesions.

Keywords: Meningioma, metastasis, thyroid follicular carcinoma


How to cite this article:
Narayanan S, Hiryur SP. Thyroid carcinoma as a dural mass: A rare mode of presentation. Int J Neurooncol 2021;4:12-5

How to cite this URL:
Narayanan S, Hiryur SP. Thyroid carcinoma as a dural mass: A rare mode of presentation. Int J Neurooncol [serial online] 2021 [cited 2022 Jun 27];4:12-5. Available from: https://www.Internationaljneurooncology.com/text.asp?2021/4/1/12/342818




  Key Messages: Top


Although uncommon, dural metastasis can be mistaken for meningiomas and should be confirmed by histopathological examination.


  Introduction Top


Skull metastasis of extracranial origin is rare. The most common forms are pulmonary, breast, and prostate carcinomas.[1] Metastasis in the skull associated with carcinoma of the thyroid accounts for only 2.5%–5.8% of cases, but the initial presentation with distant metastasis is uncommon. Isolated forms have radiological features that strongly suggest a primary tumor, and furthermore, their macroscopic appearance during surgery may even be taken as a meningioma.[2] In this report, we described a patient who initially presented with a tumor that invaded the scalp, dura mater, superior sagittal sinus, mimicking a malignant meningioma. The lesion resulted in a metastatic location of a thyroid follicular carcinoma.


  Case history Top


A 72-year-old woman was referred to our institute with a mass in the left parieto-occipital region; the mass had developed in the last two years and rapidly grown within two months. The physical examination revealed a fixed, 8-cm solid mass. The neurologic examination on admission showed no abnormalities.

The computed angiotomography showed a large, soft-tissue lesion supplied by branches of the external carotid artery. Magnetic resonance imaging showed a calvarial mass involving the left parieto-occipital bones with protrusion into the scalp, displacement of the left occipital lobe, and invasion of the posterior one-third of the superior sagittal dural sinus. Intraoperatively, the tumor was found immediately in the scalp appearing as a soft, brownish, vascularized mass with dural invasion and excised. Postoperatively, the patient remained free from neurologic deficits.

Histological examination revealed an epithelial neoplasm with the formation of macro- and microfollicles [Figure 1] and the presence of colloid [Figure 2]. Positive staining for thyroid transcription factor I (TTF-I) [Figure 3]a and thyroglobulin [Figure 3]b was seen on immunohistochemical analysis.
Figure 1: Histopathological examination (10×): Neoplasm composed of neoplastic cells in follicles

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Figure 2: Histopathological examination (40×): Follicles showed thick colloid with scalloped edges

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Figure 3: (a) Immunohistochemistry: Follicular cells showed nuclear positivity for TTF-I. (b) Immunohistochemistry: Colloid showed thyroglobulin positivity

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Postoperatively, levels of thyroid hormones were normal. Subsequent ultrasound examination of the neck revealed the presence of a 2.0-cm thyroid nodule. Fine needle aspiration cytology of the nodule showed a microfollicular pattern in the background of blood [Figure 4]. Radiological neck, chest, and abdominal examination revealed a nodule in the liver and left lung. The patient is now on treatment with sorafenib.
Figure 4: Cytopathological examination: Follicular cells arranged in microfollicular pattern and scattered singly in a background of blood

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  Discussion Top


The incidence of thyroid carcinoma is about 1 per 25,000 populations and accounts for approximately 1% of all thyroid tumors. Follicular carcinoma accounts for 10%–15% of clinically evident thyroid malignancies. Intracranial metastasis occurs in about 1% of these cases.[3] The mean age of presentation in a case series of 12 patients reported was 60 years, and a female preponderance was seen.[3],[4] Only one pediatric case has been described in the literature.[5] These statistics indicate the rarity of intracranial metastasis of thyroid follicular carcinoma. The method of spread of thyroid carcinoma is likely the hematogenous route. Batson demonstrated a vertebral venous plexus that consisted of a valveless vascular bed within the spinal canal and extended from the skull to the pelvis.[6] Batson and Eckenhoff showed that there were multiple anastomoses and free connections between this venous plexus and the dural sinuses. More recently, the arterial spread has also been suggested because of the association with secondary cutaneous locations in the territory of the ipsilateral external carotid artery.[7] This is probably the pathophysiology of the metastasis in the present case.

Patients usually have a long clinical course before the diagnosis of skull lesion, and the principal clinical features reported are a palpable scalp tumor, altered sensorium, hemiparesis, headache, cranial nerve dysfunction, and exophthalmos.[4],[8] In the present case, the period until the diagnosis of the definite metastatic focus was two years. Eighty percent of patients with thyroid follicular carcinoma are seen initially with a solitary thyroid nodule.[9] Nevertheless, there are very few reports regarding the initial presentation of patients with distant metastasis leading to the diagnosis of follicular carcinoma.[10],[11],[12],[13],[14],[15] Emerick et al. reported two patients with distant metastasis at presentation.[9] Sevinc et al. reported a rare initial manifestation of a giant mass on the right scapula of a female patient.[15] The diagnosis in the present case was surprising, because based on neuroimaging findings, the most likely diagnosis was primary intracalvarial hemangioma. Dural metastasis of follicular carcinoma interpreted as meningioma has occasionally been reported.[3],[16] Anatomically, metastatic skull lesions are most frequently located over the occipital region; isolated papers report sellar region, posterior fossa, skull base.[14],[15],[16],[17] Metastatic skull lesions were found to be osteolytic on CT scan and highly vascular on angiographic assessment,[4] the same as occurred in the present case. The primary focus of thyroid metastasis, which causes large bone defects, is difficult to define.[1],[18] Metastatic tumors with unidentified primary tumor histology have been reported in patients with normal thyroid glands.[15]

