Multiple giant scalp metastases of a follicular thyroid carcinoma

Abstract

Background

The occurrence of skin metastases are rare events in the course of a follicular thyroid carcinoma (FTC) and usually indicate advanced tumor stages. The scalp is the most affected area of these metastases.

Case presentation

We present a case of a 76 year old Woman with multiple giant scalp metastases of a follicular carcinoma. These metastases had been resected and wounds had been closed with mesh graft. The 14-months follow up is presented.

Conclusion

We demonstrate another case with multicentric form. Because of its location and size a primary wound closure was not possible. A healing could be reached using vacuum therapy and mesh graft transplantation.

Background

The occurrence of skin metastases are rare events in the course of a follicular thyroid carcinoma (FTC) and usually indicate advanced tumor stages. The scalp is the most affected area of these metastases [1–6]. Operations are mostly performed with palliative intention. We present a case with extensive and symptomatic scalp metastases in a female patient. The tumors were resected under general anaesthesia. Mesh graft was successfully used to cover the skin defects.

Case presentation

A 76-year old female patient had the initial diagnosis of FTC 18 years ago. She had total thyroidectomy with bilateral neck dissection and multiple reoperations for recurrent tumor. Because of an irresectable local recurrence with tracheal infiltration a tracheotomy was performed two years ago. Five sets of internal radiation therapy, had been performed one year ago with a cumulative activity of 55.400 MBq¹³¹I. She was admitted to our hospital because of four intensively vascularized scalp tumors, two of them of hen's egg size (Fig. 1a, b, and 2) which showed recurrent episodes of contact bleeding during hair dressing. Computed tomography revealed multiple pulmonary, hepatic and bone metastases. Thyreoglobulin level was highly elevated (6750 ng/ml) Nevertheless the patient was in a good general condition. We performed a resection of the scalp tumors under general anesthesia. Histopathology confirmed cutaneous metastases of FTC (Fig. 3). The places of resection were primary left for granulation. After achievement of a clean granulation area using vacuum therapy (V.A.C.^®, KCI International, Amsterdam, The Netherlands) we performed a mesh graft skin transplant (Fig. 4a, b).

Figure 1

a) and b) Two scalp tumors at admission of the patient, lateral view.

Figure 2

Giant parietal scalp tumor and to additional smaller tumors, intraoperative view.

Figure 3

Operative specimen, Haematoxylin-Eosin and Thyreoglobulin staining.

Figure 4

Mesh Graft transplants. a) Retroauricular mesh graft transplant; b) Parietal mesh graft transplant.

A follow up examination fourteen months later showed a very good cosmetic result with nearly complete healing of the mesh graft transplant (Fig. 5a, b). Because the local neck tumor had continued to grow the patient was now convinced to accept external radiation therapy and was admitted to our department of radiation oncology.

Figure 5

14 months follow up. a) view from on high; b) lateral view.

Discussion

Follicular thyroid carcinomas (FTC) often spread to bones and lung [7]. The occurrence of cutaneous metastases is a rare event. Many different locations have been decribed as abdomen, back and front thigh [8], but predominantely the skin of head and neck is affected [1–6]. In a review of the literature Quinn and coworkers [1] found scalp metastases in 9 of 14 patients with cutaneous metastases of FTC. In a study of Erickson and coworkers [9] none of 5 FTC metastatic to the skin showed BRAF(V600E) mutation (T1799A).

Conclusion

We demonstrate another case with multicentric form. Because of its location and size a primary wound closure was not possible. A healing could be reached using vacuum therapy and mesh graft transplantation. The palliative long term cosmetic and functional result was excellent.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.