Solitary follicular thyroid carcinoma of the skull base and its differentiation from ectopic adenoma--review, use of galectin-3 and report of a new case

With only four histologically proven cases in the literature, solitary skull base metastasis of thyroid carcinoma is extremely rare. Having treated another patient harboring a lesion with osseous destruction in the petroclival region and downward soft tissue extension we analyzed this case in conjunction with previous reports. In contrast to parenchymal brain metastasis that usually consists of the papillary type, histological examination revealed differentiated follicular tumors in all cases. All were located around the clivus. The radiographic picture resembled that of chordomas or chondrosarcomas. In the tissue obtained during thyroidectomy no evidence of primary malignancy was found in any of the cases according to standard histological criteria. In our case, a recently developed immunocytological marker - galectin-3 - was applied to differentiate between ectopic thyroid adenoma and carcinoma. The results were indicative of anaplastic growth. Tumor remnants responded well to postoperative 131I internal radiation and TSH suppression therapy. Distant metastasis of follicular thyroid carcinoma has to be considered in the differential diagnosis of destructive skull base lesions. Histological evaluation should include immunohistochemistry or clonal analysis to differentiate between adenomatous and carcinomatous growth and initiate effective radiotherapy early. Prognosis is by far not as poor as in brain metastases and appears to depend largely on location, size and histological appearance.     

Cavernous sinus metastasis from thyroid papillary adenocarcinoma.

We report here an extremely rare case of cavernous sinus metastasis from thyroid papillary adenocarcinoma presenting long after initial diagnosis. A 41-year-old patient presented with a cavernous sinus tumor causing progressive diplopia 10 years after treatment for a papillary adenocarcinoma of the thyroid. After 5 years of close observation, subarachnoid hemorrhage developed from the cavernous sinus tumor extending to the cerebellopontine angle, at which point the patient underwent surgical removal of the tumor followed by gamma knife radiosurgery. The pathological diagnosis was papillary adenocarcinoma, indicating the distant metastasis from the thyroid. This case illustrates the unique event of a cavernous sinus metastasis long after initial treatment of the primary cancer.     

Apoplexy in sellar metastasis: a case report and review of literature

Apoplexy in sellar metastasis is very rare with only a few case reports in literature. A case of apoplexy in sellar metastasis from follicular thyroid carcinoma is reported and the literature is briefly reviewed. The patient presented with sudden onset headache and bi-lateral loss of vision following thyroidectomy in a case of follicular carcinoma thyroid with proven sellar metastasis. CT scan showed hyperdense blood in sellar mass suggestive of apoplexy in sellar metastasis. The patient underwent early trans-sphenoidal decompression. Apoplexy in sellar metastasis, although very rare, can be clinico-radiologically indistinguishable from pituitary apoplexy and should be especially considered in the differential diagnosis of patients with known primary neoplastic disease. In view of similar patho-physiological mechanism, sellar metastasis with apoplexy should be managed in a similar manner as pituitary apoplexy.     

Metastasizing of follicular thyroid cancer to the skull base

Distant metastases of differentiated thyroid carcinoma are observed in 5-10% of cases. Cerebral metastases are common for papillary carcinoma while cranial bones are usually affected by metastases of follicular cancer. Diagnostics of metastases of follicular carcinoma is complicated due to absence of pathognomonic signs and in 42% of cases they represent clinical onset of the disease. Neurosurgical treatment of metastases is associated with difficulties caused by abundant vasculature and intimate contact with critical structures of the skull base. Nevertheless metastases of follicular thyroid carcinoma have relatively favorable course: after surgical resection and hormonal replacement therapy and local iodine radiotherapy life expectancy is 4.5 years longer.     

内镜经鼻前颅底肿瘤的外科治疗

目的总结内镜经鼻入路切除前颅底肿瘤的经验。方法回顾性分析2003年11月～2006年5月18例肿瘤侵犯前颅底的临床资料．其中14例单独采用内镜经鼻手术入路．4例采用颅鼻联合入路进行了治疗。病理类型包括：脑膜瘤2例，脊索瘤1例，视神经鞘瘤1例．骨纤维异常增殖症1例．鳞状细胞癌3例，嗅神经母细胞瘤3例，腺样囊性癌1例，恶性骨巨细胞瘤1例，脊索肉瘤1例．神经内分泌小细胞癌1例，透明细胞癌1例，甲状腺癌颅底转移1例，腮腺癌颅底转移1例。结果经术中镜下及术后影像学检查证实17例肿瘤被全部切除．1例大部分切除。2例术后出现脑脊液鼻漏，经保守治疗后痊愈。无颅内出血、感染及死亡病例。结论内镜经鼻入路能够充分显露和切除前颅底肿瘤．且大多数病例无需处理硬脑膜及进行颅底重建。     

