Case Report/Olgu Sunumu
Ege Journal of Medicine/ Ege Tıp Dergisi 2019;58(2):187-189
An unexpected clinical presentation of primary squamous cell carcinoma of
the thyroid gland
Beklenmedik bir klinik görüntü ile ortaya çıkan tiroid bezi primer skuamöz hücreli
karsinomu
Korhan Kılıç
1
Muhammed Sedat Sakat
1
Harun Üçüncü
2
Atatürk University Faculty of Medicine, Department of Otorhinolaryngology Head and Neck Surgery,
Erzurum, Turkey
2
Sıtkı Koçman University Faculty of Medicine, Department of Otorhinolaryngology Head and Neck
Surgery, Muğla, Turkey
1
Abstract
Primary squamous cell carcinoma of the thyroid gland (PSCCT) is a rare disease which accounts less than 1% of all
thyroid cancers. Patients usually present with enlarging neck mass. In this paper we presented a 76-year-old female
patient with PSCCT whose initial finding was a cervical abscess. To our knowledge this is the first PSCCT case in the
literature presenting as cervical abscess. The patient was referred to our clinic with dysphasia, shortness in breathing
and hyperemic right neck mass, growing in size for 1 week. On physical examination a fluctuant and hyperemic mass
was observed at the right cervical region. Magnetic resonance imaging of neck and upper thorax revealed a mass in
the area of right thyroid gland, including cystic and necrotic component, progressing to the retrosternal area,
surrounding right jugular vein and common carotid artery. An open biopsy was performed. The histopathological
diagnosis was squamous cell carcinoma. Because of the extended invasion and infiltration of adjacent tissues, the
patient was accepted as inoperable in oncologic council. PSCCT is a rare and aggressive neoplasm of the thyroid
gland with poor prognosis. In a patient with deep neck spaces abscess, an underlying PSCCT should be kept in mind
to avoid delays in the diagnosis and treatment.
Keywords: Squamous cell carcinoma, thyroid cancer, cervical abscess.
Öz
Tiroid bezi primer yassı epitel hücreli karsinomu tüm tiroid kanserlerinin yaklaşık %1’ini oluşturan nadir bir hastalıktır.
Hastalar genellikle büyüyen bir boyun kitlesi ile başvururlar. Bu makalede, ilk bulgusu boyunda apse olan ve tiroid
bezinin primer skuamöz hücreli karsinomu tanısı alan 76 yaşında bir kadın hastayı sunduk. Hasta kliniğimize yutma
güçlüğü, nefes almada zorluk, boyun sağ kısmında son 1 haftadır iyice büyüyen hiperemik kitle şikayetleri ile
başvurdu. Fizik muayenede sağ boyun bölgesinde fluktuasyon gösteren, hiperemik kitle izlendi. Boyun ve üst toraks
manyetik rezonans görüntülemesinde tiroid bezi sağ kısmında, kistik ve nekrotik alanlar içeren ve retrosternal uzanım
gösteren, sağ juguler ven ve ana karotid arteri saran kitle izlendi. İnsizyonel biyopsi yapıldı. Histopatolojik tanı
skuamöz hücreli karsinom olarak rapor edildi. Komşu dokulardaki ileri invazyon ve infiltrasyon nedeniyle onkoloji
konseyi tarafından inoperabl kabul edildi. Tiroid bezi primer skuamöz hücreli karsinomu, kötü prognozlu, agresif
seyirli ve nadir bir kanserdir. Derin boyun apsesi şikâyeti ile başvuran hastalarda, tanı ve tedavideki gecikmelerden
kaçınmak için altta yatan bir tiroid skuamöz hücreli karsinomu bulunabileceği akılda tutulmalıdır.
Anahtar Sözcükler: Skuamöz hücreli karsinom, tiroid kanseri, servikal abse.
Corresponding Author: Korhan Kılıç
Atatürk University Faculty of Medicine, Department of
Otorhinolaryngology Head and Neck Surgery, Erzurum, Turkey
E-mail: korhankilic@gmail.com
Received: 05.01.2018 Accepted: 05.03.2018
187
Introduction
Primary squamous cell carcinoma of the thyroid gland
(PSCCT) is a rare disease which accounts less than 1%
of all thyroid cancers. Von Karst published the first case
of PSCCT in 1858 (1). PSCCT often occurs at fifth and
sixth decades. The prognosis of the disease is very
poor. The overall survival is less than one year (2). It
usually presents with an enlarging neck mass and upper
airway obstruction complaints but because of potential of
early local invasion, different symptoms may also arise.
Head and neck carcinomas may generate cervical
abscesses due to direct tumor extension lasting in
necrotic changes (3). In this paper we reported a very
rare case of PSCCT presenting as cervical abscess.
