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Case Report
Open Access Peer-reviewed

Follicular Carcinoma of Thyroid with the First Presentation as Vertebral Column Metastasis: A Case-report

Mazaher Ramezani, Kaivan Mohammadi, Masoud Sadeghi
American Journal of Cancer Prevention. 2018, 6(2), 24-28. DOI: 10.12691/ajcp-6-2-2
Published online: March 30, 2018

Abstract

Follicular carcinoma of thyroid is the second most common type of thyroid cancer that its incidence has increased in recent years. Herein, the study reported a 64-year male case of follicular carcinoma of thyroid that his first presentation was vertebral column metastasis. His chief complaint was back pain. In the past medical history, the patient had hypothyroidism and was opium inhalation addict since 15 years ago. Thoraco-lumbar magnetic resonance imaging (MRI) demonstrated spinal tumor of T10. The pathology report showed metastatic follicular carcinoma of thyroid with Thyroid transcription factor-1 (TTF-1), Thyroglobulin (TG), and Cytokeratin-7 (CK-7) positivity. Then thyroidectomy confirmed the diagnosis. In conclusion, follicular carcinoma of thyroid may be presented with spinal column metastasis. Pathologist should consider this diagnosis in the differential diagnosis of metastatic carcinoma in vertebral column and use Thyroglobulin with TTF-1 in immunohistochemistry panel for definite diagnosis and identification of origin.

1. Introduction

Thyroid cancer in the US accounts for 0.6% of all cancers in men and 1.6% in women 1. Thyroid cancer 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 2. Follicular thyroid carcinoma is the second most common type of thyroid cancer, and its incidence has increased dramatically in recent years 3. The follicular type tends to typically affect middle-aged females and in 90% of the patients, it presents as a simple thyroid nodule 4. Out of 2200 differentiated thyroid cancer patients, 394 of whom had lung and/or bone metastasis; of those 394 patients, 201 had metastatic follicular thyroid cancer 5. The prognosis of metastatic thyroid carcinoma is dependent on the age of the patient, the histologic characteristics of the neoplasm, and the site of metastasis 6. Presentation with backache, lower limb weakness and perianal numbness is noted and the report is recommended in the literature 7. This study reported a male case of follicular carcinoma of thyroid that his first presentation was vertebral column metastasis.

2. Case Report

The patient was a 64-year man who presented to the Department of Neurosurgery on 10th October 2016 with the chief complaint of back pain since a few months ago with exacerbation since last month. The pain was aggravated on exercise and in nights. The patient had symptoms of pain and numbness in both lower extremities. There was no the history of weight loss and the pain was alleviated by rest. In the past medical history, the patient had hypothyroidism and was opium inhalation addict since 15 years ago. Drug history was only treatment with levothyroxine. There was no positive familial history of cancer. In the physical examination, upper limb force was 5/5 and of the lower limb was 4/5. There was sensory loss in lower limb, but with no sphincter dysfunction. Thoraco-lumbar magnetic resonance imaging (MRI) demonstrated spinal tumor of T10. The patient underwent surgery on 13th October that the pathologist reported metastatic adenocarcinoma to vertebral column (Figure 1) with recommendation of thyroid, lung and gastrointestinal assessment for the most probable origin. Immunohistochemistry was done on 15th November which showed Thyroid transcription factor-1 (TTF-1), Thyroglobulin (TG) (Figure 2), and Cytokeratin-7 (CK-7) positivity (Figure 3), but Prostatic specific antigen (PSA), Cluster of designation-5 (CD-5), Glial fibrillary acidic protein (GFAP), and CK-20 negativity compatible with metastatic follicular carcinoma of thyroid. The patient underwent total thyroidectomy on 6th February 2017. The specimen was consisted of right and left lobes; and isthmus of thyroid with 3Î3Î1, 3.5Î2Î1 and 1Î0.5 cm in size, respectively. The pathology report showed follicular carcinoma of thyroid with the involvement of both lobes and isthmus with capsular invasion, but no vascular invasion (Figure 4). The greatest size of tumor was 1.5cm. The patient was discharged on 8th February and was in the good condition on 14th February 2017.

