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Incidental Thyroid Mass in a Patient With Oropharyngeal Squamous Cell Carcinoma

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 71-year-old man with no history of smoking was referred to our tertiary center in August 2018 for an asymptomatic left level 5 neck mass that had been present for 6 months. Biopsy of the mass demonstrated metastatic p16-positive (human papillomavirus [HPV]-related) squamous cell carcinoma. Examination revealed a large left base of tongue mass filling the vallecula. Computed tomography (CT) demonstrated an enhancing mass within the left base of tongue and bilateral cervical adenopathy. The patient was treated with concurrent radiation therapy and cetuximab, completing treatment without breaks in November 2018. His 3-month posttreatment fluorodeoxyglucose (FDG) positron-emission tomography/CT (FDG-PET/CT) imaging results demonstrated resolution of the activity at the base of tongue mass and the involved cervical lymph nodes, consistent with complete treatment response.

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B. Metastatic squamous cell carcinoma

Histopathology revealed p16-positive squamous cell carcinoma of bilateral thyroid lobes, and 13 of 20 positive lymph nodes, involving left neck levels 2 through 5 and 6, with extranodal extension. The diagnosis of HPV-related metastasis was confirmed with RNA in situ hybridization for high-risk HPV (types 16, 18, 31, and 33) showing hybridization in areas of p16 immunoreactivity. Biopsy results of thyroid tumor cells were negative for chromogranin, synaptophysin, and CD56, excluding an underlying neuroendocrine component. The patient was subsequently treated with reirradiation and cisplatin.

Metastasis to the thyroid represents only 1.4% to 3% of all thyroid cancers.1 In a series of 97 patients with metastatic cancer to the thyroid, a head and neck primary site was identified in 12 (12%).1 Squamous cell carcinoma of the thyroid can present as primary thyroid cancer or secondary involvement from direct extension of adjacent disease, typically from the larynx.2 To our knowledge, there are only 19 published articles comprising a total of 32 patients with squamous cell carcinoma of the head and neck metastasizing to the thyroid.2 Of these cases, only 3 involved oropharyngeal primary sites. Nasopharyngeal cancer was the most commonly reported primary site.2,3

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Article Information

Corresponding Author: Kinneri Mehta, MD, Division of Otolaryngology–Head and Neck Surgery, University of Connecticut School of Medicine, 263 Farmington Ave, Farmington, CT 06030 (mehtakinneri@gmail.com).

Published Online: July 30, 2020. doi:10.1001/jamaoto.2020.1616

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

Hegerova  L , Griebeler  ML , Reynolds  JP , Henry  MR , Gharib  H .  Metastasis to the thyroid gland: report of a large series from the Mayo Clinic.   Am J Clin Oncol. 2015;38(4):338-342. doi:10.1097/COC.0b013e31829d1d09PubMedGoogle ScholarCrossref
Vatsyayan  A , Mandlik  D , Patel  P ,  et al.  Metastasis of squamous cell carcinoma of the head and neck to the thyroid: a single institution’s experience with a review of relevant publications.   Br J Oral Maxillofac Surg. 2019;57(7):609-615. doi:10.1016/j.bjoms.2019.05.012PubMedGoogle ScholarCrossref
Jalaludin  MA , Rajadurai  P , Va  R , Prasad  U .  Thyroid metastasis from nasopharyngeal carcinoma: a case report.   J Laryngol Otol. 1994;108(10):886-888. doi:10.1017/S0022215100128415PubMedGoogle ScholarCrossref
Aparici  CM , Win  AZ .  Two cases of thyroid metastasis from head and neck squamous cell carcinoma detected by FDG-PET/CT.   J Clin Imaging Sci. 2014;4:62.PubMedGoogle ScholarCrossref
Takenobu  M , Moritani  S , Yoshioka  K , Morisaki  T , Kitano  H .  A case report of thyroid metastasis from p16-positive oropharyngeal squamous cell carcinoma.   Endocr J. 2018;65(4):479-483. doi:10.1507/endocrj.EJ17-0553PubMedGoogle ScholarCrossref
Chen  YK , Chen  YL , Cheng  RH , Yeh  CL , Lee  CC , Hsu  CH .  The significance of FDG uptake in bilateral thyroid glands.   Nucl Med Commun. 2007;28(2):117-122. doi:10.1097/MNM.0b013e328013eaf7PubMedGoogle ScholarCrossref
Affandi  KA , Tizen  NMS , Mustangin  M , Zin  RRMRM .  p40 Immunohistochemistry is an excellent marker in primary lung squamous cell carcinoma.   J Pathol Transl Med. 2018;52(5):283-289. doi:10.4132/jptm.2018.08.14PubMedGoogle ScholarCrossref
Suzuki  A , Hirokawa  M , Takada  N ,  et al.  Diagnostic significance of PAX8 in thyroid squamous cell carcinoma.   Endocr J. 2015;62(11):991-995. doi:10.1507/endocrj.EJ15-0226PubMedGoogle ScholarCrossref
Jankowska  P , Teoh  EM , Fisher  C , Rhys Evans  P , Nutting  CM , Harrington  KJ .  Case report: isolated intrathyroid metastasis from undifferentiated and squamous carcinoma of the head and neck: the case for surgery and re-irradiation.   Br J Radiol. 2008;81(966):e154-e161. doi:10.1259/bjr/26919796PubMedGoogle ScholarCrossref
Gillison  ML , Trotti  AM , Harris  J ,  et al.  Radiotherapy plus cetuximab or cisplatin in human papillomavirus-positive oropharyngeal cancer (NRG Oncology RTOG 1016): a randomised, multicentre, non-inferiority trial.   Lancet. 2019;393(10166):40-50. doi:10.1016/S0140-6736(18)32779-XPubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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