Squamous cell carcinoma of the upper aerodigestive tract associated with well-differentiated carcinoma of the thyroid gland

De-differentiation of papillary thyroid carcinoma into squamous cell carcinoma in an elderly patient: A case report

RATIONALE

The unpredictability of thyroid cancer can be striking, as the disease may rapidly progress to death in some individuals. Herein, we reported a rare case of aggressive papillary thyroid cell carcinoma (PTC) in an elderly patient de-differentiated into squamous cell carcinoma (SCC).

PATIENT CONCERNS

We describe a case of a 79-year-old Thai woman presented with hoarseness and neck mass for 2 months and she had been diagnosed with a 3-cm papillary thyroid carcinoma (PTC) in the right side of the thyroid gland. Later on PTC de-differentiated into SCC within 3 years after initial presentation.

DIAGNOSIS

De-differentiation from papillary thyroid carcinoma to squamous cell carcinoma.

INTERVENTIONS

The patient underwent a total thyroidectomy at the initial hospital and received high dose radioactive iodine (RAI) treatment at our hospital 1 month following the surgery and then was lost to follow-up. Two years later she came back with new development of right solid-cystic neck mass which was found to be recurrent PTC. A radical neck dissection was done and another high dose RAI treatment was given. However, she developed recurrent mass with tenderness at the site above previous solid cystic mass 6 months later. Re-exploration of the neck mass revealed an inflamed midline mass 2 cm with enlarged right lateral cervical lymph nodes.

OUTCOMES

A histopathological examination of the midline neck mass showed poorly differentiated SCC with lymphatic invasion. The intermingling of two morphologically distinct tumors, a typical PTC and a poorly differentiated SCC, had been identified in 1 out of 14 excised cervical lymph nodes. The patient underwent external beam radiation without chemotherapy. She is still in stable condition at 18 months post-treatment.

LESSONS

This case clearly demonstrated that SCC transformed from a pre-existing PTC. The clinician should consider a possible transformation of papillary thyroid cancer into more aggressive histological types in elderly patients who present with rapidly progressive clinical behavior. However, some patients could have long-term survival if the tumor did not transform into anaplastic thyroid cancer.

Incidental nodal metastasis of differentiated thyroid carcinoma in neck dissection specimens from head and neck cancer patients

BACKGROUND

Occult differentiated thyroid carcinomas are not uncommon. The initial presentation of a thyroid carcinoma is often detection of a metastatic cervical lymph node.

METHODS

A retrospective review was performed of the medical records of 304 patients who underwent neck dissection between 1996 and 2008 for squamous cell carcinoma of the head and neck.

RESULTS

Ten patients (3.3 per cent) had nodal metastasis originating from papillary thyroid cancer. All of these patients underwent thyroidectomy and post-operative 131iodine radiometabolic therapy. No patient developed a thyroid tumour after surgery.

CONCLUSION

Despite its metastatic spread, thyroid cancer does not affect the overall prognosis of patients who are already being treated for a more aggressive malignancy. However, in otherwise healthy patients, it is worth treating this second malignancy to avoid potential complications related to local disease or metastatic thyroid cancer.

DIRC3 and near NABP1 genetic polymorphisms are associated laryngeal squamous cell carcinoma patient survival

Laryngeal squamous cell carcinoma (LSCC) is one of the most common and aggressive malignancies of the upper digestive tract. The present study is a retrospective analysis of data from a prospective longitudinal study. A total of 170 male LSCC patients (average age, 60.75±10.082) at the First Affiliated Hospital of Xi'an Jiaotong University School of Medicine were recruited between January 2002 and April 2013 for this study. We assessed correlations between patient characteristics and survival, and sequenced genomic DNA from patient peripheral blood samples. We found that the single nucleotide polymorphisms (SNPs), rs11903757, with closest proximity to NABP1 and SDPR, and rs966423 in DIRC3, were associated with survival in LSCC patients. Median follow-up was 38 months (range 3-122) and median survival time was 48 months. LSCC patients with total laryngectomy, poor differentiation, T3-T4 stage, N1-N2 stage or III-IV TNM stage had reduced survival. This is the first study to demonstrate that the rs11903757 GT (HR=2.036; 95% CI, 1.071-3.872; p=0.030) and rs966423 TT (HR=11.677; 95% CI, 3.901-34.950; p=0.000) genotypes predict poor patient outcome. These polymorphisms may serve as useful clinical markers to predict patient survival, and to guide individual patient therapeutic decisions.

