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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 9 | 9 | 18 |
| 2024 Octubre | 145 | 39 | 184 |
| 2024 Septiembre | 192 | 28 | 220 |
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| 2024 Enero | 153 | 36 | 189 |
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| 2023 Noviembre | 223 | 29 | 252 |
| 2023 Octubre | 205 | 30 | 235 |
| 2023 Septiembre | 158 | 28 | 186 |
| 2023 Agosto | 160 | 17 | 177 |
| 2023 Julio | 164 | 34 | 198 |
| 2023 Junio | 141 | 24 | 165 |
| 2023 Mayo | 188 | 25 | 213 |
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| 2023 Marzo | 144 | 27 | 171 |
| 2023 Febrero | 167 | 22 | 189 |
| 2023 Enero | 248 | 28 | 276 |
| 2022 Diciembre | 165 | 30 | 195 |
| 2022 Noviembre | 113 | 22 | 135 |
| 2022 Octubre | 116 | 17 | 133 |
| 2022 Septiembre | 117 | 33 | 150 |
| 2022 Agosto | 68 | 30 | 98 |
| 2022 Julio | 51 | 26 | 77 |
| 2022 Junio | 21 | 28 | 49 |
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| 2022 Abril | 253 | 39 | 292 |
| 2022 Marzo | 230 | 55 | 285 |
| 2022 Febrero | 293 | 37 | 330 |
| 2022 Enero | 387 | 43 | 430 |
| 2021 Diciembre | 285 | 41 | 326 |
| 2021 Noviembre | 142 | 49 | 191 |
| 2021 Octubre | 151 | 46 | 197 |
| 2021 Septiembre | 99 | 41 | 140 |
| 2021 Agosto | 142 | 26 | 168 |
| 2021 Julio | 116 | 20 | 136 |
| 2021 Junio | 93 | 31 | 124 |
| 2021 Mayo | 134 | 33 | 167 |
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| 2020 Noviembre | 29 | 25 | 54 |
| 2020 Octubre | 32 | 14 | 46 |
| 2020 Septiembre | 32 | 12 | 44 |
| 2020 Agosto | 35 | 18 | 53 |
| 2020 Julio | 30 | 18 | 48 |
| 2020 Junio | 36 | 31 | 67 |
| 2020 Mayo | 31 | 18 | 49 |
| 2020 Abril | 36 | 19 | 55 |
| 2020 Marzo | 23 | 16 | 39 |
| 2020 Febrero | 6 | 2 | 8 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 8 | 2 | 10 |
| 2019 Noviembre | 4 | 1 | 5 |
| 2019 Octubre | 0 | 2 | 2 |
| 2019 Septiembre | 8 | 2 | 10 |
| 2019 Agosto | 4 | 0 | 4 |
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| 2019 Junio | 4 | 1 | 5 |
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| 2019 Febrero | 4 | 0 | 4 |
| 2018 Diciembre | 3 | 0 | 3 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Octubre | 5 | 0 | 5 |
| 2018 Septiembre | 4 | 0 | 4 |
| 2018 Abril | 0 | 4 | 4 |
| 2018 Febrero | 40 | 8 | 48 |
| 2018 Enero | 49 | 6 | 55 |
| 2017 Diciembre | 64 | 6 | 70 |
| 2017 Noviembre | 53 | 6 | 59 |
| 2017 Octubre | 36 | 11 | 47 |
| 2017 Septiembre | 32 | 18 | 50 |
| 2017 Agosto | 32 | 32 | 64 |
| 2017 Julio | 25 | 13 | 38 |
| 2017 Junio | 30 | 45 | 75 |
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| 2017 Marzo | 15 | 35 | 50 |
| 2017 Febrero | 13 | 10 | 23 |
| 2017 Enero | 19 | 9 | 28 |
| 2016 Diciembre | 31 | 9 | 40 |
| 2016 Noviembre | 33 | 25 | 58 |
| 2016 Octubre | 19 | 25 | 44 |
| 2016 Septiembre | 0 | 12 | 12 |
| 2016 Agosto | 0 | 3 | 3 |
| 2016 Julio | 0 | 3 | 3 |
| 2016 Junio | 0 | 1 | 1 |
| 2016 Mayo | 0 | 4 | 4 |
| 2016 Abril | 0 | 1 | 1 |
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| 2016 Febrero | 0 | 4 | 4 |
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