A 60-year-old gentleman with past medical history of cervical disk herniation presented with a 3-year history of progressive fatigue and bilateral upper extremity weakness. MRI was performed to evaluate the spine and was consistent with cervical spinal stenosis. T2 non-contrast images incidentally revealed an infiltrating mass in the left thyroid that was incompletely visualized. Ultrasound-guided fine needle aspiration showed atypia of undetermined significance. The patient was referred to surgery and was noted to have dysphonia but no stridor or dysphagia. The differential diagnosis was felt to include papillary thyroid carcinoma, follicular thyroid carcinoma, rare thyroid neoplasms including Hurthle cell carcinoma or anaplastic carcinoma, abscess, or autoimmune thyroid disease. He underwent total thyroidectomy with central neck dissection. On exploration, the thyroid mass was seen encasing the left recurrent laryngeal nerve and was shaved off the nerve and the trachea. The nerve was not stimulatable after resection and the patient developed left vocal cord paralysis. The tumor grossly measured 7 cm with extrathyroidal extension. There was lymphvascular space invasion and perineural invasion. Three lymph nodes were identified, and all were negative. Surgical margins had extensive involvement of tumor. Histopathologic analysis of the specimen showed high-grade carcinoma with thymus-like differentiation. Immunohistochemical staining was positive for pan-CK, p63 (cyokeratin and epithelial markers) and negative for chromogranin, thyroglobulin, and calcitonin (neuroendocrine, papillary and follicular thyroid, and medullary makers, respectively).\nThe tumor was arranged in broad, pushing, smooth-bordered islands abutted against a lymphocyte rich stroma. The lobules of tumor were surrounded by lymphocytes and plasma cells (Figures and ). The tumor cells were squamoid and syncytial to spindled, with eosinophilic cytoplasm, and the nuclei show mild pleomorphism with pale vesicular chromatin. The neoplastic cells were strongly immunoreactive for pancytokeratin and p63, as shown in Figures and . These cells were also strongly positive for CD5, which marks background T lymphocytes (Figure ). The neoplastic cells were non-reactive with TTF1 and thyroglobulin.\nPostoperative staging surveillance with PET scan was performed for systemic staging and due to positive margins. It showed no abnormal FDG uptake at distant sites and increased uptake at the operative bed, indeterminate between residual disease and postoperative changes. The patient underwent adjuvant treatment with radiation therapy to 64 Gy in 32 fractions with intensity modulated radiotherapy. Concurrent chemotherapy was given based on his extensive positive margins for radiosensitization. A dose of 60 Gy was delivered to the bilateral neck including paratracheal nodes into the upper mediastinum, with a 4 Gy sequential boost to the operative site. A coronal section of the radiotherapy plan is shown in Figure . Six cycles of intravenous concurrent cisplatin 35 mg/m2 were infused. During therapy, he developed grade 2 skin reaction characterized by dry desquamation and moderate erythema of the neck and upper chest. Skin moisturizer was used for therapy. He experienced grade 2 esophagitis and mucositis of the oropharynx and grade 2 nausea requiring topical analgesics, oral narcotics, antiemetics, and intravenous fluid administration. Weight decreased from 108 to 95.5 kg by the end of therapy. Nutritional counseling by dietician and oral nutritional supplementation were provided. With chemotherapy, the patient developed a tinnitus grade 1. Toxicities are reported per the Common Terminology Criteria for Adverse Events ().\nAfter treatment, the patient initially experienced continued weight loss, and as a result underwent percutaneous endoscopic gastrostomy tube placement. Five months after end of treatment, the tube was removed after the patient was able to gain significant weight and completely obtain nutrition per oral route for 6 weeks. Dysphagia to solid foods is improving. He experienced persistent dysphonia secondary to left vocal cord paralysis since surgery and underwent left medialization thyroplasty 1 year later. He displayed improvement in voice quality. At 3-years follow-up after completion of radiotherapy, our patient is without evidence of locally recurrent or distant disease.
Patient 3 was a 67-year-old female who presented with hoarseness and dysphagia for a few weeks. CT scans showed a 3.8 cm left thyroid tumor with superior mediastinal and tracheal involvements, i.e., stage pT4bN0M0. Complete resection of the tumor was successfully achieved by total thyroidectomy and central neck dissection. Postsurgical chemotherapy was applied (docetaxel 120 mg/m2 and cisplatin 30 mg/m2), followed by a course of intensity modulated radiotherapy (70 Gy at 2.5 Gy per fraction). She remains well 4 years after diagnosis.