Follicular carcinoma of thyroid is a well differentiated thyroid malignancy. It is slow growing in nature and tends to metastasize to remote organs in advanced stage by hematogenous route. Lung and bone are the two most common sites of metastasis. In most of the reported cases of follicular thyroid carcinoma metastasizing to the skull, metastases occurred long after the diagnosis and institution of treatment for primary cancer. Very few cases have been reported with occult follicular thyroid carcinoma presenting as skull metastasis. A 48-year-old female patient presented with massive swelling in the frontal region of skull associated with swellings in occipital region. Evaluation confirmed that it is multiple metastases to skull bones from follicular thyroid carcinoma. This is a very rare presentation with such a large size of metastasis. We report this case of a metastatic follicular thyroid carcinoma presenting as massive skull tumor at our institution.

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A 60-year-old man presented with abdominal pain for 3 months. Clinical examination revealed a well-defined intra-abdominal mass lesion measuring about 5 ¥ 6 cm, which was located in the left of umbilical region and extending into the left lumbar quadrant. The mass was mobile, non-tender and had firm consistency. The rest of the clinical examination and routine investigations were normal. The patient was evaluated with ultrasound of the abdomen, which showed 7 ¥ 8 ¥ 7 cm 3 hypo-echoic and solid nature mass underneath the parietal wall, with no intervening bowel coils. Contrastenhanced computed tomography scan confirmed ultrasound findings; in addition, it showed mass in close proximity to loop of small bowel and its mesentery (Fig. 1a). The patient underwent exploratory laparotomy, and intraoperative mass was seen arising from anti-mesenteric border of the ileum about 50 cm proximal to ileocaecal junction (Fig. 1b). The mass was resected en-bloc with adjacent ileum and end-to-end anastomosis was performed. Resected specimen showed (Fig. 2) that the mass is arising from diverticulum of small bowel, that is, Meckel's diverticulum. Post-operative period was uneventful. Histopathology revealed both spindle and epitheloid-shaped tumour cells with marked nuclear atypia, suggestive of malignant gastrointestinal stromal tumour (GIST). Immunohistochemistry revealed tumour cells positive for CD 117(C-KIT). The patient was followed up after two years and showed no recurrence/metastasis.Meckel's diverticulum is the most commonly encountered congenital anomaly of the small intestine, occurring in approximately 2% of the population. 1 It is located on the anti-mesenteric border of the ileum, approximately 4560 cm proximal to ileo-caecal valve and results from incomplete closure of omphalo-mesenteric duct. An equal incidence is found among men and women. Meckel's diverticulum has lining mucosa similar to that of the adjacent bowel but may contain heterotopic mucosa, the most common of which is gastric mucosa in 50%, pancreatic mucosa in 5% and may also harbour colonic mucosa. The majority of Meckel's diverticula are incidentally discovered during autopsy, laparotomy or barium studies. The most common clinical presentations of Meckel's diverticulum are gastrointestinal bleeding (from chronic ulcer in ileum adjacent to Meckel's diverticulum containing gastric mucosa), intestinal obstruction and diverticulitis. Incidence of tumours within Meckel's diverticulum is 0.53.2%, most of them are benign tumours like leiomyomata, angiomas, lipomas and villous adenomas. Malignant neoplasms include adenocarcinoma, sarcoma, carcinoid tumour, melanoma, lymphoma and GIST. 2,3 GISTs are rare neoplasms that account for 0.1-1% of gastrointestinal malignancies. Described in 1983 by Mazur and Clark, 4 GISTs arise from interstitial cells of Cajal, the pacemaker cells of the gastrointestinal tract. 5 GIST occurs in adults at a median age of 58 years and most commonly arise from stomach (60%), small intestine (30%) and less than 10% in the oesophagus, c...

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