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      Brain metastasis from thyroid adenomatous nodules or an encapsulated thyroid follicular tumor without capsular and vascular invasion: a case report

      Cases Journal

      Cases Network Ltd

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          Abstract

          Because benign-appearing thyroid nodules with metastasis are very rare, the author reports herein four thyroid nodules (one follicular adenoma and three adenomatous nodules) with brain metastasis. A 75-year-old Japanese woman was admitted to our hospital because of thyroid mass. Imaging modalities revealed four distinct nodules in the thyroid, and tumorectomies of all nodules were performed under the clinical diagnosis of benign thyroid nodules. Grossly, one of them was a completely encapsulated tumor (35 mm in diameter). Other three nodules were non-encapsulated nodules (10 mm, 8 mm, and 7 mm in diameters). Multiple sections were obtained from the largest nodule. One section was obtained from each of the smaller three nodules. Microscopically, the largest tumor was an encapsulated follicular adenoma. The tumor consisted of normofollicles and microfollicles surrounded by a fibrous capsule. Neither capsular invasion nor vascular permeation was recognized. The parenchyma lacked nuclear atypia, mitotic figures, degenerative changes, papillary structures, nuclear inclusions, nuclear ground-glass features, and nuclear grooves. Thus, the largest tumor was diagnosed as follicular thyroid adenoma. The remaining three small nodules were typical adenomatous nodules composed of normofollicles and macrofollicles without nuclear atypia, mitotic figures, degenerative changes, papillary structures, nuclear inclusions, nuclear ground-glass features, and nuclear grooves. Therefore, a diagnosis of adenomatous nodules (goiters) was made. However, six years later, the patient showed a brain metastasis of thyroid tumor composed of macrofollicles without cellular and nuclear atypia. A diagnosis of metastatic follicular thyroid carcinoma was made. The present case suggests that benign thyroid nodules can metastasize.

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          Most cited references 14

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          A clinicopathologic study of minimally invasive follicular carcinoma of the thyroid gland with a review of the English literature.

          The criteria for minimally invasive (low grade) follicular carcinoma of the thyroid (MI) remain controversial, often resulting in unnecessary treatment. The records of 130 patients with minimally invasive (MI) follicular thyroid carcinoma were retrieved from the files of the Endocrine Tumor Registry of the Armed Forces Institute of Pathology. Ninety-five patients were confirmed to have MI based on the authors' criteria of small-to-medium vessel invasion, capsular invasion of up to full thickness, no parenchymal tumor extension, and no tumor necrosis (patients with oxyphilic tumors were excluded). The remaining 35 patients had tumors that were reclassified as "not low grade" based on large vessel invasion, extension into parenchyma, and tumor necrosis (oxyphilic cases excluded). The MI patients included 67 women and 28 men, ages 20-95 years (average, 42.0 years). Nearly all patients presented with a thyroid mass (n = 90 patients). The mean tumor size was 2.8 cm. Histologic features examined for tumor classification included cellularity, capsule nature, capsular invasion, vascular invasion, extension into parenchyma, cytoplasmic oxyphilia, mitotic activity, and necrosis. All patients were treated with surgical excision. Adjuvant radioactive iodine therapy was performed in 24 patients. Five patients developed recurrent disease: four were alive or had died without evidence of disease after additional treatment (mean, 18.1 years), and one patient died with disease (MI tumor) at 15.1 years. All of the remaining patients were disease free (mean follow-up, 16.5 years). There are reproducible histologic criteria to diagnose patients with MI follicular carcinoma. The overall excellent long term prognosis and a good patient outcome suggests that no additional surgery is necessary. Copyright 2001 American Cancer Society.
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            Distant and lymph node metastases of thyroid nodules with no pathological evidence of malignancy: a limitation of pathological examination.

            Among thyroid nodules arising from follicular cells, benign nodular goiter is thought not to metastasize to regional or distant organs. However, we encountered five cases that were pathologically diagnosed as benign nodular goiter but showed metastasis. The prevalence of benign nodular goiter showing metastasis was 0.17% (5 of 2978 patients). On pathology, there were no detectable signs of carcinoma or follicular adenoma lesions. Two patients showed lymph node metastasis that was pathologically confirmed as metastasis of nodular goiter. One was preoperatively and another was postoperatively detected by ultrasonography. These patients also showed distant metastases that could be ablated by radioiodine. One patient preoperatively showed lung metastasis and the remaining two showed lung and bone metastases and bone metastasis postoperatively. Pathological diagnosis of thyroid nodules has limitations, and cases diagnosed as benign nodular goiter should still undergo careful follow-up.
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              Follicular thyroid cancer presenting as a sellar mass: case report and review of the literature.

              To describe an uncommon initial manifestation of well-differentiated follicular carcinoma of the thyroid in an unusual metastatic site. We present clinical, laboratory, and imaging findings in our patient and review related data from the literature. A young healthy woman presented with headache and diplopia. Magnetic resonance imaging of the brain showed a complex mass in the sellar region. Endocrine evaluation was remarkable only for a modestly high serum prolactin level. Transsphenoidal biopsy of the sellar mass revealed metastatic follicular thyroid carcinoma. On subsequent examination, a thyroid nodule was palpated. She underwent total thyroidectomy and ablative therapy with 131I, after which her symptoms gradually subsided and the sellar mass ultimately decreased in size. Although well-differentiated thyroid cancer generally manifests as a thyroid nodule, metastatic disease is present at the time of initial assessment in approximately 1% of cases, and the lungs and the skeleton are the most frequent sites of involvement. Only a few cases of thyroid cancer metastasizing to the sella have been reported. Described cases occurred mainly in elderly patients with previously diagnosed thyroid cancer. The most common malignant tumors that metastasize to the sella and pituitary are lung cancer in men and breast cancer in women. Metastatic tumors frequently manifest with cranial nerve palsies or diabetes insipidus and occur in elderly patients. Follicular thyroid cancer can manifest initially as a distant metastatic tumor in young patients. Metastatic lesions should always be in the differential diagnosis of a sellar mass, even in young patients.
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                Author and article information

                Journal
                Cases J
                Cases Journal
                Cases Network Ltd
                1757-1626
                17 July 2009
                2009
                : 2
                Affiliations
                simpleDepartment of Pathology, Shizuoka City Shimizu Hospital ShizuokaJapan
                Article
                7180
                10.4076/1757-1626-2-7180
                2740070
                19829930
                © 2009 Terada; licensee Cases Network Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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                Case report

                Medicine

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