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Thyroid Carcinoma in the Parapharyngeal Space
Auris·Nasus·Larinx (Tokyo) 4,67-71, 1977
THYROID CARCINOMA IN THE PARA PHARYNGEAL SPACE Toyoharu YOSHIDA, M.D., Mieko YOSHIDA, M.D., and Goro MOGI, M.D. I Nagato Hospital, Yamaguchi, Japan and 1 Department of Otolaryngology, Yamaguchi University School of Medicine, Yamaguchi, Japan
A case of thyroid carcinoma in the parapharyngeal space is reported in this paper. The patient was a 49-year-old woman with a 6-year history of a progressively enlarging mass in the right lateral portion of the pharynx. The parapharyngeal space was explored by an intra-oral approach and a 3 x 4 x 7 cm ovoid mass was removed. Histologic examination revealed the mass to be a papillary adenocarcinoma of the thyroid tissue. On reviewing literature on this subject, cases of such parapharyngeal tumors were found to be extremely rare. The etiology and pathogenesis of this occurrence is not known.
The parapharyngeal space is a potential anatomical region invaded infrequently by tumors. Most tumors in this area are benign, particularly salivary mixed tumors and neurogenic tumors. This fact is due to the anatomy of the para pharyngeal space. On reviewing literature on this subject, the thyroid carcinoma in the parapharyngeal space was found to be extremely rare. In the present paper, a case of thyroid carcinoma in this area will be reported. REPORT OF THE CASE
C.N., a 49-year-old woman, was admitted to Nagato Hospital on February 12, 1975, with a 6-year history of a progressively enlarging mass in the throat. The patient had experienced no pain, but had experienced increased difficulty in swallowing and talking during the previous four months. She indicated having had no hearing disturbance or hoarseness. Physical examination revealed her to be well nourished. There was little external swelling overlying the angle or the ascending ramus of the right side of the mandible. However, on bimanual examination, a firm mass was palpated beneath the angle and inner portion of the ramus of the right mandible. There Received publication August 23, 1976 67
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T. YOSHIDA, M. YOSHIDA, and G. MOGI
was a large palpable swelling which pushed the uvula and tonsil to the left side. This swelling of the lateral pharyngeal wall extended upward to the epipharynx and downward to the level of the epiglottis. Facial nerve functions were normal, and no paralysis of the vocal cords was detected. Peripheral blood examination showed that hematocrit was 39 %; red cell count 423 x 104 ; and white cell count 7,800, with 66 % neutrophiles, 24 % lymphocytes, 7 % monocytes, and 3 %eosinophiles. Examination of icteric index, cholinesterase, alkali phosphatase, cholesterol, GOT, GPT, and urea N in the serum revealed no abnormalities. Values of serum protein fractions analyzed by electrophoresis were within normal limits. PBI was 5.18/100 ml, T3 23.5 %, and T4 11.0 ,ug/100 m\. Parapharyngeal tumor was diagnosed. Under endotracheal anesthesia, the parapharyngeal space was explored through an intra-oral approach to remove the tumor. A 4 x 7 cm ovoid mass was found deep in the lateral portion of the pharynx. The superficial portion of this mass was well encapsulated and removed, its deep portion was firmly fixed to the fascia of prevertebral muscles. The posterior portion of the mass included a few cysts containing brown fluid. During the course of removal by blunt dissection, the capsule of the cystic protrusions was ruptured. Parts of mass were very hard, as if they were forming calculi. There was no direct connection between the mass and the parotid gland, carotid sheath, and vagus and hypoglossal nerves. The postoperative course was uneventiful, and
Fig. 1. Gross appearance of the surgically removed tumor. A. Anterior view: the surface is relatively smooth and well encapsulated. B. Posterior view: many papillae project from the inner lining of the cysts.
THYROID CARCINOMA IN PARAPHARYNGEAL SPACE
69
ten months after surgery no signs of recurrence were found. Any sign suggesting deficiency of thyroid or parathyroid gland hormones was not seen. The size of the surgically excised mass was 3 x 4 x 7 cm (Fig. 1). Whereas the anterior portion of the mass was relatively smooth and well encapsulated, there were a few cystic formations in the posterior portion. Papillae can be
Fig. 2. Photomicrographs of the mass, showing a papillary adenocarcinoma of the thyroid tissue. A. Predominant in papillary lesion ( x 100). B. Predominant in glandular lesion (x 100).
