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Surgical management of follicular carcinoma of thyroid with spinal metastasis

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Background: Spine is the most common part of bone metastasis of follicular carcinoma and is primarily osteolytic. The primary concern with metastasis is pathologic fracture and/or spinal cord compression, which may lead to intractable pain, sensory alterations, weakness, and/or paralysis. Management is curative or palliative and includes surgery, radioiodine ablation, selective embolization, medical management. In this study, we present a retrospective analysis of five patients with follicular carcinoma of thyroid with spinal metastasis treated surgically. Methods: With the approval of the institutional review board, we retrospectively analyzed all the patients who underwent surgery for follicular carcinoma of thyroid with spinal metastasis from Jan 2011 to Jan 2015 at Sri Ramachandra Medical Centre. Patients were considered for spine surgery, when they had severe pain and/or neurological deficit, spinal instability and Tokuhashi score of at least 9. Total of 5 patients with follicular carcinoma underwent spinal surgery. Results: Three patients had improvement in KPS scores; one had no change and remaining one had lower KPS score at final follow up. Four out of the five patients (80%) had improvement in VAS pain scores. Conclusions: Even though there are no established regimens in treating spinal metastasis from follicular carcinoma of thyroid and very few reports published in this regard, curative/palliative spine surgery along with radioiodine ablation gives short to midterm remission and clinical improvement in this patient group.
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International Surgery Journal | October-December 2015 | Vol 2 | Issue 4 Page 599
International Surgery Journal
Chander A et al. Int Surg J. 2015 Nov;2(4):599-603
http://www.ijsurgery.com
pISSN 2349-3305 | eISSN 2349-2902
Research Article
Surgical management of follicular carcinoma of thyroid
with spinal metastasis
Anil Chander1, Vignesh Jayabalan1, Ganesan Ram Ganesan1*, Gauthaman
Shanmugasundaram2, Karthik Kailash Kannan1
INTRODUCTION
Differentiated thyroid cancer (DTC) account for the vast
majority (90%) of all thyroid cancers and includes
papillary (7075%) and follicular (1520%) cancers.1,2
Follicular carcinoma of thyroid is a slow growing tumour
with peak incidence in fifth decade and three times more
common in females.3 Differentiated thyroid cancer
metastasis to the lung (49%) followed by bone (25%).
Bone metastasis is commonly seen in follicular
carcinoma (7-28%) than in papillary carcinoma (1-7%).4,5
Spine is the most common part of bone metastasis of
follicular carcinoma and is primarily osteolytic. The
primary concern with metastasis is pathologic fracture
and/or spinal cord compression, which may lead to
intractable pain, sensory alterations, weakness, and/or
paralysis.6,7 Management is curative or palliative and
includes surgery, radioiodine ablation, selective
embolization, and medical management.8,9 In this study,
we present a retrospective analysis of five patients with
follicular carcinoma of thyroid with spinal metastasis
treated surgically.
ABSTRACT
Background:
Spine is the most common part of bone metastasis of follicular carcinoma and is primarily osteolytic.
The primary concern with metastasis is pathologic fracture and/or spinal cord compression, which may lead to
intractable pain, sensory alterations, weakness, and/or paralysis. Management is curative or palliative and includes
surgery, radioiodine ablation, selective embolization, medical management. In this study, we present a retrospective
analysis of five patients with follicular carcinoma of thyroid with spinal metastasis treated surgically.
Methods:
With the approval of the institutional review board, we retrospectively analyzed all the patients who
underwent surgery for follicular carcinoma of thyroid with spinal metastasis from Jan 2011 to Jan 2015 at Sri
Ramachandra Medical Centre. Patients were considered for spine surgery, when they had severe pain and/or
neurological deficit, spinal instability and Tokuhashi score of at least 9. Total of 5 patients with follicular carcinoma
underwent spinal surgery.
Results:
Three patients had improvement in KPS scores; one had no change and remaining one had lower KPS score
at final follow up. Four out of the five patients (80%) had improvement in VAS pain scores.
Conclusions:
Even though there are no established regimens in treating spinal metastasis from follicular carcinoma of
thyroid and very few reports published in this regard, curative/palliative spine surgery along with radioiodine ablation
gives short to midterm remission and clinical improvement in this patient group.
