Carcinoma in thyroglossal duct remnants; review of literature and report of 2 cases

Coincidence of Thyroid Tumor and Thyroglossal Duct Remnants. Review of the Literature and Presentation of Three Cases

Aims and Background

The coincidence of benign or malignant thyroid tumors with thyroglossal duct remnant (TDR) cysts is rare. Although the precise etiology is still unclear, thyroid origin and spread from a primary site have been suggested and this obviously has important implications for the therapeutic approach. Three cases of thyroglossal duct carcinoma are presented and its management is discussed on the basis of the current rationale for treatment of thyroid cancer. The indication for surgery depends on positive findings in the thyroid gland (nodules, FNAB). The aim of this study was to review our experience in the management of papillary thyroid diseases associated with TDR.

Materials and Methods

The records of three patients with thyroid tumors associated with TDR treated at the Department of ENT and Head and Neck Surgery of the First Medical Faculty UK of Prague between January 1991 and January 2001 were analyzed. We searched for risk factors of thyroid carcinoma: history of ionizing radiation, history of thyroid diseases, age, tumor size, tumor spread and histopathological factors.

Results

We used a triple approach consisting of clinical and ultrasound examination and fine-needle aspiration biopsy for preoperative assessment. Our diagnostic and therapeutic procedures included TDR excision (Sistrunk or Schlange procedure) and total thyroidectomy. Although the therapeutic approach could be a matter of discussion, most patients agreed with our suggestion of relatively radical but non-mutilating treatment. Postoperative radiation or radioiodine ablation is considered in cases of TDR carcinoma or thyroid carcinoma associated with TDR. Oncological follow-up included clinical and ultrasound examination three times during the first year, twice in the second year, and once yearly thereafter. Tumor marker evaluation and/or scintigraphy were performed 6, 12 and/or 24 months following surgery.

Papillary Carcinoma of the Thyroglossal Duct

A 59-year-old woman had a submental mass for 9 years. Surgical resection revealed a solid rounded tumor, 6 cm in diameter, connected with a cyst of the thyroglossal duct. The histological examination showed a non-obliterated thyroglossal duct with cystic dilation and a papillary thyroid carcinoma. This is the 20th case of carcinoma in a thyroglossal remnant described in the literature.

Thyroglossal Duct Cyst Carcinomas in Pediatric Patients: Report of Two Cases with a Comprehensive Literature Review

Thyroglossal duct cyst (TGDC) carcinomas are rarely encountered in the pediatric population. The clinical behavior of these tumors in the pediatric setting is unclear and management is not well defined. Two cases of pediatric thyroglossal duct cyst carcinoma were identified in a review of all thyroglossal duct cysts diagnosed over a ten year period. These two cases were analyzed along with 57 cases of thyroglossal duct cyst carcinoma affecting patients less than 21 years of age compiled from the English literature. Fifty-nine patients (36 females, 23 males) aged 6-20 years (mean 15.0 years) were identified. All presented with an anterior midline neck mass, which was typically mobile and non-tender. The average tumor size was 2.6 cm. Histologically, all tumors were papillary thyroid carcinomas arising in a background of a thyroglossal duct cyst. The tumors exhibited a papillary, follicular, or mixed architecture with classical papillary thyroid carcinoma nuclear features. Soft tissue extension was present in 16 cases. All patients were managed surgically with a Sistrunk procedure, with additional thyroidectomy performed in 29 patients, combined with a lymph node dissection (n = 15), or a Sistrunk and lymph node dissection (n = 5). All patients were stage I at presentation, with 11 showing lymph node metastases. Postoperative radioactive iodine was employed in 20 patients. A papillary carcinoma of the thyroid gland was reported in four of the patients who had concurrent/subsequent thyroidectomies. Recurrences were reported in four patients, with distant metastases in one patient, who died of disease (13 months). Follow up data was available for 45 patients, with an overall mean follow-up of 54.5 months. All patients were alive, with the exception of one who died with disease. TGDC carcinomas in pediatric patients is associated with a good overall prognosis, best managed by Sistrunk procedure alone, with selected lymph node dissection if clinically indicated.

Thyroglossal duct cyst carcinoma: diagnostic and management considerations in a 15-year-old with a large submental mass

A 15-year old boy presented with a 2-year history of a painless slowly enlarging submental neck mass. Head and neck imaging showed a multicystic mass with a central solid component that was closely applied to the hyoid bone. Core needle biopsy under general anaesthesia revealed a papillary thyroid neoplasm. The mass was resected and frozen section histology confirmed papillary carcinoma. Intraoperatively, enlarged cervical lymph nodes were palpable. Bilateral neck dissections and total thyroidectomy with parathyroid reimplantation were performed. On histological examination, the thyroid gland was not involved. The patient recovered uneventfully from the surgery and is planned for radioactive iodine therapy and thyroxine suppression, with subsequent follow-up with serum thyroid-stimulating hormone and thyroglobulin for surveillance. We review the literature and discuss challenges in the diagnosis and surgical management of this rare entity in the paediatric age group.

