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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 9  |  Issue : 1  |  Page : 19-21

Solitary iliac bone metastasis: Unusual presentation of follicular thyroid carcinoma diagnosed by fine needle aspiration cytology


Department of Pathology, Padm. Dr. D. Y. Patil Medical College, Pimpri, Pune, Maharashtra, India

Date of Web Publication28-Jan-2012

Correspondence Address:
Shirish S Chandanwale
Department of Pathology, Padm. Dr. D.Y. Patil Medical College, Pimpri, Pune- 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-0354.92392

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  Abstract 

A 47-year-old woman presented with pain in the right hip region. Radiograph revealed solitary osteolytic lesion in the right iliac bone. Fine Needle Aspiration Cytology (FNAC) diagnosed it as a metastasis of follicular thyroid carcinoma (FTC). Thyroid gland was clinically without any apparent disease. This case is presented to highlight unusual clinical presentation of FTC which is confused with primary bone tumor. Early diagnosis by FNAC is essential for better prognosis.

Keywords: Bone metastasis, fine needle aspiration cytology, follicular thyroid carcinoma


How to cite this article:
Chandanwale SS, Buch AC, Dharwadkar AA, Singh NA. Solitary iliac bone metastasis: Unusual presentation of follicular thyroid carcinoma diagnosed by fine needle aspiration cytology. Thyroid Res Pract 2012;9:19-21

How to cite this URL:
Chandanwale SS, Buch AC, Dharwadkar AA, Singh NA. Solitary iliac bone metastasis: Unusual presentation of follicular thyroid carcinoma diagnosed by fine needle aspiration cytology. Thyroid Res Pract [serial online] 2012 [cited 2017 Mar 22];9:19-21. Available from: http://www.thetrp.net/text.asp?2012/9/1/19/92392


  Introduction Top


Follicular thyroid carcinoma (FTC) is the second most common cancer of thyroid gland after papillary carcinoma. Common mode of presentation is solitary thyroid nodule. Reported incidence of distant metastasis is between 11 to 25%. [1] FTC commonly metastasizes to lungs, bones, brain, and liver. Skeletal metastasis of FTC are usually multiple and have predilection for shoulder girdle, sternum, skull, and iliac bones. [2] Most often they are detected after diagnosis of primary lesion. Rarely they can be presenting symptom. [1],[3],[4],[5],[6],[7] Solitary iliac bone metastasis is very unusual, very rarely can be presenting symptom, and often confused with primary bone tumors. When diagnosed early, FTC with metastatic disease have relatively better prognosis as compared with other forms of metastatic malignancies. [4] We report one such case of a 47-year-old woman in which solitary iliac bone metastasis was the initial presenting symptom of FTC which was diagnosed by Fine Needle Aspiration Cytology (FNAC).


  Case Report Top


A 47-year-old woman came to orthopedic outpatient unit with complaints of pain in the right hip region of 3-month duration. She had history of fall at that time. There was no history of fever, cough with expectoration, and weight loss. There was no other relevant medical or family history. Radiograph showed single osteolytic lesion measuring 06 × 05 cm in the right ileum [Figure 1]. Primary bone tumor was suspected. Ultrasound-guided FNAC was done from the lesion. Material obtained was smeared on glass slides and stained with Leishman stain. Smears showed many syncytial sheets of thyroid follicular cells having monotonous enlarged, hyper chromatic nuclei and microfollicles containing colloid [Figure 2]. Diagnosis of FTC metastasis was done. Bone marrow core biopsy from the lesion revealed replacement of marrow spaces by thyroid follicles containing colloid [Figure 3]. Subsequent ultrasound examination of thyroid gland revealed heterogeneous hypoechoic ill-defined lesion in right lobe of thyroid measuring 09 × 08 mm. Thyroid function tests were normal. Total thyroidectomy was done. Histological examination of thyroid confirmed FTC. Postoperatively, nuclear scan showed no evidence of metastasis elsewhere in the body. Patient received radioiodine ablation (131-I) and L-thyroxin suppressive therapy. During follow-up, serum Thyroglobulin was 45 ng/ml.
Figure 1: Radiograph showing solitary lytic lesion (Arrow) in right iliac bone

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Figure 2: Fine needle aspiration cytology showing syncytial sheets of thyroid follicular cells and microfollicles containing drop of colloid in inset (Leishman stain, ×400)

