A 58-year-old man presented to us three years ago with a history of progressive anterior neck swelling and hoarseness of voice for the past one month. On clinical examination, there was palpable left anterior neck swelling with cervical lymphadenopathy. A core needle biopsy of the lesion revealed invasive poorly differentiated carcinoma. He defaulted our follow-up and opted for a left hemithyroidectomy at another institution. The histopathological report was intrathyroid thymic carcinoma. He refused adjuvant radiotherapy despite being counselled and subsequently defaulted follow-up.\nRecently, the patient presented to us again with progressive hoarseness of voice and intermittent haemoptysis. He had shortness of breath, especially when lying flat, but no difficulty in swallowing. On clinical examination, there was a left supraclavicular mass measuring 2 × 2 cm. The mass was immobile and hard in consistency. The anterior aspect of the neck showed an irregular hard mass measuring 3 × 4 cm. An indirect laryngoscopy examination revealed a left vocal cord palsy, likely from his previous presentation. An intraluminal mass was seen over the posterior tracheal wall, occupying a third of the tracheal lumen. We proceeded with a contrasted computed tomography (CECT) of the neck and thorax, which revealed a lobulated hypodense soft tissue mass measuring 4.3 × 3.9 × 5.2 cm. It occupied the left thyroid bed from the C7/T1 to the T2/T3 vertebral level, with left retrosternal extension and tracheal deviation to the right. The soft tissue mass had displaced the left common carotid artery and internal jugular vein laterally. As the CECT showed (, ), the soft tissue mass had caused more than 80% of tracheal luminal narrowing. At retrosternal, multiple matted lymph nodes were seen.\nImage-guided fine needle aspiration cytology (FNAC) of the soft tissue mass at the left thyroid bed showed malignant cells suggestive of intrathyroid thymic carcinoma (CASTLE). After a multidisciplinary meeting, we planned for curative resection and tracheostomy. Intraoperative tracheoscopic examination showed a soft tissue mass measuring 3 cm in length at the posterior tracheal wall, 2.1 cm from the vocal cord (). The mass was debrided to achieve an adequate diameter of tracheal lumen distal to the tracheostomy insertion. The left supraclavicular solid tumour densely adhered to the left great vessels. Due to a high risk of injury to the great vessels, we proceeded with tumour debulking only.\nThe histopathology report showed an unencapsulated tumour that displayed lobular architecture. The tumour lobules were composed of sheets of neoplastic polygonal cells rimmed by a variable amount of mature lymphocytes. The neoplastic cells were mildly pleomorphic, and lymphovascular invasion was present. Skeletal muscle bundles attached at the periphery showed focal tumour cell infiltration (, ). Immunohistochemical studies were immunoreactive for CD5 (membranous pattern) and CD117 but negative for thyroglobulin and TTF1 (, ). The proliferative index, Ki67, was approximately 20%.\nPostoperative care was unremarkable, and no immediate complications were noted. The patient was counselled for adjuvant chemoradiotherapy, but he was not amenable to this course of action. He is currently under regular follow-up with no disease progression six months after the operation.
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.