Goiter

Abstract

We describe the case of a 41-year-old man with hoarseness and a hard, fixed mass in the anterior cervical region. He was referred to our endocrinology service for evaluation of possible thyroid cancer. The results of laboratory tests of thyroid function were normal. Indirect laryngoscopy revealed paralysis of the left hemilarynx and the presence of a large vegetating lesion. Computed tomography of the neck disclosed the presence of a mass in the anterior region, along with invasion and destruction of the adjacent structures. The cytologic diagnosis was established by analysis of a fine-needle aspiration biopsy specimen, which revealed a squamous cell carcinoma. The final diagnosis was carcinoma of the larynx.

Introduction

Secondary thyroid neoplasms are not uncommon, and autopsy studies of cancer patients have shown that the incidence of metastatic disease is 24%. (1) However, only a few cases are clinically relevant. (2) Secondary neoplasms are caused by hematologic or lymphatic dissemination or by direct extension of adjacent tumors. (3) The breast and lung are the most common primary sites at autopsy, but renal cell carcinoma represents more than 50% of all secondary thyroid cancers that are detected clinically. (2)

The presence of squamous cells in thyroid tissue is very uncommon, and the identification of such a cell should be interpreted as a probable secondary neoplasm. (2) In this article, we describe a case of suspected thyroid cancer that was subsequently determined to be a squamous cell carcinoma of the larynx.

Case report

A 41-year-old man with an 18-month history of hoarseness was referred to our endocrinology service for evaluation of a mass in the anterior cervical region of 7 months' duration. During the previous 30 days, he had begun to experience progressive dysphagia and dyspnea upon flexion of the head. There was no sign of thyroid dysfunction. The patient had a 30 pack-year smoking history and a minimal alcohol intake. He had no history of head and neck irradiation.

On physical examination, the patient was eupneic and dysphonic. The palpable mass in the anterior cervical region was hard, fixed, approximately 10 cm in diameter, and looked exactly like a goiter (figure 1). The patient also exhibited an anterior cervical lymphadenomegaly of 1.5 cm in diameter. Laboratory tests revealed that his thyroid-stimulating hormone level was 2.49 mU/L (normal range: 0.4 to 4.0), his free thyroxine level was 1.3 ng/dl (normal: 0.8 to 2.0), his antithyroglobulin antibody level was less than 20 U/ml, and his antiperoxidase antibody level was less than 10 U/ml.

Indirect laryngoscopy revealed paralysis of the left hemilarynx and the presence of a vegetating lesion. Computed tomography (CT) detected a large invasive mass in the anterior cervical region, destruction of the thyroid cartilage, and a partial obstruction of the larynx (figure 2). Bronchoscopy showed that the vegetating multinodular lesion was near the epiglottis and that it had caused a 90% obstruction of the larynx, which blocked the progress of the bronchoscope (figure 3). Endoscopy of the digestive tract did not detect any esophageal invasion.

The cytologic diagnosis was established by analysis of a fine-needle aspiration biopsy specimen, which showed a squamous cell carcinoma. The final diagnosis was carcinoma of the larynx.

Discussion

The occurrence of thyroid involvement in patients with laryngeal cancer is unusual. In a series of 1,053 patients treated surgically for laryngeal cancer, a secondary tumor in the thyroid was detected in only three (0.3%). (4)

Fine-needle aspiration biopsy was important in solving this case. This tool is very useful for diagnosing neo-plastic thyroid nodules, although it is not always accurate in distinguishing between primary and secondary neoplasms. (2,5) Surgical biopsy might be necessary in some cases. (1)

The prognosis of patients with secondary thyroid cancer is associated with the degree of advancement of the primary tumor. The range of survival is limited--generally between 6 and 18 months. (2,3) Treatment is defined by the stage of the tumor, and thyroidectomy should generally be avoided.

The prognosis of laryngeal carcinoma with thyroid gland involvement is poor. In a review of 173 laryngeal specimens obtained from patients who underwent laryngectomy, thyroid gland involvement was found in 23 (13.3%), 18 ofwhom died within 3 years. (6)

In conclusion, the diagnosis of laryngeal carcinoma must be considered in patients with goiter associated with hoarseness.

References

(1.) Lin JD, Weng HF, Ho YS. Clinical and pathological characteristics of secondary thyroid cancer. Thyroid 1998;8:149-53.

(2.) Harcourt-Webster JN. Secondary neoplasm of the thyroid presenting as a goiter. J Clin Pathol 1965;l8:282-7.

(3.) Schlumberger M, Caillou B. Miscellaneous tumors of the thyroid. In: Braverman LE, Utiger RD, eds. Werner and Ingbar's the Thyroid--A Fundamental and Clinical Text. Philadelphia: Lippincott-Raven, 1996:961-5.

(4.) Di Nicola V, Fiorella R. [Multiple primary tumors in patients with laryngeal carcinoma: Incidence and prognostic factors]. Acta Otorhinolaryngol Ital 1995;15:1-15.

(5.) Rosen IB, Walfish PG, Bain J, Bedard YC. Secondary malignancy of the thyroid gland and its management. Ann Surg Oncol 1995;2:252-6.

(6.) Gilbert RW, Cullen RJ, van Nostrand AW, et al. Prognostic significance of thyroid involvement in laryngeal carcinoma. Arch Otolaryngol Head Neck Surg 1986;l12:856-9.

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