Interesting Case of Cutaneous Metastases to Thoracic Skin from Anaplastic Carcinoma of Thyroid: An Unreported Entity in India.

Anaplastic thyroid carcinoma is a highly aggressive tumor with 100% mortality that constitutes 1%-2% of thyroid malignancies. Cutaneous metastases from thyroid carcinoma are extremely rare. We report a case of a 68-year-old male with anaplastic thyroid carcinoma with cervical lymph node and thoracic cutaneous metastases. Following the diagnosis of anaplastic carcinoma with stage IVB after thorough investigations, he was started on chemotherapy with cisplatin and adriamycin, and also radiotherapy was given subsequently. Dermatological examination showed a single ulcer of size 3 × 2 cm, hard nodules, and plaques of varied sizes present over the anterior chest. Skin biopsy from the nodule showed pleomorphic tumor cells in strands with colloid material and neutrophilic infiltrates in the deep dermis. The present case report demonstrates that thoracic skin metastases can occur from anaplastic thyroid carcinoma with nodules and ulcers and, to our knowledge, this is the first case report of such an extremely rare condition from India. Copyright:

Introduction

Anaplastic thyroid carcinoma is a highly aggressive tumor with increased mortality. It constitutes around 1%–2% of all thyroid malignancies.[1] The mean age at diagnosis is between 55 and 65 years. The metastasis from thyroid carcinoma is common to the lungs followed by lymph nodes, brain, and bones. The metastases may be a part of disseminated disease or sometimes due to occult carcinoma as well.[2] The cutaneous metastases are usually very rare and the scalp is the most common site affected. The clinical features of cutaneous metastases are tender skin-colored nodules, which rarely ulcerate and occasionally be associated with itching.[1] We report a case of anaplastic thyroid carcinoma with cervical lymph node and thoracic cutaneous metastases. Around 12 cases of cutaneous metastases from anaplastic thyroid carcinoma have been reported worldwide excluding India till date in which only three cases metastasizing to thoracic skin exist.

Case Report

A 68-year-old male presented to the Department of Dermatology, Venereology, and Leprosy of Tirunelveli Medical College Hospital in November 2018 with swelling in the neck and multiple skin-colored nodules, and a single painful ulcer over the anterior chest for 1 month. The patient had been earlier presented to the Oncology department with a history of swelling in the cervical and thyroid region for 4 months associated with loss of weight. Fine-needle aspiration cytology (FNAC) of the lymph node and thyroid swelling was done and it was reported as anaplastic thyroid carcinoma.

Routine blood investigations and other investigations were done to identify other sources of primary if any and were excluded. Bronchial wash cytology showed no malignant cells. Esophagogastroduodenoscopy (EGD) showed grade B esophagitis, gastric erosions, and duodenal inflammation. Gastric biopsy showed chronic nonspecific inflammation. Higher investigations such as positron emission tomography (PET) scan and computed tomography (CT) chest could not be taken as the patient was not willing. Following the diagnosis of anaplastic carcinoma with stage IV B (according to the American Joint Committee on Cancer Tumour(T), Nodes(N), Metastases (M) staging), he was started on chemotherapy with cisplatin and adriamycin, and also radiotherapy was given subsequently.

Meanwhile, 1 month after initiation of treatment, patient developed cutaneous manifestations for which he was referred to the dermatology department. The skin lesions were rapidly increasing in size and numbers over that period. On examination, a single ulcer of size 3 × 2 cm with irregular margins, purulent base with rolled edges, and tender on palpation was present over the presternal area in the upper part surrounded by multiple skin-colored discrete nodules of varying sizes ranging from 2 × 1 cm to 0.5 × 0.5 cm along with few nodules coalesced to form plaques of varying sizes ranging from 4 × 2 cm to 3 × 2 cm, hard in consistency with skin adherent to the nodule were present over the front of the chest in the periphery of the ulcer [Figure 1a and b]. No scalp skin lesions were found. Skin biopsy was taken from the nodule present over the upper chest and sent for histopathology. Biopsy from ulcer could not be taken as the patient was not willing.

