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 Table of Contents  
CASE REPORT
Year : 2011  |  Volume : 3  |  Issue : 1  |  Page : 39-42

Thyroid carcinoma presenting as a dural metastasis mimicking a meningioma: A case report


Department of Medical Oncology, National Institute of Oncology, Rabat, Morocco

Date of Web Publication9-Nov-2011

Correspondence Address:
El Mehdi Tazi
Department of Medical Oncology, National Institute of Oncology, Rabat
Morocco
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Source of Support: None, Conflict of Interest: None


DOI: 10.4297/najms.2011.339

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  Abstract 

Context: Follicular thyroid cancer rarely manifests itself as a distant metastatic lesion. Case Report: We report a case of a 41-year old man presented with a solid mass located in the left temporo-occipital region. The 3D computed tomography showed a large solid mass with high vascularity, skull erosion and supra-infratentorial epidural mass effect. After magnetic resonance imaging (MRI) a suspect diagnosis of meningioma was made. The patient underwent surgery where a soft mass with transverse sinus invasion was encountered; the tumour was successfully resected employing microsurgical techniques. Histological examination revealed a thyroid follicular neoplasm with positive staining for follicular carcinoma in immunohistochemical analysis. Postoperatively levels of thyroid hormones were normal. Treatment was planned for the thyroid gland, patient receiving 6 courses of chemotherapy including paclitaxel. Conclusions: The present case emphasizes that although they are uncommon, dural metastasis can be mistaken for meningiomas. The definitive diagnosis of a 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: Metastasis, thyroid follicular carcinoma, meningioma.


How to cite this article:
Tazi E, Essadi I, Errihani H. Thyroid carcinoma presenting as a dural metastasis mimicking a meningioma: A case report. North Am J Med Sci 2011;3:39-42

How to cite this URL:
Tazi E, Essadi I, Errihani H. Thyroid carcinoma presenting as a dural metastasis mimicking a meningioma: A case report. North Am J Med Sci [serial online] 2011 [cited 2019 Nov 14];3:39-42. Available from: http://www.najms.org/text.asp?2011/3/1/39/86398


  Introduction Top


Skull metastasis of extra cranial 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 [2] . Isolated forms have radiological features that strongly suggest a primary tumor, and furthermore, their macroscopic appearance during surgery may even be taken for a meningioma [3] .

In this paper, we described a patient who initially presented a tumor that invaded the scalp, dura mater, transverse sinus, supra and infratentorial space, mimicking a malignant meningioma. The lesion resulted in a metastatic location of a thyroid follicular carcinoma.


  Case Report Top


A 41-year-old man was referred to our institute with a 1-year history of persistent headache and a mass in the left temporo-occipital region, the mass had developed in the last year and rapidly grown within 6 months.

The physical examination revealed a fixed, five centimeters solid mass. The neurologic examination on admission showed no abnormalties. The computed Angiotomography showed a large extrinsic solid lesion with epidural mass effect and contrast enhancement causing bone destruction. MRI showed a supra-infratentorial tumour location with invasion of the scalp and left transverse dural sinus [Figure 1].
Figure 1: MRI showing an extrinsic mass with scalp, bone and dura involvement. The mass causes bone erosion and has supra-infratentorial, and left transverse sinus extension.

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Endovascular embolization was not possible and the patient underwent surgery. Intraoperatively, the tumour was found immediately in the scalp appearing as a soft, reddish, highly vascularizated mass with dural invasion. The inferior and posterior borders of the tumour encased the left transverse sinus; the tumour was successfully dissected employing microsurgical techniques. Finally, a complete resection of the tumour was achieved. Postoperatively, the patient was extubated and observed in the surgical intensive care unit. He remained free from neurologic deficits. Histological examination revealed a thyroid differentiated neoplasm with positive staining for thyroglobulin and follicular carcinoma in immunohistochemical analysis [Figure 2].
Figure 2 a: Tissue removed from the tumour zone showing cubic

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Postoperatively levels of thyroid hormones were normal. Radionuclide imaging with Tc 99 demonstrated a thyroid mass. Radiological neck, chest and abdominal examination revealed no other metastatic localisations. The patient received 6 courses of treatment with Paclitaxel.


