https://imcjms.com/public Ibrahim Medical College Journal of Medical Science https://imcjms.com/public/registration/journal_full_text/99 Tue, 04 Oct 2016 11:48:46 +0000 Abstract Ibrahim Med. Coll. J. 2007; 1(2): 25-27 Address for correspondence: Prof. Md. Tahminur Rahman, Department of Pathology, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000 Introduction   A 66 year old Malay man presented with an occipito-parietal swelling for 2 years with a sudden rapid enlargement in the last one year. He had no constitutional symptoms before but for last 2 months he complained of dizziness, tinnitus, loss of weight and loss of appetite. On examination, the swelling measured 15x15 cm in size. There was no thyroid enlargement. Ultrasonogram (USG) of the thyroid and biochemical thyroid profile (T3, T4 & TSH) were normal. X-ray skull showed the mass was eroding the occipital bone. Fine needle aspiration cytology (FNAC) performed prior to resection was reported as suggestive of a metastatic lesion from thyroid (fig:1). Fig-1: showing the FNAC of the lesion. Clusters of follicular cells (black arrow head) and colloid (white arrow head) are easily recognizable in a bloody background (papanicolaou stain X 40 ) The magnetic imaging resonance (MRI) of brain done with contrast showed a large well defined lesion noted at the vertex measuring 12x10x1 l.6cin. There was destruction of part of the occipital bone and both parietal bones (Fig 2). Fig-2: MRI of brain with contrast showing destruction of occipital  & parietal bone & well defined lesion at vertex.     Follicular thyroid carcinoma usually presents as a thyroid nodule, with rare cases showing metastatic disease at diagnosis. The initial presentation of distant metastases in patients with thyroid carcinoma is an uncommon eventl. In  two large series distant metastases were present at the initial time  of diagnosis in about 4%of cases, 5-11% in follicular carcinoma  thyroid and 2% in papillary carcinoma thyroid. Metastatic tumors to the skull, though relatively rare most often come from the 1ung, breast, prostate and kidney. Metastasis to these unusual sites has often been associated with widespread internal metastatic disease having a poor prognosis. Atypical presentation in the form of a follicular carcinoma associated with hyperthyroidism from a hot nodule in the same lobe and occurrence of both anaplastic and follicular carcinomas are also reported. But occult follicular thyroid carcinoma presenting as multiple skull metastasis in an elderly without any thyroid abnormalities (no thyroid enlargement, biochemical and other thyroid function tests remaining within normal limits) are rare.   We report here this case to caution the clinicians to bear in mind about occult follicular carcinoma of thyroid as a differential diagnosis when they come across any lytic lesion of the skuIl. Also if there is no thyroid enlargement and biochemical thyroid profile is normal in such cases, they should advise computerized tomography (CT), magnetic resonance imaging (MRI) and FNAC, histopathology of the lesion for early, correct diagnosis to exclude metastatic thyroid malignancies for better treatment of the patient. References 2.  Wong GK, Boet R, Poon WS. Ng HK. Lytic skull metastasis secondary to thyroid carcinoma in an adolescent. Hong Kong Med J 2002; 8(2): 149-5 I. 4.  Moudouni SM, En-Nia I, Rioux-Leclerq N, Manunta A, Guille F, L obel B. Follicular carcinoma of the thyroid metastasis to the kidney nine years after resection of the primary tumor. Ann Urol (Paris) 2002; 36(1): 36-7. 6.  Agarwal A, Mishra SK, Jain M. Follicular thyroid carcinoma with metastasis to the mandible. J Indian Med Assoc. 1998; 96(11): 354-5. 2026 Ibrahim Medical College. All rights reserved.