Case and Research Letters
Cutaneous metastases on the head and neck from a papillary thyroid carcinoma, follicular variant
Metástasis cutáneas craneocervicales de un carcinoma papilar de tiroides variedad folicular
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Metástasis pulmonares, conglomerado adenopático mediastínico, así como una masa de tejidos blandos en el costado derecho. b-d)<span class="elsevierStyleHsp" style=""></span>Lesiones nodulares rojo-violáceas en la región frontal, en el cuero cabelludo y en la proximidad a la cicatriz de tiroidectomía. Estructuras vasculares gruesas y ramificadas a la dermatoscopia de una lesión nodular del cuero cabelludo.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Márquez García, L. Ferrándiz Pulido, J.J. Ríos-Martín, F.M. Camacho Martínez" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Márquez García" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Ferrándiz Pulido" ] 2 => array:2 [ "nombre" => "J.J." "apellidos" => "Ríos-Martín" ] 3 => array:2 [ "nombre" => "F.M." 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A, At the first visit. B, 2 months later, with self-resolution. Histological appearance of the biopsies corresponding to the clinical images immediately above, with partial reduction of the tumor infiltrate in the second of them. C, Hematoxylin-eosin (H-E), x40. D, H-E, x400.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.R. García de la Fuente, F. Vilardell-Villellas, R.M. Martí-Laborda, J.M. Casanova-Seuma" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M.R." "apellidos" => "García de la Fuente" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Vilardell-Villellas" ] 2 => array:2 [ "nombre" => "R.M." "apellidos" => "Martí-Laborda" ] 3 => array:2 [ "nombre" => "J.M." 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Márquez García, L. Ferrándiz Pulido, J.J. Ríos-Martín, F.M. Camacho Martínez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Márquez García" "email" => array:1 [ 0 => "ana_marquez54@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "L." "apellidos" => "Ferrándiz Pulido" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J.J." "apellidos" => "Ríos-Martín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "F.M." "apellidos" => "Camacho Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Dermatología, Hospital Universitario Virgen Macarena, Sevilla, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Anatomía Patológica, Hospital Virgen Macarena, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Metástasis cutáneas craneocervicales de un carcinoma papilar de tiroides variedad folicular" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1100 "Ancho" => 1443 "Tamanyo" => 534529 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Histologic lesion of the scalp. Epithelial nodules surrounded by fibrosis and lymphatic invasion of tumor cells (hematoxylin-eosin [H-E], ×40). B, Follicular structures lined by round cells with clear cytoplasm and pleomorphic nuclei (H-E, ×100). C, TTF-1 positive (immunohistochemical staining). D, Galectine-3 positive (immunohistochemical staining).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Skin metastases in thyroid cancer are rare, and when they do occur most are associated with follicular carcinoma. They tend to appear in well-vascularized regions such as the scalp, and without predilection for sex.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 58-year-old woman with no history of interest presented with a follicular variant of stage <span class="elsevierStyleSmallCaps">iv</span> papillary thyroid carcinoma, with extrathyroidal pulmonary and bone involvement. After total thyroidectomy, she received 4 doses of radioactive iodine and hormonal suppression with levothyroxine. Despite treatment every 6 months with I<span class="elsevierStyleSup">131</span>, response was limited and metastatic uptake persisted.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient underwent close clinical and imaging follow-up. Two years after surgery, a cervical mass was detected and this was attributed to relapse of papillary thyroid carcinoma. It was decided to excise the lesion and subsequently treat with I<span class="elsevierStyleSup">131</span>. The patient remained stable, but after 7 months, constitutional symptoms occurred, along with dyspnea and pain in the right side as a result of the presence of multiple bilateral pulmonary nodular metastases, as well as a mediastinal conglomerate lymph nodal mass in both pulmonary hila (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a). The physical examination revealed indurated nodular lesions that were mildly itchy with a vascular appearance on the scalp in the frontal region and close to the thyroidectomy