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Solitary bone and brain metastasis in a patient with papillary thyroid carcinoma mimicking cavernous angioma

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In particular, brain metastasis is very rare and is reported in only 1% of patients with thyroid carcinoma... The final pathological diagnosis was metastatic columnar cell-variant PTC, which is a very rare variant... The present patient was diagnosed with the columnar cell variant, which is characterized by pseudostratified columnar cells and subnuclear vacuolization that resembles early secretory endometrium... Although this PTC variant is very rare and only accounts for 0.15% to 0.2% of all PTCs, it is associated with aggressive behaviors such as a propensity for extrathyroidal extension, distant metastasis, and the death of the tumor... The prevalence of TgAb in thyroid malignancy patients is 10% to 30%, which is higher than among the normal population, and a high serum TgAb titer decreases after thyroid malignancy treatment while a sustained high serum TgAb titer could reflect early relapse... The survival rate of PTC patients significantly decreases when metastasis occurs... The common symptoms of patients with thyroid carcinoma and brain metastasis include headache, nausea, motor weakness, gait disturbances, sensory deficits, visual loss, and seizures but some patients with brain metastasis do not exhibit any symptoms and are only diagnosed with brain metastasis upon a postmortem examination... Due to the low incidence of brain metastatic PTC, a universal standard treatment protocol has yet to be established... However, the current treatment of choice is typically surgical resection because the removal of a brain metastasis significantly improves survival and is an independent predictor of better outcomes... Radiosurgery should be considered for patients who are unable to undergo surgery and whole brain radiation therapy can also be used to treat multiple metastases... Although brain radiation is not associated with a survival benefit, several cases have been reported indicating a regression of brain metastasis after such therapy... The present case was an extremely rare example of brain metastasis from columnar cell-variant PTC in which the brain metastatic lesion mimicked a cavernous angioma... These findings suggest that, depending on the PTC variant, even small PTCs should be treated with caution because they can lead to brain metastasis.

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Microscopic findings of the brain and sternum tumor masses. (A) Low-power view of the resected right frontal mass showing a cystic and solid mass with hemorrhage (H&E, ×10). (B) Low-power view of the brain mass revealing the branching and complex papillary structure of the tumor cells (H&E, ×400). (C) High-power view of the brain mass showing the columnar atypical tumor cells with increased nuclear stratification. The eosinophilic colloid-like material within the lumen is also noted (arrowhead; H&E, ×100). (D) High-power view of the biopsied sternum mass showing the presence of histological features that were identical to the brain mass, i.e., complex papillary fronds and the same cytological findings. There are also increased mitotic figures (arrows; H&E, ×400). Immunohistochemistry (IHC) for (E) cytokeratin 7, (F) thyroid transcription factor-1 (TTF-1), (G) napsin A, and (H) thyroglobulin. Unlike the classic IHC findings for metastatic adenocarcinomas from the lung (i.e., positivity for all three tissue-specific gene expression), the sternum mass expressed only cytokeratin 7 (E) and TTF-1 (F) but not napsin A (G, ×200). The IHC analysis also revealed that the sternum mass expressed thyroglobulin (H, ×200), which is consistent with a diagnosis of metastatic thyroid cancer.
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f2-kjim-2014-321: Microscopic findings of the brain and sternum tumor masses. (A) Low-power view of the resected right frontal mass showing a cystic and solid mass with hemorrhage (H&E, ×10). (B) Low-power view of the brain mass revealing the branching and complex papillary structure of the tumor cells (H&E, ×400). (C) High-power view of the brain mass showing the columnar atypical tumor cells with increased nuclear stratification. The eosinophilic colloid-like material within the lumen is also noted (arrowhead; H&E, ×100). (D) High-power view of the biopsied sternum mass showing the presence of histological features that were identical to the brain mass, i.e., complex papillary fronds and the same cytological findings. There are also increased mitotic figures (arrows; H&E, ×400). Immunohistochemistry (IHC) for (E) cytokeratin 7, (F) thyroid transcription factor-1 (TTF-1), (G) napsin A, and (H) thyroglobulin. Unlike the classic IHC findings for metastatic adenocarcinomas from the lung (i.e., positivity for all three tissue-specific gene expression), the sternum mass expressed only cytokeratin 7 (E) and TTF-1 (F) but not napsin A (G, ×200). The IHC analysis also revealed that the sternum mass expressed thyroglobulin (H, ×200), which is consistent with a diagnosis of metastatic thyroid cancer.

