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 Table of Contents 
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 1047-1049  

A rare case of sacral metastasis of unknown follicular thyroid carcinoma radiologically mimicking as chordoma


1 Department of Pathology and Lab Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Surgical Oncology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission27-Aug-2020
Date of Decision27-Oct-2020
Date of Acceptance05-Dec-2020
Date of Web Publication27-Feb-2021

Correspondence Address:
Dr. Sudeep Khera
Department of Pathology, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_1755_20

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  Abstract 


Follicular thyroid carcinoma (FTC) presenting as an isolated spinal metastasis with features of compression myelopathy is extremely rare with <10 cases reported in world literature. FTC is the second most common thyroid cancer with an indolent course. It predominantly occurs in females. The most common route of metastasis is through hematogenous routes to lung, liver, bones, etc., Herein we report a case of 47-year-old female presented with lesion involving sacral vertebrae and biopsy showing metastatic follicular carcinoma with morphology and immunohistochemistry of thyroid gland. The present case highlights the rarity of FTC to present as upfront solitary vertebral metastases with history of prior hemithyroidectomy. All the cases of spinal mass should be evaluated thoroughly to exclude any metastatic deposits.

Keywords: Follicular type thyroid carcinoma, spinal metastasis, spinal tumor


How to cite this article:
Khera S, Elhence P, Jayakumar D, Gupta A. A rare case of sacral metastasis of unknown follicular thyroid carcinoma radiologically mimicking as chordoma. J Family Med Prim Care 2021;10:1047-9

How to cite this URL:
Khera S, Elhence P, Jayakumar D, Gupta A. A rare case of sacral metastasis of unknown follicular thyroid carcinoma radiologically mimicking as chordoma. J Family Med Prim Care [serial online] 2021 [cited 2021 Apr 21];10:1047-9. Available from: https://www.jfmpc.com/text.asp?2021/10/2/1047/310294




  Introduction Top


Follicular thyroid carcinoma (FTC) ranks the second most common thyroid cancer with an indolent course[1] presenting as an asymptomatic solitary thyroid nodule. It has a predilection for hematogenous spread with 10-15% of patients presenting with metastatic disease to lung followed by bone with brain, liver, and skin less commonly involved.[2] Most common site for bone metastases is vertebral bodies followed by pelvis, femur, skull, and ribs. However, spinal metastasis with symptomatic cord compression as the initial presenting feature with solitary site of involvement of FTC is extremely rare. Herein an unusual case of spinal metastasis of occult follicular thyroid carcinoma with compression myelopathy is discussed.


  Case Report Top


A 47-year-old woman presented with progressive lower back pain for 1 year associated with fecal incontinence for 2 years and urinary incontinence for 1 year. However, no past history of pulmonary tuberculosis and diabetes mellitus was recorded. On examination, no obvious swelling was noted. However, patient complained of local tenderness at sacral region. No cervical lymphadenopathy was recorded. On radiological imaging studies, she had an approximately 6.5 × 5 cm lobulated expansile mass involving S1 and S2 vertebrae. The mass was encroaching sacral canal and foramina, superiorly reaching upto L5- S1 recess. On imaging, diagnosis of chordoma was rendered. All hematological and biochemical parameters were within normal limits. Thyroid hormone assay were also normal. Sagittal MRI scan revealed an extradural mass with spinal canal stenosis [Figure 1]. Core needle biopsy was performed from the mass under guidance. Biopsy revealed follicles/acini arranged in back to back manner. Keeping in mind the architectural pattern differential diagnosis of metastatic adenocarcinoma from breast, colon, etc., and FTC were deliberated on histology alone [Figure 2]. Subsequently, panel of immunohistochemical markers was carried out. These follicles were intensly and diffusely positive for TTF-1 & thyroglobulin [Figure 3]. These follicles were non immunoreactive for CK7 & CK20, respectively. Thus, diagnosis of metastatic follicular carcinoma from thyroid was rendered on histology and immunohistochemistry. Further eliciting the clinical history, patient had history of hemithyroidectomy 6 years back, following which the patient was put on thyroxine. Unfortunately, patient had no histopathology reports available from prior surgery. Subsequently, thyroid ultrasound study revealed a 3 × 2.5 mm cystic nodule filled with colloid was identified in the left thyroid lobe. Right thyroid lobe was not visualized. Subsequently, patient underwent completion thyroidectomy. On histological examination, it was reported as hyperplastic cellular nodule without any evidence of capsular or vascular invasion. The patient postoperative course was uneventful. Patient was put on high dose thyroxine therapy to suppress TSH stimulation which relieved pain to some extent. Patient was discharged with the advice of I-131 ablation therapy for further management. Unfortunately, the patient did not turn up for further treatment. We tried to establish the contact with the patient and patient was doing fine but refused to come for further management.
Figure 1: A magnetic resonance imaging scan, lobulated expansile mass is seen at sacral vertebrae