Keywords: Spinal metastasis, Thyroid carcinoma, Tokuhashi score, Radioiodine
1Department of Orthopedics, Sri Ramachandra University, Chennai, India
2Department of Surgical Oncology, Sri Ramachandra University, Chennai, India
Received: 06 August 2015
Revised: 17 August 2015
Accepted: 07 October 2015
*Correspondence:
Dr. Ganesan Ram Ganesan,
E-mail: ganesangram@yahoo.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: http://dx.doi.org/10.18203/2349-2902.isj20151086
Chander A et al. Int Surg J. 2015 Nov;2(4):599-603
International Surgery Journal | October-December 2015 | Vol 2 | Issue 4 Page 600
METHODS
With the approval of the institutional review board, we
retrospectively analysed all the patients who underwent
surgery for follicular carcinoma of thyroid with spinal
metastasis from Jan 2011 to Jan 2015 at Sri Ramachandra
Medical Centre. Patients were considered for spine
surgery, when they had severe pain and/or neurological
deficit, spinal instability and Tokuhashi score 10 of at
least 9. Total of 5 patients with follicular carcinoma
underwent spinal surgery. All the patients underwent
FNAC/biopsy for thyroid swelling and MRI evaluation of
the spine. All patients had total/subtotal thyroidectomy
with radical neck nodal dissection for the primary tumour
after cytological evaluation. Post operatively; patients
were put on thyroid and calcium replacement therapy. In
each case, tumour pathology was confirmed to be
follicular carcinoma, from both the primary lesion and
spinal metastatic lesion. Number of factors such as, age,
sex, presenting symptoms, characteristics of primary
tumour, spinal and extra spinal metastasis and co
morbidities was analysed. Type of spinal procedure
performed, use of adjuvant therapy, pre and postoperative
functional status (measured by karnofsky performance
score) 11, neurological status (measured by modified JOA
score) and pain status (using VAS scores) were assessed.
Intra operative and postoperative complications, Length
of survival, Recurrence and repeat surgery for recurrence
were also assessed.
The demographic details and clinical presentation of all
the five patients were described in Table 1. The mean age
at the time of surgery was 63.4 years. One patient was a
male (20%) and four patients (80%) presented with neck
swelling with back/neck pain. Three of the five patients
(60%) presented with neurological deficits. One patient
presented without neck swelling and with isolated back
pain (lumbar spine involvement) and right lower limb
weakness. Thyroid swelling was only diagnosed on
physical examination. One patient had dorsal spine
involvement with motor weakness of both lower limbs
and was wheelchair bound. One patient had both cervical
and dorsal involvement with right upper limb weakness.
Two patients had neck swelling along with neck and back
pain with cervical and lumbar spine involvement
respectively, without neurological deficits. Two of the
five patients had skull metastasis with no intra cranial
extension. The surgical procedure and clinical outcome
for each patient was given in Table 2.
RESULTS
Of the three patients with neurological deficits, 2 patients
had improvement of JOA scores. One patient with
paraparesis had deterioration and developed complete
weakness. Three patients had improvement in KPS
scores, one had no change and remaining one had lower
KPS score at final follow up. Four out of the five patients
(80%) had improvement in VAS pain scores. Four
patients underwent radioactive iodine therapy after
surgery. Two patients in our series expired and the mean
survival after primary surgical procedure is 3.06 years
including the three patients who are alive. No implant or
surgery related complications were noted. One patient
had recurrence of thyroid and vertebral disease. The
patient did not undergo revision surgery.
Table 1: Demographic details of patients.
No
sex
Primary
tumour
Extra
spinal
metastasis
Presentation
Spinal level
1
F
T1 N0 M1
Nil
Low back pain, right lower limb weakness
L3
2
M
T4N1M1
Skull
Neck and skull swelling, neck and upper back pain,
right upper limb weakness
C5, D4
3
F
T3N1M1
Nil
Neck swelling, skull swelling, upper back pain,
paraparesis
D7, D8
4
F
T2N0M1
Nil
Neck swelling, neck pain
L2
5
F
T2N1M1
skull
Neck swelling, upper back pain
C6
DISCUSSION
Spinal metastasis in thyroid carcinoma indicates
advanced disease and causes significant morbidity12; they
have a favourable prognosis compared to metastatic
disease from other tumours.13,14 Since tumour invasion
compromises structural integrity of spine, treatment of
spinal metastasis should help preserve its anatomy,
thereby reducing pain and neurological complications.