Mentions: A chest computed tomography (CT) scan was performed to assess the mass in the sternum and revealed a huge infiltrating tumor mass with necrosis extending into the manubrium (Fig. 1C). The patient underwent a craniotomy to remove the brain tumor and the manubrium mass was biopsied. A histological analysis of the brain mass under a low-power view revealed a cystic and solid tumor mass that was infiltrating into the brain parenchyma with hemorrhage (Fig. 2A and 2B) and a histological analysis under a high-power view revealed predominant branching papillary structures in the tumor that were composed of columnar cells with increased nuclear stratification (Fig. 2C). The sternum mass had identical histological features, i.e., the presence of complex papillary structures and equivalent cytological findings (Fig. 2D). To determine whether the sternum mass was a metastatic lesion from the lung, the mass was subjected to immunohistochemistry (IHC) analyses for cytokeratin 7, thyroid transcription factor-1 (TTF-1), and napsin A. The mass was positive for cytokeratin 7 and TTF-1 but negative for napsin A (Fig. 2E-2G). Because metastatic thyroid cancer is characterized by a papillary structure and TTF-1 expression, the sternum mass was assessed for thyroglobulin expression and the IHC analysis revealed a strong expression of thyroglobulin (Fig. 2H). The final pathological diagnosis was metastatic columnar cell-variant PTC, which is a very rare variant [3].


Solitary bone and brain metastasis in a patient with papillary thyroid carcinoma mimicking cavernous angioma
Microscopic findings of the brain and sternum tumor masses. (A) Low-power view of the resected right frontal mass showing a cystic and solid mass with hemorrhage (H&E, ×10). (B) Low-power view of the brain mass revealing the branching and complex papillary structure of the tumor cells (H&E, ×400). (C) High-power view of the brain mass showing the columnar atypical tumor cells with increased nuclear stratification. The eosinophilic colloid-like material within the lumen is also noted (arrowhead; H&E, ×100). (D) High-power view of the biopsied sternum mass showing the presence of histological features that were identical to the brain mass, i.e., complex papillary fronds and the same cytological findings. There are also increased mitotic figures (arrows; H&E, ×400). Immunohistochemistry (IHC) for (E) cytokeratin 7, (F) thyroid transcription factor-1 (TTF-1), (G) napsin A, and (H) thyroglobulin. Unlike the classic IHC findings for metastatic adenocarcinomas from the lung (i.e., positivity for all three tissue-specific gene expression), the sternum mass expressed only cytokeratin 7 (E) and TTF-1 (F) but not napsin A (G, ×200). The IHC analysis also revealed that the sternum mass expressed thyroglobulin (H, ×200), which is consistent with a diagnosis of metastatic thyroid cancer.
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f2-kjim-2014-321: Microscopic findings of the brain and sternum tumor masses. (A) Low-power view of the resected right frontal mass showing a cystic and solid mass with hemorrhage (H&E, ×10). (B) Low-power view of the brain mass revealing the branching and complex papillary structure of the tumor cells (H&E, ×400). (C) High-power view of the brain mass showing the columnar atypical tumor cells with increased nuclear stratification. The eosinophilic colloid-like material within the lumen is also noted (arrowhead; H&E, ×100). (D) High-power view of the biopsied sternum mass showing the presence of histological features that were identical to the brain mass, i.e., complex papillary fronds and the same cytological findings. There are also increased mitotic figures (arrows; H&E, ×400). Immunohistochemistry (IHC) for (E) cytokeratin 7, (F) thyroid transcription factor-1 (TTF-1), (G) napsin A, and (H) thyroglobulin. Unlike the classic IHC findings for metastatic adenocarcinomas from the lung (i.e., positivity for all three tissue-specific gene expression), the sternum mass expressed only cytokeratin 7 (E) and TTF-1 (F) but not napsin A (G, ×200). The IHC analysis also revealed that the sternum mass expressed thyroglobulin (H, ×200), which is consistent with a diagnosis of metastatic thyroid cancer.
Mentions: A chest computed tomography (CT) scan was performed to assess the mass in the sternum and revealed a huge infiltrating tumor mass with necrosis extending into the manubrium (Fig. 1C). The patient underwent a craniotomy to remove the brain tumor and the manubrium mass was biopsied. A histological analysis of the brain mass under a low-power view revealed a cystic and solid tumor mass that was infiltrating into the brain parenchyma with hemorrhage (Fig. 2A and 2B) and a histological analysis under a high-power view revealed predominant branching papillary structures in the tumor that were composed of columnar cells with increased nuclear stratification (Fig. 2C). The sternum mass had identical histological features, i.e., the presence of complex papillary structures and equivalent cytological findings (Fig. 2D). To determine whether the sternum mass was a metastatic lesion from the lung, the mass was subjected to immunohistochemistry (IHC) analyses for cytokeratin 7, thyroid transcription factor-1 (TTF-1), and napsin A. The mass was positive for cytokeratin 7 and TTF-1 but negative for napsin A (Fig. 2E-2G). Because metastatic thyroid cancer is characterized by a papillary structure and TTF-1 expression, the sternum mass was assessed for thyroglobulin expression and the IHC analysis revealed a strong expression of thyroglobulin (Fig. 2H). The final pathological diagnosis was metastatic columnar cell-variant PTC, which is a very rare variant [3].