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Figure 2: H&E, 40× & 400×, shows core biopsy from the mass exhibiting thyroid follicles

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Figure 3: IHC reveals diffuse nuclear expression of TTF-1(Thyroid transcription factor1) & diffuse cytoplasmic expression of thyroglobulin

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  Discussion Top


Thyroid malignancy accounts for 1% of cancers occurring in humans. Few case reports have been mentioned in literature of FTC metastasizing to the sacrum as a solitary site of metastases with neurological symptoms because of spinal cord compression. The frequency of follicular thyroid malignancy is the second most common thyroid malignancy with usual predilection in elderly females. These patients have a significant past history of long standing multinodular goitre.[3] In the present case, patient did not present with multi nodular goitre. The most common mode of spread is through vascular invasion resulting in metastases to the lung, bone, and lymph nodes.[4] The incidence of metastatic spread reported as 10–50% from follicular carcinoma by Harkness et al.[5] Okuntan presented a case of FTC metastasizing to the lumbar vertebra.[6] Quinn confirmed four cases as sacral metastasis from FTC.[7] Tazi reported a case which presented as dural metastasis.[8] Fanchiang reported the occurrence rate of bony metastasis in thyroid carcinomas as 4.3% and 71% of all cases.[9] Of 127 autopsy cases, only three cases of metastasis to the thoracolumbar spine of thyroid carcinoma were reported by Baron.[10] There are very few case reports of FTC presenting as distant metastasis as the initial manifestation leading to the diagnosis of FTC.[11],[12],[13] Compression myelopathy is extremely unusual presenting feature of metastatic thyroid carcinoma. Of 1,038 patients with thyroid malignancy presented as distant metastasis in 11% of the cases, in which 4% presented with initial distant metastasis reported by Shaha.[13] In our case, patient presented with spinal mass, followed by guided biopsy aided in the detection of metastatic thyroid malignancy which in turn elicited clinical history of thyroidectomy. Complete excision of the thyroid gland and removal of the metastatic foci as much as possible is considered as the best management strategy for metastatic thyroid carcinoma. It offers the best chance of prolonged survival.[10],[13] Inoperable/highly vascularised metastatic spinal tumors can be managed by biopsy followed by radiotherapy and I-131 internal radiation. High-dose radioiodine treatment is recommended for vertebral body metastases as bony lesions are less likely to concentrate radioiodine and are associated with a worse prognosis than pulmonary metastases.[14]

Radioactive iodine is preferred over radiotherapy in younger individuals with total resection of secondaries in the spine presented with bony metastases of the FTC.[15]

In our patient, completion thyroidectomy was performed followed which the patient was advised for radioactive iodine ablation therapy but patient refused for further treatment. The prognosis is said to be favorable for differentiated thyroid cancers which remains around 80–95% for 10 years, whereas the survival rates drop down to 40% with distant metastasis.[16]

As a primary care physician while dealing with a case of spinal mass, thorough clinical history including any past history of thyroidectomy, thyroid hormone assay, thyroid biomarkers such as serum thyroglobulin levels to monitor for any recurrence and imaging studies are recommended before referring the patient for any surgical management. Since all the cases of spinal mass are not primary in nature, some may turn out to be metastatic in nature. Thus, it is imperative to be vigilant to exclude any past history of thyroid malignancy.


  Conclusion Top


One must keep in mind metastatic deposits of thyroid malignancy as a differential diagnosis while dealing with cases of spinal mass. So preoperative detailed clinical evaluation, imaging of thyroid and thyroid function tests ought to be performed to exclude any thyroid lesion. In our case eliciting past history of thyroidectomy was essential to correlate with the histopathological diagnosis on core biopsy.