Radioiodine therapy is the mainstay of treatment of
thyroid carcinoma and its metastasis.15,16 Studies have
shown that, radioiodine ablation reduces pain scores and
improve functional outcome in metastatic thyroid
disease.17 Radioiodine absorption is an important
prognostic factor, and patients with avid uptake should
receive radioiodine therapy.18
In our study, four patients had radioiodine ablation,
initiated 1 month after primary surgery and was
Chander A et al. Int Surg J. 2015 Nov;2(4):599-603
International Surgery Journal | October-December 2015 | Vol 2 | Issue 4 Page 601
associated with clinical and improvement in most
patients. Selective embolization therapy offers rapid but
transient symptomatic therapy and has synergistic benefit
when used along with radioiodine ablation but is rarely
curative.17,19 It also would help reduce intra operative
blood loss when done pre operatively, though none of our
patients had selective embolization.20
Table 2: Surgical procedure and clinical outcomes.
No
Surgery
Clinical outcome
Recurrence
Survival after
primary surgical
procedure (Yrs)
1
Anterior corpectomy pf L3
through anterolateral
retroperitoneal approach with
fusion of L2-L4
Improved lower limb mJAO
score (3 to 6), VAS pain score
(7 to 2) and Karnofsky score(50
to 80)
nil
5.1
2
Posterior spinal stabilization
cervical and dorsal spine followed
by anterior corpectomy of C5 with
fusion of C4-C6
Improved upper limb mJAO
score (2 to 4), and VAS pain
score (9 to 3), no change in
Karnofsky score
Recurrence of
primary and
spinal lesions.
1.8
(expired)
3
Posterior spinal decompression of
D7 and D8 with fusion of D6-D9
Loss of sphincter control,
decreased lower limb mJAO
score (2 to 0), and karnofsky
score (40 to 20), no change in
VAS pain score of 8
nil
1.2
(expired)
4
Percutaneous posterior
stabilization from L2-L4 with
vertebroplasty of L3
Resumed ambulation
immediately, improved
karnofsky and VAS pain scores
(8 to 2)
nil
4.4
5
Anterior corpectomy of C6 with
fusion of C5-C7
Resumed ambulation
immediately, improved
karnofsky and VAS pain scores
(9 to 2)
nil
2.8
Figure 1: Intra op pictures thyroid.
Figure 2: Anterior corpectomy with fusion implant in
situ.
Figure 3: C arm picture showing both anterior and
posterior implants.
Figure 4: MRI picture of metastasis.
Chander A et al. Int Surg J. 2015 Nov;2(4):599-603
International Surgery Journal | October-December 2015 | Vol 2 | Issue 4 Page 602
Figure 5: Percutaneous stabilization with
vertebroplasty lateral view.
Figure 6: Post op AP view.
Quan et al suggests that surgery is indicated for patients
with intractable pain, cord compression, neurological
deficit or cervical instability.13 Cervical metastasis can
produce severe pain and neurological deficits due to
instability and pathological fracture, affecting the
activities of daily living.9 Management includes anterior
reconstruction and stabilisation, which is done in two of
our patients (patients 2 and 5).21 Demura et al suggested
that total en bloc spondylectomy (TES) might provide
better local control of thyroid cancer spinal metastasis,
compared with debulking surgery and improve survival
rates and decrease recurrence.22 One of our patients who
had recurrence (patient 2) underwent of debulking
cervical corpectomy (Figure 1, 2, 3) rather than a radical
spondylectomy due to his age, but revision surgery was
deferred due to medical issues.
