Papillary thyroid (PTC), follicular thyroid (FTC), and Hurthle cell carcinoma are the three types of differentiated thyroid cancers (DTC) [1]. In the DTC, the spine is the most common osseous metastases of all bones metastases [2]. The cervical spine represents 4% of osseous metastases [3]. DTC can cause significant neurologic deficits by cervical spine metastases [4-6]. Initial presentation as cervical spine compression of metastatic papillary thyroid cancer is rare [7]. We report a case of the effect of surgical management of a cervical cord compression due to extension of papillary thyroid carcinoma, in a limited resource setting, on a patient of 70 years old.

Observation

A 70-year-old woman with a history of anterior cervical mass presented with complaints of cervical pain with progressive arms and legs weakness for four weeks. She previously had been in good health. Her medical history was unremarkable. On physical examination, she was normotensive, non-anemic. There was quadriplegia (loss of muscle function with grade 1/5), an exaggeration of ankle and knee reflexes. The planter reflex was in extension on both feet. Modalities of sensations were diminished from C4. The ultrasound of the anterior cervical mass showed a multinodular right lobar thyroid hypertrophy measuring 163 cm³ in volume. There was no jugular-carotid lymphadenopathy. That mass was classified TIRADS III.     

Magnetic resonance imaging showed a severe cord compression by a mass with C4 vertebral body destruction and enhanced mass with a displacement of the cervical cord by the mass (Figure 1).

Figure 1: Magnetic Resonance Imaging Whowing a Cervical Spinal Cord Compression, C4 Destruction and Anterior Cervical Mass

At the same time, the patient underwent total thyroidectomy (Figure 2) and C4 corporectomy with pyramesh cage and plating (Figure 3). 

Figure 2 : Total Thyroidectomy Piece

Figure 3 : Postoperative X Ray Control (A : Side ; B : Front) C4 Replaced by Pyramesh Cage, and Cervical Plate

The histopathologic examination concluded with papillary thyroid carcinoma (Figure 4). After that surgical management, she can walk alone at a one-month follow-up.

Figure 4: Showing Vertebral Metastasis (Black Square) of Papillary Thyroid Carcinoma (Black Star) HE; x20

In Subsaharan countries, DTC are mainly dected at clinical stages, with patients over the mean age of 40 years; and women being the most affected [8-10]. Our reported case is a woman of 70 years old. Bukasa Kakamba et al [10] reported that age ≥ 60, the presence of adenopathies upon palpation or on ultrasound, the solid nature and hypoechogenicity modules, the presence of macro nodules and calcifications were the factors independently associated with the diagnosis of thyroid cancer. DTC infrequently metastasizes to the vertebrae. However, lung, breast, and prostate are the most common sources of vertebral metastases [11]. The most typical site of spinal metastases affects thoracic vertebrae [12]. The time from diagnosis of DTC to the diagnosis of distant metastases can be variable, with long periods of remission in between [13,14]. 

Spine metastases can be detrimental to patient quality of life, causing pain and neurologic deficits [5,6,15]. According to Sellin et al. [16], spine metastases from thyroid cancer are three or four times more likely to lead to cord compression. It was the initial presentation for our patient (cervical cord compression). She had a story of anterior cervical mass non-documented, without previous symptoms of malignancy. Referral to a spine surgeon should be the attitude after diagnosis, according to Yin et al. [17]. Not treated cervical spine metastasis can lead to skeletal-related events [18] defined as cord compression or pathologic fractures (DTC bone metastases are lytic) [2,19].

Yin et al. [17] reported that surgical management of cervical spine metastases in DTC is associated with significantly improved local disease control and overall survival. That surgery may consist of complete excision of thyroid spine metastases [5] At the same time, our patient had total thyroidectomy by an otolaryngologist and decompression with stabilization by anterior approach.

Otolaryngologists and spine surgeons often work together closely in the operating room to ensure adequate exposure and access to the cervical spine [17] In addition, many spine decompression and stabilization procedures require an anterior cervical approach in DTC metastases [20-22]. Yin et al. [17] reported that surgical therapy is an effective treatment for cervical spine metastases and superior to alternative therapies. Therefore, surgical management may be considered first in selected patients, in our conditions where there are no alternative therapies.

There are some clinically aspects in this case:

• There were no no symptoms related to the primary thyroid cancer

• The first manifestation was a cervical spinal cord compression

• The good evolution after double-teamed surgical management

We report a rare case of papillary thyroid carcinoma on a 70 years-old woman. This case manifested as a cervical cord compression without any previous symptoms related to the primary thyroid cancer. The case was managed surgically with thyroidectomy, decompression-stabilization, with a good outcome.