Spontaneous epidural hematoma due to skull metastasis of hepatocellular carcinoma

Although “spontaneous” epidural hematomas are rare, they can occur in patients with metastatic skull tumors. We describe a case caused by skull metastasis of hepatocellular carcinoma (HCC), and review the relevant literature. In patients with HCC, potential skull metastasis should be kept in mind, since skull metastases from HCC seem to often cause devastating epidural hematoma.     

Petroclival intravascular papillary endothelial hyperplasia with psammoma body-like structures

Masson's tumor or intravascular papillary endothelial hyperplasia (IPEH) is considered a non-neoplastic lesion. It is probably an unusual exaggerated reorganization of a thrombus. IPEH may be present as a secondary lesion in hemangiomas. Symptomatic osseous hemangiomas are rare tumors. Few cases of clival and petrous bone hemangiomas have been described. None of them shows secondary IPEH. So far, there are only four reported cases of cranial bone IPEHs in the literature, two in the skull, one in the clivus and one in the petrous apex. The aim of this study is to report an additional case of osseous hemangioma with secondary IPEH of the petroclival region. We review the literature and describe the main clinical features of IPEHs and hemangiomas of the clivus and the petrous bone. Additionally, we report an unusual histological feature observed in our case of IPEH, the presence of psammoma body-like structures. This feature has been rarely mentioned previously in IPEH. We consider that IPEH should be included in the lesions that may present psammoma bodies to avoid misdiagnosing it as a tumor that commonly shows psammoma bodies, such as intraosseous meningioma or, less frequently, metastasis of thyroid or ovarian carcinoma.     

Primary orbito-cranial adenoid cystic carcinoma with torcular metastasis: a case report and review of the literature.

Adenoid cystic carcinoma is a rare neoplasm arising from the exocrine glands such as salivary glands, lachrymal glands, upper respiratory tract, breast or uterine cervix. Intracranial involvement is commonly from direct skull base involvement, although metastasis may rarely be seen. The predisposition of the adenoid cystic carcinoma for perineural and perivascular invasion is the prime reason for the locally invasive character of the tumour, often extending into the cranium via foramina at the skull base. The authors report a case of primary orbito-cranial extradural adenoid cystic carcinoma and cranial metastasis away from the primary site. This patient initially had a local excision, and later an exenteration of the right eye followed by with radiotherapy. Within months she presented with an extradural cranial recurrence, distant torcular metastasis without any neurological deficit. Craniotomy and radical excision was undertaken as these tumours have slow growth rates, and long term survival of the se patients even in the presence of local recurrence and metastasis has been well documented.     

Spontaneous Epidural Hematoma from Skull Base Metastasis of Hepatocellular Carcinoma

We report a case of an acute spontaneous epidural hematoma (EDH) due to skull base metastasis in a 46-year-old male patient with hepatocellular carcinoma (HCC). The patient presented with the acute onset of severe headache followed by unconsciousness, and computed tomography showed a large EDH in the right temporal and parietal lobes with midline shift. Emergency evacuation of the EDH was performed, and the hemorrhage was determined to be secondary to skull base metastasis of HCC.     

Multiple cerebral metastases as a primary presentation in papillary thyroid carcinoma

Cerebral metastases from papillary thyroid carcinoma are rare. They are aggressive tumours associated with a poor prognosis. We report a patient presenting with multiple cerebral metastases as the primary presentation of her disseminated disease. These metastases were treated with surgical resection followed by external beam radiotherapy and radioactive iodine therapy. We suggest that early diagnosis and treatment of cerebral metastases of papillary thyroid carcinoma can result in good outcomes.     