Incidental findings of thyroid tissue in cervical lymph nodes: old controversy not yet resolved?

The clinical significance of papillary or follicular thyroid tissue incidentally discovered in cervical lymph nodes during pathological assessment of neck dissections for non-thyroid cancers of the upper aero-digestive tract is critically reviewed. Special emphasis is given to controversies over normal-looking, nodal, thyroid follicles. Arguments for and against the benign nature of these follicles are considered together with processes that could be involved in their formation. The admittedly limited evidence suggests that benign, thyroid follicular inclusions rarely occur in cervical lymph nodes. Histological criteria that could be helpful in recognizing the inclusions, which include assessing their extent in conjunction with the size of the node, are discussed. Finally, an algorithm based on collaboration between specialists, correlating histological findings with imaging and loco-regional control of the upper aero-digestive tract cancer, is suggested for the management of patients with incidentally discovered, nodal thyroid tissue.

Triple primary cancers of the head and neck: case report and literature review

BACKGROUND

Coincident thyroid and head and neck squamous cell carcinomas are rare. This paper presents a case of synchronous laryngeal squamous cell carcinoma, follicular thyroid carcinoma and micropapillary thyroid carcinoma.

METHODS

A PubMed search was performed for articles describing synchronous thyroid and head and neck squamous cell carcinomas, using the search terms 'thyroid cancer', 'cancer of the head and neck', 'synchronous' and 'synchronous neoplasm'.

RESULTS

The literature suggests that the head and neck squamous cell carcinoma stage is a better predictor of outcome than the extent of surgical treatment of the thyroid gland in synchronous malignancies.

CONCLUSION

The decision regarding surgical treatment of the thyroid in synchronous thyroid and head and neck squamous cell carcinomas should take several factors into account. The head and neck squamous cell carcinoma stage is the strongest predictor of outcome, although patient-related factors and the location of malignant thyroid tissue may also affect management.

Incidental thyroid cancer found during surgery for head and neck squamous cell carcinoma

OBJECTIVE

To quantify the incidence of occult thyroid cancer encountered during neck dissection in patients with head and neck squamous cell carcinoma (HNSCC), to discuss the management of these patients, and to assess the need for further treatment of the incidentally discovered thyroid cancer.

STUDY DESIGN

Case series with chart review.

SETTING

University-based tertiary care hospital.

METHODS

The authors retrospectively reviewed 2538 neck dissections performed at their institution over a 15-year period. Twenty-nine patients had an incidental pathologic finding of thyroid cancer at surgery. The authors reviewed demographics, diagnoses, histopathology, initial and subsequent management, and outcome.

RESULTS

Well-differentiated thyroid cancer (WDC) was found in every case in this cohort. Fifteen patients died during the period of the study (2.4-year follow-up), with 14 patients still alive (4.3-year follow-up). Seven patients, all of whom are still alive, received further treatment for their thyroid cancer: 2 with completion thyroidectomy, 2 with I-131 ablation, and 3 with both. There was no clinical evidence of recurrence of thyroid cancer in any of the patients who died, and none died as a result of thyroid cancer. In addition, none of the patients still alive have biopsy-proven evidence of thyroid cancer recurrence.

CONCLUSION

None of the patients in this cohort died as a result of their thyroid disease, and none of the patients had evidence of recurrence of their WDC during the follow-up period. The results suggest that further management of occult WDC discovered in patients receiving neck dissections for HNSCC is not necessary.

Thyroid cancer incidentally found in radical surgery for laryngeal/hypopharyngeal cancer

OBJECTIVES

To report on four patients with thyroid cancer found in their specimen of laryngectomy for laryngeal/hypopharyngeal cancer.

STUDY DESIGN

Retrospective case series.

SETTING

Patients with laryngeal cancer and hypopharyngeal cancers treated at our institution between 1991 and 2005 were enrolled.

SUBJECTS AND METHODS

There were 463 patients with laryngeal cancer and 219 patients with hypopharyngeal cancers under retrospective review.

