Calvarium and dura mater as delayed sites of distant metastasis from papillary thyroid carcinoma

Khalid Hussain AL-Qahtani,1 Mutahir A Tunio,2 Mushabbab Al Asiri,3 Hanadi Fatani,4 Yasser Bayoumi5 1Department of Otolaryngology-Head and Neck Surgery, College of Medicine, King Saud University, 2Radiation Oncology Department, King Fahad Medical City, 3Radiation Oncology Department, 4Histopathology Department, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia; 5Radiation Oncology Department, National Cancer Institute, Cairo, Egypt Background: Skull calvarium and dura mater are rare sites of distant metastasis, and mostly have been reported in lung, breast, and prostate malignancies. However, the calvarial and dural metastases from papillary thyroid cancer (PTC) are rare entities and pose diagnostic and therapeutic challenges. To date, only seven cases of calvarial metastasis with intracranial extension from PTC have been reported in literature. However, true dural metastasis from PTC has not yet been reported. Case presentation: A 65-year-old Saudi woman presented with 6 months history of painful posterior scalp lump, 7 years after initial diagnosis of PTC. Computed tomography and magnetic resonance imaging showed occipitoparietal calvarial lesion with massive intracranial extension. Another para-sagittal lesion was found at the top of corpus callosum mimicking a meningioma. Histopathology of para-sagittal lesion and the biopsy of calvarial mass confirmed the diagnosis of metastatic PTC. After surgical resection, residual tumors were treated with postoperative intensity-modulated radiation therapy. At 13 months of follow-up, patient was alive and without any signs of recurrence. Conclusion: Calvarial and dural metastases from PTC are extremely rare clinical entities. Surgical resection followed by postoperative radiotherapy is the treatment of choice. However, for such cases, multidisciplinary approach can prolong the treatment outcome and survival. Keywords: papillary thyroid carcinoma, calvarial metastasis, intracranial extension, true dural metastasi

Skull base metastasis from papillary thyroid carcinoma: a report of three cases

Mutahir A Tunio,1 Mushabbab Al Asiri,2 Khalid Hussain Al-Qahtani,3 Sadiq Aldandan,4 Khalid Riaz,5 Yasser Bayoumi,6 1Radiation Oncology, King Fahad Medical City, Riyadh, Saudi Arabia; 2Radiation Oncology, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia; 3Department of Otolaryngology - Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 4Department of Histopathology, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia; 5Radiation Oncology, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia; 6Radiation Oncology, National Cancer Institute, Cairo University, Cairo, Egypt Abstract: Skull base metastasis from differentiated thyroid carcinoma, including papillary and follicular thyroid carcinoma, is a rare manifestation. Herein, we present three cases of skull base metastasis of papillary thyroid carcinoma. The mean age of the patients was 68.6 (65–74) years, and the mean interval between initial diagnosis and skull base metastasis was 56.3 (28–89) months. Cranial nerve palsies were seen in all patients. Intensity modulated radiation therapy to deliver 6,000–6,600 cGy to the skull base metastasis was given to all patients, in addition to partial resection in one patient. At the time of last follow-up, all skull base metastases were well controlled. Keywords: papillary thyroid carcinoma, skull base metastasis, treatmen

Nasolacrimal duct obstruction following radioactive iodine 131 therapy in differentiated thyroid cancers: review of 19 cases

Khalid Hussain Al-Qahtani,1 Mushabbab Al Asiri,2 Mutahir A Tunio,2 Naji J Aljohani,3 Yasser Bayoumi,4 Iqbal Munir,5 Ayman AlAyoubi6 1Department of Otolaryngology – Head and Neck Surgery, College of Medicine, Advanced Head and Neck Oncology, King Saud University, 2Radiation Oncology, Comprehensive Cancer Center, King Fahad Medical City, 3Endocrinology and Thyroid Oncology, King Fahad Medical City, Riyadh, Saudi Arabia; 4Radiation Oncology, NCI, Cairo University, Cairo, Egypt; 5Nuclear Medicine Sulaiman Al-Habib Hospital, 6Clinical Ophthalmology, King Fahad Medical City, Riyadh, Saudi Arabia Background: Radioactive iodine 131 (131I) therapy has long been used in the treatment of differentiated thyroid cancers (DTC). While salivary and lacrimal glandular complications secondary to 131I therapy are well documented, there is little in the literature addressing nasolacrimal duct obstruction (NLDO). We aimed to evaluate the frequency of 131I therapy-acquired NLDO, its correlation to 131I therapy doses, and the surgical treatment outcome of this rare side effect.Methods: From 2000–2012, a retrospective review of 864 among 1,192 patients with confirmed DTC who were treated with 131I therapy was performed to examine the frequency of NLDO, its causative factors, as well as imaging, surgical intervention, and outcomes.Results: Nineteen (2.2%) patients were identified with NLDO. The mean age was 51.9±10.5 years (range: 39–72 years). Fifteen (78.9%) were female and four were male (21.1%). The mean individual 131I doses were 311.1±169.3 millicurie (mCi) (range: 150–600 mCi). The mean duration between the date of 131I therapy and the occurrence of NLDO was 11.6±4.1 months (range: 6.5–20). Fourteen (73.7%) patients had bilateral epiphora. Computed tomography dacryography allowed for the detection of all NLDO. Eighteen (94.7%) patients underwent dacryocystorhinostomy. Complete recovery was obtained in 14 (73.7%) patients. Age >45 years and 131I therapy doses >150 mCi were significantly correlated with NLDO (P=0.02 and P=0.03, respectively).Conclusion: NLDO is an underestimated complication of 131I therapy in DTC patients. Clinicians should be aware of this rare complication for prompt intervention. Keywords: nasolacrimal duct obstruction, radioactive iodine 131 therapy, differentiated thyroid cancer

