Sudan Medical Journal

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1 :29-32 Sudan Medical Journal ث ؾ ث طذ ١ ث هث ١ Unusual skull metastasis from a follicular thyroid carcinoma: a case report Abdelmoniem MM Makkawi, MD FMAS *, Moataz MA Ali, MD **, Baderaldien H Idris, MD *** Department of Surgery *, Department of Pathology **, Department of Radiology ***, Faculty of Medicine, University of Elimam Elmahadi, Kosti, Sudan وسو ا تقبني غيش يأنىف ببند د ت ي سشطب انغذة انذسقيت اندشيب :يهخص حبنت ه.ػذوث ؼ ق و ث ق ق ه ىج. ثال ضجى ث جػو دم ث ؾ ثفز.و ١ ز ث طخ. ؽج ؼز ثإل ج ث و ه. ؼض ق و ث ق ػ. ثال ضجى ث جػو دم ػ ثال ثع.و ١ ز ث طخ. ؽج ؼز ثإل ج ث و ه.دو ث و ٠ ج إه ٠. ثال ضجى ث شج ن دم ثالشؼز.و ١ ز ث طخ. ؽج ؼز ثإل ج ث و يهخص : ٠ جص ؽج ث غور ث و ل ١ ز ث ؾ ٠ ذ ف ث صذز ث غج ١ ز ف ١ ظ ث قو ط دؼو ؽج ث غور ث و ل ١ ز ث ق ١. صؼضذ ثال ث ثال ضمج ١ ز ؾ ؾ ز ذ ١ ج جه ر ث قو ط صى ظجه ج غج ذج ث ةض ١,ث غو ث ذ ضجس ث ج ثال ث ثال ضمج ١ ز ؾ ؾ ز ؽج ث غور ث و ل ١ ز ف جه ر ث قو ط.فمؾ ف ث %1.7 ػ ؽج ث غور ث و ل ١ ز ض ج ٠ ث نال ٠ ج ٠ مو دج ث ث ضمج ١ ز ف ث ؼظ. ضؼ ع ف يث ث ضم ٠ فج ز ث أر ف دوث ٠ ز ث ؼمو ث جدغ صؼج ث ضفجك غ ١ ؤ د مو ز ث أ ور ػج لو ثؽ ٠ ش ج ػ ١ ز ث ضتظجي غور ث و ل ١ ز لذ 8 ثػ ث. ط ثالشؼز ؾ ؾ ز ثظ س ثفز فج ز ؼظ دج فض ثال ج.ثوو ث فقض ث ن ث ١ ؾ ؽ ه ث ضمج ؽ ٠ ذ غور ث و ل ١ ز. لو ؽ ٠ ش ج ث ث ز فض ثال ٠ غور ث و ل ١ ز غ صغذ ١ ؾ ث غور ث و ل ١ ز ع ث ش ؼالػ ثالشؼجػ ث نج ؽ ١ ط ر ث ػؼ ١ ز ثال ضمج دج ؾ ؾ ز. Abstract Follicular thyroid carcinoma is the second most common cancer of the thyroid after papillary carcinoma. Metastatic tumours to the skull are relatively rare and originate most often from the lung, breast or prostate. Skull metastasis from thyroid carcinomas are rare and only about 1.7% of patients with differentiated thyroid carcinomas present with bone Here we are reporting a case of an elderly lady who presented with a swelling in the skull of one year duration. She underwent thyroidectomy 8 years before. Radiology revealed osteolytic lesion on the skull. Cytology and histopathology from the skull lesion confirm the diagnosis of metastatic follicular carcinoma of the thyroid. She underwent right hemithyroidectomy for recurrent goitre and levothyroxine suppression Corresponding author Abdelmoniem MM Makkawi abdelmoniemmakkawi2@gmail.com and then sent for external beam radiation therapy for locoregional control of skull Keywords: Follicular thyroid carcinoma, skull metastasis, lytic lesion Introduction Thyroid cancers account for around 0.5% of all cancers in males and 1.5% of all cancers in female. Follicular thyroid carcinoma is the second most frequent malignancy of the thyroid gland after papillary carcinoma. Follicular carcinomas of the thyroid are usually slow growing tumours and have a high propensity for blood borne Papillary thyroid carcinoma usually remains intrathyroidal and tends to metastasize only to the regional lymph nodes. Distant spread may occur to bones, lungs, brain, skin and sometimes kidneys and adrenal glands. According to literature, the reported incidence of distant metastasis is between 10% and 25%, but it is very uncommon for the disease to present with distant metastasis as initial presentation itself (1). Skull metastasis is often 29

from primaries of lung, breast and prostate malignancies but is rare from thyroid carcinomas. In a series of 473 patients with thyroid cancers, Nagamine et al. reported skull metastasis in only 2.

