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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 26  |  Issue : 2  |  Page : 74-76

Unexpected synchronous diagnosis of papillary thyroid carcinoma in a patient with lower lip squamous cell carcinoma


1 Department of Plastic Reconstructive and Aesthetic Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
2 Ankara Training and Research Hospital, Plastic Reconstructive and Aesthetic Surgery Clinic, Ankara, Turkey
3 Guru Aesthetic Surgery Clinic, Ankara, Turkey

Date of Web Publication13-Apr-2018

Correspondence Address:
Dr. Veysel Murat Isik
Ankara Training and Research Hospital, Plastic Reconstructive and Aesthetic Surgery Clinic, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.TJPS_28_18

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  Abstract 


The presentation of differentiated thyroid carcinoma occurring as a second primary associated with head and neck squamous cell carcinoma is quite unusual. Here, we present an unexpected synchronous diagnosis of two independent head and neck malignancies. A 78-year-old male with a rapidly growing, firm, and ulcerated lesion on the lower lip was referred to our clinic. Positron emission tomography-computed tomography scan performed for systemic screening demonstrated a dense hypermetabolic activity located in the right thyroid lobe, suggesting a second malignancy. Fine-needle aspiration cytology of the right thyroid gland performed to differentiate the presence of a metastatic lesion, or primary thyroid cancer was compatible with malign cytology related to papillary thyroid carcinoma. Multiple malignancies may be diagnosed synchronously in the head and neck region and these patients with multiple malignant lesions should be evaluated carefully before being accepted as metastatic.

Keywords: Head, malignancy, neck, papillary thyroid carcinoma, squamous cell carcinoma, synchronous diagnosis


How to cite this article:
Calis M, Isik VM, Ulusoy MG, Sungur N, Kocer U. Unexpected synchronous diagnosis of papillary thyroid carcinoma in a patient with lower lip squamous cell carcinoma. Turk J Plast Surg 2018;26:74-6

How to cite this URL:
Calis M, Isik VM, Ulusoy MG, Sungur N, Kocer U. Unexpected synchronous diagnosis of papillary thyroid carcinoma in a patient with lower lip squamous cell carcinoma. Turk J Plast Surg [serial online] 2018 [cited 2019 Sep 17];26:74-6. Available from: http://www.turkjplastsurg.org/text.asp?2018/26/2/74/230115




  Introduction Top


Squamous cell carcinoma (SCC) of the lower lip is a common malignant tumor comprising 25%–30% of all oral cancers.[1],[2] It is predominantly seen among male patients. The etiopathogenesis of lip cancer is multifactorial including smoking, alcohol use, exposure to sunlight, genetic predisposition, immunosuppression, and immunodeficiency. The presentation of differentiated thyroid carcinoma occurring as a second primary associated with head and neck SCC (HNSCC) is quite unusual. Moreover, estimated incidence of papillary thyroid carcinoma (PTC) with head and neck squamous cell primary tumor is estimated to be <0.5%.[3] We would like to share an unexpected presentation of lower lip SCC coincidentally with PTC.


  Case Report Top


A 78-year-old male with a rapidly growing, firm, and ulcerated lesion on the lower lip of 3-month duration was referred to our clinic. He had a history of 50 pack year smoking but no alcohol intake. On physical examination, an ulcerated red-brown lesion (3 cm × 2 cm) with raised margins, extending into the internal mucosal surface was observed on the central one-third of the lower lip [Figure 1]. No clinically palpable lymphadenopathies were found. Initially, an incisional biopsy was performed, and diagnosis of well-differentiated minimally invasive SCC was confirmed. Neck ultrasound imaging for the preoperative assessment revealed a few lymph nodes ranging from 1.0 to 1.5 cm in size at the left upper cervical chain. Fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) scan performed for systemic screening demonstrated a dense hypermetabolic activity located in the right thyroid lobe, suggesting a malignancy [Figure 2]. Technetium-99m pertechnetate thyroid scan showed a hypoactive nodule in the right lobe of the thyroid gland. Fine-needle aspiration cytology of the right thyroid gland performed to differentiate the presence of a metastatic lesion or primary thyroid cancer was compatible with malign cytology related to PTC. Once the preoperative evaluations were completed V-shaped wedge excision of the lower lip lesion and total thyroidectomy was performed. The pathologic evaluation identified the well-differentiated minimally invasive SCC without perineural invasion and PTC in gross specimens. The patient had no recurrence after more than 6 months of follow-up without receiving any adjuvant therapy.
Figure 1: Preoperative appearance of the ulcerated lesion with raised margins suggesting squamous cell carcinoma of the lower lip

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Figure 2: Positron emission tomography-computed tomography scan of the patient demonstrates a dense hypermetabolic activity (red arrow) located in the right thyroid lobe

