A 77-year-old woman with no history of interest consulted for a scalp lesion of more than two years of evolution with progressive growth in the last year and who was bothered by the rock.
It was a 6 mm hard erythematous-violaceous papular lesion in the parieto-occipital region.
This lesion was excised by slitting and nitrate fertilizer, bleeding a lot and it was not possible to obtain sufficient sample for pathological study (AP).
Six months later, the lesion grew again with similar characteristics in the same place and was removed by elliptical excision and electric scalpel.
The AP analysis reported the presence of differentiated thyroid tissue in the skin.
It was a tumor located in the middle and deep dermis consisting of follicular structures of size containing colloid material with peripheral vascularization and surrounded by a small number of cubic cells.
Immunohistochemical examination detected intense cytoplasmic and intracolloid expression of thyroglobulin, keratin 7 and 19.
With these findings the patient was referred for evaluation of metastasis of thyroid cancer not previously known.
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In the anamnesis the patient was asymptomatic and had no medical history of interest.
Physical examination revealed a grade Ib goiter with a 2-3 cm nodule in LTD ascended well with palpable adenopathies, the rest being normal.
Complementary tests: TSH 0.55 mU/L (0.35-5.5), FT4 1.23 ng/dL (0.8-1.76), FT3 3.19 ng/mL (2.3-4.2), long-term anti-TGSI antibodies remained unchanged.
Thyroid ultrasound showed a multinodular goiter; in the LTD, a dominant nodule of 25 x 15 mm of mixed echogenicity was identified with hyper-hypoechogenic areas and poorly defined caudal areas.
One month later, thyroidectomy and lymphadenectomy of the central compartment were performed.
Intraoperative biopsy was reported as papillary carcinoma.
The AP analysis of the surgical specimen was reported as mixed papillary and follicular carcinoma well differentiated (90%) and solid with a 10% little differentiated, partially encapsulated with extensive disturbance of the capsule and its vessels.
The encapsulated portion size was 15 mm and the entire tumor was 30 mm.
No extrathyroid extension was observed and the surgical margins were closest to one mm. Four lymph nodes were obtained in the central compartment, which were tumor-free.
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An extension study was performed before radioiodine treatment by metabolic study with 8.26 mCi of 18FDG, cerebral and pelvic MRI and bone scintigraphy which was negative.
70 days after surgery, 104.7 mCi of I131 were administered after TSH.
Baseline serum TG was 351 μg/L (1.6-60).
Stimulated TG 1788.7 μg/L (47-1) with basal TSH of 117 mU/L (0.37-4.7).
In post-I131 CTR, post-thyroidectomy remnants were observed in the left posterior chamber, along with diffuse miliary involvement in both lung parenchyma compatible with metastasis.
One month after radioiodine ablation and treatment with 100 μg levothyroxine showed TG 37 μg/L (1.6-60), TSH 1.96 mU/L and FT4 1.43 ng/L.
In the evaluation 6 months after radioiodine ablation, TG was 2.78 with TSH 0.03 and FT4 1.96, so other radioiodine doses of TSH 0.125 μg/dl were detected with TSH 0.04 μg/dl; and
The patient will be reassessed within 4 months by quantification of stimulated TG after TSH and subsequent CTR to confirm cure.