There were few reports regarding initial presentation of a
patient with distant metastasis leading to the diagnosis of
follicular thyroid carcinoma.26,27 Metastasis of thyroid
carcinoma presenting as distant spinal cord compression
is extremely rare. We had a patient in our series that had
similar presentation (patient 1). Patient had complete
remission as well as improvement of neurological deficit
after surgery. Although percutaneous
vertebroplasty/kyphoplasty has been successfully used in
osteolytic metastatic lesions, complications in this group
are higher compared to its use in osteoporotic and
myeloma patients.23 There is an increased risk of
symptomatic leakage of polymethylmethacrylate into the
spinal canal and neural foramina in metastatic lesions.24
Fourney et al in one of the largest series of cement
augmentation for metastatic spinal disease found that
significant reduction of pain was seen in 84% of
procedures with asymptomatic leakage of cement seen in
less than 10% of levels operated.25 They concluded that,
percutaneous cement augmentation provided
considerable, lasting relief from pain with a
corresponding decrease in the narcotic requirements in
the patients treated. One of our patients (Patient 4- Figure
4, 5, 6) who underwent percutaneous stabilisation and
vertebroplasty had significant clinical improvement,
although there was minimal cement extravasation.
CONCLUSION
Even though there are no established regimens in treating
spinal metastasis from follicular carcinoma of thyroid and
very few reports published in this regard,
curative/palliative spine surgery along with radioiodine
ablation gives short to midterm remission and clinical
improvement in this patient group. Further studies with
larger sample size and longer follow up are needed to
formulate regimens in managing these patients.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: Not required
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Cite this article as: Chander A, Jayabalan V, Ganesan
GR, Shanmugasundaram G, Kannan KK. Surgical
management of follicular carcinoma of thyroid with
spinal metastasis. Int Surg J 2015;2:599-603.
... This characteristic is probably due to that FTC usually spreads via blood, however, papillary type prefers lymphatic route for dissemination (2). There is bone involvement in 7-12% of the cases with FTC (3), and the most frequently involved region is spinal column (4). However, most of the spinal metastases occur in the late stage of the disease, and presentation of the disease with spinal metastasis is extremely rare during initial diagnosis. ...
... were not introduced into the study because there was not adequate data in the articles (5,6). The characteristics of total 27 cases including our one were evaluated (1,2,4,(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24) ( Outcome was accepted as good if the patient was neurologically normal or could mobilize without external support, and it was accepted as poor if the patient could not mobilize without support or was dead. ...
... [1] FTC has a higher rate of bony metastasis -there is bone involvement in 7%-12% of the cases with FTC, [2] and the most frequently involved region is spinal column. [3] However, spinal metastasis as the initial presentation of FTC is rare. [4] Treatment protocol is usually focused on the establishment of histopathological diagnosis, stabilization, and decompression of neural elements followed by radiotherapy/ radioactive iodine. ...
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Vertebral metastasis as initial presentation for follicular thyroid carcinomas is rare and requires proactive management to minimize disability considering a good associated long-term survival. A review of literature in 2019 noted 27 such cases – most of the patients had solitary vertebral metastases or multiple adjacent level involvement. Surgical treatment in such cases is usually based on the extent of fractures or neural compression in the form of decompression, debulking, or total en bloc resection and biopsy. Pedicle screw placement has been studied in several large studies, and clinically relevant misplacement is rare and revision may be required. We present a case where a patient with a pathological fracture previously evaluated and operated came to us with radiculopathy caused by metastatic mass lesion and a misplaced pedicle screw.
... tively [15]. Sellin., et al. [16] in his study of factors affecting survival in 43 consecutive patients after surgery for spinal metastases from thyroid carcinoma found that preoperative embolization was significantly associated with fewer complications. ...
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Distant metastases from differentiated thyroid carcinoma occur in up to 20% of cases and represent the most frequent cause of thyroid cancer-related death. Metastatic disease to the spine has the potential to cause severe morbidity, including pain, neurological deficit, and paraplegia. We present a case series of eight consecutive patients with symptomatic spinal metastases due to thyroid carcinoma treated by our multidisciplinary team consisting of spinal surgeons, oncologists, and radiologists, with management of each case determined by our surgical algorithm. Four patients underwent surgical decompression and stabilization for spinal metastases causing instability, spinal cord compression, neurological deficit, or intractable pain. Three patients underwent vertebroplasty for focal mechanical pain due to osteolytic metastases in the absence of significant spinal cord compression or spinal instability; one of these patients required subsequent surgical decompression for spinal cord compression. One patient was nonoperatively treated. All patients underwent total thyroidectomy for the primary cancer and adjuvant radioiodine-131 treatment. The only patient with poorly differentiated thyroid cancer, which was refractory to radioiodine-131 died at 6 months after vertebroplasty procedures for symptomatic spinal metastases. One patient with medullary thyroid carcinoma died at 18 months after vertebroplasty. All remaining six patients who had well-differentiated papillary or follicular thyroid carcinoma were alive at an average of 50 months (range: 17-96 months) after diagnosis and treatment of symptomatic spinal metastases and were ambulant, independent, and able to perform activities of daily living and had no significant pain or neurologic symptoms. The potential for long-term survival of several years following development of spinal metastases should be considered during the counseling and decision-making process for patients with thyroid cancer.
