Papillary thyroid cancer (PTC) is a follicular cell-derived carcinoma. It is a differentiated form of thyroid carcinoma. The follicular variant of PTC is generally a slow growing tumor. Differentiated thyroid cancers, which ordinarily behave in an indolent manner, can have unusual metastatic presentations and patterns. Skull calvarium are rare sites of distant metastasis and mostly have been reported with lung, breast, and prostate malignancies. However, the Calvarial metastases from papillary thyroid cancer (PTC) are rare entities and pose diagnostic and therapeutic challenges. To date, only eight cases of Calvarial metastasis with intracranial extension from PTC have been reported in literature.
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A 64-year-old female presented to ED with incidental finding of a large lump on the back of her head that first got noticed by her hairdresser. Past medical history was significant for Right hemi-thyroidectomy due to unifocal papillary thyroid carcinoma at an outside facility two years ago. Computed tomography and magnetic resonance imaging showed large parietal calvarial lesion measuring 6x8x8cm with adjacent mass effect. Additionally, two small lesions were noted: a left frontal calvarial lesion and a right orbital extraconal lesion. Excision of the large parietal lesion confirmed the diagnosis of follicular variant of papillary thyroid carcinoma (FV-PTC). Subsequent completion thyroidectomy was performed although there were no signs of malignancy on the surgical pathology. However, before the planned date for radioactive iodine ablation, patient presented to ED again with severe tearing, pain in right eye and proptosis. Magnetic resonance imaging showed significant expansion of right orbital lesion with pressure effect on right optic nerve. Eventual excision was performed followed by outpatient RAI ablation with 175mCi.
Papillary Thyroid Cancer metastases to the calvarium are extremely rare. Surgical resection followed by postoperative iodine ablation is the treatment of choice. Bisphosphonate therapy is second line treatment for patients who respond poorly to RAI ablation. Although Follicular variant PTC are commonly encapsulated’ the invasive type of FV-PTC may harbor certain mutations rendering these generally indolent tumors to behave more aggressively. Multidisciplinary approach can improve the treatment outcome and survival.
Manav Nayyar– PostDoctoral fellow, University of Missouri- Columbia, Columbia, Missouri
Richa Patel– PGY4, University of missouri, Columbia, MO, Columbia, Missouri
Camille McLean– Endocrinology Fellow, PGY5, University of Missori-Columbia
Rajaa Almourani– post doctoral fellow, University o Missouri Columbia
University of Missouri- Columbia
I am a Final year Post-doctoral fellow in Endocrinology. Before joining the Endocrinology Fellowship, I have worked as an Internist for 6 years, initially in Mason City, Iowa and then at University of Missouri, Columbia. While practicing medicine I saw how diabetes, hypertension and osteoporosis is affecting the health of the people and also realized that if we can educate and help change patient’s dietary habits it will lead to stark improvement in their health. This lead me to seek more training in Diabetes & other Endocrinological disorders. And I’m very confident that the experience I have gained during these past 18 months including doing peer based education in High School will help me achieve my goals in future.
University of missouri, Columbia, MO
I recently started my Endocrinology fellowship and I enjoy it thoroughly. I am looking forward to be a part of ACE which I am certain will help me greatly with my academic pursuit.
Endocrinology Fellow, PGY5
University of Missori-Columbia
Camille McLean is a 2nd year fellow in the Endocrinology, Diabetes and Metabolism Fellowship program at the University of Missouri-Columbia. She received her Doctor of Medicine degree from Meharry Medical College.
She is currently a fellow in the Endocrine Society Future Leaders Advancing Research in Endocrinology (FLARE) program.