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CORRESPONDENCE
Year : 2013  |  Volume : 9  |  Issue : 2  |  Page : 320-323

Metastatic follicular thyroid carcinoma to the body of the mandible mimicking an odontogenic tumor


Department of oral and Maxillofacial ­Pathology, Farooqia Dental College and Hospital, Mysore, Karnataka, India

Date of Web Publication13-Jun-2013

Correspondence Address:
Kumaraswamy Kikkeri Laxminarayana
# 1717, 6th Main, Vijay Nagar, 2nd stage, Mysore -570 017, ­Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.113412

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 > Abstract 

Metastatic tumors to the jawbones are uncommon. Metastatic lesions to the oro-facial region may be the first evidence of dissemination of an unknown tumor from its primary site. Follicular thyroid carcinoma rarely presents initially as a distant metastatic lesion within the mandible. This case of metastatic follicular thyroid carcinoma is presented to emphasize its unusual initial presentation within the body of the mandible, which mimicked an odontogenic tumor. It's important to detect the carcinoma early so that it can be treated successfully and also improves the prognosis of the patient. The histopathological features and immunohistochemical findings are also discussed.

Keywords: Follicular thyroid carcinoma, metastasis, odontogenic tumor, serum thyroglobulin, thyroglobulin marker


How to cite this article:
Vishveshwaraiah PM, Mukunda A, Laxminarayana KK, Kasim K. Metastatic follicular thyroid carcinoma to the body of the mandible mimicking an odontogenic tumor. J Can Res Ther 2013;9:320-3

How to cite this URL:
Vishveshwaraiah PM, Mukunda A, Laxminarayana KK, Kasim K. Metastatic follicular thyroid carcinoma to the body of the mandible mimicking an odontogenic tumor. J Can Res Ther [serial online] 2013 [cited 2019 Nov 19];9:320-3. Available from: http://www.cancerjournal.net/text.asp?2013/9/2/320/113412


 > Introduction Top


Carcinoma of the thyroid gland is the most common malignancy of human endocrine system. The four histopathological variants are papillary, follicular, medullary and anaplastic. Follicular thyroid carcinoma (FTC) occurs in older age group, and rarely occurs after radiation therapy. It is usually an asymptomatic tumor and initially presents either as a solitary nodule or a multinodular goiter or as cervical lymphadenopathy . [1] Occasionally it is accompanied with hoarseness of voice and neck pain. Metastasis of thyroid carcinomas to distant sites without primary presentation is uncommon . [2] Metastasis to bone commonly appears as an osteolytic lesion and in mandible it may mimic an odontogenic tumor. In this paper we emphasize the importance to rule out metastasis of FTC in the oral and maxillofacial regions and differentiate it from common odontogenic lesions.


 > Case Report Top


A 56-yr-old female patient presented with a non-painful swelling on the right side of the lower face, of 6-months duration, and associated with paresthesia of the lower lip and body of the mandible. Patient had earlier undergone an incisional biopsy elsewhere which was diagnosed as an odontogenic tumor.

On extra oral examination a solitary, oval, diffuse swelling was seen in the right lower third of the face [Figure 1] and [Figure 2], measuring around 2.5 × 2 inches in the body of mandible, along the lower border. Intra oral examination [Figure 3] revealed a solitary bony hard swelling measuring 3 × 2 cm in size extending from lower right third molar to first molar. Grade II mobility in relation to right mandibular permanent second and third molar (tooth no. 47 and 48) was seen along with paresthesia of inferior alveolar nerve. Panoramic radiograph revealed a unilocular radiolucency with ill-defined borders in the right body of mandible with external resorption of root in relation to 48 [Figure 4]. Based on the above findings a radiographic diagnosis of odontogenic tumor was made. H and E stained sections of an incisional biopsy revealed epithelial cells arranged in ducts or follicles of varying sizes enclosing an eosinophillic colloid like material. The microfollicular architecture was uniform throughout. The cells lining the ducts were cuboidal to columnar in shape with vesicular nuclei [Figure 5]. Few areas of nuclear atypia, hyperchromatism and focal mitosis were noted [Figure 6]. Above histologic features were suggestive of follicular thyroid carcinoma. Immunohistochemical analysis was positive for thyroglobulin in cells lining the ducts as well as the colloid material [Figure 7] and [Figure 8]. This further confirmed our histopathological diagnosis and the patient was then subjected to ultrasonography of the thyroid gland which revealed a solitary, hypoechoic 1.5 × 1 cm nodule in the right lobe, which was not detected by physical examination. Metastasis to other parts of the body was ruled out by whole body scan. The serum thyroglobulin (TG) level was elevated to 480ng/ml (normal<60ng/ml). The patient was referred to an oncologist for further management.
Figure 1: Extra oral photograph showing swelling in the lower 3rd of the face causing facial asymmetry