1. Cabanillas, M.E. et al. “Thyroid cancer.” Lancet, vol. 388, no. 10061, 2016, pp. 2783–2795.

2. Pittas, A.G. et al. “Bone metastases from thyroid carcinoma: Clinical characteristics and prognostic variables in one hundred forty-six patients.” Thyroid, vol. 10, no. 3, 2000, pp. 261–268.

3. Osorio, M. et al. “Systematic review of site distribution of bone metastases in differentiated thyroid cancer.” Head & Neck, vol. 39, no. 4, 2017, pp. 812–818.

4. Mazziotti, G. et al. “Real-life management and outcome of thyroid carcinoma-related bone metastases: Results from a nationwide multicenter experience.” Endocrine, vol. 59, no. 1, 2018, pp. 90–101.

5. Kato, S. et al. “The impact of complete surgical resection of spinal metastases on the survival of patients with thyroid cancer.” Cancer Medicine, vol. 5, no. 9, 2016, pp. 2343–2349.

6. Quan, G.M.Y. et al. “Multidisciplinary treatment and survival of patients with vertebral metastases from thyroid carcinoma.” Thyroid, vol. 22, no. 2, 2012, pp. 125–130.

7. Goldstein, S.I. et al. “Metastatic thyroid carcinoma presenting as distal spinal cord compression.” Annals of Otology, Rhinology & Laryngology, vol. 97, no. 4, 1988, pp. 393–396.

8. Darre, T. et al. “Descriptive epidemiology of thyroid cancers in Togo.” Asian Pacific Journal of Cancer Prevention, vol. 16, no. 15, 2015, pp. 6715–6717.

9. Woodruff, S.L. et al. “Global variation in the pattern of differentiated thyroid cancer.” American Journal of Surgery, vol. 200, no. 4, 2010, pp. 462–466.

10. Bukasa Kakamba, J. et al. “Thyroid cancer in the Democratic Republic of the Congo: frequency and risk factors.” Annales d’Endocrinologie, 2021.

11. Barron, K.D. et al. “Experiences with metastatic neoplasms involving the spinal cord.” Neurology, vol. 9, no. 2, 1959, p. 91.

12. Ramadan, S. et al. “Spinal metastasis in thyroid cancer.” Head & Neck Oncology, vol. 4, no. 1, 2012, p. 39.

13. Lee, J. and Soh, E.-Y. “Differentiated thyroid carcinoma presenting with distant metastasis at initial diagnosis: clinical outcomes and prognostic factors.” Annals of Surgery, vol. 251, no. 1, 2010, pp. 114–119.

14. Bernier, M.O. et al. “Survival and therapeutic modalities in patients with bone metastases of differentiated thyroid carcinomas.” Journal of Clinical Endocrinology & Metabolism, vol. 86, no. 4, 2001, pp. 1568–1573.

15. Kushchayeva, Y.S. et al. “Spinal metastases due to thyroid carcinoma: an analysis of 202 patients.” Thyroid, vol. 24, no. 10, 2014, pp. 1488–1500.

16. Sellin, J.N. et al. “Factors affecting survival in 43 consecutive patients after surgery for spinal metastases from thyroid carcinoma.” Journal of Neurosurgery: Spine, vol. 23, no. 4, 2015, pp. 419–428.

17. Yin, L.X. et al. “Prognostic factors in patients with differentiated thyroid cancers metastatic to the cervical spine.” The Laryngoscope, vol. 131, no. 5, 2021, pp. E1741–E1747.

18. Choksi, P. et al. “Skeletal complications and mortality in thyroid cancer: a population-based study.” Journal of Clinical Endocrinology & Metabolism, vol. 102, no. 4, 2017, pp. 1254–1260.

19. Meier, M.F. et al. “Imaging of cervical metastases in thyroid cancer.” PM&R, vol. 5, no. 5, 2013, pp. 442–444.

20. Fehlings, M.G. et al. “Decision making in the surgical treatment of cervical spine metastases.” Spine, vol. 34, no. 22, 2009, pp. S108–S117.

21. Byrne, T.N. et al. “Metastatic epidural spinal cord compression: update on management.” Seminars in Oncology, vol. 33, no. 3, 2006, pp. 307–311.

22. Stojadinovic, A. et al. “The role of operations for distantly metastatic well-differentiated thyroid carcinoma.” Surgery, vol. 131, no. 6, 2002, pp. 636–643.