Warning: include_once(../article_type.php): failed to open stream: No such file or directory in /home/suxhorbncfos/public_html/gjo/GJO.MS.ID.555602.php on line 83
Warning: include_once(): Failed opening '../article_type.php' for inclusion (include_path='.:/opt/alt/php56/usr/share/pear:/opt/alt/php56/usr/share/php') in /home/suxhorbncfos/public_html/gjo/GJO.MS.ID.555602.php on line 83
An occult Follicular Thyroid Carcinoma revealed by an Isolated Caudaequina syndrome: a Rare Presentation
Chafiki Z*, Merzouki B, Hasnaoui J, Rouadi S, Abada R, Roubal M and Mahtar M
Department of ENT; 20 Août hospital, Ibn Rochd University Hospital, Morocco
Submission: December 19, 2016; Published: January 02, 2017
*Corresponding author: Chafiki Zakaria, Hopital 20 Aout, ENT Service, CHU Ibn Rushd, Casablanca, Morocco, Email:Zakaria.firstname.lastname@example.org
How to cite this article: Chafiki Z, Merzouki B, Hasnaoui J, Rouadi S, Abada R et.al . An occult Follicular Thyroid Carcinoma revealed by an Isolated Caudaequina syndrome: a Rare Presentation. Glob J Oto 2017; 3(1): 555602 DOI: 10.19080/GJO.2017.03.555602
Background:Follicular thyroid cancer (FTC) is a well-differentiated thyroid cancer that accounts for 15-20% of all Thyroid cancers. It is more likely to manifest as a distant metastasis than PTC as it tends to spread hematogenously with bones being the second most common site of metastasis after lungs.We report an unusual case of an occult FTC revealed by caudaequinasyndrome secondary to spinal metastasis as a first clinical manifestation of the disease.
Results:An 81 year old female presented to neurosurgery clinic with paraplegia and sphincteric dysfunction.Dorso-lumbo-sacral CT and MR imagingshowed an ill-limited expansilelytic tissue processinvolving L4, L5 and S1 vertebrae,extendinginto spinal canal with an invasion of caudaequina nerves. Biopsy’sresults wereconsistent with spinal metastasis of FTC.The patient was referred to the ENT department where a total thyroidectomy was carried out, and the primary tumor pathology was consistent with FTC.
Conclusion:Caudaequinasyndrome secondary to spinal metastasis is very uncommon as an initial finding of FTC without any previous symptoms of malignancy.Early diagnosis and prompt management of the primary carcinoma and the metastatic lesion may extend long‑term survival and allow a favorable prognosis. Thyroidectomy with radioactive iodine ablation increases the 10-year survival in patients with metastatic disease.
Thyroid cancer is rare and accounts for roughly 1% of all new malignant disease with a male to female ratio of 1:3 . Follicular thyroid cancer (FTC) is a well-differentiated thyroid cancer that accounts for 15-20% of cases [2,3]. Thyroid cancer initially presents with clinical symptoms due to metastatic lesions in less than 5% of cases . FTC metastasizes to bone in 2-13% of patients with the spine being the most common bony metastatic site . Spinal metastases most commonly involve the vertebral body and can lead to pathologic compression fractures and instability . Caudaequina syndrome due to a spinal metastasis as a first presentation is extremely rare. We report an unusual case of an occult FTC revealed while a workup of caudaequinasyndrome was carried out to find out the lesion in question.
An 81 year old female with no remarkable medical history, was referred to the ENT consultation for total thyroidectomy. Her
medical history goes back to 1 year ago with a chronic lumbar pain recalcitrant to pain killers. The course was marked by the onset of weakness and heaviness of both legs along with gradual difficulties on walking for the last 5 months. A total functional impotence of the lower limbs was established 2 months after with constipation and urinary retention. This symptomatology prompted the patient to consult in Neurosurgeryclinic. Physical examination found paraplegia, numbness, tingling of saddle region andboth legs, and distal hypoesthesia. Due to the neurological status, an urgentdorso-lumbar CT scan was performed, revealing an ill-limited (65x74mm) lytic tissue process centered on the last 3 lumbar vertebrae, extending into
spinal cannel, homogeneously enhanced aftercontrast material
injection, extended over 81mm in height (Figures 1 & 2).