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Figure 2: Lateral view of the extra oral swelling seen extending along the body of the mandible

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Figure 3: Intra oral swelling extending from the distal aspect of 46 to mesial aspect of 48

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Figure 4: OPG showing unilocular radiolucency with resorption of root apices in relation to 48

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Figure 5: Photomicrograph showing uniform microfollicular architecture lined by cuboidal cells enclosing colloid like material (H and E stain, original magnification 4x)

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Figure 6: Photomicrograph showing cells lining the follicle showing areas of nuclear atypia, hyperchromatism and few mitotic (H and E stain, original magnification 10x)

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Figure 7: Photomicrograph of IHC show positive staining in most of the areas (thryoglobulin stain, original maginification 4x)

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Figure 8: Photomicrograph of IHC slides show uptake of stain by both cells as well as colloid material (thyroglobulin stain, original magnification 10x)

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 > Discussion Top


Metastatic lesions are the first clinical evidence of many primary unknown tumors. [3] The common sources of metastasis include lungs, breast, kidney, gastrointestinal tract, thyroid etc with the most common sites of metastasis being lungs and bones. Metastasis to the oral cavity is uncommon and account for 1% of all oral malignancies. In the oral cavity, metastatic tumors to jaw bones is more frequent than to oral mucosa. [4],[5] Mandible is more commonly affected than maxilla and the premolar-molar region being the most frequent site of metastasis. [4] This site favors metastasis due to the presence of hematopoeitic bone marrow and greater entrapment of metastatic cells related to slow regulation of blood flow. [3],[6] Malignancies can metastasize to the jaw bones either through blood vessels or lymphatics, with the hematogenous route being most common one. [5] Molecular mechanism for distant metastasis of thyroid carcinoma is not well understood but recent studies suggest reactivation of embroyonic pathways involved in cell movement to include epithelial to mesenchymal transition and collective cell migration. [7]

Carcinoma of thyroid has four histopathological variant viz-papillary, follicular, medullary and anaplastic. FTC is the second most common cancer of the thyroid gland . FTC arises from the follicular cells and resembles the normal microscopic pattern of the thyroid. Papillary and follicular variants are well differentiated, highly treatable and usually have a good prognosis but FTC is more aggressive than papillary variant due to mutation in p21 Ras oncogene. [8]

FTC more commonly occurs in females above 40 yrs. Metastasis to bones, lungs, brain, skin and adrenal glands occurs through hematogenous routes but rare. [9] Few cases of metastasis has been documented in sites like mandible, parotid gland, base of the tongue and labial mucosa. Distant metastasis with primary presentation is common but distant metastasis without primary presentation is uncommon. [6],[10]

The histopathology ranges from well differentiated to a poorly differentiated tumor. The well-differentiated tumor exhibits follicles lined with cuboidal cells enclosing an eosinophilic colloid like material with the microfollicular architecture maintained. These features of well-differentiated tumor are associated with a good prognosis. The poorly differentiated lesions are marked with solid growth, absence of follicles, marked nuclear atypia, and extensive vascular and/or capsular invasion, these features are associated with a worse prognosis. [11]

Investigations for FTC diagnosis include FNAC, histopathology, X-ray, CT scan, MRI, ultrasound, thyroid scan and genetic screening. Thyroglobulin and calcitonin are used as sensitive and specific histogenetic markers for follicular and parafollicular cell derived thyroid carcinomas respectively. [12] Thyroglobulin is the suggested marker, which is expressed in more than 95% of follicular thyroid carcinoma but it cannot differentiate between a follicular adenoma and follicular carcinoma.

