Clin Exp Otorhinolaryngol.  2013 Mar;6(1):52-55.

Follicular Thyroid Carcinoma Presenting as Bilateral Cheek Masses

• Kim DW
• Hah JH
• An SY
• Chang H
• Kim KH

Abstract

Mandibular metastasis of thyroid carcinoma is extremely rare. We present the case of a 46-year-old woman who had bilateral huge cheek masses that had grown rapidly over several years. Intra-oral mucosal tissue biopsy and imaging work-up including computed tomography scan and magnetic resonance imaging were performed and the initial diagnosis was presumed to be central giant cell granuloma. Incidentally detected thyroid lesions were studied with ultra-sonography guided fine needle aspiration and diagnosed as simple benign nodules. Due to continuous oral bleeding and the locally destructive feature of the lesions, we decided to excise the mass surgically. To avoid functional deficit, a stepwise approach was performed: Firstly, the larger left mass was excised and the mandible was reconstructed with a fibular free flap. The final pathologic diagnosis was follicular thyroid cancer. Postoperative I-131 thyroid scan and whole body positron-emissions-tomography were performed. Right side mass was revealed as a thyroid malignancy. Multiple bony metastases were detected. Since further radioactive iodine therapy was required, additional total thyroidectomy and right side mandibulectomy with fibular free flap reconstruction was performed. The patient also underwent high dose radioactive iodine therapy and palliative extra-beam radiotherapy for the metastatic lumbar lesion. Follicular thyroid carcinoma should be considered as a differential diagnosis for mandibular mass lesions.

Keyword

Follicular; Thyroid; Metastasis; Mandible

MeSH Terms

Adenocarcinoma, Follicular
Biopsy
Biopsy, Fine-Needle
Cheek
Diagnosis, Differential
Female
Free Tissue Flaps
Granuloma, Giant Cell
Hemorrhage
Humans
Iodine
Magnetic Resonance Imaging
Mandible
Mucous Membrane
Neoplasm Metastasis
Thyroid Gland
Thyroid Neoplasms
Thyroidectomy
Iodine

Figure

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  Fig. 1 Preoperative gross appearance of the patient (A) and intraoral masses (B). She had huge bilateral cheek tumors. The lesions had grown intra-orally and filled the whole oral cavity.

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  Fig. 2 Bilateral lesions were aggravated and the size of the mass increased rapidly. Large bilateral masses showed strongly enhanced solid tumors originating from the mandible which resulted in both expansile destruction and erosion of the mandible. These lesions extended from the body to the condyle of the mandible (A, B). Incidentally detected thyroid lesions were studied with ultra-sonography guided fine needle aspiration cytology and the results were simple benign nodules (C, black arrow head).

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  Fig. 3 The left mandibular tumor showed highly differentiated thyroid malignancy (A: H&E, ×100). The thyroid nodule contains mildly differentiated thyroid follicles and demonstrates atypia of the follicular epithelium with blood vessel invasion (B: H&E, ×400). Immunoreactivity for thyroid transcription factor-1 of the left mandibular tumor revealed thyroid origin of the tumor (C: Immunostain, ×400).

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  Fig. 4 On thyroid scan (A) and positron emission tomography (B), after right side hemimandibulectomy, the thyroid gland and right side mass were revealed as a thyroid malignancy and multiple bony metastases involving the lumbar spine and femur neck were detected.

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  Fig. 5 At postoperative 1 year, she showed good cosmetic result without local recurrence (A). Postoperative panorama view of the mandible shows bilateral reconstruction plates (B). The shape and viability of the bilateral osteocutaneous flaps are also excellent (C).

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