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ANALYTICAL REPORT
Year : 2012  |  Volume : 8  |  Issue : 3  |  Page : 436-438

Metachronous solitary metastasis of papillary thyroid cancer in the cavernous sinus: Case report and review of literature


1 Department of Surgical Oncology, Division of Neurosurgical Services, Tata Memorial Centre, Mumbai, India
2 Department of Pathology, Tata Memorial Centre, Mumbai, India
3 Department of Head-Neck Surgical Oncology, Tata Memorial Centre, Mumbai, India

Date of Web Publication17-Nov-2012

Correspondence Address:
Aliasgar V Moiyadi
Main Building, Tata Memorial Centre, Dr. E. Borges Road, Parel, Mumbai - 400012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.103528

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 > Abstract 

Papillary carcinoma is a well-differentiated type of thyroid carcinoma with very good overall prognosis. The commonest site of metastases is the lymph node, distant metastases being rare. We present a case of a 52-year-old male who presented with a solitary metastasis in the left para-sellar region and cavernous sinus more than three years after treatment of primary. Given the atypical radiological features and longstanding symptoms, a surgical excision was performed and focal radiotherapy was given after confirmation of the diagnosis. We discuss this case and review the relevant literature.

Keywords: Cavernous sinus metastasis, extradural approach, papillary carcinoma thyroid


How to cite this article:
Chandarana MN, Epari S, Chaukar D, Moiyadi AV. Metachronous solitary metastasis of papillary thyroid cancer in the cavernous sinus: Case report and review of literature. J Can Res Ther 2012;8:436-8

How to cite this URL:
Chandarana MN, Epari S, Chaukar D, Moiyadi AV. Metachronous solitary metastasis of papillary thyroid cancer in the cavernous sinus: Case report and review of literature. J Can Res Ther [serial online] 2012 [cited 2019 Nov 19];8:436-8. Available from: http://www.cancerjournal.net/text.asp?2012/8/3/436/103528


 > Introduction Top


Papillary carcinoma is the most common carcinoma of thyroid with a 10-year survival rate of 93%. [1] The commonest site of metastasis from papillary carcinoma is regional lymph nodes. [2] Distant metastases are rare, most presenting synchronously. Brain metastases in papillary carcinoma are rare, reported with a frequency of 0.1-5% and cavernous sinus metastasis is extremely rare. [3]


 > Case Report Top


A 52-year-old man presented with a history of redness and decreased sensation over the left eye since three years, numbness over the left side of face, difficulty in chewing and tinnitus since eight months. He was a known case of papillary carcinoma of the right lobe for which a total thyroidectomy with right-sided Level II-IV lymph node dissection, and left-sided lymph node sampling had been done three years back. The histopathology was papillary carcinoma thyroid-follicular variant. He received radioiodine therapy postoperatively, in view of his age above 45 years, male sex and histopathology showing extrathyroid extension. He had no other significant medical and surgical illnesses. On examination, he had loss of sensation over the left side of the face and loss of corneal reflex. Investigations revealed a rise in thyroglobulin level from 2.4 ng/ml to 115.1 ng/ml during the preceding year. A whole-body Positron emission tomography (PET) scan revealed a hypermetabolic lesion in the left para-sellar region of the brain with no uptake in the thyroid bed. Magnetic resonance imaging (MRI) of the brain [Figure 1] revealed a 2.2 × 1.9 cm, well-defined, left para-sellar lesion extending into the Meckel's cave [Figure 1] with a small nubbin in the posterior fossa and smooth scalloping of the bone of the middle cranial fossa. In view of the rise in thyroglobulin levels and MRI features, a differential diagnosis of metastasis, meningioma or schwannoma was considered. Considering the solitary nature and resectability, a decision to resect the tumor was taken.
Figure 1: (Preoperative MRI): T2-weighted (a, b) and post-contrast T1 (c, d) images showing a well-defi ned tumor in the left para-sellar region extending into Meckel's cave

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The tumor was approached extradurally through a left temporobasal craniotomy. It was identified in the medial basal dura in the lateral wall of the cavernous sinus-well-defined, interdural, reddish, soft and vascular. It was internally debulked, leaving a thin rim of capsule on the internal carotid artery. The postoperative MRI brain [Figure 2] showed a resection cavity with residual enhancement along the walls of the cavity. The postoperative course was uneventful. His preoperative symptoms had significantly reduced. Histopathology revealed a tumor with diffuse papillary architecture [Figure 3] with areas of hyalinization and fibrovascular cores [Figure 3]a and b with nuclear overlapping and clearing [Figure 3]f and g and occasional foci of psammomatous calcification [black arrow-[Figure 3]c. On immunohistochemistry the tumor was positive for thyroid transcription factor-1 [Figure 4]a; epithelial membrane antigen [Figure 4]d and cytokeratins 19 and 7 [Figure 4]b and c. Based on the histopathological features and characteristic immunophenotype, a diagnosis of metastatic papillary carcinoma was made. The patient was subsequently given focal radiation.
Figure 2: (Postoperative MRI): T1-weighted (a) T2-weighted (b,c) and post-contrast (d) images showing a resection cavity with residual enhancement along the wall

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Figure 3: (Hematoxylin and Eosin): Photomicrographs showing a tumor with papillary architecture (a and b × 50 c × 200 d × 100 and e × 200). Occasional psammomatous calcifi cation (shown by the black arrow in the c) nuclear overlapping and nuclear clearing (f and g × 400) noted