The patient complained that swelling was slow growing in size and not causing pain or any other distressing symptoms.

She has neither no symptoms suggestive of pressure on neck structure, nor features of toxicity or malignancy.

The swelling is soft to firm and not attached to skin but fixed to underlying bone. There was no pulsation over the swelling.

2 from primaries of lung, breast and prostate malignancies but is rare from thyroid carcinomas. In a series of 473 patients with thyroid cancers, Nagamine et al. reported skull metastasis in only 2.5% of cases (2). A 70 years old female presented to surgical out-patient clinic with complains of head swelling of one year duration. The patient complained that swelling was slow growing in size and not causing pain or any other distressing symptoms. On taking a detailed history, she revealed that she underwent thyroidectomy 8 years before and since then she did not noticed any increase in size of her neck swelling. She has neither no symptoms suggestive of pressure on neck structure, nor features of toxicity or malignancy. The examination of the patient revealed a hemi-spherical shaped, well circumscribed swelling in the frontal region of skull, of about 10x10 cm size and with smooth surface (Fig 1). The swelling is soft to firm and not attached to skin but fixed to underlying bone. There was no pulsation over the swelling. In the examination of the neck there was nicely healed collar incision, there was no thyroid enlargement or palpable regional lymph nodes. The trachea was central and there was no sign of retrosternal extention or features of carotid compression. revealed a discrete osteolytic lesion in the frontal bone (Figs. 2&3). Figure 2: (Lateral view) Figure 3: (AP view) Figure 1: (Frontal and Lateral views) The patient underwent thyroid function tests which revealed normal values and euthyroid status and X-ray of the skull was done and An ultrasound of the neck showed lobe hypoecoic nodule with no detectable lymph nodes in the neck. A Fine-Needle Aspiration Cytology (FNAC) of the thyroid nodule revealed follicular neoplasm. FNAC of the skull lesion suggested a possibility of metastases from follicular thyroid neoplasm. Incisional biopsy was taken and it revealed metastatic follicular thyroid carcinoma. Chest X-ray was normal. All routine investigations were within normal limits. 30

3 Right hemithyroidectomy was done with uneventful post-operative course. Intraoperatively right small hard nodule of 2x2 cm was found. Following suture removal, she was send with levothyroxine suppression and then sent for external beam radiation therapy (EBRT) for locoregional control of skull Discussion Thyroid cancer is the most common endocrine malignancy. Thyroid cancers are divided into major histological subtypes, papillary, follicular, medullary and anaplastic. The most common subtype of thyroid cancer is papillary thyroid cancer (PTC). The second most common subtype is follicular thyroid cancer (FTC). Together, papillary and follicular cancers are termed differentiated thyroid cancer (DTC) which account for 90% of all thyroid cancers (3,4). Bone is the most common single site for FTC and the second most common single site for PTC (5). Bone metastasis from FTC are more often to the long bone, such as femur and flat bones, particularly the pelvis and sternum, the bones most often involved in metastasis of PTC are ribs, vertebrae and sternum, while skull metastasis from both FTC and PTC are extremely rare, accounting for 2.5% from all bone metastasis, the majority of skull metastasis from thyroid cancers is of the FTC followed by PTC (6,7). The method of spread of thyroid cancers to the skull is likely via the haematogenous route. Batson demonstrated a vertebral venous plexus which consisted of a valveless vascular bed within the spinal canal and extended from the skull to the pelvis (8). Batson and Eckenhoff showed that there were multiple anastomoses and free connections between this venous plexus and the dural sinuses, the emissary veins of the skull as well as numerous junctions with the cervical plexus (9). Recently arterial spread has also been suggested because of the association with secondary cutaneous locations in the territory of the ipsilateral external carotid artery (10). Anatomically skull metastatic lesions are most frequently located at the midline of the frontal and parietooccipital region (8). Skull metastasis 31 is usually present as a soft painless slow growing scalp mass, growth of the disease causes brain compression that may result in increased intracranial pressure and neurological symptoms including head-aches, neurological deficits, meningeal irritation and seizures (2), these lesions are osteolytic on skull X-ray and CT scan and highly vascular on angiographic assessment (2). As reported, the largest case series of skull metastases from all types of thyroid cancers consist of 12 cases (2). In this series mean time from the diagnosis of thyroid tumours until discovery of skull metastases was 23.3 years. Most metastatic skull lesions are asymptomatic. The commonest mode of presentation of skull metastases from follicular cancer is as pulsatile skull swellings. Very rarely, there can be features of cranial nerve dysfunction, focal brain symptoms or symptoms due to increased intracranial pressure. Most of these tumours are highly vascular, and there is potential for significant morbidity and mortality associated with surgical resection. As per general recommendations, histo-pathologic tissue diagnosis should always be attempted, followed by total thyroidectomy, radioiodine ablation, or external beam radiation, and chronic thyroid stimulating hormone suppression. Surgical resection of the metastatic lesion should only be performed in carefully selected cases because of the associated morbidity (11). The effectiveness of Iodine-131 (I-131) in bone metastases treatment is suboptimal. Bone metastases associated with radiographic changes are particularly known not to respond well to I-131 therapy. Also, high doses of radioactive iodine have been linked to an increased risk of leukaemias as well as bone, soft tissue, colorectal, and salivary gland cancers (12). In addition to thyroidectomy and I- 131 treatment, studies also support the use of External Beam Radiation Therapy (EBRT) for locoregional control of inoperable metastases (13). Bisphosphonates which have been used widely to control bone metastasis of solid tumours such as breast and prostate cancers, have also been reported in some

