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  Table of Contents    
CASE REPORT  
Year : 2018  |  Volume : 61  |  Issue : 3  |  Page : 399-400
Metastatic squamous cell carcinoma in autotransplanted thyroid: A diagnostic dilemma


1 Department of Pathology, Maulana Azad Medical College, New Delhi, India
2 Maulana Azad Medical College, New Delhi, India

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Date of Web Publication13-Jul-2018
 

   Abstract 


Metastasis to the thyroid is uncommon. Mostly, they are tumors that originate in the lung or head or neck. Metastases from breast or kidney carcinomas and metastatic melanoma have also been reported. Autotransplantation of benign thyroid tissue is a surgical procedure designed to achieve normal thyroid hormonal status following surgery. Metastasis into autotransplanted thyroid tissue has not been reported earlier. We report a case of squamous cell carcinoma (SCC) metastatic to autotrasplanted thyroid diagnosed on fine-needle aspiration. Further workup revealed a primary oral cavity SCC.

Keywords: Autotransplanted thyroid, thyroid metastasis, thyroid neoplasm

How to cite this article:
Mallya V, Narayan S, Jain S. Metastatic squamous cell carcinoma in autotransplanted thyroid: A diagnostic dilemma. Indian J Pathol Microbiol 2018;61:399-400

How to cite this URL:
Mallya V, Narayan S, Jain S. Metastatic squamous cell carcinoma in autotransplanted thyroid: A diagnostic dilemma. Indian J Pathol Microbiol [serial online] 2018 [cited 2019 Dec 13];61:399-400. Available from: http://www.ijpmonline.org/text.asp?2018/61/3/399/236611





   Introduction Top


Metastasis to the thyroid gland (MTG) is uncommon in most cases discovered at autopsy. The incidence of MTG, which can be solitary or multiple at autopsy ranges from 0.5% to 24% with carcinomas from the lung, head, and neck, breast, gastrointestinal tract, and malignant melanoma being a primary site.[1],[2],[3],[4] Incidental thyroid tumors are discovered during resection of thyroid for multinodular goiter.[5] The median age at presentation is 62 years. In selected patients who undergo total thyroidectomy, benign thyroid tissue is surgically implanted into the sternocleidomastoid (SCM) or subcutaneous tissue to achieve a euthyroid state and reduce the need for exogenous hormones. The autotransplanted thyroid tissue (AT) usually exhibits normal histology.[6] The possibility of metastasis into the AT should be considered before primary thyroidal squamous cell carcinoma (SCC), especially if the tumor is well differentiated.[4] Here, we report the fine-needle aspiration (FNA) diagnosis of a clinically unsuspected SCC metastatic to AT in the SCM. We believe this is the first reported case of metastatic SCC to AT.


   Case Report Top


A 61-year-old woman presented with hoarseness and a painful swelling in the left SCM for 15 days [Figure 1]a. On further examination, a 1 cm × 1 cm ulcer was found on the buccal mucosa of the left cheek near the upper molar. A contrast-enhanced computed tomography of the neck revealed an enhancing lesion in the left SCM and multiple enlarged necrotic neck nodes [Figure 1]b. The patient was a chronic (22 years) betel nut chewer who had undergone a thyroidectomy for multinodular goiter 18 years earlier. At thyroidectomy, she had thyroid tissue autotransplanted into the left SCM to achieve a postthyroidectomy euthyroid state. Her hemogram and thyroid function tests were within normal limits. FNA from the SCM was performed and Giemsa stained smears showed scattered atypical squamous cells in a background of scant colloid [Figure 2]a. The following differential diagnosis (D/D) was considered SCC (primary/metastasis), anaplastic carcinoma (AC), and papillary thyroid carcinoma (PTC). The absence of highly pleomorphic cells and necrosis excluded AC. As metaplastic squamoid cells may be seen in PTC, the absence of characteristic morphology including nuclear features that is intranuclear inclusions and grooves excluded this D/D also. Biopsy of the ulcerated buccal mucosa lesion revealed well-differentiated SCC [Figure 2]b. Based on the cytohistological findings, a final diagnosis of well-differentiated SCC of the buccal mucosa with metastasis to autotransplanted thyroid was rendered.
Figure 1: (a) Clinical image showing swelling in the left sternocleidomastoid. (b) Contrast-enhanced computed tomography showing contrast-enhancing lesion in the left sternocleidomastoid