3. Discussion

Follicular carcinoma of thyroid originates from follicular cells and resembles the normal microscopic pattern of the thyroid and is usually a well-differentiated tumor 8. Thyroid cancer is rare and accounts for roughly 1% of all new malignant disease with a male/female ratio of 1/3 9. This case presented a case with follicular carcinoma of thyroid and the first presentation as vertebral column metastasis. The follicular type tends to typically affect middle-aged females 4. The patient’s presenting symptom was bone pain caused by metastatic follicular thyroid cancer in two reports 10, 11. Of all thyroid cancer subtypes, follicular is more likely to present as distant metastases 12 or develop distant metastases during the course of the disease 13.In fact in a pathologic fracture in the vertebral column, metastatic thyroid cancer should be considered in the differential diagnosis along with prostatic and breast origin 14.The pathologist must be familiar with the histopathological characteristics of the follicular thyroid carcinoma 15. TTF-1 can be used as an immunohistochemistry marker in patients with metastatic bone tumor of unknown origin 11. Table 1 shows a number of characteristics of patients with metastatic follicular thyroid cancer. Out of seventeen cases, 10 cases (58.8%) were males (male/female ratio: 1/0.7). The mean age of all cases was 53.2 years. Also, back pain was the most common complaint in the patients.

This tumor may be well encapsulated and demonstrates vascular invasion and spread via vascular channel 22. In one report correct diagnosis of the tumor with excision of metastases, thyroidectomy and following radioiodine culminated in being symptom free and returning to job in the one -year follow-up 7.

4. Conclusions

Follicular carcinoma of thyroid may be presented with spinal column metastasis. Pathologist should consider this diagnosis in the differential diagnosis of metastatic carcinoma in vertebral column and use Thyroglobulin with TTF-1 in immunohistochemistry panel for definite diagnosis and identification of origin.

References

[1]  Boring CC, Squires TS, Tang T. Cancer Statistics, 1993. CA Cancer J Clin. 1993; 43(1): 7-26.
In article      View Article  PubMed
 
[2]  Toshkezi G, Galgano M, Libohova S, Marawar S. Isolated Spinal Metastasis with Spinal Cord Compression Leads to a Diagnosis of a Follicular Thyroid Carcinoma. Cureus. 2015; 7(10): e346.
In article      View Article
 
[3]  Alvarado M, Ramirez-Vick M, Lopez L, Marcos-Martinez MJ, Saavedra FM, Negron-Rivera JC, et al. An uncommon presentation of follicular thyroid carcinoma: when chronic back pain should raise a flag. Bol Asoc Med P R. 2014; 106(3): 36-9.
In article      PubMed
 
[4]  Ogbodo E, Kaliaperumal C, Keohane C, Bermingham N, Kaar G. Sciatica as a presenting feature of thyroid follicular adenocarcinoma in a 79-year-old woman. BMJ Case Rep. 2011; 2011.
In article      View Article
 
[5]  Schlumberger M, Challeton C, De Vathaire F, Travagli JP, Gardet P, Lumbroso JD, et al. Radioactive iodine treatment and external radiotherapy for lung and bone metastases from thyroid carcinoma. J Nucl Med. 1996; 37(4): 598-605.
In article      PubMed
 
[6]  Goldstein SI, Kaufman D, Abati AD. Metastatic thyroid carcinoma presenting as distal spinal cord compression. Ann Otol Rhinol Laryngol. 1988; 97(4 Pt 1): 393-6.
In article      View Article  PubMed
 
[7]  Akhtar S, Adeel M. An Unusual Case of Cauda Equina Secondary to Spinal Metastasis of Thyroid Cancer. Iran J Otorhinolaryngol. 2016; 28(84): 67-71.
In article      PubMed  PubMed
 
[8]  Ismail SB, Abraham MT, Zaini ZB, Yaacob HB, Zain RB. Metastatic follicular thyroid carcinoma to the mandible: A case report. Cases J. 2009; 2: 6533.
In article      View Article  PubMed
 
[9]  McHenry CR, Phitayakorn R. Follicular adenoma and carcinoma of the thyroid gland. Oncologist. 2011; 16(5): 585-93.
In article      View Article  PubMed
 
[10]  Carhill AA, Vassilopoulou-Sellin R. Durable Effect of Radioactive Iodine in a Patient with Metastatic Follicular Thyroid Carcinoma. Case Rep Endocrinol. 2012; 2012: 231912.
In article      View Article
 
[11]  Kim DH, Yoo SD, Kim SM, Im SJ, Kang JK, Cho EH. Thyroid Cancer Initially Presenting Compression Fracture without Common Thyroid Symptoms. Ann Rehabil Med. 2012; 36(5): 735-8.
In article      View Article  PubMed
 
[12]  Shaha A, Shah J, Loree T. Differentiated thyroid cancer presenting initially with distant metastasis. J Surg. 1997; 174(5): 474-6.
In article      View Article
 
[13]  Lin KD, Lin JD, Huang MJ, Huang HS, Jeng LB, Chao TC, et al. Clinical presentations and predictive variables of thyroid microcarcinoma with distant metastases. Int Surg. 1997; 82(4): 378-81.
In article      PubMed
 