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Figure 4: (Immunohistochemistry × 400): The tumor showed immunopositivity for thyroid transcription factor-1 (a) cytokeratin 19 (b) cytokeratin 7 (c) and epithelial membrane antigen (d) It was negative for cytokeratin 20

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 > Discussion Top


Adenocarcinomas of the thyroid gland are of papillary, follicular, medullary and anaplastic subtypes. [2] Papillary and follicular are well-differentiated varieties and papillary carcinomas account for 79% of all thyroid cancers with a 10-year survival rate of 93%, causing more than 50% mortality due to thyroid cancers. The incidence of distant metastases from papillary carcinomas is reported to be 6-23%, the majority occurring within five years of the initial diagnosis. [3]

There have been case reports of papillary carcinoma with metastasis at unusual sites like the pancreas, breast and cavernous sinus. [4],[5] But all these cases were associated with a missed diagnosis of thyroid carcinoma, locally recurrent tumor, multiple distant metastases, or metastases presenting synchronously with the primary. Our case, presenting three and a half years after total thyroidectomy, with a solitary metastasis in the para-sellar region and the cavernous sinus, without any other distant metastasis or local recurrence, should be considered exceptional. There have been five reports of papillary carcinoma with metastasis to the skull base, of which four patients had multiple local recurrences with or without other sites of distant metastases. [4] Takami et al. have reported an isolated cavernous sinus metastasis which was managed conservatively. The patient developed local recurrence one year later. [3] The likely route of metastasis to the skull base could be the low-pressure vertebral venous plexus or possibly even the intervening lymphatic channels that exist between the thyroid and skull base. [4]

The diagnosis of metastatic disease was considered preoperatively in this patient but in view of the rarity of a metachronous solitary brain metastasis in a thyroid papillary carcinoma coupled with the radiological features suggestive of a longstanding, slowly-growing probably benign tumor, a possibility of a meningioma or a schwannoma was also considered. Intraoperatively it was a medial dural-based mass, well-defined and vascular, making it difficult to distinguish from a meningioma. A gross total resection of the tumor was attempted.

There is no consensus for the treatment of papillary thyroid carcinoma with skull base or cavernous sinus metastasis presenting after treatment of the primary. Radioiodine effectively controls papillary carcinoma thyroid after neck surgery and is indicated in patients showing increased uptake in the thyroid bed, or patients with Stage-III, II or high-risk Stage-I disease. [2],[4] Rosahl et al. in their review on follicular carcinoma metastasis to the skull base have suggested a treatment algorithm. [6] They recommend total thyroidectomy followed by radioiodine scan. Patients with an increased uptake on the scan received radioiodine and those who did not, were given external beam radiation. Surgery was limited to the few with impending herniation or symptoms of nerve compression. Our patient had no signs of impending herniation but had symptoms of trigeminal nerve compression. With a radiological differential diagnosis of meningioma or schwannoma, and a potentially resectable lesion causing nerve compression, a decision to operate was taken. The role of external beam radiation therapy for well-differentiated thyroid carcinoma is controversial and recommended for patients with brain metastases in combination with surgery. [7],[8] In the case reported by Takami et al., a combination of external beam radiation with gamma-knife surgery was used. [3] Thus, we conclude that solitary distant metastasis from a treated primary of the thyroid though rare, is a possibility, a difficult diagnosis to be made on radiology, and a rise in thyroglobulin levels may be of value in predicting the same.

 
 > References Top

1.Sipos JA, Mazzaferri EL. Thyroid Cancer Epidemiology and Prognostic Variables. Clin Oncol 2010;22:395-404.  Back to cited text no. 1
[PUBMED]    
2.Carling T, Udelsman R. Thyroid tumors. In: Pine JW, DeVita Jr, editors. Hellman and Rosenberg's Cancer Principles and Practice of Oncology. 9 th ed. Philadelphia: Lippincott Williams and Wilkins; 2011.p. 1457- 72.  Back to cited text no. 2
    
3.Takami T, Ohata K, Tsuyuguchi N, Mao Y, Inoue Y, Wakasa K, et al. Cavernous sinus metastasis from thyroid papillary adenocarcinoma. J Clin Neurosci 2002;9:598-600.  Back to cited text no. 3
[PUBMED]    
4.Mydlarz WK, Wu J, Aygun N, Olivi A, Carey JP, Westra WH, et al. Management Considerations for Differentiated Thyroid Carcinoma Presenting as Metastasis to the Skull Base. Laryngoscope 2007;117:1146-52.  Back to cited text no. 4
    
5.Angeles AA, Montero FC, Benitez BM, Saavedra JA. Unusual metastases of papillary thyroid carcinoma: Report of 2 cases. Ann Diagn Pathol 2009;13:189-96.  Back to cited text no. 5
    
6.Rosahl SK, 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. 6
[PUBMED]    
7.Mazzarotto R, Cesaro MG, Lora O, Rubello D, Casara D, Sotti G. The role of external beam radiotherapy in the management of differentiated thyroid cancer. Biomed Pharmacother 2000;54:345-9.  Back to cited text no. 7
[PUBMED]    
8.Powell C, Newbold K, Harrington KJ, Bhide SA, Nutting CM. External Beam Radiotherapy for Differentiated Thyroid Cancer. Clin Oncol 2010;22:456-63.  Back to cited text no. 8
    


    Figures

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


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