70
T. YOSHIDA, M. YOSHIDA, and G . MOGI
seen projecting from the inner lining of the cysts (Fig. 1). In places, colloidal masses and very hard masses like calcifications were detected. Histologic examination revealed the mass to be a papillary adenocarcinoma of the thyroid tissue. The tumor cells were cuboidal or columnar with a homogenous, amphophilic cytoplasm surrounding an ovoid nucleus containing the chromatin. As shown in Fig. 2, these tumor cells form papillary or glandular structures in the hyaloid connective tissues. The epithelium was mostly single layered, but multilayering did occur. Atypism of tumor cells was not only prominent, but mitosis was extremely rare. Occasional follicles contained an eosinophilic colloid substance, being positive in the PAS stain. Figure 2A shows a follicle, surrounded by a single squamous epithelium containing the PAS positive colloid substance. Psammoma bodies were also detected. The histologic examination failed to find any lymphoid structure. DISCUSSION
Nearly all tumors of the para pharyngeal space are usually asymptomatic in spite of the remarkable differences in their pathologic features. MCILRATH et al. (1963), on reviewing their 101 patients having parapharyngeal tumors, reported that salivary mixed tumors totaled 42.6 % of the cases, malignant lymphomas 24.7 %, neurilemmomas 15.8 %, chemodectomas 11.9 %, and miscellaneous tumors 5.0 %. WORK and HYBELS (1974) evaluated 40 patients with parapharyngeal tumors and reported that benign tumors accounted for 82 % of the cases, while malignant lesions totaled 18 %. However, neither study included any cases of thyroid carcinoma or thyroid tumors. However, it has been reported that thyroid tissue or thyroid carcinoma is incidentally found in lymph nodes of the lateral neck and that thyroid carcinoma in the cervical lymph nodes is occasionally more prominent than occult thyroid carcinoma, its primary lesion in the thyroid (GERARD-MARCHANT, 1964, CLARK et al., 1966, BUTLER et aI., 1967, FISH and MOORE, 1963). Ectopic thyroid tissue or ectopic thyroid carcinoma in also not unusual (GIKAS et aI., 1967). Although the etiology and pathogenesis of the occult or ectopic thyroid carcinoma are in a state of controversy, several authors (CLARK et al., 1966, BUTLER et al., 1967, GIKAS et al., 1967) have suggested that thyroid tissue found in a lymph node represents metastatic thyroid cancer. NOGUCHI et al. (1970) investigated the pattern of cervical lymph node metastases from thyroid cancers. According to their findings, the initial metastases were most commonly observed in the pre- and para-tracheal nodes, and subsequently, metastases were noted in the deep inferior and lateral nodes. However, they did not find any metastatized lymph node in the parapharyngeal space. FISH et aZ. (1963) reported that ectopic thyroid tissue had been found in the lingual, suprahyoid, infrahyoid, intralaryngeal, intratracheal, intraesophageal, aortic, pericardial, and cardiac regions. They did not indicate that ectopic thyroid cancer occurred in the parapharyngeal space. On reviewing liter-
THYROID CARCINOMA IN PARAPHARYNGEAL SPACE
71
ature on this subject, we found no reports of thyroid carcinoma in the parapharyngeal space. In the present case, the thyroid gland was not explored surgically, and the histologic examination revealed no remnant of lymphoid tissue in the tumor mass removed. Therefore, it is not certain whether this thyroid carcinoma in the parapharyngeal space was a metastatic lesion or developed from an ectopic thyroid tissue deposit. SUMMARY
A case of papillary adenocarcinoma of the thyroid tissue in the parapharyngeal space of a 49-year-old woman is reported in this paper. REFERENCES BUTLER, J. J. et at.: Significance of thyroid tissue in lymph nodes associated with carcinoma of the head, neck or lung. Cancer 20: 103-112, 1967. CLARK, R. L. et al. : Thyroid cancer discovered incidentally during treatment for an unrelated head and neck cancer: Review of 16 cases. Ann. Surg. 163: 665-671, 1966. FISH, J., MOORE, R. M.: Ectopic thyroid tissue and ectopic thyroid carcinoma: A review of the literature and report of a case. Ann. Surg. 157: 212-222, 1963. GERARD-MARCHANT, R.: Thyroid follicle inclusions in cervical lymph nodes. Arch. Path. 77: 633-637, 1964. GIKAS, P. W. et at.: Occult metastasis from occult papillary carcinoma of thyroid. Cancer 20: 2100-2104, 1967. MCILRATH, D. C. et at.: Tumors of the parapharyngeal region. SUrg. Gynec. Obst. 116: 88-94, 1963. NOGUCHI, S., NOGUCHI, A., and MURAKAMI, N.: Papillary carcinoma of the thyroid. 1. Developing pattern of metastasis. Cancer 26: 1053-1060, 1970. WORK, W. P., and HYBELS, R. L.: A study of tumors of the parapharyngeal space. Laryngoscope 84: 1748-1755, 1974.