[14]  Yang W, Cho W, Das S, Conboy P. Follicular thyroid carcinoma presenting with pathological fracture of the humerus at initial diagnosis. J Surg Case Rep. 2017; 2017(1). pii: rjx002.
In article      View Article  PubMed
 
[15]  Bansal A, Kaur M, Narula V. Cutaneous and bone metastasis of follicular thyroid carcinoma:a case report. Tumori. 2016; 102 (Suppl. 2).
In article      View Article
 
[16]  Khan MN, Sharfuzzaman A, Mostafa MG. Spinal cord compression as initial presentation of metastatic occult follicular thyroid carcinoma. J Neurosci Rural Pract. 2014; 5(2): 155-59.
In article      View Article  PubMed
 
[17]  Upreti V, Sridhar MS, Dhull P, Sen A. An unusual cause of progressive quadriparesis. Indian J Endocrinol Metab. 2013; 17(Suppl 1): S155-6.
In article      View Article  PubMed
 
[18]  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(4): 245-8.
In article      View Article
 
[19]  Kant S, Srivastava A, Kumar R, Verma AK, Mishra AK, Husain N. An intra-thoracic follicular carcinoma of thyroid: An uncommon presentation. Lung India. 2017; 34(2): 193-6.
In article      View Article  PubMed
 
[20]  Koca E, Sokmensuer C, Yildiz BO, Engin H, Bozkurt MF, Aras T, et al. A patient presenting with spinal cord compression who had two distinct follicular cell type thyroid carcinomas. J Endocrinol Invest. 2004; 27(6): 562-4.
In article      View Article  PubMed
 
[21]  Matsumoto M, Tsuji T, Iwanami A, Watanabe K, Hosogane N, Ishii K, et al. Total en bloc spondylectomy for spinal metastasis of differentiated thyroid cancers: a long-term follow-up. J Spinal Disord Tech. 2013; 26(4): 137-42.
In article      View Article  PubMed
 
[22]  Rahman MT, Naik VR, Rao P. Occult follicular thyroid carcinoma- an unusual presentation of multiple lytic bony metastasis in the skull of a 66-year Malay man. Ibrahim Med Coli J. 2007; 1(2): 25-2.
In article      View Article
 

Published with license by Science and Education Publishing, Copyright © 2018 Mazaher Ramezani, Kaivan Mohammadi and Masoud Sadeghi

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

Cite this article:

Normal Style
Mazaher Ramezani, Kaivan Mohammadi, Masoud Sadeghi. Follicular Carcinoma of Thyroid with the First Presentation as Vertebral Column Metastasis: A Case-report. American Journal of Cancer Prevention. Vol. 6, No. 2, 2018, pp 24-28. http://pubs.sciepub.com/ajcp/6/2/2
MLA Style
Ramezani, Mazaher, Kaivan Mohammadi, and Masoud Sadeghi. "Follicular Carcinoma of Thyroid with the First Presentation as Vertebral Column Metastasis: A Case-report." American Journal of Cancer Prevention 6.2 (2018): 24-28.
APA Style
Ramezani, M. , Mohammadi, K. , & Sadeghi, M. (2018). Follicular Carcinoma of Thyroid with the First Presentation as Vertebral Column Metastasis: A Case-report. American Journal of Cancer Prevention, 6(2), 24-28.
Chicago Style
Ramezani, Mazaher, Kaivan Mohammadi, and Masoud Sadeghi. "Follicular Carcinoma of Thyroid with the First Presentation as Vertebral Column Metastasis: A Case-report." American Journal of Cancer Prevention 6, no. 2 (2018): 24-28.
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[1]  Boring CC, Squires TS, Tang T. Cancer Statistics, 1993. CA Cancer J Clin. 1993; 43(1): 7-26.
In article      View Article  PubMed
 
[2]  Toshkezi G, Galgano M, Libohova S, Marawar S. Isolated Spinal Metastasis with Spinal Cord Compression Leads to a Diagnosis of a Follicular Thyroid Carcinoma. Cureus. 2015; 7(10): e346.
In article      View Article
 
[3]  Alvarado M, Ramirez-Vick M, Lopez L, Marcos-Martinez MJ, Saavedra FM, Negron-Rivera JC, et al. An uncommon presentation of follicular thyroid carcinoma: when chronic back pain should raise a flag. Bol Asoc Med P R. 2014; 106(3): 36-9.
In article      PubMed
 
[4]  Ogbodo E, Kaliaperumal C, Keohane C, Bermingham N, Kaar G. Sciatica as a presenting feature of thyroid follicular adenocarcinoma in a 79-year-old woman. BMJ Case Rep. 2011; 2011.
In article      View Article
 