RESULTS

There were 254 patients with laryngeal caner and 130 patients with hypopharyngeal cancer receiving surgery. Thyroid cancer was observed in the resected thyroid gland in two cases of laryngeal cancer and in two cases of hypopharyngeal cancer. They received treatment only for their laryngeal/hypopharyngeal cancers. Two patients died of distant metastases from larynx/hypopharynx cancer within one year. The other two patients are currently alive without disease from either of the two types of cancer.

CONCLUSIONS

It is rare to discover an unexpected simultaneous thyroid cancer confirmed postoperatively from thyroid tissue partially removed in laryngectomy. A conservative approach is suggested for such patients.

Algorithm for safe and effective reoperative thyroid bed surgery for recurrent/persistent papillary thyroid carcinoma

BACKGROUND

The aim of this study was to review our experience with reoperative thyroid bed surgery (RTBS) for recurrent/persistent papillary thyroid cancer (PTC), and present an algorithm for safe and effective RTBS.

METHODS

This is a retrospective study. Records of 33 consecutive patients who underwent RTBS for recurrent/persistent PTC in a previously operated thyroid bed, and were operated upon by the senior author (R.P.T.) July 2001 to January 2006 were reviewed. Reports of the pre- and post-RTBS serum thyroglobulin (TG) levels, the high-resolution thyroid bed ultrasound examination, pre-RTBS FNA cytopathology, as well as the post-RTBS final histopathology were reviewed. Recurrent laryngeal nerve (RLN) monitoring was used for all patients. Reports of the intra-RTBS condition of the RLN and any reported surgical complications were reviewed. In addition, reports of the pre- and post-RTBS fiberoptic laryngoscopy as well as pre- and post-RTBS serum calcium levels were reviewed.

RESULTS

In our study, 33 consecutive patients underwent RTBS for recurrent/persistent PTC with or without lateral neck dissection. In 30 patients, recurrent/persistent PTC was suspected because of rising serum TG levels, interpreted in conjunction with serum anti-TG-antibody titers by the endocrinology service at our institution. Three patients had serum anti-TG antibodies and their disease was detected and FNA confirmed by a regularly scheduled surveillance ultrasound examination. All patients underwent pre-RTBS high-resolution thyroid bed ultrasound examination and FNA for all suspicious masses. All patients had FNA-confirmed PTC in the thyroid bed. All patients had detailed diagrams localizing areas of FNA-confirmed PTC in the thyroid bed provided to the surgeon. In all study patients, post-RTBS histopathologic findings confirmed sites of recurrent/persistent PTC determined by pre-RTBS US guided FNA. All RLNs (53/53) that were at risk were successfully identified. In 3 patients, the RLN was electively resected because of the envelopment by a large paratracheal mass or tumor densely adherent to the RLN insertion point at the cricothyroid region. There was no incidence of unexpected RLN injury, permanent hypocalcemia, or any other surgery-related complication. Post-RTBS serum TG levels were significantly decreased or undetectable in most patients (2 patients had concurrent lung metastases), when compared with pre-RTBS levels. No patient exhibited thyroid bed recurrent/persistent PTC in the post-RTBS period based on semiannual high resolution neck ultrasound examination with a median follow-up of 2 years.

CONCLUSIONS

Safe and effective RTBS is based on a multidisciplinary approach that enables the identification and localization of recurrent/persistent PTC. The surgical algorithm for RTBS described, provides a pathway that all endocrine-head and neck surgeons can comfortably utilize to treat this complex and challenging patient population.

Thyroid carcinoma associated with squamous cell carcinoma of the head and neck: which policy?

BACKGROUND

Thyroid carcinoma occurring as a second primary associated with head and neck squamous cell carcinoma (HNSCC) is unusual. The clinical management of thyroid cancer in such cases has been debated.

METHODS

Between 1975 and 2004, we collected 33 cases. The associated thyroid carcinoma was diagnosed either during or as a consequence of surgery planned as head and neck cancer treatment.

RESULTS

The associated thyroid carcinoma was never seen to recur. Five-year overall survival was 41%. Disease-free survival after 40 and 66 months was 11.1% and 5.6%, respectively.

CONCLUSIONS

We consider the treatment of thyroid cancer to be complete when the thyroid gland, either with or without lymph nodes, has been included in the specimen obtained during surgery for HNSCC. In the group of cases in which associated thyroid carcinoma was only found within the neck lymph nodes and the thyroid gland has not been treated, we discourage further surgical treatment or radioactive iodine therapy.

