Squamous cell carcinoma arising in a tall cell papillary carcinoma of the thyroid

Anaplastic spindle cell squamous carcinoma arising from classical papillary thyroid carcinoma with foci of columnar cell component: A case report

We report a case of the anaplastic spindle cell squamous carcinoma(SC) arising from classical papillary thyroid carcinoma(PTC) with foci of columnar cell component in a 69-year-old Chinese woman. The tumor of the right lobe was composed of spindle cell SC and PTC. Histologically,the spindle cell SC were arranged into bundles with marked cellular atypia, nuclear pleomorphism and more mitotic figures. The tumor of the left lobe was a PTC without any SC elements,which was composed of two components, namely classical and columnar cell variants PTC. The columnar cell elements occupied more than 20 % of PTC, which showed striking stratification of nuclei with no characteristic nuclei for the classical type of PTC. The patient has not received any other treatment after radical surgery. She had no tumor recurrence and other complications 13 months after operation. Only classical PTC but not columnar cell PTC and SC had been identified in 7 out of 50 excised cervical lymph nodes. In order to clarify the origin of PTC and spindle cell SC, we performed the BRAF^V600E(c.1799 T > A) mutational analysis. The results of molecular analysis showed that BRAF^V600E(c.1799 T > A) mutation existed in both components, which further confirmed that spindle cell SC was transformed from PTC.

A case report of papillary thyroid carcinoma dedifferentiated to squamous cell carcinoma presenting as a lung metastasis: A potential diagnostic pitfall

Papillary thyroid carcinoma (PTC) tall cell variant (TCV) with squamous dedifferentiation is a rare entity. We present a case of 90-year-old woman who initially had a 2.8 cm conventional PTC in right lobe of thyroid who, couple decades later, had metastatic dedifferentiated PTC to right neck lymph nodes level II and IV with tall cell features; to right level IV and V lymph nodes with tall cell and squamous components, which recently presented exclusively as squamous cell carcinoma (SCC) metastasizing to lung. The squamous component in the lymph node and SCC in the lung were both positive for squamous marker p63 and PTC markers TTF1, PAX-8 and BRAF V600E while negative for thyroglobulin and p16. The papillary component was positive for TTF-1, BRAF V600E and P63 (majority); negative for thyroglobulin and p16. Final diagnoses were rendered based on combination of cytological features and immunohistochemical profiles. This report highlights the utilization of current biomarkers to distinguish between metastatic dedifferentiated PTC with squamous features and primary lung SCC, as well as the importance of recognizing this rare entity.

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.

Cytologic features of aggressive variants of follicular-derived thyroid carcinoma

Certain carcinomas of the thyroid gland behave aggressively resulting in increased patient morbidity and poor patient prognosis. The diagnosis of these aggressive thyroid cancer subtypes is sometimes challenging and subject to increased interobserver variability. This review deals with the cytological features of such tumors including aggressive variants of papillary thyroid carcinoma, poorly differentiated thyroid carcinoma, and anaplastic thyroid carcinoma. These malignancies fall into 2 groups based on their cytomorphology: those that exhibit distinct microscopic features (eg, nuclear findings typical of classical papillary thyroid carcinoma or marked anaplasia) and those that present with more subtle cytologic features (eg, nuclear pseudostratification, "soap bubble" nuclei, supranuclear or subnuclear cytoplasmic vacuoles, rosette-like structures, hobnail cells). We review the literature regarding these aggressive thyroid cancers and highlight important phenotypic characteristics that can be useful for their diagnosis based on fine needle aspiration.

Primary Squamous Cell Carcinoma of the Thyroid: Immunohistochemical Profile and Literature Review

Background

Squamous cell carcinoma accounts for 1% of primary thyroid malignancies and is characterized by a rapidly unfavorable outcome.

