AUTHORS:* DR. A. R. OYESEGUN, DR. AREWA F.E.O.
DR. A. AJIBADE, DR IKECHUKWU NWACHUKWU,
DR A. M. BELLO,
+MRS. O. A. LADIPO, MR. C. S. J. GADO.
ALL CORRESPONDENCE TO; DR. A. R. OYESEGUN. DEPARTMENT OF RADIOTHERAPY AND ONCOLOGY NATIONAL HOSPITAL, ABUJA.
*DEPARTMENT OF RADIOTHERAPY AND ONCOLOGY, NATIONAL HOSPITAL, ABUJA.
NATIONAL HOSPITAL, ABUJA.
A 44-year old woman presented with long-standing quadriplegia from metastatic thyroid carcinoma. The general rule with most tumours is that the longer the duration of a neurological deficit, the slimmer the chances of recovery especially when there is associated autonomic dysfunction.
We are presenting this lady who recovered from spinal cord compression of 2-year duration which is unusual to encourage clinicians to aggressively treat such case rather than assume palliative posture.
Neurological deficit from cord compression due to metastatic cancer is a well known phenomenon1 The recovery rates from spinal cord compression with most tumours are inversely proportional to the duration of lesion. Recovery when the lesion is treated at the stage of pain sensation but still ambulatory is 99%, with limb heaviness ( patient still ambulant) is over 82%and drops to about 30% when full neurological deficit has manifested and less than 10% with autonomic function affected1.
The outcome of treatment of cord compression varies with the treatment modality. Good result could be achieved with radiation alone in some cases, better result achievable with both lamination and radiation in most cases, but the best result is achievable when radiation, surgery and radioiodine are combined as treatment modality. 1,6.
Thyroid cancer is not common2. Well differentiated thyroid carcinoma have a relatively favourable prognosis with 10year survival being 90-95% 2,5.
The incidence of distant metastases from thyroid carcinoma however is as high as 33% especially with follicular variant. The two most frequent sites of distant metastases are lungs and bones 2,5. 1 to 2% of papillary thyroid cancer patients and 2 to 5% of follicular thyroid cancer have distant metastases outside the neck and medistinum at the time of diagnosis. Patient with distant metastastic disease either at presentation or with recurrence do much worse2.
Treatment options in patients with bone metastases of differentiated carcinoma are mostly aimed at palliation3. However, unlike most tumours with spinal metastases and associated neurological deficit resulting in poor prognosis, unexpectedly good results can sometimes be achieved with the use of radioiodine and other adjuvant therapies2.
We therefore report a case of complete recovery from cord compression from thyroid carcinoma after treatment with radioiodine and other therapies.
A 44-year old female Nigerian was referred to the National Hospital Abuja from Saudi German Hospital, Jeddah in July 2000 with a history of progressive thyroid swelling of 20-year duration, progressive parapareisis of over one year duration and quadriplegia 6 month before presentation. There was associated history of urinary and faecal incontinence.
There was no past history of radiation exposure, she is the first of the husband’s two wives. There was no family of thyroid disease. Review of her systems showed no significant contribution.
Examination revealed a middle-aged woman, who was not pale nor jaundiced. She had no palpable peripheral nodes and no pedal oedema.
The thyroid gland was enlarged, nodular, measuring about 10cm in diameter mostly on the right. The gland was fixed to the underlying neck muscles and the trachea.
The power in both upper and lower limbs was grade 0.
The chest was clinically clear and no palpable organ in the abdomen. Baseline investigations done included a full blood count, urea and electrolytes, liver function tests, abdominal ultrasound and chest x-ray, which were all essentially normal..Thyroid function tests showed elevated level of thyroxine (T4) of 170Ung/ml (normal value 51.2 – 141Ung/ml).Bone scan revealed a minimal uptake seen over C5, C6 and C7 vertebral bodies.Magnetic Resonance Imaging of the cervical and dorsal spine showed pathologic destruction involving C5, C6 and C7 vertebra bodies with significant compression of the spinal cord.
She had surgery at the Saudi German Hospital. She had near-total thyroidectomy and partial capectomy done for C5, C6 and C7 lesion to decompress the cord.Histology of the thyroid specimen and vertebral body tissue showed follicular carcinoma and metastastic disease respectively.
Post-operatively, there was some improvement. She was able to move her hands and hold object, she was able to walk with assistance and she gained her continence. This was however short-lived as her limb weakness and incontinence recurred barely 2 months after the surgery. She had external beam radiotherapy to the cervical lesion – C3 to C8 and received 30Gy in 10 fractions over 2 weeks with 6MV linear accelerator. She was treated lying prone and the depth of treatment was 4cm. She also had steroid (Dexamethazone) tablets at high dose initially and later tapered down over 4 weeks.
