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CASE REPORT
Year : 2016  |  Volume : 13  |  Issue : 2  |  Page : 80-82

Scalp metastasis from follicular thyroid carcinoma diagnosed by fine needle aspiration cytology: A case series


1 Department of Pathology, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication1-Jun-2016

Correspondence Address:
Dr. Madhu Kumar
Assistant Professor, Department of Pathology, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-0354.159529

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  Abstract 

The scalp metastasis of follicular thyroid carcinoma is a rare condition and the lesion should be differentiated from primary skin tumors. It account for 10–20% of all thyroid malignancies and is most commonly seen in female of 40–50 years of age. We present a case series of four cases showing cutaneous metastases from follicular thyroid carcinoma in patients presenting with a nodular thyroid mass and scalp swelling. Fine needle aspiration cytology (FNAC) of thyroid gland and scalp nodule, both shows repetitive microfollicles and clusters of follicular epithelial cells. The cases were diagnosed as scalp metastasis from follicular thyroid carcinoma on FNAC.

Keywords: Fine needle aspiration cytology, follicular thyroid carcinoma, scalp metastasis


How to cite this article:
Kumar M, Singh A, Mishra S. Scalp metastasis from follicular thyroid carcinoma diagnosed by fine needle aspiration cytology: A case series. Thyroid Res Pract 2016;13:80-2

How to cite this URL:
Kumar M, Singh A, Mishra S. Scalp metastasis from follicular thyroid carcinoma diagnosed by fine needle aspiration cytology: A case series. Thyroid Res Pract [serial online] 2016 [cited 2019 Nov 14];13:80-2. Available from: http://www.thetrp.net/text.asp?2016/13/2/80/159529


  Introduction Top


Thyroid carcinoma is most common endocrine malignancy and responsible for more deaths than other endocrine cancers.[1] Follicular cancer is the second most common cancer after papillary carcinoma but is ranked first in producing distant metastases among thyroid cancers. It account for 10–20% of all thyroid malignancies. The incidence of carcinoma in multinodular goiter and adenomas is reported to ranges between 7–17%.[2] Most common sites of distant metastasis from follicular thyroid carcinoma are the bones and lungs. The occurrence of cutaneous metastases is rare events and usually indicates advanced tumor stages. Scalp metastases are a rare presentation in 2.5–5.8% of follicular thyroid carcinoma.[3],[4]


  Case Reports Top


Case 1

A 45-year-old female patient, presented to our department with a scalp swelling since six months [Figure 1]a. The swelling was increasing in size associated with fever on and off and weight loss for one month. Not associated with pain, headache or visual impairment. No history of loss of appetite, tremor, alopecia, weight gain, heat or cold intolerance and patient was euthyroid on thyroid function test. Previous Ultrasonography (USG) of thyroid suggested a large adenomatous nodule in the right lobe of thyroid. Thyroidectomy was done one year back and previous histopathological or FNAC report of thyroid was not available. Now X-Ray of head [Figure 1]b showed an expansile soft tissue (Space Occupying Lesion) involving left temporal scalp with involvement of underlying bone suggestive of malignant lesion.
Figure 1: (a) Large scalp swelling. (b) X-Ray of skull showed an expansile soft tissue SOL involving left temporal scalp with involvement of underlying bone suggestive of malignant lesion

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Case 2

A 35-year-old patient presented to us with a diffuse midline neck swelling and scalp swelling [Figure 2]a. The midline neck swelling was present since 2 years, progressively increasing in size, not associated with any pain or discharge. There was no history of dysphagia or change in voice. Patient gave negative history for any loss of appetite, gain or loss of weight, insomnia, palpitation, numbness, tingling, heat or cold intolerance. A small lump developed in the scalp since 6 months. No history of headache or dizziness was present. Hemogram, T3, T4 and TSH were within normal limit. Thyroid radiological investigation was not available. X-Ray and computed tomography (CT) scan of skull [Figure 2]b showed a well-defined enhancing extra axial Space Occupying Lesion in high temporo-parietal region with involvement of overlying calvarium and extra calvarial extension, most likely neoplastic etiology.
Figure 2: (a) Diffuse midline neck swelling and scalp swelling. (b) X-ray skull showing wide lytic lesion on parietal region

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Case 3

A 40-year-old patient came to our department for FNAC from a scalp swelling since 3 months. No other significant history or clinical examination findings were present. It was suspected to be a scalp nodule on the clinical examination. FNAC of the lesion showed a cluster of repetitive follicles lying in a hemorrhagic background. Suspicion of some metastatic lesion was raised and an extensive workup with more concentration on the thyroid and renal system was conducted. USG neck showed a nodular swelling involving the right lobe and progressing towards the isthmus. X-Ray skull showed wide lytic vault lesion on temporal region with prominence of vascular markings in the direction of the lytic lesion.

