Turkish Neiirosiirgery 6: 93 - 95, 1996 Güner: Fo/licu/ar CarcillOma Metastasis
Frontal Epidural Metastasis of FollicularThyroid Carcinoma
Frontal Epidural Folliküler Tiroid Kanseri Metastazi
.. ..METIN GÜNER, ARIF ÜSÜN, ENGIN UÇAR, NERIMAN GÖKDEN, EMEK ÜZEN
Dokuz Eylül University School of Medicine, Departments of Neurosurgery (MG,AÖ,EU),and Pathology (NG,EÖ), Izmir, Turkey
Abstract: Papillary-follicular thyroid carcinoma usuallyremains loca1Ized to the thyroid bed, and in cases ofmetastasis, almost always involves the lungs, bones, orliver. Brain metastasis is rare and there has been noreported case of epidural metastasis of thyroid carcinomasin the literature up to date. A frontal epidural mass lesionwas excised and histologically found to be a follicularthyroid carcinoma metastasis.Key words: Carcinoma, epidural, metastasis, thyroid.
INTRODUCTION
Treatment of metastatic brain tumors is still
controversial. Thyroid careinoma metastasis to thebrain is ra re and surgery alone is not successful.Aggressive surgery and radioactive iodine treatmentshould be performed. Recurrences are evaluated byserum thyroglobulin levels
CASE REPORT
A 50 year-old female patient presented withcomplaints of progressive headache and tinnitus.Neurological examination was normaL.On plain skullradiographs, erosion of the frontal bone was seen.Computerized tomography (CT) revealed a left-sidedfrontal epidural mass lesion 7x4x6 cm in size withsignificant contrast enhancement and frontal boneerosion (Figure 1). A left frontal craniotomy wasperformed. The tumor was well vascularized and thedura was involved. During the operation severebleeding occurred and was controlled by eircular
Özet: Tiroidin papiller-folliküler karsinomu çogunluklatiroid beziyle sinirlidir ve metastazlari hemen daimaakciger, kemik veya karacigerde görülür. Beyin metastazinadirdir, kafaiçinde epidural metastaz bildirilmemistir.Frontal yerlesimli epidural kitle lezyonu saptanarakçikarilan bir hastamizda histopatolojik inceleme sonucufolliküler tiroid karsinomu olarak bildirilmistir.
Anahtar sözcükler: Epidural, karsinoma, metastaz, tiroid
Figure 1:Preoperative CT sean shows a left frontal epiduralmass lesion.
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Turkish Neiirosiirgery 6: 93 - 95, 1996
dural incision. The tum or was totally excised. Therewas no sign of subdural invasion. Histopathologicalexamination revealed follicular thyroid carcinomametastasis (Figure 2). Serum T3, T4 and TSH levelswere normal but thyroid sintigraphy showed activenodules, and serum thyroglobulin level was 191mg/mL (normal values: 0-75 mg/mL). Subtotalthyroidectomy was performed, and histopathologicalexamination revealed follicular thyroid carcinoma(Figure 3). Radioactive iodine (100 mCi P31) wasgiyen. Postoperative thyroid sintigraphy showedminimal enhancement. Bone scintigraphy, chest xray, and abdominal ultrasonography showed noevidence of metastases. Throughout thepostoperative nine month period, the patient had noneurological deficit and no sign of recurrence. Serumthyroglobulin level was still above normal value,102mg/mL.
Figure 2: Histologic examination reveals the tumor andthe intact dura. (H&E, XL O)
Figure 3: Microscopic appearance of the primary thyroid
tumor. Area of the follicular cardnoma (right
upper corner) with intravascular invasion andnormal areas (left lower corner). (H&E, XlOO)
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Gfi/ier: FailiClIlar Careinoma Metastasis
DISCUSSION
The incidence of thyroid carcinoma is estimatedto be 1/25000 -1/27000. Although metastasis to thelungs and bones occur commonly, brain metastasisis ra re (9). Papillary-follicular thyroid carcinomausually remains localized to the thyroid bed, and incases of metastasis almost always involves the lungs,bones or liver. Parker et aL.(8), and Venkatesh et aL.(9) reported papillary-follicular thyroid carcinomametastases to the brain parenchyma. Prevalence ofbrain metastasis in reported series of thyroidcarcinoma is summarized in Table i.
