|Year : 2019 | Volume
| Issue : 2 | Page : 67-70
Synchronous tumors in head neck oncology: A rare case and its management
Hemish H Kania1, Aditya Joshipura2
1 Department of Surgical Oncology, Gujarat Cancer Research Institute, Ahmedbad, Gujarat, India
2 Department of Head Neck Oncology, Gujarat Cancer Research Institute, Ahmedbad, Gujarat, India
|Date of Web Publication||30-Dec-2019|
Dr. Hemish H Kania
MS Fellow Surgical Oncology, House No 29, First Floor, Santipur, Indira Gandhi Path, Near Pragjyotish College, Guwahati, Assam.
Source of Support: None, Conflict of Interest: None
Although double cancers in the upper aerodigestive tract mucosa are not uncommon collision tumors that are composed of a papillary thyroid carcinoma and a laryngeal giant cell tumour are rare. The term ‘synchronous tumor’ refers to the coexistence of two histologically distinct malignant tumors within the same mass. There are case reports of the Synchronous Tumour composed of papillary thyroid carcinoma with laryngeal squamous cell carcinoma. However, even isolated presentation of giant cell tumour of the larynx is very rare and only 8 cases have been reported. Giant cell tumors of the larynx (GCTL) are extremely rare benign tumors arising in the osteocartilaginous tissue of the larynx. Complete surgical resection is adequate for local control in all the reported cases. Radiation therapy and/or chemotherapy are not a necessary adjunct in the treatment of these laryngeal tumors. This paper reports the case of a 55-year-old male who presented with a synchronous tumor in the neck.
Keywords: Collision tumor, giant cell tumor larynx, laryngeal squamous cell carcinoma, papillary thyroid carcinoma
|How to cite this article:|
Kania HH, Joshipura A. Synchronous tumors in head neck oncology: A rare case and its management. J Curr Oncol 2019;2:67-70
| Introduction|| |
Although double cancers in the upper aerodigestive tract mucosa are not uncommon,,,,,, collision tumors that are composed of a papillary thyroid carcinoma and a laryngeal giant cell tumor are rare. The term “collision tumor” refers to the coexistence of two histologically distinct malignant tumors within the same mass.
There are case reports of the collision tumor composed of papillary thyroid carcinoma with laryngeal squamous cell carcinoma. However, even isolated presentation of giant cell tumor of the larynx is very rare and only eight cases have been reported.
Giant cell tumors of the larynx (GCTL) are extremely rare benign tumors arising in the osteocartilaginous tissue of the larynx. The majority of the tumors reported in the literature arise from the thyroid cartilage (thyroid cartilage: 80%, cricoid cartilage: 15%, epiglottis: 5%) and have predilection for male (M:F = 10:1), with the mean age at the presentation of 40 years. The site of origin has been localized to the thyroid or cricoid cartilage that has undergone endochondral ossification. The common signs and symptoms are palpable neck mass, hoarseness, airway obstruction, and dysphagia. Other symptoms include sore throat, chronic sinusitis, voice loss, and ear pain. There is no definitive association with smoking, heavy alcohol use, or radiation exposure. The duration of symptoms ranges from 1 to 9 months. GCTL seem to behave less aggressively than their long-bone counterparts. Although there are no sufficient numbers of cases and follow-up to accurately predict future biologic behavior of these lesions, GCTL appear to be, to date in all reported cases, non-metastasizing lesions. Complete surgical resection is adequate for local control in all the reported cases. Radiation therapy and/or chemotherapy are not a necessary adjunct in the treatment of these laryngeal tumors. This article reports the case of a 55-year-old male who presented with a collision tumor in neck that initially appeared to be single tumor but ultimately consisted of papillary carcinoma thyroid and giant cell tumor of the laryngeal cartilage.
Written informed consent was obtained from the patient.
| Case Report|| |
A 55-year-old male presented with complaints of bilateral neck swelling for 6 months, difficulty in swallowing for 2 months, and change in voice for 15 days. He had history of using tobacco products, both smokeless and smoked, for more than 10 years [Figure 1].
A single, hard, midline mass 4 × 4 × 2 cm size, fixed to the underlying structures and free from the skin, was seen. On direct laryngoscopy (DL), there was a bulky growth involving left pyriform fossa, ary epiglottic fold, true and false vocal cord anterior and posterior commissure, and lateral and posterior hypopharyngeal wall. The contrast-enhanced computerized tomography scan of the neck revealed a single mass lesion of left ary epiglottic fold and pyriform fossa involving the laryngeal surface of epiglottis, and true and false vocal cord with obliteration of left paraglottic fat space. The posterior commissure was involved and the lesion was seen to involve the hypopharyngeal wall. The lamina of the thyroid cartilage was involved. Both lobes of the thyroid gland were enlarged, of size 46 × 30 and 38 × 22 mm. Multiple enlarged necrotic nodes were present in levels 2, 3, 4, and 5 bilaterally. According to DL scopy and biopsy report, the tumor is possibly “Giant Cell tumor of Laryngeal Cartilage,” and fine needle aspiration cytology from right neck node showed metastatic papillary carcinoma of thyroid origin.
