The occurrence of skin metastases are rare events in the course of a follicular thyroid carcinoma (FTC) and usually indicate advanced tumor stages. The scalp is the most affected area of these metastases 123456. Operations are mostly performed with palliative intention. We present a case with extensive and symptomatic scalp metastases in a female patient. The tumors were resected under general anaesthesia. Mesh graft was successfully used to cover the skin defects.

A 76-year old female patient had the initial diagnosis of FTC 18 years ago. She had total thyroidectomy with bilateral neck dissection and multiple reoperations for recurrent tumor. Because of an irresectable local recurrence with tracheal infiltration a tracheotomy was performed two years ago. Five sets of internal radiation therapy, had been performed one year ago with a cumulative activity of 55.400 MBq¹³¹I. She was admitted to our hospital because of four intensively vascularized scalp tumors, two of them of hen's egg size (Fig. 1a, b, and 2) which showed recurrent episodes of contact bleeding during hair dressing. Computed tomography revealed multiple pulmonary, hepatic and bone metastases. Thyreoglobulin level was highly elevated (6750 ng/ml) Nevertheless the patient was in a good general condition. We performed a resection of the scalp tumors under general anesthesia. Histopathology confirmed cutaneous metastases of FTC (Fig. 3). The places of resection were primary left for granulation. After achievement of a clean granulation area using vacuum therapy (V.A.C.^®, KCI International, Amsterdam, The Netherlands) we performed a mesh graft skin transplant (Fig. 4a, b).

A follow up examination fourteen months later showed a very good cosmetic result with nearly complete healing of the mesh graft transplant (Fig. 5a, b). Because the local neck tumor had continued to grow the patient was now convinced to accept external radiation therapy and was admitted to our department of radiation oncology.

Follicular thyroid carcinomas (FTC) often spread to bones and lung 7. The occurrence of cutaneous metastases is a rare event. Many different locations have been decribed as abdomen, back and front thigh 8, but predominantely the skin of head and neck is affected 123456. In a review of the literature Quinn and coworkers 1 found scalp metastases in 9 of 14 patients with cutaneous metastases of FTC. In a study of Erickson and coworkers 9 none of 5 FTC metastatic to the skin showed BRAF(V600E) mutation (T1799A).

We demonstrate another case with multicentric form. Because of its location and size a primary wound closure was not possible. A healing could be reached using vacuum therapy and mesh graft transplantation. The palliative long term cosmetic and functional result was excellent.

The authors declare that they have no competing interests.

KC had idea to publish the case report and drafted the manuscript, UR was our pathologist and performed the immunohistochemistry, AR and MK helped to to search and analyse thoroughly the literature, AR and WTK performed the initial operation, mesh graft transplantation and follow up examination of the patient. They also initiated the temporary vaccum therapy. All authors read and approved the final manuscript.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.