4 patients with skull metastases from thyroid cancers (14). Prognosis in case of metastasis is generally poor and the 10 years survival with bone metastases from differentiated thyroid cancer is reported to be 27% (15). However, the reported mean survival in patients who present skull metastases in the case series was only 4.5 years (2). References 1. Shha AR, Shah JP, Loree TR. Differentiated thyroid cancer presenting initially with distant Am J Surg 1997;174: Nagamine Y, Suzuki J, Katakura R, Yoshimoto T, Matoba N, Taktaya K, et al. Skull metastasis of the thyroid carcinoma. Study of 12 cases. J Neurosurg 1985;63: Cooper DS, Doherty GM, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009;19: Jasim S, Ozsari L, Harba MA. Multikinase inhibitors use in differentiated thyroid carcinoma. Biologics 2014;8: Khan SH, Hassan MU, Bhau RS. Iodine- 131 avid distant metastasis in differentiated thyroid cancer: An intiial institutional experience from the northern part of India. Indian J Nucl Med 2015;30: Zettinig G, Fueger BJ, Passler C. Longterm follow-up of patients with bone metastasis from differentiated thyroid carcinoma- surgery or conventional therapy? Clin Endocrinol (Oxf) 2002;56: Atkinson AL, Rosenthal A, Nardiello D. Follicular thyroid carcinoma presenting as palpable head mass: a case report. Case Rep On-Col 2010;3: Baston OV. The function of the vertebral veins and their role in the spread of Ann Surg 1940;12: In conclusion, metastasis from differentiated thyroid malignancy should always be suspected in patients who present with suspicious skull After confirmation such patients should undergo thyroidectomy and radio-iodine ablation or external irradiation for local control of the 9. Florence -Laigle D. Skull-base J Neuro Oncol 2005;75; Ortiz LP, Lopez RG, Vargas SR et al. Thyroid follicular carcinoma presenting as as skull and dural metastasis mimicking a meningioma: a case report. J Neuro Oncol 2009;95: Mydlarz WK, Wu J, Aygun N, Olivi A, Carey JP, Westra WH. Management considerations for differentiated thyroid carcinoma presenting as a metastasis to the skull base. Laryngoscope 2007;117(7): De Vathaire F, Schlumberger M, Delisle MJ, Francese C, Challeton C, de la Genardiére E. Leukaemias and cancers following Iodine-131 administration for thyroid cancer. Br J Cancer 1997;75: Meadows KM, Amadur RJ, Morris CG, Villaret DB, Mazzaferri EL, Mendenhall WM. External beam radiotherapy for differentiated thyroid cancer. Am J Otolaryngol 2006;27: Tassinari D, Poggi B, Nicoletti S, Fantini M, Tamburini E, Possenti C. Zoledronic acid treatment at home: safety data from an observational prospective trial. J Palliat Med 2007;10: Schlumberger M, Tubiana M, De Vathair F, Hill C, Gardet P, Travagli JP, et al. Long-term results of treatment of 283 patients with lung and bone metastases from differentiated thyroid cancer. J Clin endocrinol Metab 1986;63:

