An Unusual Presentation of Recurrent Hurthle Cell Carcinoma of Thyroid
Authors: Saeed Akhtar, Hira Andleeb, Sobia Tabassum
Received: Jan 05, 2020
Revised: Jun 24, 2020
Accepted: Jul 12, 2020
Corresponding Auhtor: Hira Andleeb (email@example.com)
This is the case of 55 years old male who was known of hurthle cell carcinoma (HCC) and underwent total thyroidectomy and right neck dissection in July 2015, followed by radioactive iodine (RAI). He was in close follow-up after the treatment when he presented with right sided neck swelling for 6 weeks followed by hoarseness for 4 weeks and fiber optic laryngoscopy revealed right vocal cord palsy. CT scan was done that showed a mass involving right supraglottic and glottis region, he then underwent right vertical partial laryngectomy. Tumor removed completely (grossly and histopathologically). The case was discussed in tumor board meeting and he was advised RAI scan to look for residual disease, by close follow-up. This case report emphasizes on the unusual clinical presentation and recurrence of HCC of thyroid.
Keywords: Hurthle cell carcinoma, thyroid, oncocytic carcinoma.
Hurthle cell carcinoma (HCC) of the thyroid, also called Oncocytic carcinoma, is a rare form of differentiated thyroid cancer. Preoperative clinical, cytological, and genetic studies have not shown to reliably discriminate between benign and malignant variants of hurthle cell neoplasms (HCN). Therefore, histopathological analysis remains the gold standard for diagnosis; although, it may be apparent preoperatively if there is evidence of metastasis . The overall recurrence rate 12.1%, with average time for relapse of 90.74 months and average time without any signs of the disease of 222.4 months. Overall 5-year, 10-year and 20-year survival rates are 89.4%, 77.2% and 61.9% respectively .
This is a case of 55 years old male, who underwent total thyroidectomy along with right modified radical neck dissection and central compartment clearance done at LNH in July 2015. Neck dissection was planned on the basis of clinically palpable multiple lymph nodes at right level 2, 3 and 4. Final H/P showed hurthle cell carcinoma, involving the right lobe and thymus measuring 8.5x7x5cm, sparing left lobe with no lymphovascular invasion or extra capsular spread. There was no metastasis to lymph nodes.
The case was then discussed in tumor board and radioactive iodine ablation was advised. He underwent RAI ablation and was on close follow up as an outpatient till July 2019, when he presented with right sided neck swelling measuring 4x5 cm which was non tender, firm, fixed mass overlying right thyroid cartilage. U/S neck showed a heterogeneous area measuring 2.4 x1.9 cm in right side of neck with increased vascularity, suspicious of a neoplastic lesion. His RAI scan showed no residual functioning thyroid tissue. Fine needle aspiration cytology (FNAC) was done which showed suspicion of hurthle cell neoplasm (Thy III Bethesda 4).
He then developed hoarseness of voice after 15 days of presentation of the neck swelling, which was persistent. Fiber-optic laryngoscopy was done as an outpatient that revealed right vocal cord palsy but no obvious mucosal lesion.
CT scan neck and chest was done. It showed absence of previous large mass in right lobe of thyroid, sternocleidomastoid, internal jugular vein and submandibular gland, due to previous neck dissection. Small sized left lobe of thyroid measured 1.7x 1cm.
Scan showed a heterogeneously enhancing mass in right glottis and supraglottic region eroding through the thyroid cartilage (Figs. 1&2). It is causing mild narrowing of the air column, abutting the cricoid and arytenoid cartilages with possible focal erosion. Superiorly this mass is involving the right aryepiglottic fold causing mild obliteration of the pyriform sinus. Laterally it is abutting right common carotid artery with blurring of intervening fat planes. Posteriorly mass was abutting the posterior pharyngeal wall, and anteriorly involving the strap muscles, and measures 3.7x 3.5 x 2.8 cm. Significant surrounding fat stranding is present.
PLAN OF SURGERY
This case was discussed in tumor board meeting and after discussing the radiological, histopathological and
clinical aspects of the tumor, we decided to go for the surgical excision of the tumor as it was possible to remove the tumor. A right partial laryngectomy was planned but as the tumor was also involving the thyroid cartilage and overlying strap muscles there was a need to provide tissue coverage for the right hemilarynx. A pectoralis major flap was to be used for this purpose. The procedure was done successfully
Tumor was involving right thyroid lamina and right paraglottic region (causing bulging of right false and true cord with obliteration of ventricle).
Right sided sternocleidomastoid muscle and strap muscles were absent.