|Year : 2013 | Volume
| Issue : 3 | Page : 207-208
Simultaneous laryngeal squamous cell carcinoma and thyroid carcinoma in the contralateral lobe of a nonsmoker woman
Ezzeddin Elsheikh1, Mohammad W. Elanwar1, Hesham R. Abdel-aziz2
1 Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
2 Department of Pathology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
|Date of Submission||08-Feb-2013|
|Date of Acceptance||08-Mar-2013|
|Date of Web Publication||11-Jun-2014|
Mohammad W. Elanwar
Department of Otorhinolaryngology, and Head and Neck Surgery, Faculty of Medicine, Zagazig University, 0552309843 Zagazig
Source of Support: None, Conflict of Interest: None
We report a 60-year-old nonsmoker woman with laryngeal squamous cell carcinoma for which total laryngectomy and right conservative neck dissection was decided. Right hemithyroidectomy is usually a part of this procedure, but in this case, because of inadvertent ligation of the left inferior thyroid artery, total thyroidectomy was performed. A small nodule 0.5 cm of papillary microcarcinoma in the left lobe that was not diagnosed preoperatively was discovered in the final pathological examination. Therefore, ultrasound evaluation of the thyroid gland should be added to the work-up of all cases undergoing total laryngectomy and there is a need for new guidelines to treat incidental thyroid lesions in the context of laryngeal cancer.
Keywords: squamous cell carcinoma, thyroid carcinoma, total laryngectomy
|How to cite this article:|
Elsheikh E, Elanwar MW, Abdel-aziz HR. Simultaneous laryngeal squamous cell carcinoma and thyroid carcinoma in the contralateral lobe of a nonsmoker woman. Egypt J Otolaryngol 2013;29:207-8
|How to cite this URL:|
Elsheikh E, Elanwar MW, Abdel-aziz HR. Simultaneous laryngeal squamous cell carcinoma and thyroid carcinoma in the contralateral lobe of a nonsmoker woman. Egypt J Otolaryngol [serial online] 2013 [cited 2020 Jan 21];29:207-8. Available from: http://www.ejo.eg.net/text.asp?2013/29/3/207/134177
| Introduction|| |
Papillary mirocarcinoma (PMC) of the thyroid is less than 1 cm in its greatest dimension and is generally identified incidentally; its incidence in autopsy series reaches up to 35% and it has the potential to recur and metastasize .
Laryngeal carcinomas are common in smoker men, whereas thyroid lesions are more frequent in women. Second primaries in patients with laryngeal carcinoma in the upper aerodigestive tract and lungs are relatively common because of the common predisposing factors . Only a few cases of simultaneous thyroid cancer associated with laryngeal malignancy are reported in the literature 2,3. The aim of this work is to report a case of PMC discovered in the contralateral lobe of the thyroid gland as a part of the total laryngectomy specimen in a nonsmoker woman.
| Case presentation|| |
A 60-year-old nonsmoker housewife with no history of previous malignancy or radiotherapy presented with hoarseness of voice and a right vocal cord mass with a fixed cord; clinical neck examination did not detect any thyroid or lymph node enlargement. Thin section computed tomography (CT) scanning showed a right transglottic mass that was confirmed by a direct laryngoscopic examination under general anesthesia; this mass was diagnosed as squamous cell carcinoma after histopathological examination of a punch biopsy.
The patient was prepared for total laryngectomy with right functional neck dissection. Hemithyroidectomy on the tumor side is usually a part of the procedure, but in this case, total thyroidectomy was performed as the left inferior thyroid artery was inadvertently ligated and the left lobe became devascularized. Postoperative pathological examination confirmed the laryngeal mass to be squamous cell carcinoma [Figure 1] and the thyroid gland showed a small (0.5 cm) grayish white firm nodule in the left lobe that proved to be PMC [Figure 2]. Lymph nodes had no metastatic deposits (0/29).
|Figure 1: Photomicrograph showing sheets of nonkeratinized malignant squamous epithelial cells infiltrating the subepithelial tissues of the larynx; H&E, ×100.|
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|Figure 2: Photomicrograph of total thyroidectomy showing three small foci of papillary thyroid carcinoma (microfollicular type) (stars). Inset showing numerous small microfollicles (arrows) lined by tall columnar epithelial cells with nuclear grooving; H&E ×100, inset, ×400.|
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The postoperative period was uneventful and the patient was discharged after 1 week on thyroxin therapy with no further complaint and she being followed up currently.
| Discussion|| |
Routine ipsilateral hemithyroidectomy has long been considered the standard surgical practice for all patients undergoing total laryngectomy. However, with hemithyroidectomy, 65% of patients develop hypothyroidism, and when combined with radiotherapy, the incidence is as high as 70–90% .
Because not all thyroid glands are invaded in laryngeal cancer, selective thyroidectomy was advocated; selective criteria included invasion of the anterior commissure, extension to the subglottic space more than 15 mm, and T3–T4 transglottic cancer, and this is usually based on CT examination. However, preoperative CT failed to show more than one-third of thyroid gland invasion either by direct extension or by metastasis .
Ultrasound has become the gold standard for evaluating thyroid nodules; nodules are generally not biopsied unless they are at least 1 cm 5, which decreases the likelihood that PMC would be detected by fine needle aspiration (FNA). However, currently, nodule size is no longer recommended as a threshold of biopsy as studies have shown that malignancy rates are equivalent in lesions below and above 1 cm 6. FNA biopsy was considered unnecessary by some surgeons because of the high rate of false-negative results and they suggested that male patients with thyroid nodules should proceed directly to surgery .
The management of PMC, a common incidental finding, is a controversial issue. Some clinicians believe that it is indolent and observation is appropriate, whereas others support surgical resection; however, the optimal extent of resection is unknown . Thyroid lobectomy is frequently offered to those patients to avoid the increased risk of complications and to avoid the need for life-long thyroid hormone replacement; those patients are potentially subject for reoperation. Is this valid for PMC in the context of laryngeal cancer? If FNA biopsy indicates a benign nature, the recommendation is follow-up with repeat ultrasound in 6–18 months, and if there is no further progression, ultrasound can be repeated every 3–5 years 7; again, are these regulations the same for benign thyroid nodules in the context of laryngeal cancer with the risk of reoperation. In contralateral lobe lesions, should total thyroidectomy be performed, considering that almost 50% of those patients may require hormone therapy anyway , and in patients with head and neck cancer, the reported rate of malignancy in incidental thyroid nodules is as high as 41% 9, or is this considered an overtreatment .
| Conclusion|| |
Ultrasound evaluation of the thyroid gland should be added to the work-up of all cases undergoing total laryngectomy and there is a need for new guidelines to treat incidental thyroid lesions in the context of laryngeal cancer.
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[Figure 1], [Figure 2]