Case Report
A 76-year-old female referred to our clinic with
dysphasia, shortness in breathing and hyperemic right
neck mass, growing in size for 1 week. She had a history
of goiter for twenty years. On physical examination a
fluctuant and hyperemic mass was observed at right
cervical region. The pre-diagnosis of the patient was
cervical abscess. Drainage of the abscess and medical
treatment was administered. Laryngeal examination
revealed paralysis of right vocal cord. A magnetic
resonance imaging (MRI) of neck and upper thorax
which revealed a mass in the area of right thyroid gland,
including cystic and necrotic component, progressing to
the retrosternal area, surrounding right jugular vein and
common carotid artery was performed. The trachea was
restricted and displaced to left (Figure-1a-b). Fine needle
aspiration biopsy (FNAB) of thyroid gland showed
atypical cells but was non-diagnostic. An open biopsy
was performed. The histopathological examination
revealed moderately differentiated squamous cell
carcinoma in which some, but not all, of the neoplastic
cells in nests have pink cytoplasmic keratin. High power
of squamous cell carcinoma showed the presence of
intercellular bridges. Mitosis can also be seen. The
histopathological diagnosis was squamous cell
carcinoma (Figure-1c). As panendoscopic examination
and positron emission tomography ruled out the
possibility of other primary sites, the diagnosis of the
patient was PSCCT. According to the extended invasion
and infiltration of adjacent tissues, the patient was
accepted as inoperable in oncologic council. Supportive
treatment options including tracheotomy and PEG tube
were undertaken. Informed consent was obtained from
the patient.
Discussion
Head and neck cancers presenting as a neck abscess
are rare. Only a few cases have been reported about
initial presentation of head and neck cancers as neck
abscess (4). In a study performed by Wang et al. (5) an
underlying malignancy was found in 2 of 196 patients.
188
Figure-1. a. Axial MRI with contrast showed mass at right
thyroid lobule. Asterisk: Necrotic component,
Arrow: Common carotid artery surrounded by the
mass. b. Coronal MRI with contrast showed the
retrosternal progression of the mass. Arrow:
Displaced and restricted trachea. c. Moderately
differentiated squamous cell carcinoma in which
some, but not all, of the neoplastic cells in nests
have pink cytoplasmic keratin. High power of
squamous cell carcinoma showed the presence of
intercellular bridges. Mitosis can also be seen.
In another study, deep neck infections caused by a head
and neck cancer was found in 13 of 234 patients (6).
The pathophysiology of head and neck cancers
presenting as neck abscess is unclear. One of the
suspected mechanisms is cystic nodal metastasis of
thyroid, tonsil or nasopharynx carcinomas. Direct tumor
extension with central necrosis is another mechanism for
neck abscess (3). In our case, the abscess was caused
by direct tumor extension. To our knowledge, this is the
first case of PSSCT presenting as neck abscess.
PSCCT is a very rare disease account 1% of all thyroid
malignancies. Besides there is not squamous epithelium
in thyroid tissue, the pathophysiology of the PSCCT is
controversial. Two main opinions are present for the
pathophysiology of PSCCT. The first opinion suggests
that the squamous cells were derived from embryogenic
remnant. The second opinion which is the most widely
accepted theory believes that the presence of squamous
cells in thyroid gland depend cell metaplasia (1).
Patients usually present with enlarging neck mass.
Complaints of upper airway obstruction, shortness in
breathing, hoarseness and dysphagia are other common
symptoms. Some of the patients with PSCCT have a
long history of goiter (1). In our patient the initial
presenting symptom was cervical abscess which makes
our case unique. Also she had a 20-year history of goiter
before diagnosis of PSCCT.
The diagnosis of the disease depends on clinical,
radiological and histopathological findings. When the
histopathological results reveal SCC of the thyroid gland,
it is important to differentiate SCC arising from the
thyroid gland from cancers metastasized or invaded to
thyroid gland (7). In our patient, panendoscopic
examination and PET scan failed to show another
primary focus for SCC thus the patient was diagnosed
as PSCCT.
The treatment of PSCCT is aggressive surgery
combined with radiotherapy and chemotherapy.
Unfortunately, the cancer is usually invaded to
Ege Tıp Dergisi
neighborhood tissues at the time of diagnosis and total
excision is impossible. The prognosis of the disease is
very poor and median survival is 1 year. In our patient,
as the tumor was invaded to adjacent structures and
surrounded vital vascular tissues, the patient was
accepted as inoperable and referred to oncology clinics.
Conclusion
PSCCT is a rare and aggressive neoplasm of the thyroid
gland with poor prognosis. Like other head neck
cancers, thyroid cancers may also present with cervical
abscess. In a patient with deep neck spaces abscess, an
underlying malignancy should be kept in mind. If the
malignancy is not clinically suspected, the diagnosis and
treatment will be delayed. We presented a patient with
PSCCT whose initial finding was cervical abscess. To
our knowledge this was the first PSCCT case in the
literature presenting as cervical abscess.
Conflict of interest statement: There is no conflict of
interest to declare.
References
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Cilt 58 Sayı 2, Haziran 2019 / Volume 58 Issue 2, June 2019
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