Case Presentation

A 64-year-old woman presented with a painless mass in the left neck, coexisting with thyroid goiter. Total thyroidectomy with lymphadenectomy was performed and a primary thyroid squamous cell cancer was confirmed histo-logically after excluding any other possible primary malignancies. The tumor's immunohistochemical profile was explored using a large panel of antibodies. The tumor featured a positive immunoreaction to cytokeratins 7–19 and to squamous cell carcinoma antigen. Low-molecular-weight cytokeratins 5–6 and epithelial membrane antigen were also expressed. The neoplasm's proliferative index (Mib1) was 60%. No immunostaining was detected for cytokeratins 10–20, thyroglobulin, TTF-1, CD5, galectin-3 or p53.

Conclusions

This case of primary thyroid squamous cell carcinoma immunohistochemically profiled using a large panel of immunoreactions may offer useful information on the histological differentiation of thyroid squamous cell carcinoma from other (uncommon) thyroid carcinomas and the distinction between primary and secondary thyroid cancers.

Primary Squamous Cell Carcinoma of the Thyroid: A Population-Based Analysis

Objectives To analyze the epidemiology and describe the prognostic indicators of patients with primary squamous cell carcinoma of the thyroid. Study Design and Setting Retrospective cohort study based on a national database. Methods The US National Cancer Institute's SEER registry (Surveillance, Epidemiology, and End Results) was reviewed for patients with primary squamous cell carcinoma of the thyroid from 1973 to 2012. Study variables included age, sex, race, tumor size, tumor grade, regional and distant metastases, and treatment modality. Survival measures included overall survival (OS) and disease-specific survival (DSS). Results A total of 199 cases of primary squamous cell carcinoma of the thyroid were identified. Mean age at diagnosis was 68.1 years; 58.3% were female; and 79.4% were white. Following diagnosis, 46.3% of patients underwent surgery; 55.7%, radiation therapy; and 45.8%, surgery with radiation therapy. Kaplan-Meier analysis demonstrated OS and DSS of 16% and 21% at 5 years, respectively. Median survival after diagnosis was 9.1 months. Multivariate Cox regression analysis showed that predictors of OS and DSS included age ( P < .001, P < .001, respectively), tumor grade ( P < .001, P = .001), and tumor size ( P < .001, P = .001). Surgical management was a predictor of OS but not DSS. Conclusion Squamous cell carcinoma of the thyroid is a rare malignancy with a very poor prognosis. Surgical resection confers an overall survival benefit. Age, tumor grade, and tumor size are predictors of OS and DSS.

Metastatic Collision Tumour (Papillary Thyroid Carcinoma and Squamous Cell Carcinoma) in Cervical Lymph Nodes: An Immunohistochemical Analysis

Collision tumours are a rare entity, in this report, we describe a case of 73-year-old woman presented with a rapid enlargement of left upper cervical lymph node (LN) associated with right thyroid nodular goiter. The histopathological examination of the excised LN showed definite areas of papillary thyroid carcinoma admixed with moderately differentiated squamous cell carcinoma (SCC). Thyroglobulin immunostaining was positive in papillary carcinomatous areas confirming thyroid gland as a source of metastasis. Then the patient underwent total thyroidectomy and neck dissection, which revealed multicentric classic papillary thyroid carcinoma with an absence of squamous differentiation on extensive sampling. The patient received adjuvant radioactive iodine, but the neck swelling was rapidly progressing, ulcerated and infected. Computed tomography (CT) revealed left large cervical amalgamated LN and two metastatic lung nodules, the patient received 2 cycles of chemotherapy and was planned for external beam radiotherapy but she died within 7 months of first presentation. Collision tumours pose a diagnostic as well as therapeutic challenge and carry a rapidly progressive course and a fatal outcome. SCC is considered as a dedifferentiation of papillary thyroid carcinoma, which may appear in metastatic site rather than the primary site.

