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The
Evan Shapiro Case Study: Primary Squamous Cell Carcinoma of
the Thyroid
-June Chan, M.D.
The following case study is made possible by the Evan Shapiro
Memorial Fund, commemorating the life of a gifted and talented
young man who was stricken with Ewing’s sarcoma while
in high school. It is with deep appreciation that the U-M
Cancer Center thanks those who have made this on-going series
possible in Evan’s memory.
Presentation of Case
J.G. is a 31-year-old woman who presented with right ear pain
and an anterior neck mass associated with dysphagia after
delivering her fourth child. She denied any symptoms of dyspnea,
neck pain or voice changes. A fine needle aspiration was positive
for poorly differentiated carcinoma. She underwent a right
thyroid lobectomy/isthmusectomy that revealed infiltrating
squamous cell carcinoma with positive margins and an involved
right paratracheal lymph node. A triple endoscopy to rule
out other sources of squamous cell carcinoma was negative.
CT imaging of the neck post-operatively showed a soft tissue
mass measuring 3 cm x 3 cm x 4 cm located in the right thyroid
bed without lymphadenopathy. Chest CT and bone scan were both
negative. J.G. was treated with 3D post-operative radiation
therapy to a total dose of 65 Gy to the tumor bed and bilateral
neck. She returned for follow-up one month after completion
of radiation and although her acute radiation toxicity (oral
mucositis) had improved, she continued to experience ear pain.
Clinical exam noted palpable left neck lymphadenopathy. A
CT scan at that time showed ring-enhancing lesions throughout
the nodal chains consistent with metastatic involvement, as
well as evidence of recurrence in the local tumor bed. A biopsy
confirmed squamous cell carcinoma. It was felt that an extensive
bilateral neck dissection with pharyngectomy would be necessary
for any chance of local control. After considering her options
given her poor prognosis, she opted to enter an experimental
immunotherapy protocol.
Primary Squamous Cell Carcinoma of the Thyroid
Primary squamous cell carcinoma (SCC) of the thyroid gland is an extremely
rare malignancy, with only about 50 cases in the world-wide literature.
Usually, SCC involving the thyroid gland results because of direct extension
from the adjacent larynx, trachea or esophagus. SCC arising directly from
the thyroid tends to affect older patients (5th to 6th decade), that have
a long-standing history of goiter. Its etiology is not definitely known,
but hypotheses include the “metaplasia theory” (squamous metaplasia
of underlying thyroid disease) and “embryonic-rest theory” (squamous
cells originating from remnant ultimobranchial duct or thyroglossal duct).
Patients present with sudden increase in size of a chronic neck mass,
with or without cervical adenopathy. Other symptoms include dysphagia,
dyspnea and hoarseness secondary to infiltration of adjacent structures.
At the time of diagnosis, these tumors are usually locally advanced with
invasion into the trachea, esophagus and major vessels. If possible, surgical
resection should be attempted, followed by adjuvant radiation therapy
(doses in the literature range from 40 to 55 Gy). Although SCC of the
thyroid is felt to be radioresistant and unresponsive to chemotherapy,
there have been a few cases where complete excision and post-operative
radiation have been curative. Overall however, this disease has a poor
prognosis with a median survival of <6 months in the majority of cases.
Death is usually secondary to progression of local disease although some
cases have distant metastases at autopsy.
References
- Goldman R. Primary
squamous cell carcinoma ofthe thyroid gland: report of a case and review
of the literature. American Surgeon. 30(4): 247-251, 1964.
- Misonou J et al.
Pure squamous cell carcinoma of the thyroid gland - report of an autopsy
case and review of the literature. Japanese Journal of Surgery.
18(4): 459-474, 1988.
- Sarda AK et al.
Squamous cell carcinoma of the thyroid. J Surg Onc. 39:175-78, 1988.
- Simpson WJ. Squamous
cell carcinoma of the thyroid gland. Amer J Surg. 156:44-46, 1988.
- Tsau-Yuen Huang
et al. Primary squamous cell carcinoma of the thyroid gland: a report
of four cases. Amer J Clin P55:93-98, 1971.ath.
June Chan, M.D., is a resident in the department of Radiation Oncology.
Editor’s Note:
The Evan Shapiro case study on Stevens-Johnson syndrome, which was presented
in the summer 1997 issue, was authored by Getha Rao, M.D., of the department
of Radiation Oncology
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