View Article: PubMed Central - PubMed

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

In particular, brain metastasis is very rare and is reported in only 1% of patients with thyroid carcinoma... The final pathological diagnosis was metastatic columnar cell-variant PTC, which is a very rare variant... The present patient was diagnosed with the columnar cell variant, which is characterized by pseudostratified columnar cells and subnuclear vacuolization that resembles early secretory endometrium... Although this PTC variant is very rare and only accounts for 0.15% to 0.2% of all PTCs, it is associated with aggressive behaviors such as a propensity for extrathyroidal extension, distant metastasis, and the death of the tumor... The prevalence of TgAb in thyroid malignancy patients is 10% to 30%, which is higher than among the normal population, and a high serum TgAb titer decreases after thyroid malignancy treatment while a sustained high serum TgAb titer could reflect early relapse... The survival rate of PTC patients significantly decreases when metastasis occurs... The common symptoms of patients with thyroid carcinoma and brain metastasis include headache, nausea, motor weakness, gait disturbances, sensory deficits, visual loss, and seizures but some patients with brain metastasis do not exhibit any symptoms and are only diagnosed with brain metastasis upon a postmortem examination... Due to the low incidence of brain metastatic PTC, a universal standard treatment protocol has yet to be established... However, the current treatment of choice is typically surgical resection because the removal of a brain metastasis significantly improves survival and is an independent predictor of better outcomes... Radiosurgery should be considered for patients who are unable to undergo surgery and whole brain radiation therapy can also be used to treat multiple metastases... Although brain radiation is not associated with a survival benefit, several cases have been reported indicating a regression of brain metastasis after such therapy... The present case was an extremely rare example of brain metastasis from columnar cell-variant PTC in which the brain metastatic lesion mimicked a cavernous angioma... These findings suggest that, depending on the PTC variant, even small PTCs should be treated with caution because they can lead to brain metastasis.

No MeSH data available.


Related in: MedlinePlus