Surgery, radioactive iodine treatment, andradiotherapy are the main therapies used in thesepatients (6,9). An aggressive surgical approach forisolated rnetastasis may be beneficial (9). We totallyexcised the intracranial tumor and two months later
subtotal thyroidectomy was performed. Radioactiveiodine treatment was also giyen.
Many thyroid carcinomas secretethyroglobulin, and in the presence of metastasis highconcentrations of this marker may be detectable inthe serum. Thyroglobulin levels are used as a markerof recurrence during follow-up (1). In this patient,serum thyroglobulin level has increased two-fold atthe beginning.
Table i. Prevalence of brain metastases in reportedseries of thyroid carcinoma
Souree Number ofPredominantNumber ofNumber of
patienls
Tumorpatienis withpatienls with
Hislology
loeal exlensionbrainor melaslasis
metaslases
lo bone lung or liverlbanez el aL.
12Papillary51
(5)
4Follicular2O
Harness et aL.260Papillary28O
(4)
73Follicular8O
Mazzafferi el al.(7)
576Papillary77O
Figg el aL.(2)
105Papillary23O
20
Follicular2O
Frauenhoffer
152Papillary27O
el al (3)
39Follicular7O
Young el aL.(10)
214Follicular20O
Edmonds (1)
128 TotalPapillary41
Follicular4O
Venkatesh (9)
571 TotalPapillary?8
Follicular
1
Hurlhle-cell2
TOTAL
2154 20713
TlIrkish Neiirosiirgery 6: 93 - 95, 1996
Prognosis of thyroid careinomas is poor in thepresence of brain metastasis. Venkatesh et aL.reported survival to be between 3-75 months (mean8 months) from time of diagnosis in eleyen cases (9).There was no sign of recurrence in our patient in thepostoperative ninth month.
Metastasis of thy ro id carcinoma to the brain israre. Aggressive surgery, and radioactive iodinetreatment should be performed. After treatment,serum thyroglobulin level should be checkedperiodicaiiy. Prognosis is poor.
Correspondence: Metin Güner, MDDokuz Eylül UniversitySchool of Medicine
Department of Neurosurgery35340 Inciralti, Izmir, TurkeyTelephone: (232) 259 59 59 i 3300
REFERENCES
1. Edmonds CI, Willis CL: Serum thyroglobulin in theinvestigation of patients presenting with metastases.Br J Radiol 61:317-9,1988
2. Figg DM, Bratt HJ, VanVliet PD, Dean RE: Thyroid
Güiier: Failiclilar Carciiioma Metastasis
caneer: diagnosis and management based on a reviewof 142 cases. Arn J Surg 135: 671-674,1978
3. Frauenhoffer CM, Patchefsky AS, Çobanoglu A:Thyroid careinorna: a clinical and pathologic study of125 cases. Cancer 43: 2414-2421,1979
4. Hamess JK, Thornpson NW, Sisson JC, BeierwaltesWH: Proceedings: Differentiated thyroid careinomas.Treatment of distant metastases. Arch Surg 108: 410419,1974
5. Ibanez ML, Russell WO, Albores SI, Lampertico-P,White EC, Clark RL: Thyroid carcinoma-biologicbehavior and mortality. Postmortem findings in 42cases, including 27 in which the disease was fataL.Cancer 19:1039-1052,1966
6. Maheshwari YK, Hill CS, Haynie TP, Hickey RC,Samaan NA: 131! therapy in differentiated thyroidcarcinoma. Cancer 47:664-671,1981
7. Mazzaferri EL, Young RL: Papillary thyroid careinorna:a 10 year follow-up report of the impact of therapy in576 patients. Arn J Med 70: 511-518,1981
8. Parker LN, Wu SY, Kim DD, Kollin J, Prasasvinichai S:Recurrence of papillary thyroid carcinoma as a focalneurologic deficit. Arch Intem Med 146:1985-7,1986
9. Venkatesh S, Leavens ME, Samaan NA: Brainmetastases in patients with well differentiated thyroidcareinorna: study of 11 cases. Eur J Surg OncoI16:448450,1990
10. Young RL, Mazzaferri EL, Rahe AI, Dorfman SG: Purefollicular thyroid carcinoma: impact of therapy in 214patients. J Nucl Med 21: 733-737,1980
11th Scientific Convention
Turkish Neurosurgical Society
May 16-20/ 1997Dedeman Hotel, Antalya, Turkey
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