Request reprints from:
Dr. Toyoharu Yoshida, Nagato Hospital, 85 Higashifukagawa, Nagato, Yamaguchi, Japan
THYROID CARCINOMA IN THE PARA PHARYNGEAL SPACE Toyoharu YOSHIDA, M.D., Mieko YOSHIDA, M.D., and Goro MOGI, M.D. I Nagato Hospital, Yamaguchi, Japan and 1 Department of Otolaryngology, Yamaguchi University School of Medicine, Yamaguchi, Japan
A case of thyroid carcinoma in the parapharyngeal space is reported in this paper. The patient was a 49-year-old woman with a 6-year history of a progressively enlarging mass in the right lateral portion of the pharynx. The parapharyngeal space was explored by an intra-oral approach and a 3 x 4 x 7 cm ovoid mass was removed. Histologic examination revealed the mass to be a papillary adenocarcinoma of the thyroid tissue. On reviewing literature on this subject, cases of such parapharyngeal tumors were found to be extremely rare. The etiology and pathogenesis of this occurrence is not known.
The parapharyngeal space is a potential anatomical region invaded infrequently by tumors. Most tumors in this area are benign, particularly salivary mixed tumors and neurogenic tumors. This fact is due to the anatomy of the para pharyngeal space. On reviewing literature on this subject, the thyroid carcinoma in the parapharyngeal space was found to be extremely rare. In the present paper, a case of thyroid carcinoma in this area will be reported. REPORT OF THE CASE
C.N., a 49-year-old woman, was admitted to Nagato Hospital on February 12, 1975, with a 6-year history of a progressively enlarging mass in the throat. The patient had experienced no pain, but had experienced increased difficulty in swallowing and talking during the previous four months. She indicated having had no hearing disturbance or hoarseness. Physical examination revealed her to be well nourished. There was little external swelling overlying the angle or the ascending ramus of the right side of the mandible. However, on bimanual examination, a firm mass was palpated beneath the angle and inner portion of the ramus of the right mandible. There Received publication August 23, 1976 67
68
T. YOSHIDA, M. YOSHIDA, and G. MOGI
was a large palpable swelling which pushed the uvula and tonsil to the left side. This swelling of the lateral pharyngeal wall extended upward to the epipharynx and downward to the level of the epiglottis. Facial nerve functions were normal, and no paralysis of the vocal cords was detected. Peripheral blood examination showed that hematocrit was 39 %; red cell count 423 x 104 ; and white cell count 7,800, with 66 % neutrophiles, 24 % lymphocytes, 7 % monocytes, and 3 %eosinophiles. Examination of icteric index, cholinesterase, alkali phosphatase, cholesterol, GOT, GPT, and urea N in the serum revealed no abnormalities. Values of serum protein fractions analyzed by electrophoresis were within normal limits. PBI was 5.18/100 ml, T3 23.5 %, and T4 11.0 ,ug/100 m\. Parapharyngeal tumor was diagnosed. Under endotracheal anesthesia, the parapharyngeal space was explored through an intra-oral approach to remove the tumor. A 4 x 7 cm ovoid mass was found deep in the lateral portion of the pharynx. The superficial portion of this mass was well encapsulated and removed, its deep portion was firmly fixed to the fascia of prevertebral muscles. The posterior portion of the mass included a few cysts containing brown fluid. During the course of removal by blunt dissection, the capsule of the cystic protrusions was ruptured. Parts of mass were very hard, as if they were forming calculi. There was no direct connection between the mass and the parotid gland, carotid sheath, and vagus and hypoglossal nerves. The postoperative course was uneventiful, and
Fig. 1. Gross appearance of the surgically removed tumor. A. Anterior view: the surface is relatively smooth and well encapsulated. B. Posterior view: many papillae project from the inner lining of the cysts.
THYROID CARCINOMA IN PARAPHARYNGEAL SPACE
69
ten months after surgery no signs of recurrence were found. Any sign suggesting deficiency of thyroid or parathyroid gland hormones was not seen. The size of the surgically excised mass was 3 x 4 x 7 cm (Fig. 1). Whereas the anterior portion of the mass was relatively smooth and well encapsulated, there were a few cystic formations in the posterior portion. Papillae can be
Fig. 2. Photomicrographs of the mass, showing a papillary adenocarcinoma of the thyroid tissue. A. Predominant in papillary lesion ( x 100). B. Predominant in glandular lesion (x 100).