Spontaneous Intracranial Epidural Hematoma Originating from Dural Metastasis of Hepatocellular Carcinoma

Spontaneous intracranial epidural hematoma (EDH) due to dural metastasis of hepatocellular carcinoma is very rare. A 53-year-old male patient with hepatocellular carcinoma, who was admitted to the department of oncology, was referred to department of neurosurgery because of sudden mental deterioration to semicoma with papillary anisocoria and decerebrate rigidity after transarterial chemoembolization for hepatoma. Brain computed tomography (CT) revealed large amount of acute EDH with severe midline shifting. An emergent craniotomy and evacuation of EDH was performed. Active bleeding from middle cranial fossa floor was identified. There showed osteolytic change on the middle fossa floor with friable mass-like lesion spreading on the overlying dura suggesting metastasis. Pathological examination revealed anaplastic cells with sinusoidal arrangement which probably led to spontaneous hemorrhage and formation of EDH. As a rare cause of spontaneous EDH, dural metastasis from malignancy should be considered.     

Sella turcica metastasis from follicular carcinoma of thyroid

A case of metastasis to the sella turcica from a follicular adenocarcinoma of the thyroid gland is presented. Metastasis to this site is rare and review of the literature reveals only 12 cases of metastatic thyroid carcinoma involving the sella turcica and pituitary gland. The optimal treatment strategy is still to be determined. A 43-year-old woman presented with headache, nausea, visual impairment and galactorrhea. An MRI scan of the cranium revealed an enhancing destructive sellar lesion. The patient underwent transsphenoidal removal of the lesion to alleviate visual loss. The histological features of the sellar tumor were identical to those of a follicular adenocarcinoma partially removed from the thyroid gland 22 months earlier. Total thyroidectomy followed by three courses of iodine-131 ablation enhanced with synthetic thyrotropin and thyroid hormone suppression therapy was instituted. The post-operative course was satisfactory with improved vision and ceased galactorrhea. This case was successfully treated with a combination of surgical removal, iodine-131 ablation and hormone suppression therapy, which resulted in disease control duration of four years. Sella turcica metastases of thyroid carcinoma are exceedingly rare and currently there are no established therapeutic guidelines.     

Hurthle cell carcinoma presenting as a single choroid plexus metastasis

Choroid plexus masses represent approximately 0.3–0.8% of intracranial tumors. Herein we present, to our knowledge, the first reported patient with an isolated Hurthle cell papillary thyroid carcinoma metastasis to the choroid plexus of the lateral ventricle. Unresponsive to iodine ablation and refusing surgery, the patient underwent Gamma Knife radiosurgery (Elekta AB, Stockholm, Sweden), receiving 15 Gy to the 50% isodose line. The lesion regressed until 5 years later at which time it was unresponsive to 18 Gy and required surgical resection. Although extraneural metastatic cancers are recognized as potential sources for the single choroid plexus mass, we must consider even the unusual culprit in patients with a history of cancer.     

Direct ethanol injection for skull metastasis from hepatocellular carcinoma. The techniques and consequences of a therapeutic trial

Abstract

The frequency of skull metastasis from hepatocellular carcinoma (HCC) is increasing together with the recent progress in the management of the primary lesion. Cases are often complicated with poor general conditions or metastasis to the other organs, and not readily indicated for surgery. A direct injection of ethanol to the lesion could be one of the therapeutic options to cope with this complicated situation. To evaluate the feasibility of this technique, we planned a therapeutic trial in a patient with HCC associated with lumbar and skull metastasis, the latter metastasis repeated twice during the past one year. A total of 10 ml of ethanol was injected into the skull metastasis percutaneously under ultrasound (US) guidance. US guidance was very useful in determin.ing the sites of injections and the distribution of ethanol as well as monitoring the blood flow within the tumor vessels. The patient transiently.complained. of local.pan at the injection sites, but there were no other adverse effects. Four days after the injection the les of well as resected by surgery, which confirmed the pathologic diagnosis as well as the nearly-total necrosis: of the tumor This technique is simple, safe and repeatable with low cost. The technical details and the histologic effects are described. [Neural Res 1998; 20: 737-741]     