Figure 1

(a) Swelling in the anterior neck; nodules and ulcer in the anterior chest. (b) Ulcer in the presternal area with nodules in the periphery

Skin biopsy showed a large nodular collection of metastatic deposits containing pleomorphic cells involving mid-to-deep dermis with one or two focal collections in the upper dermis [Figure 2a]. Those pleomorphic cells have atypical round cells with pale blue cytoplasm and hyperchromatic small nuclei [Figure 2d] of varying sizes in the center of the cells arranged in an acinar pattern engulfing eosinophilic amorphous colloid material trapped within [Figure 2c]. Tumor cells are also arranged in irregular strands and cords with large atypical oval to ellipsoidal cells admixed with colloid, especially in the deeper dermis [Figure 2b]. All areas showed collections of neutrophils that were dense in the deep dermis.

Figure 2

(a) Metastatic deposits in mid-to-deep dermis and inflammatory infiltrates in the upper dermis (hematoxylin and eosin ×10). (b) Tumor cells in cords and strands admixed with colloid in 2'o clock position—black arrow showing colloid (hematoxylin and eosin × 40). (c) Tumor cells engulfing eosinophilic amorphous material (hematoxylin and eosin × 40). (d) Pleomorphic cells with hyperchromatic small nuclei (hematoxylin and eosin × 100)

The patient died 1 month after the diagnosis of cutaneous metastases while continuing chemotherapy (one cycle out of six cycles) and radiotherapy (1 month and 5 days).

Discussion

Papillary carcinoma has the highest propensity for cutaneous metastasis (41%) followed by follicular (28%), anaplastic (15%), and medullary carcinoma (15%).[1] However, Koller et al.[3] have reported that follicular carcinoma has greater preponderance than papillary carcinoma for cutaneous metastases. Anaplastic thyroid carcinoma is very rare which affects females more than males (3:1)[4] that metastasize to the skin in the event of diffuse body metastases. The metastases were found in around 50% at initial presentation and 25% developed it during the clinical course.[5]

Besic et al.[6] have reported that metastases from anaplastic thyroid carcinoma were common to lungs (78%) followed by intrathoracic lymph nodes (58%) and less common to the skin (9%) and other organs. In this case, chest X-ray was normal; CT chest could not be done as the patient was not willing, and hence lung metastasis was not ruled out. However, he had cervical lymph node metastasis.

In general, no sex disparity was seen in thyroid malignancies metastasizing to the skin. Danialan et al.[4] proposed that the male to female ratio was 3:5 for cutaneous metastases from anaplastic thyroid carcinoma and it is male in the present case scenario which is uncommon. Gross presentation of those metastases will be solitary or multiple nodules with areas of hemorrhage and necrosis but in this case, an ulcer with multiple hard nodules was the clinical presentation. Primary adnexal tumors can be considered as a differential diagnosis in this context.

Histology will have varied morphology such as spindle, giant cell, rhabdoid or squamous cells, mitotic figures, necrosis, and vascular invasion.[7]

Anaplastic thyroid carcinoma is a very rare tumor with 100% mortality even with treatment.[7] As per literature, the 10-year overall relative survival rates of thyroid carcinomas were found to be papillary (93%), follicular (85%), medullary (75%), and anaplastic carcinoma (14%).[8] The response rate with chemotherapy was found to be around 53%, but the survival rate was not increased.[9] The average duration of survival is 4 to 12 months following the diagnosis[1] as per literature, which turned out to be true in our case too as the patient died within 4 months after the diagnosis.

Newer investigation modalities include immunohistochemical markers such as keratins, absent expression of thyroid transcription factor (TTF-1) differentiates it from other well-differentiated thyroid carcinomas.[10]

The present case report demonstrates that thoracic skin metastases can occur from anaplastic thyroid carcinoma with nodules and ulcers and, to our knowledge, this is the first case report of such an extremely rare condition from India.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.