The best treatment for skull metastasis remains to be determined, but the current literature supports the excision of the lesion of the skull, removal of the thyroid tissue, and maintenance of thyroid stimulating hormone suppression. Radiotherapy and iodine-131 internal radiation are other treatment options recommended for highly vascularized metastatic skull tumors.


  Conclusion Top


This is a rare case of follicular thyroid carcinoma metastasized to the bone with dural sinus extension. Metastatic follicular carcinoma should be kept in mind in the differential diagnosis of cranial masses.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
McCormack KR Bone metastases from thyroid carcinoma. Cancer 1966; 19:181-84.  Back to cited text no. 1
    
2.
Tagle P, Villanueva P, Torrealba G, Huete I Intracranial metastasis or meningioma? An uncommon clinical diagnostic dilemma. Surg Neurol 2002; 58:241-45.  Back to cited text no. 2
    
3.
Ogawa Y, Sugawara T, Seki H, Sakuma T Thyroid follicular carcinoma metastasized to the lung, skull, and brain 12 years after initial treatment for thyroid gland—case report. Neurol Med Chir (Tokyo) 2006; 46: 302-05.  Back to cited text no. 3
    
4.
Nagamine Y, Suzuki J, Katakura R, Yoshimoto T, Matoba N, Takaya K Skull metastasis of thyroid carcinoma. Study of 12 cases. J Neurosurg 1985; 63:526-31.  Back to cited text no. 4
    
5.
Kim SH, Kosnik E, Madden C, et al. Lytic skull metastasis from a follicular thyroid carcinoma in a child. Pediatr Neurosurg 1988; 28: 84-88.  Back to cited text no. 5
    
6.
Batson OV The function of the vertebral veins and their role in the spread of metastasis. Ann Surg 1940; 112:138.  Back to cited text no. 6
    
7.
Sgouros S, Walsh AR Synchronous dural and cutaneous metastasis along the distribution of the external carotid artery. Br J Neurosurg 1994; 8: 617-19.  Back to cited text no. 7
    
8.
Sevinc A, Buyukberber S, Sari R, Baysal T, Mizrak B Follicular thyroid cancer presenting initially with soft tissue metastasis. Jpn J Clin Oncol 2000; 30: 27-29.  Back to cited text no. 8
    
9.
Emerick GT, Duh QY, Siperstein AE, Burrow GN, Clark OH Diagnosis, treatment and outcome of follicular thyroid carcinoma. Cancer 1993; 72: 3287-3295.13.  Back to cited text no. 9
    
10.
Ruchti C, Balli-Antunes M, Gerber HA Follicular tumor in the sellar region without primary cancer of the thyroid. Heterotopic carcinoma? Am J Clin Pathol 1987; 87:776-80.  Back to cited text no. 10
    
11.
Rosahl KS, Erpenbeck V, Vorkapic P, Samii M Solitary follicular thyroid carcinoma of the skull base and its differentiation from ectopic adenoma-review, use of galectin-3 and report of a new case. Clin Neurol Neurosurg 2000; 102:149-55.  Back to cited text no. 11
    
12.
Shaha AR, Shah JP, Loree TR Differentiated thyroid cancer presenting initially with distant metastasis. Am J Surg 1997; 174:474-76.  Back to cited text no. 12
    
13.
Ozdemir N, Senoglu M, Acar UD, Canda MS Skull metastasis of follicular thyroid carcinoma. Acta Neurochir (Wien) 2004; 146(10):1155-58.  Back to cited text no. 13
    
14.
Boehm T, Rothouse L, Wartofsky L Metastatic occult follicular thyroid carcinoma. JAMA 1974; 253:2420-21.  Back to cited text no. 14
    
15.
Yodonawa M, Tanaka S, Kohno K, Ishii Z, Tamura M, Ohye C Brain metastasis of follicular carcinoma of the thyroid gland. Meningioma-like features demonstrated by CT scan and cerebral angiography—case report. Neurol Med Chir (Tokyo) 1987; 27:995-99.  Back to cited text no. 15
    
16.
Wong GK, Boet R, Poon WS, Ng HK Lytic skull metastasis secondary to thyroid carcinoma in an adolescent. Hong Kong Med J 2002; 8: 149-51.  Back to cited text no. 16
    
17.
Akdemir I, Erol FS, Akpolat N, Ozveren MF, Akfirat M, Yahsi S Skull metastasis from thyroid follicular carcinoma with difficult diagnosis of the primary lesion. Neurol Med Chir (Tokyo) 2005; 45(4): 205-08.  Back to cited text no. 17
    
18.
Biswal BM, Bal CS, Sandhu MS, Padhy AK, Rath GK Management of intracranial metastases of differentiated carcinoma of thyroid. J Neurooncol 1994; 22:77-81.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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