Comparative clinicopathological and outcome analysis of differentiated thyroid cancer in Saudi patients aged below 60 years and above 60 years

Khalid Hussain AL-Qahtani,1 Mutahir A Tunio,2 Mushabbab Al Asiri,2 Yasser Bayoumi,3 Ali Balbaid,2 Naji J Aljohani,4 Hanadi Fatani5 1Department of Otolaryngology-Head & Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 2Department of Radiation Oncology, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia; 3Department of Radiation Oncology, NCI, Cairo University, Cairo, Egypt; 4Department of Endocrinology and Thyroid Oncology, 5Histopathology, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia Introduction: The aim of this study was to evaluate the treatment outcomes of differentiated thyroid cancer in Saudi patients aged above 60 years. Materials and methods: Comparative analysis was performed in 252 patients aged 46–60 years (Group A) and 118 patients aged above 60 years (Group B), who had thyroidectomy, radioactive iodine-131, and thyroid-stimulating hormone suppression therapy between July 2000 and December 2012. Different clinicopathological features, treatment, complications, disease-free survival, and overall survival rates were compared. Results: Mean age of patients in Group A was 51.9 years (range: 46–60), and mean age of those in Group B was 68.6 years (range: 62–97). Group B patients had higher positive lymph nodes (43.2%), P=0.011. The frequency of extrathyroidal extension, multifocality, and lymphovascular space invasion was seen more in Group B than in Group A. Postsurgical complications (permanent hypoparathyroidism, bleeding, and wound infections) were also seen more in Group B (P=0.043, P=0.011, and P=0.021, respectively). Group B patients experienced more locoregional recurrences (11.0%, P=0.025); similarly, more distant metastases were observed in Group B (15.3%, P=0.003). The 10-year disease-free survival rates were 87.6% in Group A and 70.8% in Group B (P<0.0001). Conclusion: Differentiated thyroid cancer in patients aged above 60 years are more aggressive biologically and associated with a worse prognosis, and the morbidity is significantly high as compared to patients aged below 60 years. Keywords: differentiated thyroid cancers, patients aged above 45 years, aged above 60 years, clinicopathological characteristics, treatment outcomes, elderly patients, aged below 60 years, comparative analysi

Patterns of failure and survival in patients with nasopharyngeal carcinoma treated with intensity-modulated radiation therapy in Saudi Arabia

Ahmed Marzouk Maklad,1,2 Yasser Bayoumi,2,3 Mohamed Abdalazez Senosy Hassan,2,4 AbuSaleh A Elawadi,5,6 Hussain AlHussain,2 Ashraf Elyamany,7,8 Saleh F Aldhahri,9 Khalid Hussain Al-Qahtani,10 Mubarak AlQahtani,11 Mutahir A Tunio12 1Clinical Oncology, Sohag University, Sohag, Egypt; 2Radiation Oncology, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia; 3Radiation Oncology, NCI, Cairo University, Cairo, 4Radiation Oncology, Minia Oncology Center, Minia, 5Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt; 6Medical Physics, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia; 7Medical Oncology, SECI-Assiut University, Assiut, Egypt; 8Medical Oncology, Comprehensive Cancer Center, King Fahad Medical City, 9Department of Otolaryngology, Head and Neck Surgery, King Saud University, 10Department of Otolaryngology-Head and Neck Surgery, College of Medicine, King Saud University, 11Department of ENT, King Fahad Medical City, 12Radiation Oncology, King Fahad Medical City, Riyadh, Saudi Arabia Background: We aimed to investigate the patterns of failure (locoregional and distant metastasis), associated factors, and treatment outcomes in nasopharyngeal carcinoma patients treated with intensity-modulated radiation therapy (IMRT) combined with chemotherapy. Patients and methods: From April 2006 to December 2011, 68 nasopharyngeal carcinoma patients were treated with IMRT and chemotherapy at our hospital. Median radiation doses delivered to gross tumor volume and positive neck nodes were 66–70 Gy, 63 Gy to clinical target volume, and 50.4–56 Gy to clinically negative neck. The clinical toxicities, patterns of failures, locoregional control, distant metastasis control, disease-free survival, and overall survival were observed. Results: The median follow-up time was 52.2 months (range: 11–87 months). Epstein–Barr virus infection was positive in 63.2% of patients. Overall disease failure developed in 21 patients, of whom 85.8% belonged to stage III/IV disease. Among these, there were seven locoregional recurrences, three regional recurrences with distant metastases, and eleven distant metastases. The median interval from the date of diagnosis to failure was 26.5 months (range: 16–50 months). Six of ten (60%) locoregional recurrences were treated with reirradiation ± concurrent chemotherapy. The 5-year locoregional control, distant metastasis control, disease-free survival, and overall survival rates of whole cohort were 81.1%, 74.3%, 60.1%, and 73.4%, respectively. Cox regression analyses revealed that neoadjuvant chemotherapy, age, and Epstein–Barr virus were independent predictors for disease-free survival. Conclusion: Neoadjuvant chemotherapy followed by IMRT with or without chemotherapy improves the long-term survival of Saudi patients with nasopharyngeal carcinoma. Distant metastasis was the main pattern of treatment failure. Neoadjuvant chemotherapy, age, and Epstein–Barr virus status before IMRT were important independent prognostic factors. Keywords: nasopharyngeal carcinoma, treatment outcomes, patterns of failures, prognostic factor