scar (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b-d). They had appeared 6 months earlier and showed thick vessels with a mottled appearance on dermoscopic examination (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>c), giving rise to suspicion of metastatic lesions. Biopsy of one of the elements of the scalp revealed a well-delimited intradermal neoplasm, made up of epithelial nodules surrounded by bands of fibrotic tissue and tumoral invasion of superficial skin lymph nodes (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>a). Neoplastic cells that formed follicular structures had a polygonal form with a clear cytoplasm and pleomorphic nuclei, some of which had a ground-glass appearance (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>b).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Immunohistochemical study was positive for TTF-1 (thyroid transcription factor 1) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>c) and galectin-3 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>d) but negative for thyroglobulin (Tg).</p><p id="par0025" class="elsevierStylePara elsevierViewall">With these findings, cutaneous metastasis of follicular variant of papillary thyroid carcinoma was diagnosed.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient received another dose of radioactive iodine, but some months later neurologic symptoms occurred due to bilateral supratentorial and infratentorial brain metastases and osteolytic images were observed in the cranial vault. Given this disease progression, sorafenib was administered in combination with zoledronic acid in the compassionate use setting, but the patient finally died 6 months later.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Cutaneous metastases of thyroid carcinomas are rare (occurring in less than 1% of primary thyroid carcinomas). When they do occur, they present as slow-growing erythematous lesions, purpuric plaques, or soft and mildly itchy erythematous nodules, which may become ulcerated. In 70% of the cases, these lesions are found on the scalp and the rest of the face or neck, due to the extensive vascularization of the dermis at these sites.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1–3</span></a> The condition affects men and women equally and is most frequently associated with follicular thyroid carcinoma (42%) even though papillary carcinoma is the most frequent primary carcinoma (50%-89%).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> Metastases may present as the first manifestation of an occult papillary carcinoma (worse prognosis) or appear in advanced tumors, as was the case with our patient.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The presence of vascular structures in dermoscopy of a nodular lesion in a patient with a history of cancer should require differential diagnosis with cutaneous metastases.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> The histological and immunohistochemical characteristics with TTF-1 in the present case, in the clinical context of the patient, suggested diagnosis of metastasis of thyroid carcinoma, although the possibility of a pulmonary origin could not be ruled out given the absence of staining with Tg (characteristically positive). Immunostaining with galectin-3 enabled definitive diagnosis of metastasis of thyroid origin. Galectin plays an important role in cell adhesion and in the interaction between matrix and cells. In addition, it is the primary potential tumor marker for local and distant metastases, particularly in cases of papillary thyroid carcinoma.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Anatomopathologic diagnosis of metastases of a well-differentiated follicular carcinoma of the thyroid glands is relatively simple given the presence of follicles with colloid material. However, in cases of the follicular variant of papillary thyroid carcinoma, papillary architecture is usually absent and the nuclear characteristics are not always present, and so immunohistochemical techniques are necessary using Tg (sensitivity of close to 100% in follicular cancer, 95% in papillary cancer, and lower in poorly-differentiated carcinomas), TTF-1, RET/PTC, HBME-1, CK19, CD10, and galectin-3.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,7,8</span></a> The <span class="elsevierStyleItalic">BRAFV600E</span> mutation has been identified in cutaneous metastases of papillary thyroid carcinoma and its presence is associated with worse prognosis although new chemotherapeutic agents can be used. Mean survival is 19 months after diagnosis of the cutaneous metastases in patients with advanced disease.