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Figure 2: (a) Photomicrograph showing atypical squamous cells against a background of colloid (Giemsa, ×400). (b) Photomicrograph showing features of well-differentiated squamous cell carcinoma (H and E, ×100)

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   Discussion Top


While a highly vascular organ such as the thyroid might be expected to be a frequent site for metastasis, it has been suggested that the rapid arterial blood flow coupled with increased iodine and oxygen levels prevents the growth of metastatic tumor cells in the thyroid.[7],[8] In 1871, Virchow et al. first described metastasis to thyroid from a testicular tumor.[9] The high incidence of oral cavity carcinoma in India is attributable to an interplay of genetic factors and environmental factors among which tobacco and betel nut chewing are the most important. The present case is of particular interest given the location of the thyroidal tissue and fact that the FNA diagnosis was clinically unsuspected. There is an increasing incidence of reported MTG, probably because of more use of FNA cytology (FNAC) as primary investigative modality in evaluating enlarging neck masses.

The cytological D/D included AC, PT, primary SCC and metastasis, and primary SCC of the thyroid to chronic inflammation.[9] In the present case, the presence of well-differentiated SCC of the buccal mucosa was instrumental in leading to the diagnosis of metastatic SCC of the AT. The mean age of presentation of SCC of the buccal mucosa is 66 years and a very high rate of locoregional spread has been documented.[4],[10] The secondary SCC is either due to direct extension or metastasis.

These patients are usually treated with radiotherapy and chemotherapy. Our patient received radiotherapy and has responded well to it.

The present case highlighted the importance of FNAC in diagnosing rare and unsuspected metastasis in a palpable swelling in the head and neck region. It also illustrates that although thyroid is rarely the site for metastasis, an enlarging swelling in the thyroid tissue whether at its normal or ectopic/autotransplanted location warrants evaluation to exclude the possibility of MTG. This case underscores the importance of a multidisciplinary approach involving radiologist, surgeon, and pathologist to diagnose an unusual lesion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Nixon IJ, Coca-Pelaz A, Kaleva AI, Triantafyllou A, Angelos P, Owen RP, et al. Metastasis to the thyroid gland: A Critical review. Ann Surg Oncol 2017;24:1533-9.  Back to cited text no. 1
    
2.
Khandelia BK, Chakraborti S, Rai S, Kini H. Metastatic lesions to thyroid associated with dual primaries: A report of two cases. Thyroid Res Pract 2013;10:111-3.  Back to cited text no. 2
  [Full text]  
3.
Gerges AS, Shehata SR, Gouda IA. Metastasis to the thyroid gland; Unusual site of metastasis. J Egypt Natl Canc Inst 2006;18:67-72.  Back to cited text no. 3
    
4.
Nakhjavani M, Gharib H, Goellner JR, Heerden JA. Direct extension of malignant lesions to the thyroid gland from adjacent organs: Report of 17 cases. Endocr Pract 1999;5:69-71.  Back to cited text no. 4
    
5.
Kaliszewski K, Strutyńska-Karpińska M, Zubkiewicz-Kucharska A, Wojtczak B, Domosławski P, Balcerzak W, et al. Should the prevalence of incidental thyroid cancer determine the extent of surgery in multinodular goiter? PLoS One 2016;11:e0168654.  Back to cited text no. 5
    
6.
Charous D, Heffilfinger R, Ambro BT, Pribitkin EA, Keane WM, Rothstein JL. Thyroid autotransplantation followed by total thyroidectomy restores function in mice. Otolaryngol Head Neck Surg 2004;131:183.  Back to cited text no. 6
    
7.
Kundu R, Punia RS, Mohan H, Handa U, Gupta N. Fine-needle aspiration cytology of metastatic squamous cell carcinoma thyroid: A rare entity. J Cytol 2014;31:210-2.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Chavan RN, Chikkala B, Biswas C, Biswas S, Sarkar DK. Primary squamous cell carcinoma of thyroid: A Rare entity. Case Rep Pathol 2015;2015:838079.  Back to cited text no. 8
    
9.
Willis RA. Metastatic tumours in the thyreoid gland. Am J Pathol 1931;7:187-208.3.  Back to cited text no. 9
    
10.
Fang QG, Shi S, Li ZN, Zhang X, Liua FY, Xu ZF, et al. Squamous cell carcinoma of the buccal mucosa: Analysis of clinical presentation, outcome and prognostic factors. Mol Clin Oncol 2013;1:531-4.  Back to cited text no. 10
    

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Correspondence Address:
Varuna Mallya
Room No 269, Maulana Azad Medical College, New Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_418_17

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