An adolescent with a rare midline neck tumor: thyroid carcinoma in a thyroglossal duct cyst

Occurrence of malignancy in a thyroglossal duct cyst (TDC) in children and adolescents is very rare, preoperative diagnosis is a challenge, and appropriate management is still debated. We report a 19-year-old male patient referred for a midline neck mass diagnosed as an atypical TDC after initial and subsequent investigations. Ultrasound-guided fine-needle aspiration (FNA) of the mass was diagnostic for papillary thyroid carcinoma. Sistrunk procedure and total thyroidectomy were performed. Histologic analysis confirmed the presence of papillary thyroid carcinoma within TDC, infiltrating surrounding soft tissues. Postoperatively, radioiodine ablation treatment was administered, followed by TSH suppression therapy.

Thyroglossal duct carcinoma: a case report

We describe a 47-year-old woman with a 13-year history of asymptomatic midline submental swelling. Cytologic examination of a fine-needle aspiration specimen from the solid mass revealed adenocarcinoma. The preoperative diagnosis was thyroglossal duct carcinoma. A Sistrunk procedure was performed and microscopic examination revealed papillary adenocarcinoma. The postoperative course was uneventful and there were no signs of local recurrence or metastasis at one year after surgery.

The thyroglossal cyst

The thyroglossal cyst is the most common nonodontogenic cyst in the neck. This cyst may also occur in the lingual or submental areas, though more rarely. Malignant changes have been described. Clinically, no differentiation between a benign cyst and a malignancy can be made. The literature is reviewed regarding the embryology, epidemiology, etiology, symptomatology, radiology, histology, and treatment of this cyst and its malignant counterpart.

Clinicopathological studies on thyroglossal duct remnant

The clinicopathological findings in 48 cases underwent complete surgical excision of epithelial tissue of the thyoglossal duct remnants were reviewed. Simple incision of the cyst does not seem to have any therapeutic value and would be followed frequently by recurrence. The widely used Sistrunk procedure 2,6 surgical excision of the central portion of the hyoid bone together with fibrous tract extending to the base of tongue, seems to be warranted in some cases so long as complete eradication of the epithelial tissue can be made.

Thyroglossal duct carcinoma

Primary carcinoma of the thyroglossal duct is rare. This discussion reports two cases and reviews the 50 previously reported in the literature. The criteria for diagnosis include evidence of a thyroglossal duct remnant and a normal thyroid gland. The differentiation from cystic metastases to lymph nodes is pointed out. The histologic types parallel those of carcinoma of the thyroid gland, papillary carcinoma being the most common and having a generally favorable prognosis. The clinical presentation of these tumors is similar to that with benign cysts and thus is of limited value in the diagnosis.

Carcinoma arising in thyroglossal duct remnant: case reports and review of the literature

Two cases of thyroglossal duct cyst carcinoma are presented and the world literature is reviewed. There are only 74 cases reported to date. In nearly all the cases the clinical diagnosis was thyroglossal cyst. Although the great majority of the tumours were papillary adenocarcinomas, 13-15 per cent were of other histological types. The treatment has been quite variable, but the most common initial treatment was Sistrunk's (1928) operation. Following the establishment of the diagnosis of malignancy, thyroidectomy was done in several cases, but it failed to show any evidence of malignancy in most of the thyroids removed, which establishes firmly the de novo origin of these tumours from the thyroglossal duct remnant. In only one case had tumour disseminated to distant organs, the lung, liver, etc. The scepticism as to whether some of the carcinomas associated with thyroglossal duct remnants may not in fact represent metastases from a small primary tumour of thyroid gland is examined. It appears that, though a possibility of primary or metastatic tumour in the thyroid does exist, the probability does not appear to be high. From our own experience it is suggested that local excision followed by radiotherapy, irrespective of recurrence, may be worth considering for the treatment of such carcinomas.

Thyroid carcinomas arising in thyroglossal ducts

Six cases of thyroid carcinoma arising in a thyroglossal duct cyst are described and combined with previously reported cases to provide a total of 66 cases for retrospective analysis. Most presented as benign thyroglossal duct cyst, and the malignant nature of the lesion was not recognized until the permanent pathology sections were reviewed. Eight of 10 patients with metastatic disease in retrospect had preoperative indications of malignancy as manifest by clinically suspicious nodes or a thyroglossal cyst larger than the mean for the series. The primary cell type in all cases was papillary thyroid carcinoma. Local resection by the Sistrunk method and suppressive doses of thyroid are recommended for the patient with papillary thyroid carcinoma arising in a thyroglossal duct cyst when there is no evidence of extension of the malignancy beyond the confines of the cyst. The patient presenting with metastatic carcinoma should, of course, be treated with appropriate local resection, hormonal manipulation, thyroid ablation, and lymphadenectomy as indicated by his age and sex, the cell type of the tumor, and the extent of local and metastatic disease.

An unusual thyroid gland

A patient is described in whom the only thyroid tissue present was a mass approximately 4 cm. in diameter situated high up in the neck and just lateral to the laryngeal prominence of the thyroid cartilage. Degenerative changes in this ectopic gland were marked. An ectopic gland in such a position has not previously been described in euthyroid adults. The embryological development, functional activity, and pathology of ectopic thyroid glands are discussed.