  Discussion Top


The incidence of thyroid carcinoma is about 1 per 25,000 populations, accounts for approximately 1% of all thyroid tumours. Follicular carcinoma accounts for 10-15% of clinically evident thyroid malignancies. Intracranial metastasis occurs about 1% of these cases [4],[5] . The mean age of presentation in a case series of 12 patients reported was 60 years and a female preponderance was seen [6] . Only one paediatric case has been described in the literature [7] . These statistics indicate the rarity of intracranial metastasis of thyroid follicular carcinoma. The method of spread of thyroid carcinoma is likelihood via the haematogenous route. Batson demonstrated a vertebral venous plexus which consisted of a valveless vascular bed within the spinal canal and extended from the skull to the pelvis [8] . Batson and Eckenhoff showed that there were multiple anastomosis and free connections between this venous plexus and the dural sinuses [9] . More recently arterial spread has also been suggested because of the association with secondary cutaneous locations in the territory of ipsilateral external carotid artery [10] . This is probably the physiopathology of the metastasis in our case. Patients usually have a long clinical course before the diagnosis of skull lesion, and the principal clinical features are a palpable scalp tumour, disturbance of consciousness, hemiparesis, headache, cranial nerve dysfunction and exophthalmos have all been reported [6, 11] . In our case, the period until diagnosis of the definite metastatic focus was 1 year. Eighty percent of patients with thyroid follicular carcinoma are seen initially with a solitary thyroid nodule [12] . Nevertheless, there are very few reports regarding the initial presentation of patients with distant metastasis leading to diagnosis of follicular carcinoma [13],[14],[15],[16],[17],[18],[19],[20] . Emerick et al. reported two patients with distant metastasis at presentation [12] . Sevinc et al. reported a rare initial manifestation of a giant mass on the right scapula of a female patient [11] .

The diagnosis in our case was difficult, because based on neuroimaging findings the most likely diagnosis was malignant meningioma. Dural metastasis of follicular carcinoma interpreted as meningioma has occasionally been reported [3],[21] . Anatomically, skull metastatic lesions are most frequently located over the occipital region, isolated papers report sellar region, posterior fossa, skull base [14],[15],[16] . Skull metastatic lesions were found to be osteolytic on CT scan, and highly vascular on angiographic assessment [6] , the same as occurred in our case. The differential diagnosis of sarcoma and metastasis should always be considered when a lytic skull lesion with irregular edges and absence of peripheral sclerosis is identified, even in the young patient [7],[22] . The primary focus of thyroid metastasis, which causes large bone defects, is difficult to define [1],[23] , metastatic tumours with unidentified primary tumour histology have been reported in patients with normal thyroid glands [13] .

The best treatment for skull metastasis remain to be determined, but the current literature supports the excision of the lesion of the skull, removal of the thyroid tissue and maintenance TSH-suppression. Radiotherapy and iodine 131 internal radiation are other treatment options recommended for highly vascularised metastatic skull tumours [24] . Only 17% of metastatic lesions to the brain take up iodine 131 , so the effect of radioactive ablation on brain metastasis is very restricted [25] . Intracranial metastasis have been treated by external beam radiation or radioactive ablation using iodine 131 but the effect was very limited [26] . Complete resection of brain secondary sites remains the optimal treatment. The primary tumor is treated with radioactive iodine 131[5] . In the absence of established treatment protocols to follow up in patients with intracranial metastasis from follicular carcinoma, the practitioner is especially challenged when faced with this disease.


  Conclusion Top


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


  Acknowledgement Top


El Mehdi Tazi and Ismail Essadi analyzed, interpreted the patient data regarding its oncological features, and has been involved in drafting the manuscript. Hassan Errihani has given final approval of the version to be published. All authors read and approved the final manuscript.

The author(s) declare that they have no competing interests.