Papillary thyroid carcinoma recurring as squamous cell carcinoma 10 years after total thyroidectomy: lessons from rapidly progressive papillary thyroid carcinoma

Primary squamous cell carcinoma (SCC) of the thyroid is very rare. There are no reports of metastatic papillary thyroid carcinoma (PTC) converting to SCC in cervical lymph nodes following total thyroidectomy due to conventional PTC. An 86-year-old woman with a remote history of total thyroidectomy due to PTC underwent palliative neck surgery to treat recurrent bleeding originating from a metastatic tumor of the cervical lymph nodes. The resected mass was composed of mixed SCC and PTC. Although primary SCC rarely occurs in the thyroid, conversion of PTC to SCC should be suspected if preexisting PTC exhibits highly aggressive behavior.

De-differentiation of papillary thyroid carcinoma into squamous cell carcinoma. A case of coexistence within an excised neck lesion

An 80-year-old man with papillary thyroid carcinoma of the neck underwent surgery and radioiodide therapy. He presented 11 years later with a lesion adjudged from fine needle aspiration to be a squamous cell carcinoma (SCC). Histological analysis of the excised mass revealed a lymph node overwhelmed with papillary thyroid carcinoma and moderately differentiated SCC thought to have transformed from papillary cells. A very small number of similar transformations specifically involving the 'tall cell variant' of papillary carcinoma transforming to spindle cell carcinoma have been reported previously. This case report demonstrates clear images of this rare occurrence and briefly considers factors leading to de-differentiation. The clinician should consider possible transformation from papillary thyroid cancer in cases of SCC of the head and neck as this variation may be more aggressive.

De-differentiation of papillary thyroid carcinoma into squamous cell carcinoma. A case of coexistence within an excised neck lesion

An 80-year-old man with papillary thyroid carcinoma of the neck underwent surgery and radioiodide therapy. He presented 11 years later with a lesion adjudged from fine needle aspiration to be a squamous cell carcinoma (SCC). Histological analysis of the excised mass revealed a lymph node overwhelmed with papillary thyroid carcinoma and moderately differentiated SCC thought to have transformed from papillary cells. A very small number of similar transformations specifically involving the 'tall cell variant' of papillary carcinoma transforming to spindle cell carcinoma have been reported previously. This case report demonstrates clear images of this rare occurrence and briefly considers factors leading to de-differentiation. The clinician should consider possible transformation from papillary thyroid cancer in cases of SCC of the head and neck as this variation may be more aggressive.

American Thyroid Association guidelines for management of patients with anaplastic thyroid cancer

BACKGROUND

Anaplastic thyroid cancer (ATC) is a rare but highly lethal form of thyroid cancer. Rapid evaluation and establishment of treatment goals are imperative for optimum patient management and require a multidisciplinary team approach. Here we present guidelines for the management of ATC. The development of these guidelines was supported by the American Thyroid Association (ATA), which requested the authors, members the ATA Taskforce for ATC, to independently develop guidelines for ATC.

METHODS

Relevant literature was reviewed, including serial PubMed searches supplemented with additional articles. The quality and strength of recommendations were adapted from the Clinical Guidelines Committee of the American College of Physicians, which in turn was developed by the Grading of Recommendations Assessment, Development and Evaluation workshop.

RESULTS

The guidelines include the diagnosis, initial evaluation, establishment of treatment goals, approaches to locoregional disease (surgery, radiotherapy, systemic therapy, supportive care during active therapy), approaches to advanced/metastatic disease, palliative care options, surveillance and long-term monitoring, and ethical issues including end of life. The guidelines include 65 recommendations.

CONCLUSIONS

These are the first comprehensive guidelines for ATC and provide recommendations for management of this extremely aggressive malignancy. Patients with stage IVA/IVB resectable disease have the best prognosis, particularly if a multimodal approach (surgery, radiation, systemic therapy) is used, and some stage IVB unresectable patients may respond to aggressive therapy. Patients with stage IVC disease should be considered for a clinical trial or hospice/palliative care, depending upon their preference.