No response was seen after radiotherapy. Infact, progressive disease was noted confirmed radiologically as metastatic deposits on D2 and L1-L5 and these sites were also treated to 30Gy in 10 fractions with the same machine and the same energy and to a depth of 4cm.
With no improvement noticeable radioiodine therapy was instituted on 26/02/01. She received 2 doses of 250mci of radioiodine at seven months interval.
She commenced active physiotherapy after the first dose of radioiodine with gradual but steady improvement. The power in all the muscle groups became better and she could walk with walker shortly after the second dose of radioiodine. The power in both upper and lower limbs was grade 5 on discharge.
She had been on replacement therapy with levothroxinine 10microgram t.i.d. Her thyroid function has remained normal on this dose and she has since returned to her normal duty. She is due to visit the clinic again in six months.
Thyroid cancer is uncommon and with a uniform world incidence of 40/million, it account for less than 1% of all malignancy. 6 per million die from it yearly. It is seen from childhood to old age with peak incidence in the 6th decade in Europe and America but in the 4th decade in Africa and Asia most probably because of lower life expectancy. It is three times more common in females5.
In Nigeria, the incidence rate is about 0.8/100,000 in male and 1.7/100,000 in female4. Follicular and papillary thyroid cancer are generally referred to as differentiated thyroid carcinoma1,4,5.
One major difference in the incidence in terms of race is that the proportion of well-differentiated thyroid carcinoma that are follicular is increased greatly in blacks as compared to whites1. It is reported that follicular carcinoma accounts for 15% of all well-differentiated tumours in whites as compared to 34% in blacks5,6.
Corticosteroids (dexamethazone, methyl prednisolone) are among the most effective treatment of neurologic dysfunction resulting from spinal cord compression Dexamethazone reduces oedema, inhibits Prostaglandin E2 synthesis and decrease the specific gravity of the compressed spinal cord1,7,5,8.
It was also shown to delay the onset of paraplegia. Steroids reduced the bulk of tumour and as such temporarily reduce the degree of neural compression by direct cytotoxic activity 8.
Treatment modality regarding the use of radiotherapy surgery or radioiodine should be individualized. Despite the common occurrences of cord compression, there have been no randomized trials containing more than 30 patients. Thus the guidelines for treatment of cord compression are largely empiric. Appropriate treatment recommendation can only be made after assessing the patients expected survival, the location, number and mechanism of spinal cord compression(s), the tumour histology, the rapidity of neurologic progression and any history of previous radiotherapy administered to the site under current consideration 1,9,10.
Although radiation therapy is currently the treatment of choice for most spinal metastases, it has a less prominent role in the initial management of cord compression from thyroid cancer. It is usually given post operatively or follow 131 therapy1,9,10.
Remission rates in bone metastases from well differentiated thyroid carcinoma vary from 7% 20%9. A major problem in this category of patients is the diminished ability of thyroid cancer cells to accumulate or incorporate radioiodine1,4,9.
In individuals with bone metastases the age has a very important prognostic bearing on treatment outcome. Excellent outcome was reported in young individuals while in the elderly, the outcome was poor. This is the only tumour in the entire human body where age is included in the American Joint Committee on Cancer ( AJCC) staging classification 1,9,11.
Radioiodine plays a major role in the diagnosis and therapy of patients with differentiated thyroid carcinoma. It is used post-operatively to ablate normal thyroid remnants and during follow-up for whole body scanning and in patients with recurrent disease for treatment 1,4.
Curative or therapeutic possibilities in patients with bone metastases of differentiated thyroid carcinoma are limited, especially when there is no uptake of radioiodine 12. Nevertheless these patients will have a life expectancy that may extend for several years2,3. As a consequence, these patients may be exposed to the burden of symptomatic metastases for a long period of time necessitating the need for palliative therapy. Surgery, external beam irradiation and to a lesser extent radioiodine therapy are the conventional palliative treatment modalities in these patients 1,2.
She had a total cumulative dose of 500ci before appreciable response was noted. With such a high dose, associated complications may include damage to the gonads, bone marrow damage, induction of solid tumour and leukaemia11. These risks are relatively small compared to the derivable benefit.
Spinal cord compression from cancer has poor prognostic feature; patients with compression from well differentiated thyroid carcinoma should be given the benefit of all the treatment modalities as some of them could recover.
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- Smit JW, Vielyaye GJ, Cashings BM 2000 Embolization for vertebral metastases of follicular thyroid carcinoma. J. Clin. Endcrinol metab 85, 989-994.