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Figure 3: Bone marrow core biopsy showing metastasis of follicular thyroid carcinoma (H and E, ×100)

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  Discussion Top


FTC comprises approximately 5% of the thyroid cancers. But its prevalence increases up to 25 to 45% in iodine deficient areas. [8] FTC has marked propensity for vascular invasion and commonly metastasizes to lungs, bones, brain, and liver. True lymph node metastasis is exceedingly rare. Incidence of bone metastasis in well-differentiated FTC range from 7% to 28%, while in papillary carcinoma, incidence ranges from 1.4% to 7%. [9] Vertebrae is the commonest site followed by ribs, pelvic bones, and skull. [4],[9] Metastatic tumors are often multiple and have impact on prognosis. Rarely patients with FTC initially present to the clinicians with distant metastasis. [1],[3],[4],[5],[6],[7]

Solitary metastasis in thyroid carcinoma is well documented in many studies. [1],[2],[3],[4],[6],[7],[9] Very few reports are published where FTC has initially presented with solitary metastasis in skull, soft tissue skin. [1],[3],[4],[5],[6],[7] But, solitary iliac bone metastasis is unusual presentation of FTC which was diagnosed by FNAC in our case. Cytologic diagnosis of metastatic FTC has been rarely reported which happened in our case. Metastasis may exhibit a better differentiated appearance than that of the primary tumor to the point of simulating normal thyroid as an expression of terminal differentiation which was seen in our case. [10]

Metastatic disease is the primary cause of death in FTC. However, with appropriate initial evaluation and management, good survival rate is possible, [4],[9] which happened in our case. To conclude, females presenting with large solitary iliac bone destructive lesions, apart from primary bone tumor, metastasis of FTC must be kept in mind. Early diagnosis is essential for better prognosis.

 
  References Top

1.Sevinc A, Buyukberber S, Sari R, Baysal T, Mizrak B. Follicular thyroid cancer presenting initially with soft tissue metastasis. Jpn J Clin Oncol 2000;30:27-9.  Back to cited text no. 1
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2.Pittas AG, Adler M, Fazzari M, Tickoo S, Rosai J, Larson SM, et al. Bone metastasis from thyroid carcinoma: clinical characteristics and prognostic variables in 146 patients. Thyroid 2000;10:261-8.  Back to cited text no. 2
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3.Shaha AR, Shah JP, Loree TR. Differentiated thyroid cancer presenting initially with distant metastasis. Am J Surg 1997;174:474-6.  Back to cited text no. 3
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4.Shreedharan S, Pang CE, Chan GS, Soo KC, Lim DT. Follicular thyroid carcinoma presenting as axial skeletal metastasis. Singapore Med J 2007;48:640-4.  Back to cited text no. 4
    
5.Dae KK, Cheol SJ, Kang HK, Jae KK. Spinal cord compression as initial presentation of follicular thyroid carcinoma. J Korean Neurosurg Soc 2007;41:269-71.  Back to cited text no. 5
    
6.Shamim MS, Khursheed F, Bari ME, Chisti KN, Enam SA. Follicular thyroid carcinoma presenting as solitary skull metastasis: report of two cases. J Pak Med Assoc 2008;58:575-7.  Back to cited text no. 6
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7.Portocarrero-Ortiz L, Garcia-Lopez R, Romero-Vargas S, Padilla JA, Gómez-Amador JL, Salinas-Lara C, et al. Thyroid follicular carcinoma presenting as skull and dural metastasis mimicking a meningioma: a case report. J Neurooncol 2009;95:281-4.  Back to cited text no. 7
    
8.Thompson LD, Wieneke JA, Paal E, Frommelt RA, Adair CF, Heffess CS.A clinicopathologic study of minimally invasive follicular carcinoma of thyroid gland with a review of the English literature. Cancer 2001;91:505-24.  Back to cited text no. 8
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9.Do MY, Rhee Y, Kim DJ, Kim CS, Nam KH, Ahn CW, et al. Clinical features of bone metastasis resulting from thyroid cancer: A review of 28 patients over a 20-year period. Endocr J 2005;52:701-7.  Back to cited text no. 9
[PUBMED]  [FULLTEXT]  
10.Tickoo SK, Pittas AG, Adler M, Fazzari M, Larson SM, Robbins RJ, et al. Bone metastasis from thyroid carcinoma: A histopathologic study with clinical correlates. Arch Pathol Lab Med 2000;124:1440-7.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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