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Differential diagnosis should be considered with primary apocrine tumors and other metastatic lesions, with immunohistochemical study with TTF-1, Tg, and galectin-3 being particularly useful.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion, despite the rarity of cutaneous metastases of thyroid carcinoma, we should be aware of this possibility in the differential diagnosis of cutaneous metastases, given that diagnosis and early treatment may improve prognosis.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Márquez García A, Ferrándiz Pulido L, Ríos-Martín JJ, Camacho Martínez FM. Metástasis cutáneas craneocervicales de un carcinoma papilar de tiroides variedad folicular. Actas Dermosifiliogr. 2016;107:86–88.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1250 "Ancho" => 1513 "Tamanyo" => 379655 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Computed tomography of the chest. Pulmonary metastases, mediastinal conglomerate mass of lymph nodes, as well as a mass of soft tissues on the right side. B-D, Red-violaceous lesions in the frontal region, the scalp, and in the proximity of the thyroidectomy scar. Thick, branched vascular structures in dermoscopy of a nodular lesion on the scalp.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1100 "Ancho" => 1443 "Tamanyo" => 534529 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Histologic lesion of the scalp. Epithelial nodules surrounded by fibrosis and lymphatic invasion of tumor cells (hematoxylin-eosin [H-E], ×40). B, Follicular structures lined by round cells with clear cytoplasm and pleomorphic nuclei (H-E, ×100). C, TTF-1 positive (immunohistochemical staining). 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 9 | 16 |
| 2024 October | 145 | 39 | 184 |
| 2024 September | 192 | 28 | 220 |
| 2024 August | 190 | 51 | 241 |
| 2024 July | 211 | 37 | 248 |
| 2024 June | 185 | 37 | 222 |
| 2024 May | 159 | 36 | 195 |
| 2024 April | 114 | 30 | 144 |
| 2024 March | 193 | 29 | 222 |
| 2024 February | 151 | 31 | 182 |
| 2024 January | 153 | 36 | 189 |
| 2023 December | 174 | 25 | 199 |
| 2023 November | 223 | 29 | 252 |
| 2023 October | 205 | 30 | 235 |
| 2023 September | 158 | 28 | 186 |
| 2023 August | 160 | 17 | 177 |
| 2023 July | 164 | 34 | 198 |
| 2023 June | 141 | 24 | 165 |
| 2023 May | 188 | 25 | 213 |
| 2023 April | 184 | 22 | 206 |
| 2023 March | 144 | 27 | 171 |
| 2023 February | 167 | 22 | 189 |
| 2023 January | 248 | 28 | 276 |
| 2022 December | 165 | 30 | 195 |
| 2022 November | 113 | 22 | 135 |
| 2022 October | 116 | 17 | 133 |
| 2022 September | 117 | 33 | 150 |
| 2022 August | 68 | 30 | 98 |
| 2022 July | 51 | 26 | 77 |
| 2022 June | 21 | 28 | 49 |
| 2022 May | 189 | 41 | 230 |
| 2022 April | 253 | 39 | 292 |
| 2022 March | 230 | 55 | 285 |
| 2022 February | 293 | 37 | 330 |
| 2022 January | 387 | 43 | 430 |
| 2021 December | 285 | 41 | 326 |
| 2021 November | 142 | 49 | 191 |
| 2021 October | 151 | 46 | 197 |
| 2021 September | 99 | 41 | 140 |
| 2021 August | 142 | 26 | 168 |
| 2021 July | 116 | 20 | 136 |
| 2021 June | 93 | 31 | 124 |
| 2021 May | 134 | 33 | 167 |
| 2021 April | 143 | 54 | 197 |
| 2021 March | 101 | 34 | 135 |
| 2021 February | 72 | 31 | 103 |
| 2021 January | 66 | 19 | 85 |
| 2020 December | 52 | 23 | 75 |
| 2020 November | 29 | 25 | 54 |
| 2020 October | 32 | 14 | 46 |
| 2020 September | 32 | 12 | 44 |
| 2020 August | 35 | 18 | 53 |
| 2020 July | 30 | 18 | 48 |
| 2020 June | 36 | 31 | 67 |
| 2020 May | 31 | 18 | 49 |
| 2020 April | 36 | 19 | 55 |
| 2020 March | 23 | 16 | 39 |
| 2020 February | 6 | 2 | 8 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 2 | 10 |
| 2019 November | 4 | 1 | 5 |
| 2019 October | 0 | 2 | 2 |
| 2019 September | 8 | 2 | 10 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 1 | 5 |
| 2019 May | 6 | 0 | 6 |
| 2019 April | 2 | 1 | 3 |
| 2019 March | 2 | 4 | 6 |
| 2019 February | 4 | 0 | 4 |
| 2018 December | 3 | 0 | 3 |
| 2018 November | 1 | 0 | 1 |
| 2018 October | 5 | 0 | 5 |
| 2018 September | 4 | 0 | 4 |
| 2018 April | 0 | 4 | 4 |
| 2018 February | 40 | 8 | 48 |
| 2018 January | 49 | 6 | 55 |
| 2017 December | 64 | 6 | 70 |
| 2017 November | 53 | 6 | 59 |
| 2017 October | 36 | 11 | 47 |
| 2017 September | 32 | 18 | 50 |
| 2017 August | 32 | 32 | 64 |
| 2017 July | 25 | 13 | 38 |
| 2017 June | 30 | 45 | 75 |
| 2017 May | 25 | 15 | 40 |
| 2017 April | 25 | 13 | 38 |
| 2017 March | 15 | 35 | 50 |
| 2017 February | 13 | 10 | 23 |
| 2017 January | 19 | 9 | 28 |
| 2016 December | 31 | 9 | 40 |
| 2016 November | 33 | 25 | 58 |
| 2016 October | 19 | 25 | 44 |
| 2016 September | 0 | 12 | 12 |
| 2016 August | 0 | 3 | 3 |
| 2016 July | 0 | 3 | 3 |
| 2016 June | 0 | 1 | 1 |
| 2016 May | 0 | 4 | 4 |
| 2016 April | 0 | 1 | 1 |
| 2016 March | 0 | 2 | 2 |
| 2016 February | 0 | 4 | 4 |
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