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

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Güiier: Failiclilar Carciiioma Metastasis

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11th Scientific Convention

Turkish Neurosurgical Society

May 16-20/ 1997Dedeman Hotel, Antalya, Turkey

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