Markers like Galectin-3 (GAL-3), CD44, oncofetal fibronectin, telomerase, high mobility group protein, RET/p56 rearrangement [13] are used in studies, but their universal efficient application is yet to be established.

A combination of various treatment modalities is commonly used in the management of metastatic lesions with varying success rates. [2] The therapeutic approaches include thyroidectomy followed by radioactive iodine therapy. Prognosis of follicular thyroid carcinoma is dependant on age, size of lesion, extent of vascular invasion, capsular invasion and distant metastasis. Over all FTC shows 10-year survival rate i.e., 90% in non-invasive tumors and below 50% in invasive tumors. However, there is a need for long term strict vigilant follow up of the patient with a diagnosis of FTC.

Metastatic FTC are of great significance, since at times their appearance may be the only symptom of an undiscovered underlying malignancy and metastatic lesions may be the first or only clinical manifestation.


 > Acknowledgement Top


We are thankful to Dr. Kalappa Prof and HOD, and Department of Oral and Maxillofacial surgery.

 
 > References Top

1.Sreedharan S, Pang CE, Chan GS, Soo KC, Lim DT. Follicular thyroid carcinoma presenting as axial skeletal metastases. Singapore Med J 2007;48:640-4.  Back to cited text no. 1
    
2.Sevinc A, Buyukberber S, Sari R, Baysal T, Mizrak B. Follicular thyroid cancer presenting initially with soft tissue metastasis. Jpn J Clin Oncol 2000;30:27-9.  Back to cited text no. 2
    
3.van der Waal RI, Buter J, van der Waal I. Oral metastases : r0 eport of 24 cases. Br J Oral Maxillofac Surg 2003;41:3-6.  Back to cited text no. 3
    
4.Lim SY, Kim SA, Ahn SG, Kim HK, Kim SG, Hwang HK, et al. Metastatic tumours to the jaws and oral soft tissues : a0 retrospective analysis of 41 Korean patients. Int J Oral Maxillofac Surg 2006;35:412-5.  Back to cited text no. 4
    
5.Zachariades N. Neoplasms metastatic to the mouth, jaws and surrounding tissues. J Craniomaxillofac Surg 1989;17:283-90.  Back to cited text no. 5
    
6.Hirshberg A, Buchner A. Metastatic tumours to the oral region. An overview. Eur J Cancer B Oral Oncol 1995;31B:355-60.  Back to cited text no. 6
    
7.Vasko VV, Saji M. Molecular mechanisms involved in differentiated thyroid cancer invasion and metastasis. Curr Opin Oncol 2007;19:11-7.  Back to cited text no. 7
    
8.Wright PA, Lemoine NR, Mayall ES, Wyllie FS, Hughes D, Williams ED, et al. Papillary and follicular thyroid carcinomas show a different pattern of ras oncogene mutation. Br J Cancer 1989;60:576-7.  Back to cited text no. 8
    
9.Girelli ME, Casara D, Rubello D, Piccolo M, Piotto A, Pelizzo MR, et al. Metastatic thyroid carcinoma of the adrenal gland. J Endocrinol Invest 1993;16:139-41.  Back to cited text no. 9
    
10.Emerick GT, Duh QY, Siperstein AE, Burrow GN, Clark OH. Diagnosis, treatment, and outcome of follicular thyroid carcinoma. Cancer 1993;72:3287-95.  Back to cited text no. 10
    
11.Tatic S. Histopathological and immunohistochemical features of thyroid carcinoma. Archive of Oncology. 2003;11:173-174. doi: 10.2298/AOO0303173T.   Back to cited text no. 11
    
12.Kostoglou-Athanassiou I, Athanassiou P, Vecchini G, Gogou L, Kaldrymides P. Mixed medullary-follicular thyroid carcinoma. Report of a case and review of the literature. Horm Res 2004;61:300-4.  Back to cited text no. 12
    
13.Bojunga J and Zeuzem S. Molecular detection of thyroid cancer: An update. Clinical Endocrinology, 2004;61:523-530. doi: 10.1111/j.1365-2265.2004.02131.x  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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