Incidental metastases of well-differentiated thyroid carcinoma in lymph nodes of patients with squamous cell head and neck cancer: eight cases with a review of the literature

The examination of a large series of cervical lymph nodes in patients with head and neck cancer revealed the presence of incidental metastases of occult thyroid carcinoma in eight patients, of which six cases were squamous cell carcinoma of glottic and supraglottic sites of the larynx and two cases were pyriform sinus and tongue carcinomas. Three patients had two lymph nodes and the remaining patients had one lymph node each involved. The nodal chains affected were the jugular (n=5; level IV), Kuttner (level II), supraomohyoid (level III) and supraclavicular (level VI). In four cases, a subtotal thyroidectomy or unilateral lobectomy was performed during laryngectomy (for surgical reasons) or after histologic nodal examination; a minimal focus of thyroid papillary carcinoma was detected in one patient. Three of eight patients died from recurrence of the squamous cell carcinoma; no case presented clinical evidence of thyroid malignancy. The differential diagnosis from benign thyroid heterotopia was based on the presence of minimal nuclear atypia. The choice of treatment of patients with a coexisting neoplasm characterized by poor prognosis is difficult, and contrasting opinions exist regarding the use of radical thyroidectomy and the subsequent management. As reported in the literature (66 cases), the more aggressive squamous cell carcinoma will determine the prognosis of these patients; in fact, only one of the referred cases died of cerebellar metastases of the thyroid cancer. Our results emphasize the importance of an accurate re-evaluation and follow-up of patients with incidental occult metastases for detection of a primary thyroid tumor. In the general population, this incidental nodal involvement may be related to a minimal occult thyroid carcinoma.

Incidental metastatic papillary thyroid carcinoma in microvascular reconstruction

OBJECTIVES/HYPOTHESIS

Occult papillary thyroid carcinoma has a reported prevalence of 1% to 35% based on autopsy studies. Cervical lymphatic metastases from papillary thyroid carcinoma have been associated with a higher likelihood of recurrence with a questionable impact on survival. Without clinically evident disease in the thyroid or cervical nodes, management of these patients presents a treatment dilemma. We propose an individualized treatment plan for patients in whom metastatic papillary thyroid carcinoma is incidentally detected during neck exploration for other purposes.

STUDY DESIGN

Retrospective review and discussion of the literature.

METHODS

The clinical course of two patients with incidentally discovered metastatic papillary thyroid carcinoma to the cervical lymph nodes is described. Both patients had previously received head and neck irradiation in childhood and required free flap reconstruction of extensive skull base defects following extirpation of meningiomas.

RESULTS

Neck dissection specimens from levels I and II obtained during exposure of recipient vessels for microvascular tissue transfer revealed papillary thyroid carcinoma in both cases. The patients subsequently underwent total thyroidectomy, neck dissection, and postoperative radioactive iodine ablation of residual thyroid tissue. After 1 year of follow-up, both patients were without evidence of recurrent disease.

CONCLUSIONS

An individualized approach is justified to treat metastatic papillary thyroid carcinoma incidentally discovered during other procedures. The case reports underscore the importance of pathological analysis of surgical specimens obtained during head and neck reconstruction.

Significance and management of thyroid lesions in lymph nodes as an incidental finding during neck dissection

BACKGROUND

The incidental discovery of thyroid lesions in lymph nodes during a lymph node dissection performed for a separate primary head and neck tumor is an unusual clinical entity. Its discovery has led to controversy regarding its significance and management.

METHODS

We identified five patients over the years 1991-1999 with this finding. All five patients were subsequently treated with a total thyroidectomy and a level VI lymph node dissection.

RESULTS

Pathological examination revealed three papillary carcinomas and level VI lymph node metastases in the two patients who had carcinoma in their thyroid glands. All five patients are presently free of their primary and thyroid disease on follow-up examinations.

CONCLUSIONS

These patients should be addressed with additional work-up and surgery if metastatic thyroid cancer is documented in the lymph node. We offer a diagnostic algorithm that may aid in further work-up and treatment in these unusual cases.