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Thyroid carcinoma generally has a favorable prognosis, and patients rarely present with distant metastases. Authors of several studies have proposed piecemeal resection for spinal metastases in thyroid carcinoma; however, few have analyzed the impact of local curative surgery such as total en bloc spondylectomy (TES) for thyroid carcinoma. The purposes of the present study are to determine the strategy of surgical treatment for spinal metastases of thyroid carcinoma and to evaluate the surgical results of and the prognosis associated with TES. Twenty-four cases of spinal metastases were retrospectively reviewed. The patients included 16 women and 8 men, with a mean age of 60.7 years. Histological examination showed follicular carcinoma in 15 cases, papillary carcinoma in 8, and medullary carcinoma in 1. Total en bloc spondylectomy was performed in 10 cases; debulking surgery, such as piecemeal excision or eggshell curettage, was performed in 14. The average follow-up time was 55 months (12-180 months). Four patients had no evidence of disease, 8 were alive with the disease, and 12 had died of the disease. The overall survival rate from the time of surgery was 74% at 5 years. Patients with visceral metastases had a significant, higher risk of death. The survival rate of patients following TES was 90% at 5 years, which was higher than the rate in patients who underwent debulking surgery (63%). However, no significant difference was observed between the 2 types of surgery. There was a local recurrence after debulking surgery in 8 (57%) of 14 cases. Because of the recurrences, reoperation was required after a mean of 41 months. In contrast, there was a local recurrence after TES in only 1 (10%) of 10 cases. The difference between debulking surgery and TES regarding local recurrence was statistically significant. Total en bloc spondylectomy with enough of a margin provided favorable local control of spinal metastases of thyroid carcinoma during a patient's lifetime.
Article
Selective embolization therapy (SET) has been employed to treat a number of malignant tumors, but experience with its use in metastatic epithelial thyroid carcinoma (ETC) is limited. Here we report our experience with the effect of SET on symptoms and serum thyroglobulin (Tg) in patients with bone metastases from ETC. This was a retrospective study of 13 patients with bone metastases from ETC who underwent 65 embolizations for bone metastases in 43 sessions. In the treated patients, symptoms considered related to bone metastases were compared before and about 4-7 weeks after the embolization session. Embolization sessions were excluded for analysis if concomitant therapy had taken place within 4-7 weeks before and/or after the session. Serum Tg concentrations were employed as an index of tumor debulking by SET. We attempted to estimate the influence of SET on survival time in patients with disseminated ETC who did, and an historical control group of patients with disseminated ETC who did not receive SET. After exclusion of 12 (of which 3 sessions failed) out of 43 sessions, clinical symptoms, such as pain, and neurological symptoms decreased after 17, increased after 6, and did not change after 8 procedures. In 43 sessions, 20 of which were excluded (including the 3 sessions that failed), serum Tg decreased after 14 and increased after 9. The median standardized survival time of the group that received embolization was not significantly different to that of the group that did not receive embolization. Embolization therapy does not appear to improve life expectancy, but in selected patients can achieve palliation of pain, prevent neurological damage, reduce tumor burden, and give devascularization of the tumor before surgery.
Article
The prognosis of metastatic thyroid carcinoma is dependent on the age of the patient, the histologic characteristics of the neoplasm, and the site of metastasis. A more favorable prognosis is found in patients less than 40 years old with follicular carcinoma and without any bony metastases. Metastatic thyroid carcinoma presenting as distal spinal cord compression is extremely rare. We report one such case and review the literature. As reported in the literature, the combination of decompressive laminectomy followed by total thyroidectomy and radioactive iodine therapy has proved to be effective in the treatment of patients with thyroid carcinoma metastatic to the distal vertebral bodies.