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  Discussion Top


SCC is the second most common type of skin cancer. It often presents as an ulcerative or fungating lesion of the head and neck and other sun-exposed areas. Most cases of primary cutaneous SCC are induced by ultraviolet (UV) radiation. Chronic sun exposure is the major risk factor. Moreover, it is important for the clinician to recognize other risk factors including light skin tone, UV exposure, indoor tanning, previous history of actinic keratosis, prior irradiation, immunosuppression, human immunodeficiency virus, human papillomavirus, chronic wounds and burn scars, coal tar, and arsenic exposure. The pathogenesis of SCC is unclear. More than 90% of patients diagnosed in the US demonstrate functional loss of the P53 tumor suppressor gene. UV radiation is thought to damage host DNA, resulting in a genetic mutation of P53.[4]

18F-FDG PET CT has become an important diagnostic tool for evaluation of HNSCCs and is applied in various clinical settings, ranging from pretreatment staging to radiotherapy planning, treatment response assessment, and posttherapy follow-up. The main indication of 18F-FDG PET-CT in newly diagnosed HNSCCs is the detection of cervical lymph node involvement, which is one of the most important prognostic factors. Data from the literature support the superiority of PET-CT over morphologic imaging in detecting lymph node involvement. However, it must be stressed that small lymph node lesions may be missed (possible false-negative results), and that inflamed lymph nodes may take up the tracer (possible false-positive results). The screening for distant metastases is important in patients with advanced disease. The most common sites are lungs, bone, and liver. In this context, a higher accuracy of 18F-FDG PET-CT than CT for the detection of distant metastasis has been clearly demonstrated. Secondary primary tumors are notably the first cause of death with a decisive impact on overall survival rates of early-stage HNSCC patients. 18F-FDG PET-CT is an accurate method to detect second primaries.[5]

Surgical excision is the primary modality of treatment. Regional lymph node dissections are only indicated for clinically positive nodal disease or lymphatic basins that are positive after sentinel lymph node biopsy.

The synchronous diagnosis of multiple primary cancers in the head and neck region is not uncommon among the population. After the head and neck region, lung and oral cavity are the following most common primary sites, and these second primaries are usually SCC as well.[3] However, the incidence of differentiated thyroid carcinoma as a second primary site associated with HNSCC is extremely rare.[3] In the retrospective evaluation of Clark et al., 16 patients out of 1516 patients were incidentally found to have thyroid cancer diagnosed during treatment for an unrelated head and neck cancer.[6] In two patients in this group, the thyroid cancer was discovered simultaneously with lower lip SCC. However, the pathologies of these two patients were reported as follicular carcinoma and solid carcinoma. Vassilopoulou-Sellin and Weber have reviewed the record of 2855 patients with the diagnosis of SCC of the tongue.[7] They detected that 12 patients also had a secondary diagnosis of coexisting differentiated thyroid cancer. The type of thyroid malignancies was the papillary variant in four cases and follicular type in the others. To best of our knowledge, this is the first report of a patient presenting with lower lip SCC and a simultaneous PTC.


  Conclusion Top


We believe that it is important to emphasize that multiple malignancies may be diagnosed synchronously and these patients with multiple malignant lesions should be evaluated carefully before being accepted as metastatic.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hasson O. Squamous cell carcinoma of the lower lip. J Oral Maxillofac Surg 2008;66:1259-62.  Back to cited text no. 1
[PUBMED]    
2.
Casal D, Carmo L, Melancia T, Zagalo C, Cid O, Rosa-Santos J, et al. Lip cancer: A 5-year review in a tertiary referral centre. J Plast Reconstr Aesthet Surg 2010;63:2040-5.  Back to cited text no. 2
    
3.
Pitman KT, Johnson JT, Myers EN. Papillary thyroid carcinoma associated with squamous cell carcinoma of the head and neck: Significance and treatment. Am J Otolaryngol 1996;17:190-6.  Back to cited text no. 3
    
4.
Black AP, Ogg GS. The role of p53 in the immunobiology of cutaneous squamous cell carcinoma. Clin Exp Immunol 2003;132:379-84.  Back to cited text no. 4
    
5.
Castaldi P, Leccisotti L, Bussu F, Miccichè F, Rufini V. Role of (18) F-FDG PET-CT in head and neck squamous cell carcinoma. Acta Otorhinolaryngol Ital 2013;33:1-8.  Back to cited text no. 5
    
6.
Clark RL, Hickey RC, Butler JJ, Ibanez ML, Ballantyne AJ. Thyroid cancer discovered incidentally during treatment of an unrelated head and neck cancer: Review of 16 cases. Ann Surg 1966;163:665-71.  Back to cited text no. 6
    
7.
Vassilopoulou-Sellin R, Weber RS. Metastatic thyroid cancer as an incidental finding during neck dissection: Significance and management. Head Neck 1992;14:459-63.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

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