5 Sudan Med J 2017 April;53(2):33-38 Short Communication Sudan Medical Journal ث ؾ ث طذ ١ ث هث ١ On the Centenary of bilharzia cure discovery at Khartoum Civil Hospital ( ); Jack Christopherson, and modern Sudanese medicine: A re-appraisal of a biography Tarik Elhadd, MD FRCP FACE Endocrine Section, Department of Medicine, The National Diabetes & Endocrine Centre Alwakra Hospital, Hamad Medical Corporation, Doha Qatar & Adjunct Professor of Medicine Sudan International University, Khartoum, Sudan. عهي هبيص يئىيت اول عالج ن شض انبههبسسيب ( ) دكتىس خبك كشيستىفشس و انطب انحذيث في انسىدا. قىش عهي سيشة راتيه 33 د ف ١ ؽج ق ػذو ث ى ٠ ث و ؤ ز ف و ث طذ ١ ز ث و فز يهخص ٠ ظجهف يث ث ؼج ث يو ث ت ٠ ز قوط ؽذ ف صج ٠ ل ث طخ ث قو ٠ ظ أال ثوضشجف أ ي ػمج ؼالػ ع ث ذ ج ١ ج وخ " ثال ض ١ صج صج ٠ ش " أ ي ث ضؼ جي ف ػ ذ 10 ػ ف ضشف ث ن ؽ ث ى ف ث ؼج 1917 ش ضجةؼ ى ه ثالوضشجف ف لز ػ ١ ز ف ؾ ز ث ال ش ث ذ ٠ طج ١ ز ث ض وج ش الص ثي ث ؾالس ث ؼ ١ ز ث طذ ١ ز ث ثةور ث ف ١ ؼز. ثالوضشجف وج ع ر ؽ ه ؼ ١ ز لج د ج ث ووض ؽجن و ٠ ض ف ث ػ ١ ثأل ي ألؽذجء ث ذ ٠ طج ١١ أ ي و ٠ ظ قز ث طذ ١ ز ث هث ١ ز ث ض ث شتش ف ث ؼج 1904 ف ث ؼش ٠ ز ثأل ث ض ص ش ث غ ثال ؾ ١ ث ظ هث ث غ ر ث و ٠ ز. هوض و ٠ ض ف ث ي و ف ػج 1868 ف مجؽؼز ٠ وشج ٠ ف إ ؾ ض ث ه ثدضوثء ف ؽج ؼز وج ذ هػ ع أو ه ث ز ث طخ صن ػ و ١ ز ؽخ ج دج ع ١ ث ضجدؼز ؾج ؼز و ف ث ؼج أص و ٠ ض ف إ ث هث ف ث ؼج 1902 دظفض عج ؽذ ١ خ و دؼو ث غ ػ ف و ث ن ؽ أ ه ج فض ث ؼج 1919 ف ١ ػجه إ د ٠ طج ١ ج. وج و ٠ ض ف ؽذ ١ ذج ج ث طج ج دج ػج ؽ غ د ١ ىجس ث ؾ ثؿ ث ض ١ ث ذجؽ ث قجىق ث ذجفظ ث فط ث ؼذم ضؼوه ث ث خ ش ج ٠ د ػ ص ؼ ١ ١ ف ثأل ثق ث ذق ط ث طذ ١ ز ف أ ١ ث ؾالس ث و ٠ جس ث طذ ١ ز ف ث ؼم ه ثال دؼز ثأل ث م ث ظ. صمجػو و ٠ ض ف ف ضظف عالع ١ ١ جس ث م ث ؼش ٠ ف ضؾؼز "أد ثح ث جء" ف مجؽؼز ل ضش ١ ف ث ؾ ض ث فض فجص ف ١ ٠ 21 ث مظز ث ىج ز ي ه ثالوضشجف ث ١ ر ث يثص ١ ز ووض ؽ د ث ٠ ج )ؽجن( و ٠ ض ف ش س لذ ثس ػو ٠ ور لذ ث ىجصذز ث ى و ٠ ز ث ذ ٠ طج ١ ز ثألط ث و ث ٠ ض ج ٠ ث ض ٠ ؼضذ و ٠ ض ف ؽو ج ثالوذ. صض ج ي ي ث لز نظج ١ ر هوض و ٠ ض ف ث ي ٠ ؼو أ ث شنظ ١ جس ث ض ث ش هػجة ث طخ ث ؾ ثفز ف ث هث ث قو ٠ ظ. When Earth s last picture is painted and the tubes are twisted and dried, When the oldest colours have faded, and the youngest critic has died, We shall rest, and, faith, we shall need it- lie down for an aeon or two Till the master of All Good Workmen shall put us to work anew And only the Master of shall praise us and only The Master shall blame And no one shall work for money and no one shall work for fame But each for the joy of the working, and each, in the separate star, Shall draw the Thing as he sees it for the God of Things as they are! Rudyard Kipling Summary A landmark feature of the Sudan Medical Department ( ) was the historical contribution of its first director and one of the first few civil doctors to work in Sudan. To Corresponding author Tarik Elhadd tarikelhadd58@gmail.com Dr Jack (John) Christopherson, goes the credit of researching and then masterminding the discovery of the first cure for Bilharziasis. Bilharzia, at the turn of the twentieth century was a major scourge and an ominous medical condition with no cure. The full story and the biography of Jack Christopherson has been published some time ago by his great niece,

Multi-Organ Distant Metastases in Follicular Thyroid Cancer- Rare Case Report

Multi-Organ Distant Metastases in Follicular Thyroid Cancer- Rare Case Report Dr. Mohammed Raza 1, Dr. Sindhuri K 2, Dr. Dinesh Reddy Y 3 1 Professor, Department of Surgery, JSS University, Mysore, India