Management of the clinically negative cervical lymph nodes in patients with non-conventional squamous carcinoma of the larynx

This paper discusses the indications for neck dissection in those patients with laryngeal tumours which prove to be, on pathologic examination, not conventional squamous carcinomas but rather fall into the category either of one of the uncommon histological subtypes of carcinoma, or another type of unusual histological variant of laryngeal malignancy, a mesenchymal tumour. It appears as though these unusual laryngeal malignancies may manifest both biological behaviours and propensities to metastasize to regional lymph nodes that differ from those of the more commonly encountered conventional squamous carcinomas of the larynx. This heterogeneous group of tumours accounts for about 10 per cent of all malignant tumours of the larynx.

Thyroid carcinoma causing fatal laryngeal occlusion

Pure squamous carcinoma of the thyroid gland is an uncommon tumour and is thought to arise in glands containing metaplastic squamous epithelium. Extrinsic compression or tumour invasion of the larynx causing fatal respiratory obstruction are recognized complications. We report a case of primary squamous carcinoma of the thyroid gland where obstruction of laryngeal mucous gland outflow resulted in fatal laryngeal compression. This appears to be the first description of such a sequence of events.

Papillary thyroid carcinoma associated with squamous cell carcinoma of the head and neck: significance and treatment

Several studies in the recent literature would suggest that PTC found incidentally in the cervical lymphatics may be significant. By age alone, most of our head and neck cancer patients will fall into an intermediate risk group. There are also data to suggest that cervical metastasis from PTC may portend higher recurrence and mortality and that occult PTC may be a biologically significant situation. Many patients with cancer of the head and neck either have a good prognosis or don't follow the rules of their predicted prognosis, and for these patients living with the knowledge of an untreated thyroid, cancer may be an unnecessary concern. Other factors to be considered are that early PTC is probably curable disease and that there is real risk of transformation to higher grade or anaplastic cancer. Finally, there is no way to accurately predict the behavior of PTC. The decision to treat these cancers is ultimately made by the patient and the physician, and if there is a treatment with low morbidity that will alleviate concern of PTC recurrence, then this may outweigh the risk of treatment. Situations may exist when treating incidental PTC could be deferred. These include: a dismal prognosis for the head and neck primary when quality time outside of the hospital is the goal of the patient and the physician; or if the head and neck primary tumor requires external beam radiation therapy, because this may be adequate therapy for occult PTC. In summary, the scenario of PTC found incidentally in the neck treated for a head and neck SCC is unusual. Each patient will have a unique clinical situation based on the site and stage of the SCC, the age of the patient, and the treatment required for the SCC. Treatment options include total thyroidectomy, thyroid lobectomy, the administration of I131, and/or the use of external beam radiation, which must be weighed against the option of close clinical follow-up. In general, we recommend total thyroidectomy for PTC found incidentally in the cervical LNs for the reasons that have emerged from a recent review of the medical literature. We report 7 patients with synchronous head nad neck SCC and PTC who have all received surgical treatment for PTC (Table 1). In addition, we advocate postoperative radioiodine scanning with radioablation of metastatic or persistent PTC, or remnant ablation if uptake is greater than 2%. Our goal as head and neck surgeons should be to avoid inadequate therapy for incidental PTC.

Metastatic thyroid cancer as an incidental finding during neck dissection: significance and management

Occult thyroid cancer is an occasional incidental finding during surgery for other indications and is usually considered of minor clinical significance; however, the appropriate approach for incidentally found metastatic thyroid cancer is less clear especially when it occurs in the context of another malignancy that has more aggressive potential. Among 2,855 patients treated for squamous cancer of the tongue at The University of Texas M. D. Anderson Cancer Center, eight patients had coexisting differentiated thyroid cancer metastatic to cervical lymph nodes which was found incidentally during regional lymph node dissection. The eight patients included three women and five men with a median age of 47 years (range, 32-62 years); tumors were of the papillary variety in four patients and follicular in the other four. In one patient, no gross or microscopic primary tumor could be identified after thyroidectomy; in another patient, no gross tumor was evident, but whole organ section revealed an area of fibrosis consistent with a primary lesion. Two patients had primary lesions less than 1 cm in maximal diameter. In four patients who had no surgery, physical exam and radiologic evaluation failed to show any intrathyroidal lesions. Clinically relevant thyroid cancer did not develop in any of those patients during the duration of documented follow-up (1-15 years). Three patients died of progressive tongue cancer, one patient of unrelated pulmonary disease, and four patients remain alive without evidence of disease for 1 to 15 years of available follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)