A 34-year-old woman presented with a 2-month history of sore throat. The patient had no notable medical or family history. Physical examination revealed a palpable right thyroid mass. Thyroid function and calcium tests were within normal limits. Ultrasound showed a 1.7-cm, well demarcated, heterogeneous, low echoic solid mass in the lower pole of the right thyroid (). A computed tomography scan of the neck revealed a 3.3-cm, exophytic, low-attenuated mass in the lower pole of the right thyroid. The FNA biopsy of the mass was performed, which was accompanied by the standard Papanicolaou stain.\nThe smear was composed of not only cohesive three dimensional clusters and sheets but also singly scattered cells (). The tumor cells showed mild anisonucleosis and high nuclear : cytoplasmic (N/C) ratios. Nuclei were round to ovoid with irregular nuclear contours and small, distinct nucleoli (). The nuclear chromatin was vesicular or coarsely granular. Nuclear grooves were rarely seen. Cytoplasm was scanty and amphophilic. Cytoplasmic border was indistinct. Some tumor cells showed dense orangeophilic cytoplasm, which is suggestive of individual cell keratinization (). Some lymphocytes were found on the background and within clusters, which was accompanied by the presence of a few stripped nuclei (). Mitotic figures were rarely seen. Intranuclear cytoplasmic inclusions were not observed. Papillary or follicular structure was not observed. The aspirate was interpreted as a high-grade malignant thyroid neoplasm without further definitive classification. The total thyroidectomy was performed.\nOn gross examination, the thyroid contained a 4.0-cm solid mass replacing most of the right thyroid. The mass had a lobular, tan-colored cut surface and a firm consistency (). On microscopic examination, the tumor was well-circumscribed and it was composed of variably sized and irregularly shaped lobules of cohesive polygonal tumor cells which were separated by bands of dense fibrous stroma (). The tumor cells had high N/C ratios, eosinophilic cytoplasm and ill-defined cell borders. The nuclei were vesicular or coarsely granular with prominent nucleoli. The mitotic figures were sparse. There was mild lymphoplasmacytic infiltration within the tumor nodules and septae. Cytoplasmic keratinization was seen. The tumor cells showed positivity for CD5, carcinoembryonic antigen, high molecular weight keratin (HMWK), cytokeratin 5 (CK5), and p63. The tumor was negative for thyroid transcription factor-1, thyroglobulin, and calcitonin. Vascular invasion and extensive extra-thyroidal extension were present. One regional lymph node was found and involved by tumor.\nOver a 27-month follow-up period, the patient had no evidence of tumor recurrence.
A 76-year-old man was referred to our hospital for investigation of a 20-day history of rapidly deteriorating dyspnea and severe cough. This was associated with dysphagia and cervical pain. The patient was an ex-marble craftsman and an active smoker. His medical history included chronic pulmonary obstructive disease (COPD). A chest X-ray (CXR) showed an imprint at the right side of the trachea. Thyroid ultrasound (US) revealed a large and heterogenous thyroid gland and the presence of a calcified mass, 4.76 × 4.01 cm with high blood perfusion in the right upper lobe of the gland. A contrast-enhanced computed tomography (CT) scan of the neck and thorax reported the corresponding lesion as heterogenous, with irregular borders, extending from the sternoclavicular joints to the upper borders of the thyroid gland. The mass was surrounding the trachea anterolaterally displacing it to the left and the right common artery to the right (). There were no enlarged lymph nodes. Bronchoscopy revealed a fracture of the first tracheal ring but there was no evidence of tumour invasion (). Cytology from bronchial lavage was negative for cancer cells. Laboratory tests were within normal limits with the exception of elevated D-dimers (2,994 μg/L) and elevated white blood cells (19.27 K/μL). Tumour markers were within normal range values.\nOn admission, the patient was intubated, due to acute respiratory failure, and he was admitted to the intensive care unit (ICU). Subsequently, he underwent an emergency procedure and a collar incision was carried out. At surgery, a suspicious looking tumour, which was in continuity with the superior pole of the right thyroid lobe, the sheath of right common carotid artery, and the anterolateral portion of the cartilaginous trachea, was identified. Macroscopically, the tumour looked whitish and scleroelastic with moderately regular borders and was firmly adhered to the aforementioned structures. After the right recurrent laryngeal nerve was identified, the tumour was carefully dissected off the right thyroid lobe and the adventitia of the right common carotid artery. A similar approach was carried out to dissect the tumour off the left lobe; hence, an en bloc tumour resection with total thyroidectomy and a regional lymph node dissection was performed. Rapid frozen section biopsy of the tumour in the right thyroid lobe proved to be malignant with features of squamous cell carcinoma and negative surgical margins.\nPostoperatively, the patient experienced swallowing difficulty and hoarseness and a tracheostomy was performed on day 2.\nFinal pathology examination confirmed frozen section's diagnosis of a squamous cell carcinoma invading the right lobe of the thyroid gland, as well as extracapsular structures of the left lobe. Microscopically, the tumour was described as nonencapsulated, irregularly lobulated, with broad fibrous septa, and lymphoplasmacytic, eosinophilic, histiocytic, and multinuclear infiltration. The neoplastic cells were largely polyhedral or oval with eosinophilic or amphophilic cytoplasm, arranged in islands or nests that showed focal keratinization. The nuclei were vesicular or hyperchromatic with nucleoli. A panel of immunohistochemical stains was performed; the tumour was positive for p63, CD117, CKH, CD5, and CD3 in the lymphocytic part (Figures , , and ). It was also negative for the expression of TTF1.\nThe patient subsequently improved and was discharged home on postoperative day 20. The patient did not receive any additional treatment.