Case 4

A 30-year-old patient with midline neck swelling since 2 years presented to our department along with a newly developed occipital scalp nodule since 3 months. Hemogram was within normal limit. Patient gave history of cold intolerance and weight loss. USG of thyroid showed a thyroid nodule and thyroid function test was not available at the time of FNAC.

FNAC was advised from both the lesions in all cases except case one because when it was previously operated for thyroid only scalp FNAC was done.

Microscopic examination

FNAC of thyroid gland showed many uniform sizes follicular epithelial cells clusters forming repetitive microfollicles with nuclear pleomorphism [Figure 3]a and [Figure 3]b. The FNAC from scalp nodule also showed similar morphological features [Figure 3]c and [Figure 3]d. So, on the basis of FNAC from both the sites the cytomorphological diagnosis was scalp metastasis from follicular thyroid carcinoma.
Figure 3: (a and b) FNAC of thyroid gland showing many uniform sizes, repetitive Microfollicles with nuclear pleomorphism (Geimsa stain; ×400 and H and E stain; ×200) (c and d) FNAC from scalp nodule showing many uniform sizes microfollicules (Geimsa stain; ×400 and H and E stain; ×200)

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  Discussion Top


Follicular carcinoma has a greater preponderance than papillary carcinoma for cutaneous metastases. Besides the scalp, the most common affected areas of cutaneous metastasis of follicular thyroid carcinomas are abdomen, back, thigh, and pelvic.[3],[4] The rich dermal capillary network of the scalp, face and chest wall as well as choroids may initially trap the tumor cell emboli from the circulation and provide the environment for the successful formation of metastatic foci. We find a single case with such a wide lytic skull metastatic involvement with follicular carcinoma documented in the literature.[5] Advance stage at presentation and high rate of cutaneous and bony metastases of follicular carcinoma have contributed to poor outcome of follicular thyroid carcinomas in developing countries.[6] The treatment included a total thyroidectomy, an excision of the scalp nodule, administration of radioiodine therapy as well as thyroid stimulating hormone suppression therapy.[3]

Few cases of scalp metastases from follicular thyroid carcinoma diagnosed by FNAC have been reported.[7] Our report adds more cases of cutaneous metastases from follicular thyroid carcinomas that were diagnosed by FNAC to the literature. To conclude, the skin nodule, particularly in the scalp area should include the possibility of metastatic thyroid carcinoma.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients 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.

 
  References Top

1.
Agarwal S, Rao S, Arya A, Gupta K, Arora R, Dhawan I. Follicular thyroid carcinoma with metastasis to skin diagnosed by fine needle aspiration cytology. Indian J Pathol Microbiol 2008;51:430-1.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Gandolfi PP, Frisina A, Raffa M, Renda F, Rocchetti O, Ruggeri C, et al. The incidence of thyroid carcinoma in multinodular goiter: Retrospective analysis. Acta Biomed 2004;75:114-7.  Back to cited text no. 2
    
3.
Cupisti K, Ramp U, Raffel A, Krausch M, Rehders A, Knoefel WT. Multiple giant scalp metastases of a follicular thyroid carcinoma. World J Surg Oncol 2008;6:82.  Back to cited text no. 3
    
4.
Durante C, Haddy N, Baudin E, Leboulleux S, Hartl D, Travagli JP, et al. 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. 4
    
5.
Rahman GA, Abdulkadir AY, Olatoke SA, Yusuf IF, Braimoh KT. Unusual cutaneous metastatic follicular thyroid carcinoma. J Surg Tech Case Rep 2010;2:35-8.  Back to cited text no. 5
    
6.
Ogawa Y, Sugawara T, Seki H, Sakuma T. Thyroid follicular carcinoma metastasized to the lung, skull and brain 12 years after initial treatment for thyroid gland-case report. Neurol Med Chir (Tokyo) 2006;46:302-5.  Back to cited text no. 6
    
7.
Kumar PV, Monabati A, Tabei SZ, Ramzy M, Husseini SV, Khajeh F. Metastatic follicular thyroid carcinoma diagnosed by fine needle aspiration cytology: A report of three cases. Acta Cytol 2005;49:177-80.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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