Lombo-sacral MRI showed a 90x52x77mm advanced lesion
process, involving L4, L5 and S1 vertebrae, causing a cuneiform
compression of L5, with a broad pre and paravertebral soft
tissue invasion most importantly of the posterior arches of L4,
L5 and S1 vertebrae, extension into spinal canal with an invasion
of the roots of caudaequina nerves and infiltration of sacred
holes with a corporal metastasis of L3 (Figures 3-5). A US-guided
percutaneous Tru-cut biopsy of the tumor was performed. The
histopathological examination revealed thyroid follicles filled
with colloid material. The follicle cells were generally cuboid
and round-oval shaped with hyperchromatic nuclei showing
mild pleomorphism which was consistent with metastatic FTC.
Regarding these results, the patient was referred to the
ENT department where a Thyroid US was considered, which
demonstrated a small spongiform 9x8x4xmm TI-RADS-2 nodule
in the right lobe of the thyroid gland, and awell limited with a
calcified wall, 12x12x9mm, TI-RADS-4A left basi-lobar nodule,
avascular on doppler examination. Total thyroidectomy was
performed, and the primary tumor pathology was reported to
be FTC. Thyroid function tests were within the normal limits.
Staging including chest and abdominopelvic CT was performed
with no evidence of others distant metastases. The patient
was then put on radioiodine therapy pending a neurosurgical
Thyroid cancer is a rare entity that accounts for roughly
1% of all new malignant disease with a male to female ratio
of 1:3  broadly divided into two categories. Differentiated
thyroid cancer (DTC) accounts for most malignancies 90% of all
thyroid cancers. DTC is also categorized into papillary thyroid
cancer (PTC) which represents 70-75% of all cases, where
follicular thyroid cancer (FTC) is only seen in 15-20% of cases.
Undifferentiated carcinomas, represented by anaplastic cancers
which account for <5% of thyroid cancers. Medullary carcinoma
of the thyroid accounts for 5-10% [2,3].
Distant metastasis of thyroid cancer is well known, although
it is present in only approximately 9 % of patients with DTC . FTC is more likely to manifest as a distant metastasis than
PTC as it tends to spread hematogenously with bones being the
second most common site of metastasis after lungs  and the
spine being the most common bony metastatic site . Distant
bone metastasis of DTC usually occurs at the late stage of the
disease with a higher incidence ranging from 7 to 20% in FTC
comparing to PTC, which has an incidence of spinal metastasis
of 1-7% . Spinal metastases from FTC most commonly involve
the vertebral body and can lead to pathologic compression
fractures and instability . The involvement of pelvis, sternum,
long bones, and ribs is also described .
FTC presents as a solitary thyroid nodule, such localized
cases are associated with favorable outcomes, with an 80-95%
overall 10-year relative survival. However, the 10-year survival
rate diminishes to about 40% when distant metastasis is present
. Caudaequina syndrome secondary to spinal metastasis is
a rare manifestation of the disease, and is a late-stage finding
of thyroid carcinoma. It is very uncommon as an initial finding
without any previous symptoms of malignancy. Only a few cases
of this latter have been reported as the initial manifestation of
FTC in the literature .
Early diagnosis of metastatic spinal disease is important
because functional outcome depends on neurologic status at
the time of presentation and also allows the research for the
primarytumor and subsequently a correct and rapid management
of the whole condition. Proye et al.  demonstrated that
follicular carcinoma is usually less life threatening, and that early
diagnosis and appropriate treatment for distant metastases
can significantly prolong the life span and improve life quality.
Shaha et al.  also reported that total thyroidectomy followed
by radioactive iodine therapy (RAI) and thyroxine suppressive
treatment extended long-term survival (10-15 years) in 44% of
patients with metastatic follicular thyroid carcinoma.
Treatment modalities available for metastatic spine tumors
include radiation therapy (RT), surgery, and chemotherapy.
The appropriate treatment for an individual patient requires a
multidisciplinary approach. The case we present here is unique
as the patient’s first clinical manifestation was a paraplegia, and
it was caused by a spinal metastasis with caudaequina nerves
compression from an undiagnosed follicular thyroid cancer
which makes thyroid carcinoma a differential diagnosis of every
patient with neurological compression signs.
Through this case report, we wanted to emphasize that
thyroid cancer is a possibility in the differential diagnosis in patient presenting with compressive neurological signs from a
spinal mass lesion detected on imaging findings. Early diagnosis
with a thorough assessment of thyroid gland when a spinal
metastasis is suspected and prompt management of the primary
carcinoma and the metastatic lesion, sustainable maintenance
of thyroid suppression, and consideration of the patient’s age,
response to therapies, and comorbidities, may extend long-term
survival and allow a favorable prognosis. Thyroidectomy with
radioactive iodine ablation increases the 10-year survival in
patients with metastatic disease .