Primary squamous cell carcinoma of thyroid: a case report and review of literature

BACKGROUND

Thyroid gland lacks squamous epithelium (except in some rare situations like embroyonic remnants or in inflammatory processes); for that reason the primary squamous cell carcinoma (SCC) of thyroid is extremely rare entity, seen only in less than 1% of all thyroid malignancies and is considered almost fatal. So, far, only few case reports have been published in literature.

CASE PRESENTATION

Herein we present a 54 years old Saudi female with 3 months history of progressive neck swelling and hoarse voice, who was referred to us by her primary care physician as suspected case of anaplastic carcinoma of thyroid for radical external beam radiation therapy (EBRT). Fine Needle aspiration cytology (FNAC) revealed squamous cell carcinoma. Computed tomography (CT) neck showed 10 × 10 cm mass in left lobe of thyroid invading trachea and skin. Extensive staging work up ruled out the possibility of any primary site of SCC other than thyroid gland. Tumor was found unresectable and was referred to radiation oncology. She received palliative EBRT 30 Gy in 10 fractions. After completion of EBRT, there was progression of disease and patient died 3 months after completion of EBRT by airway compromise.

CONCLUSION

Primary SCC of thyroid is rare and aggressive entity. FNAC is reliable and effective tool for immediate diagnosis. Surgery is a curative option, but it is not always possible as most of cases present as locally advanced with adjacent organs involvement. EBRT alone was found ineffective. Aggressive combined modality (debulking surgery, radiation and chemotherapy) shall be considered for such cases.

Clinical trial of weekly paclitaxel chemotherapy for papillary thyroid carcinoma with squamous cell carcinoma component

Papillary thyroid carcinoma (PC) can occasionally include a squamous cell carcinoma (SCC) component. In this study, we evaluated the effect of weekly paclitaxel chemotherapy in 3 patients with PC including an SCC component. None of these patients had lesions of anaplastic carcinoma on pathological examination. Weekly paclitaxel chemotherapy was performed as an induction chemotherapy for 2 patients. All 3 patients underwent locally curative surgery and weekly paclitaxel chemotherapy after surgery as an adjuvant therapy. The response to the chemotherapy was evaluated based on the RECIST guideline (version 1.1). Two patients had partial responses (PRs) and the remaining 1 had stable disease (SD). The response rate was 67% and the clinical benefit rate (PR+SD) was 100%. One patient died of the growth of lung metastases that had been detected before surgery 22 months after the diagnosis. The remaining 2 are still alive, 14 and 22 months after the diagnosis, respectively. Taken together, weekly paclitaxel may be one of the effective adjuvant therapies for PC with an SCC component.

Papillary thyroid carcinoma: differential diagnosis and prognostic values of its different variants: review of the literature

Papillary thyroid carcinoma is the most common thyroid malignancy, and has an excellent prognosis, even with cervical lymph node metastasis; however, histological variants are considered relevant, which may be associated with familial adenomatous polyposis and tumor aggressiveness. Histological features, such as vascular and/or lymphatic invasion, angiogenesis, multifocality, high cellular proliferation rate, neoplastic cell dissemination, and the histological varieties, are indicative of poor prognosis, together with associated clinical factors: age, sex, and tumor size.

Merged histological types of malignant thyroid tumor: experience and controversy

Malignant tumors of the thyroid that consist of merged histological types are a rare clinical entity, with an obscure pathogenesis and no consensus of opinion on nomenclature. Eight patients with merged histological types of thyroid malignant tumor at a single medical center were enrolled between January 1977 and December 2009. These patients were surgically treated and were followed postoperatively from 1 month to 34 years. Preoperative patient characteristics, B-type ultrasonography, computed tomography scan, thyroid function tests, postoperative pathology, immunohistochemistry, and prognosis data were collected. Merged histological types of thyroid malignant tumor accounted for 0.12% of all thyroid malignant tumors treated during this period. Preoperative imageology and laboratory data have no specific value toward diagnosis of merged histological types of thyroid malignant tumor. Merged histological types of thyroid carcinoma that had undergone radical resection in combination with hormonal therapy and I(131) radiotherapy achieved a satisfactory outcome, while other merged thyroid malignant tumors were usually associated with a poor prognosis. Prognosis depended on the highest grade among an individual group of malignant tumors.

