Recurrent Thyroid Cancer with Epidural Metastases

History: A 48-year-old female with a history of thyroidectomy for papillary cancer of thyroid. She presented six months later with a palpable mass in the left thyroid region and with backache radiating to left upper limb.

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Ax Spine

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Ax Thyroid

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Cor Spine

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SAG

Contrast MRI of the cervical spine and neck revealed a hyperintense, enhancing extradural soft tissue mass in the left lateral cervical spinal canal extending from C1 to C5 levels and extending into the left C1-2 and C2-3 neural foramina. This mass was compressing the cord from the left lateral aspect and completely filling the left sided lateral recesses with infiltration of the nerve roots. This is consistent with epidural metastases. There was no obvious vertebral destruction or marrow involvement to suggest bony metastases.

Another well defined rounded necrotic mass was present in the left thyroid region showing shaggy marginal enhancement, consistent with a recurrent thyroid mass. The mass was insinuating into the prevertebral space but there did not appear to be an obvious communication of the extradural mass with the left thyroid region mass.

Diagnosis: Recurrent thyroid Cancer with epidural metastases

Discussion: The incidence of spinal metastases in thyroid malignancy varies from 3 percent to 20 percent and depends on the type of tumor. Hurthle cell cancers have the highest incidence of spinal metastases (20 percent), follicular cancers have an incidence of 7 percent to 10 percent and the least common is papillary carcinoma with an incidence of 1 percent to 7 percent. The thoracic spine is the commonest site of involvement (60 percent to 80 percent) followed by lumbar (15 percent to 30 percent) and cervical (<10 percent) spinal regions.

Extradural lesions are the most common type of spinal metastases and account for up to 95 percent of spinal lesions. Intradural and intramedullary metastases are uncommon with an average incidence of 5 percent to 6 percent and 0.5 percent to 1 percent respectively.

The most common route of epidural spread is the spinal venous plexus and arteries, resulting in multifocal lesions. Other potential routes are direct infiltration from paraspinous disease, or rarely via the lymphatics or CS. In the majority of cases it is the vertebral body which is involved first (85 percent) with secondary spread to the epidural space.

In a small percentage of patients, the paravertebral spaces (10 percent to 15 percent) and the epidural space (<5 percent) may also initial sites of metastatic involvement. Thyroid papillary carcinoma in particular has a propensity to metastasize preferentially to the epidural space.

Spinal cord and cauda equina compression by the epidural tumor will present with neurological deficits of varying degrees. Nerve root compression will cause typical radicular or neuropathic pain. Tumoral soft tissue material impinging upon the epidural venous plexus may result in venous hypertension and vasogenic edema. 

Spinal radiotherapy is effective for palliation of spinal epidural metastases. Studies have also demonstrated good results with a combination of surgical decompression and radiation in some patients with spinal epidural metastases.

The aim of presenting this case is to highlight the uncommon occurrence of isolated epidural metastases in the cervical spine in a patient with recurrent thyroid cancer.

Arti Chaturvedi, MD
Senior Consultant, Department of Radiodiagnosis
Fortis International Hospital, Noida, India

References

1.Ramadan S, Ugas MA, Berwick RJ, Notay M, Cho H, Jerjes W, Giannoudis PV. Spinal metastasis in thyroid cancer. Head & Neck Oncology 2012, 4:39

2. Brian P. Walcott, MD; Jeffrey R. Jaglowski, MD; William T. Curry, Jr, MD. Spinal Epidural Metastasis. Arch Neurol. 2010;67(3):358-359. doi:10.1001/archneurol.2010.7

3. Shah LM, Salzman KL. Imaging of Spinal Metastatic Disease. International Journal of Surgical Oncology. Volume 2011, Article ID 769753, 12 pages doi:10.1155/2011/769753

4. Patchell RA, Tibbs PA, Regine WF et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomized trial. Lancet 2005; 366(94-81) 643-648.