 
  References Top

1.McCormack KR. Bone metastases from thyroid carcinoma. Cancer 1966; 19:181-184.  Back to cited text no. 1
    
2.Turner O, German WJ. Metastases in the skull from carcinoma of the thyroid. Surgery 1941; 9:403-414.  Back to cited text no. 2
    
3.Tagle P, Villanueva P, Torrealba G, Huete I. Intracraneal metastasis or meningioma? An uncommon clinical diagnostic dilemma. Surg Neurol 2002; 58:241-245.   Back to cited text no. 3
    
4.Venkatesh S, Leavens ME, Samaan NA. Brain metastases in patients with well-differentiated thyroid carcinoma: study of 11 cases. Eur J Surg Oncol 1990;16:448-450.  Back to cited text no. 4
    
5.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; 46:302-305.   Back to cited text no. 5
    
6.Nagamine Y, Suzuki J, Katakura R, Yoshimoto T, Matoba N, Takaya K. Skull metastasis of thyroid carcinoma. Study of 12 cases. J Neurosurg 1985; 63:526-531.  Back to cited text no. 6
    
7.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. 7
    
8.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. 8
    
9.Eckenhoff JE. The physiologic significance of the vertebral venous plexus. Surg Gynecol Obstet 1970; 131:72-78.  Back to cited text no. 9
    
10.Sgouros S, Walsh AR. Synchronous dural and cutaneous metastasis along the distribution of the external carotid artery. Br J Neurosurg 1994; 8: 617-619.  Back to cited text no. 10
    
11.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(1): 27-29.  Back to cited text no. 11
    
12.Emerick GT, Duh QY, Siperstein AE, Burrow GN, Clark OH. Diagnosis, treatment and outcome of follicular thyroid carcinoma. Cancer 1993; 72: 3287-3295.   Back to cited text no. 12
    
13.Inci S, Akbay A, Bertan V, Gedikoglu G, Onol B. Solitary skull metastasis from occult thyroid carcinoma. J Neurosurg Sci 1994; 38:63-66.  Back to cited text no. 13
    
14.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; 87:776-780.  Back to cited text no. 14
    
15.Song IS, Chan KF, Tey PH, Choi HS. An unusual case of thyroid carcinoma metastasis to the posterior fossa. Mt Sinai J Med 1981; 48(3):281-285.  Back to cited text no. 15
    
16.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; 102:149-155.  Back to cited text no. 16
    
17.Shaha AR, Shah JP, Loree TR. Differentiated thyroid cancer presenting initially with distant metastasis. Am J Surg 1997; 174:474-476.  Back to cited text no. 17
    
18.Caldero´n-Garciduen˜as AL, Gonza´lez-Schaffinni MA, Farias-Garcia R, Rey-Laborde R. Cranial metastasis of thyroid follicular carcinoma. Report of a case. Gac Med Mex 2001; 137(4): 356-360.  Back to cited text no. 18
    
19.Ozdemir N, Senoglu M, Acar UD, Canda MS. Skull metastasis of follicular thyroid carcinoma. Acta Neurochir (Wien) 2004; 146(10):1155-1158.  Back to cited text no. 19
    
20.Boehm T, Rothouse L, Wartofsky L. Metastatic occult follicular thyroid carcinoma. JAMA 1974; 253:2420-2421.  Back to cited text no. 20
    
21.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(10):995-999.   Back to cited text no. 21
    
22.Wong GK, Boet R, Poon WS, Ng HK. Lytic skull metastasis secondary to thyroid carcinoma in an adolescent. Hong Kong Med J 2002; 8(2):149-151.  Back to cited text no. 22
    
23.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): 205-208.   Back to cited text no. 23
    
24.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. 24
    
25.Chiu AC, Delpassand ES, Sherman SI. Prognosis and treatment of brain metastases in thyroid carcinoma. J Clin Endocrinol Metab 1997; 82:3637-3642.   Back to cited text no. 25
    
26.Varma VM, Beierwaltes WH, Nofal MM, Nishiyama RH, Copp JE. Treatment of thyroid cancer. Death rates after surgery and after surgery followed by sodium iodine I-131. JAMA 1970 ; 214:1437-1442.  Back to cited text no. 26
    


    Figures

  [Figure 1], [Figure 2]


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