Key points

  1. Metastatic lesions of the spine to be excluded in the patients having spinal mass as an initial presentation
  2. Eliciting a good clinical history is essential for establishing a diagnosis
  3. Serum thyroglobulin levels to be monitored to look for any recurrence, if past history of thyroidectomy is elicited.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient have given their consent for their clinical information to be reported in the journal. The patient understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Institutional ethical committee clearance is not warranted for case reports.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pacini F, Schlumberger M, Dralle H, Elisei R, Smit JW, Wiersinga W, et al. European consensus for the management of patients with differentiated thyroid carcinoma of the follicular epithelium. Eur J Endocrinol 2006;154:787-803.  Back to cited text no. 1
    
2.
Durante C, Haddy N, Baudin E, Leboulleux S, Hartl D, Travagli JP. Long-term outcome of 444 patients with distant metastases from papillary and follicular thyroid carcinoma: Benefits and limits of radioiodine therapy. J Clin Endocrinol Metab 2006;91:2892-9.  Back to cited text no. 2
    
3.
Rodrigues G, Ghosh A. Synchronous bony and soft tissue metastases from follicular carcinoma of the thyroid. J Korean Med Sci 2003;18:914-6.  Back to cited text no. 3
    
4.
Nam M, Chu YC, Choe W, Kim SJ, Hang SB, Kim YJ, et al. Metastatic follicular thyroid carcinoma to the thymus in a 35-year-old woman. Yonsei Med J 2002;43:665-9.  Back to cited text no. 4
    
5.
Harkness JK, Thompson NW, Sisson JC, Beierwaltes WH. Differentiated thyroid carcinomas. Arch Surg 1974;108:410-7.  Back to cited text no. 5
    
6.
Okuntan O, Kaptanoglu E, Gocmen E, Solaroglu I, Beskonakli E, Koc M. Metastasis of follicular carcinoma of the thyroid to the lumbar vertebrae: A case report. Turk Neurosurg 2005;15:32-5.  Back to cited text no. 6
    
7.
Quinn TR, Duncan LM, Zembowicz A, Faquin WC. Cutaneous metastases of follicular thyroid carcinoma: A report of four cases and a review of the literature. Am J Dermatopathol 2005;27:306-12.  Back to cited text no. 7
    
8.
Tazi el M, Essadi I, Errihani H. Thyroid carcinoma presenting as a dural metastasis mimicking a meningioma: A case report. N Am J Med Sci 2011;3:39-42.  Back to cited text no. 8
    
9.
Fanchiang JK, Lin JD, Huang MJ, Shih HN. Papillary and follicular thyroid carcinomas with bone metastases: A series of 39 cases during a period of 18 years. Changeng Yi Xue Za Zi 1998;21:377-82.  Back to cited text no. 9
    
10.
Baron K, Hirano A, Araki S, Terry RD. Experience with metastatic neoplasms involving the spinal cord. Neurology 1959;9:91-106.  Back to cited text no. 10
    
11.
Goldstein SI, Kaufman D, Abati AD. Metastatic thyroid carcinoma presenting as distal spinal cord compression. Ann Otal Rhinol Laryngol 1998;97:393-6.  Back to cited text no. 11
    
12.
Scarrow AM, Colina JL, Levy EI, Welch WC. Thyroid carcinoma with isolated spinal metastasis: Case history and review of the literature. Clin Neurol Neurosurg 1999;101:245-8.  Back to cited text no. 12
    
13.
Shaha AR, Shah JP, Loree TR. Differantiated thyroid cancer presenting initially with distant metastasis. Am J Surg 1997;174:474-6.  Back to cited text no. 13
    
14.
Sharma N, Purkayastha A. Follicular thyroid carcinoma presenting as large solitary vertebral metastasis: Report of two unusual cases treated with radiotherapy. Asia Pac J Oncol Nurs 2017;4:269-72.  Back to cited text no. 14
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15.
Tufan A, Eren B, Taş A, Berker N, Aktaş ÖY, Güleç İ, et al. Spinal metastasis as presenting feature of follicular type thyroid carcinoma: A case report and review of the literature. Bagcilar Med Bull 2019;4:1-9.  Back to cited text no. 15
    
16.
Kuşaslan R, Vartanoğlu T, Hepgül G, Altınel Y, Yigitbas H, Öncü M, et al. Metastasis of follicular thyroid carcinoma to the vertebra: A case report. Ann Clin Case Rep 2016;1:1114.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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