Patient underwent total laryngectomy with total thyroidectomy and bilateral lateral neck dissection with the hypopharynx being augmented using a pectoralis major myocutaneous patch. Intraoperatively, a large mass with extensions as suggested by the imaging was seen, with both lobes of thyroid being enlarged. The thyroid mass was distinct apart from the laryngeal mass. Also, another separate lesion of size 2 × 2 cm was found on left posterolateral wall of the hypopharynx. The patient had uneventful recovery except for post operative hypocalcemia for a short period of time [Figure 2].
|Figure 2: 1, Giant cell tumor of larynx along with the papillary carcinoma thyroid specimen; 2, posterior pharyngeal wall; 3 and 4, right and left neck nodes|
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Histopathology report was suggestive of a giant cell tumor involving left pyriform sinus, extending to the thyroid cartilage. The tumors showed no connection to the surface epithelium and arose in sites of ossification. The tumors had an expansile, infiltrative growth and consisted of numerous multinucleated osteoclast-like giant cells within a cellular stroma composed of plump, oval mononuclear cells. Of interest was that the nuclei of the giant cells were similar to the nuclei of the stromal cells [Figure 3]. Second tumor was a papillary carcinoma of size 4 × 4 cm, infiltrating both lobes, isthmus, capsule, and surrounding structures. The intervening tissue between giant cell tumor of larynx and papillary carcinoma was free of tumor. The separate hypopharyngeal lesion was free of tumor. Two of the 20 nodes (2/20) (perinodal extension negative) dissected from the right side of the neck showed metastatic tumor deposits, whereas all the nodes on the left side (0/10) were free of tumor. Hence, stage of papillary carcinoma thyroid is T4aN2M0. And as giant cell tumor of larynx is a benign tumor, there is no staging system for the same.
|Figure 3: Histological examination shows the cellular mononuclear eosinophilic stromal component (arrowhead) and multinucleated osteoclast-like giant cells (arrow) scattered throughout the lesions in an intermediate power field|
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After the patient recovered, he was referred for radioactive iodine scan in view of nodal involvement thyroid. Informed consent was obtained from the patient for this publication.
| Discussion|| |
In multiple primary cancers, each tumor is malignant and is of an independent pathological type. Multiple primary cancers may be double (i.e., two primary cancers) or triple (i.e., three primary cancers) cancers. Collision carcinomas are a special type of multiple primary tumors, which are difficult to diagnose prior to a surgical resection due to a lack of characteristic clinical features. In this patient, the mass presented as a submucosal lesion. The initial findings indicated a thyroid tumor that was invaded by a laryngeal tumor or a laryngeal tumor that was invaded by a thyroid tumor.
We initially thought it to be a papillary carcinoma thyroid that was invading the laryngeal cartilage. Tracheal invasion has been more extensively studied and characterized due to its greater frequency relative to laryngeal involvement. A widely cited staging system by Shin and colleagues is based on the depth of tracheal invasion. Stage I disease invades through the capsule of the thyroid gland and abuts but does not invade the external perichondrium of the trachea. Stage II disease invades into the cartilage or causes cartilage destruction. Stage III disease extends into the lamina propria of the tracheal mucosa with no elevation or penetration of the mucosa. Stage IV disease is full-thickness invasion with expansion of the tracheal mucosa that is visible bronchoscopically as a bulge or an ulcerated mass.
True GCTL are quite rare, and only individual case reports are documented in literature. Eight cases of GCTL were identified in the Otorhinolaryngologic Pathology Tumor Registry between 1966 and 2000.
Collision tumors may be located anywhere in the body. A collision tumor of the breast has been described, as has an intracranial collision metastasis. Similar to this case, a collision tumor of a papillary thyroid carcinoma and a laryngeal squamous cell carcinoma has been previously reported. In that patient, however, the metastatic lymph nodes were derived from both primary thyroid papillary carcinoma and laryngeal squamous cell carcinoma, with one lymph node showing metastases from the two. In this patient, the metastatic lymph nodes were all derived from the primary thyroid papillary carcinoma. As the other reported collision tumor had a squamous carcinoma component, he received both adjuvant radiotherapy and 131I adjuvant treatment, whereas the patient of this study underwent only 131I therapy.
Due to the rarity of collision tumors of the head and neck, it is difficult to determine their etiology. Two hypotheses have been suggested. The first suggests that the two primary tumors developed in the same location by chance, perhaps due to radiation. The second hypothesis suggests that the presence of the first tumor alters the microenvironment, allowing the second, adjacent tumor to develop. This patient and the earlier study patient were diagnosed with a collision tumor of a papillary thyroid carcinoma and a laryngeal squamous cell carcinoma, and the tumors were extremely large. Probably, had these patients felt uncomfortable and sought treatment earlier, they may not have developed collision tumors.
The therapy for multiple primary cancers should consist of a combination of the treatments that are normally used for each focus. As few patients with these tumors undergo a preoperative histological diagnosis, there may be differences in the postoperative patient management. A collision carcinoma is a special type of multiple primary carcinoma. Thus, en bloc resection of the two inter-infiltrating tumors should be performed. GCTL are rare tumors that can cause significant airway obstruction. Complete surgical resection yields excellent outcomes without the need for any adjuvant therapy.
Although this patient did not exhibit any preoperative characteristics that indicated a collision tumor rather than a laryngeal tumor and a thyroid carcinoma, the results indicate that patients with large tumors invading other structures should be assessed by intraoperative frozen pathology to establish a diagnosis. Although the rarity of these patients limits the therapeutic options, the results of this study indicate that no further treatment was required for laryngeal giant cell tumor and 131I treatment for the papillary thyroid carcinoma.
| Conclusion|| |
As collision tumors of the head and neck are rare, it is very difficult to obtain a preoperative diagnosis. The therapy for a collision tumor should consist of a combination of the treatments that are normally used for each focus.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]