"Collision" metastasis from unknown primary squamous cell carcinoma and papillary microcarcinoma of thyroid presenting as lateral cervical cystic mass

We report an unusual case of "collision metastasis". In a single lymph node, we found a metastatic mass composed of two immunohistochemically distinct components originating from two primary tumors: a papillary microfollicular thyroid cancer and an unknown primary squamous cell carcinoma. The clinical features and immunohistochemical profile are reported. Collision phenomena in oncology are extremely rare and pose diagnostic and management challenges which are discussed.

Primary squamous cell carcinoma of the thyroid: report of three cases

We report three cases of squamous cell carcinoma of the thyroid, which is an unusual malignant tumor that needs to be distinguished from other thyroid pathologies due to its aggressive behaviour. Three men, with an average of 63 years old, presented with progressive enlargement in the neck, hoarse voice or weight loss. Physical and radiological examinations revealed clues where malignancy was suspected and surgical resections were performed. Histopathological examination of the specimens was diagnosed as squamous cell carcinoma. Proper workup excluded the possibility of any primary site of SCC other than the thyroid. All patients died within 5 months. Adjuvant therapy evaluation is still inconclusive. Complete surgical resection still remains the primary choice for cure. We believe that radical resection with clear surgical margins followed by adjuvant chemo-radiation therapy is a curative strategy for achieving any chance of long-term survival.

Primary squamous cell carcinoma of the thyroid gland: A case report and role of radiotherapy

Primary squamous cell carcinoma is an extremely rare tumour of the thyroid gland. A case of an elderly lady who was diagnosed to have primary squamous cell carcinoma of the thyroid gland is presented and the role of radiotherapy is discussed.

Collision tumor of the thyroid: follicular variant of papillary carcinoma and squamous carcinoma

BACKGROUND

Collision tumors of the thyroid gland are a rare entity. We present a case of a follicular variant of papillary carcinoma and squamous carcinoma in the thyroid. To the best of our knowledge, this is the first documentation of a collision tumor with a papillary carcinoma and a squamous carcinoma within the thyroid gland. The clinicopathological features and immunohistochemical profile are reported. The theories of origin, epidemiology and management are discussed with a literature review.

CASE PRESENTATION

A 65 year old woman presented with a large thyroid swelling of 10 years duration and with swellings on the back and scalp which were diagnosed to be a follicular variant of papillary thyroid carcinoma with metastasis. Clinical examination, radiology and endoscopy ruled out any other abnormality of the upper aerodigestive tract. The patient was treated surgically with a total thyroidectomy with central compartment clearance and bilateral selective neck dissections. The histopathology revealed a collision tumor with components of both a follicular variant of papillary carcinoma and a squamous carcinoma. Immunohistochemical analysis confirmed the independent origin of these two primary tumors. Adjuvant radio iodine therapy directed toward the follicular derived component of the thyroid tumor and external beam radiotherapy for the squamous component was planned.

CONCLUSION

Collision tumors of the thyroid gland pose a diagnostic as well as therapeutic challenge. Metastasis from distant organs and contiguous primary tumors should be excluded. The origins of squamous cancer in the thyroid gland must be established to support the true evolution of a collision tumor and to plan treatment. Treatment for collision tumors depends upon the combination of primary tumors involved and each component of the combination should be treated like an independent primary. The reporting of similar cases with longer follow-up will help define the epidemiology, biology and establish standardized protocols for treatment of these extremely rare tumors.