[5]  Schlumberger M, Challeton C, De Vathaire F, Travagli JP, Gardet P, Lumbroso JD, et al. Radioactive iodine treatment and external radiotherapy for lung and bone metastases from thyroid carcinoma. J Nucl Med. 1996; 37(4): 598-605.
In article      PubMed
 
[6]  Goldstein SI, Kaufman D, Abati AD. Metastatic thyroid carcinoma presenting as distal spinal cord compression. Ann Otol Rhinol Laryngol. 1988; 97(4 Pt 1): 393-6.
In article      View Article  PubMed
 
[7]  Akhtar S, Adeel M. An Unusual Case of Cauda Equina Secondary to Spinal Metastasis of Thyroid Cancer. Iran J Otorhinolaryngol. 2016; 28(84): 67-71.
In article      PubMed  PubMed
 
[8]  Ismail SB, Abraham MT, Zaini ZB, Yaacob HB, Zain RB. Metastatic follicular thyroid carcinoma to the mandible: A case report. Cases J. 2009; 2: 6533.
In article      View Article  PubMed
 
[9]  McHenry CR, Phitayakorn R. Follicular adenoma and carcinoma of the thyroid gland. Oncologist. 2011; 16(5): 585-93.
In article      View Article  PubMed
 
[10]  Carhill AA, Vassilopoulou-Sellin R. Durable Effect of Radioactive Iodine in a Patient with Metastatic Follicular Thyroid Carcinoma. Case Rep Endocrinol. 2012; 2012: 231912.
In article      View Article
 
[11]  Kim DH, Yoo SD, Kim SM, Im SJ, Kang JK, Cho EH. Thyroid Cancer Initially Presenting Compression Fracture without Common Thyroid Symptoms. Ann Rehabil Med. 2012; 36(5): 735-8.
In article      View Article  PubMed
 
[12]  Shaha A, Shah J, Loree T. Differentiated thyroid cancer presenting initially with distant metastasis. J Surg. 1997; 174(5): 474-6.
In article      View Article
 
[13]  Lin KD, Lin JD, Huang MJ, Huang HS, Jeng LB, Chao TC, et al. Clinical presentations and predictive variables of thyroid microcarcinoma with distant metastases. Int Surg. 1997; 82(4): 378-81.
In article      PubMed
 
[14]  Yang W, Cho W, Das S, Conboy P. Follicular thyroid carcinoma presenting with pathological fracture of the humerus at initial diagnosis. J Surg Case Rep. 2017; 2017(1). pii: rjx002.
In article      View Article  PubMed
 
[15]  Bansal A, Kaur M, Narula V. Cutaneous and bone metastasis of follicular thyroid carcinoma:a case report. Tumori. 2016; 102 (Suppl. 2).
In article      View Article
 
[16]  Khan MN, Sharfuzzaman A, Mostafa MG. Spinal cord compression as initial presentation of metastatic occult follicular thyroid carcinoma. J Neurosci Rural Pract. 2014; 5(2): 155-59.
In article      View Article  PubMed
 
[17]  Upreti V, Sridhar MS, Dhull P, Sen A. An unusual cause of progressive quadriparesis. Indian J Endocrinol Metab. 2013; 17(Suppl 1): S155-6.
In article      View Article  PubMed
 
[18]  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(4): 245-8.
In article      View Article
 
[19]  Kant S, Srivastava A, Kumar R, Verma AK, Mishra AK, Husain N. An intra-thoracic follicular carcinoma of thyroid: An uncommon presentation. Lung India. 2017; 34(2): 193-6.
In article      View Article  PubMed
 
[20]  Koca E, Sokmensuer C, Yildiz BO, Engin H, Bozkurt MF, Aras T, et al. A patient presenting with spinal cord compression who had two distinct follicular cell type thyroid carcinomas. J Endocrinol Invest. 2004; 27(6): 562-4.
In article      View Article  PubMed
 
[21]  Matsumoto M, Tsuji T, Iwanami A, Watanabe K, Hosogane N, Ishii K, et al. Total en bloc spondylectomy for spinal metastasis of differentiated thyroid cancers: a long-term follow-up. J Spinal Disord Tech. 2013; 26(4): 137-42.
In article      View Article  PubMed
 
[22]  Rahman MT, Naik VR, Rao P. Occult follicular thyroid carcinoma- an unusual presentation of multiple lytic bony metastasis in the skull of a 66-year Malay man. Ibrahim Med Coli J. 2007; 1(2): 25-2.
In article      View Article