Sella turcica metastasis from follicular carcinoma of thyroid

Abstract

A case of metastasis to the sella turcica from a follicular adenocarcinoma of the thyroid gland is presented. Metastasis to this site is rare and review of the literature reveals only 12 cases of metastatic thyroid carcinoma involving the sella turcica and pituitary gland. The optimal treatment strategy is still to be determined. A 43-year-old woman presented with headache, nausea, visual impairment and galactorrhea. An MRI scan of the cranium revealed an enhancing destructive sellar lesion. The patient underwent transsphenoidal removal of the lesion to alleviate visual loss. The histological features of the sellar tumor were identical to those of a follicular adenocarcinoma partially removed from the thyroid gland 22 months earlier. Total thyroidectomy followed by three courses of iodine-131 ablation enhanced with synthetic thyrotropin and thyroid hormone suppression therapy was instituted. The post-operative course was satisfactory with improved vision and ceased galactorrhea. This case was successfully treated with a combination of surgical removal, iodine-131 ablation and hormone suppression therapy, which resulted in disease control duration of four years. Sella turcica metastases of thyroid carcinoma are exceedingly rare and currently there are no established therapeutic guidelines.     

Clinical features and surgical management of four peculiar cases of intracranial metastases from renal cell carcinoma

Intracranial metastasis from renal cell carcinoma is rare. In this study, four patients (age range 56–72 years) were treated for intracranial metastases from renal cell carcinoma. The metastasis was solitary in all four patients and was located in the temporoparietal region in two patients, cerebellum in one patient, and bilateral lateral ventricles in one patient. Preoperative magnetic resonance imaging showed hemorrhage and necrosis in the tumor in all four patients, and one patient had edema in the region of the tumor. All patients were treated with craniotomy for tumor resection, and histopathologic examination showed clear cell carcinoma. Marked bleeding occurred in all patients during the operation, but preoperative direct injection of ethanol into epidural metastases (2 patients) was effective in decreasing intraoperative blood loss. Prognosis was poor with limited survival time (range 2 weeks–45 months), but prognosis was best in the two patients who were treated with postoperative radiation therapy and chemotherapy (survival times 26 and 45 months). To our knowledge, this is the largest report of four uncommon intracranial metastases from RCC in Chinese patients. In summary, intracranial metastasis from renal cell carcinoma should be considered in the differential diagnosis of intracranial tumor because of the high risk of bleeding and poor prognosis.     

Unusual CNS presentation of thyroid cancer

As advanced therapies allow cancer patients to live longer, disease failure in the central nervous system increases from limited therapeutic penetration. Primary thyroid malignancies rarely metastasize to the brain and have a small number of investigations in literature on the subject. The majority of brain metastases involve the brain parenchyma, reflecting the mass and blood distribution within the brain and central nervous system. Here, we report two cases of the most common differentiated thyroid cancers; follicular thyroid cancer having brain involvement from extra-axial growth and papillary thyroid cancer having brain involvement from a single intraventricular metastasis, presumed as metastasis from the vascular choroid plexus. Both of our cases had widespread systemic involvement. For our follicular thyroid cancer, brain involvement was a result of extra-axial growth from cavarial bone, and our papillary thyroid cancer had brain involvement from a single intraventricular metastasis that was initially resected and nearly a year later developed extensive brain involvement. Unlike the usual gray-white junction metastases seen in the majority of metastatic brain tumors, including thyroid, our cases are uncommon. They reflect differences in tumor biology that allows for spread and growth in the brain. Although there is growing genetic knowledge on tumors that favor brain metastases, little is known about tumors that rarely involve the brain.     

Mandibular ameloblastoma with intracranial extension and distant metastasis

A case of mandibular ameloblastoma which invaded intracranially through the skull base and developed distant metastasis to the femur is reported. The intracranial extension of the tumor was partially removed three times and the metastasis of the femur was curetted. The remaining tumor temporarily responded to chemotherapy, but the patient died of intracranial tumor regrowth. The period from the initial treatment of the mandibular tumor to death was 21 years.     

Sixth Cranial Nerve Palsy Caused by Gastric Adenocarcinoma Metastasis to the Clivus

Tumors of the clivus and metastases to the clivus are very rare. Metastasis involving the clivus has previously been described in only two case reports. In skull metastasis, the breast and prostate are the most common primary foci, while metastasis from gastric carcinoma is extremely rare. A review of the English literature revealed only one published case of clivus metastases from gastric adenocarcinoma. There is no literature thoroughly explaining the differential diagnosis between chordoma and metastasis. Here we report a rare case of metastasis to the clivus from a gastric adenocarcinoma in a 42-year-old female patient with sudden blurry vision, presenting as bilateral cranial nerve VI palsy.