70
T. YOSHIDA, M. YOSHIDA, and G . MOGI
seen projecting from the inner lining of the cysts (Fig. 1). In places, colloidal masses and very hard masses like calcifications were detected. Histologic examination revealed the mass to be a papillary adenocarcinoma of the thyroid tissue. The tumor cells were cuboidal or columnar with a homogenous, amphophilic cytoplasm surrounding an ovoid nucleus containing the chromatin. As shown in Fig. 2, these tumor cells form papillary or glandular structures in the hyaloid connective tissues. The epithelium was mostly single layered, but multilayering did occur. Atypism of tumor cells was not only prominent, but mitosis was extremely rare. Occasional follicles contained an eosinophilic colloid substance, being positive in the PAS stain. Figure 2A shows a follicle, surrounded by a single squamous epithelium containing the PAS positive colloid substance. Psammoma bodies were also detected. The histologic examination failed to find any lymphoid structure. DISCUSSION
Nearly all tumors of the para pharyngeal space are usually asymptomatic in spite of the remarkable differences in their pathologic features. MCILRATH et al. (1963), on reviewing their 101 patients having parapharyngeal tumors, reported that salivary mixed tumors totaled 42.6 % of the cases, malignant lymphomas 24.7 %, neurilemmomas 15.8 %, chemodectomas 11.9 %, and miscellaneous tumors 5.0 %. WORK and HYBELS (1974) evaluated 40 patients with parapharyngeal tumors and reported that benign tumors accounted for 82 % of the cases, while malignant lesions totaled 18 %. However, neither study included any cases of thyroid carcinoma or thyroid tumors. However, it has been reported that thyroid tissue or thyroid carcinoma is incidentally found in lymph nodes of the lateral neck and that thyroid carcinoma in the cervical lymph nodes is occasionally more prominent than occult thyroid carcinoma, its primary lesion in the thyroid (GERARD-MARCHANT, 1964, CLARK et al., 1966, BUTLER et aI., 1967, FISH and MOORE, 1963). Ectopic thyroid tissue or ectopic thyroid carcinoma in also not unusual (GIKAS et aI., 1967). Although the etiology and pathogenesis of the occult or ectopic thyroid carcinoma are in a state of controversy, several authors (CLARK et al., 1966, BUTLER et al., 1967, GIKAS et al., 1967) have suggested that thyroid tissue found in a lymph node represents metastatic thyroid cancer. NOGUCHI et al. (1970) investigated the pattern of cervical lymph node metastases from thyroid cancers. According to their findings, the initial metastases were most commonly observed in the pre- and para-tracheal nodes, and subsequently, metastases were noted in the deep inferior and lateral nodes. However, they did not find any metastatized lymph node in the parapharyngeal space. FISH et aZ. (1963) reported that ectopic thyroid tissue had been found in the lingual, suprahyoid, infrahyoid, intralaryngeal, intratracheal, intraesophageal, aortic, pericardial, and cardiac regions. They did not indicate that ectopic thyroid cancer occurred in the parapharyngeal space. On reviewing liter-
THYROID CARCINOMA IN PARAPHARYNGEAL SPACE
71
ature on this subject, we found no reports of thyroid carcinoma in the parapharyngeal space. In the present case, the thyroid gland was not explored surgically, and the histologic examination revealed no remnant of lymphoid tissue in the tumor mass removed. Therefore, it is not certain whether this thyroid carcinoma in the parapharyngeal space was a metastatic lesion or developed from an ectopic thyroid tissue deposit. SUMMARY
A case of papillary adenocarcinoma of the thyroid tissue in the parapharyngeal space of a 49-year-old woman is reported in this paper. REFERENCES BUTLER, J. J. et at.: Significance of thyroid tissue in lymph nodes associated with carcinoma of the head, neck or lung. Cancer 20: 103-112, 1967. CLARK, R. L. et al. : Thyroid cancer discovered incidentally during treatment for an unrelated head and neck cancer: Review of 16 cases. Ann. Surg. 163: 665-671, 1966. FISH, J., MOORE, R. M.: Ectopic thyroid tissue and ectopic thyroid carcinoma: A review of the literature and report of a case. Ann. Surg. 157: 212-222, 1963. GERARD-MARCHANT, R.: Thyroid follicle inclusions in cervical lymph nodes. Arch. Path. 77: 633-637, 1964. GIKAS, P. W. et at.: Occult metastasis from occult papillary carcinoma of thyroid. Cancer 20: 2100-2104, 1967. MCILRATH, D. C. et at.: Tumors of the parapharyngeal region. SUrg. Gynec. Obst. 116: 88-94, 1963. NOGUCHI, S., NOGUCHI, A., and MURAKAMI, N.: Papillary carcinoma of the thyroid. 1. Developing pattern of metastasis. Cancer 26: 1053-1060, 1970. WORK, W. P., and HYBELS, R. L.: A study of tumors of the parapharyngeal space. Laryngoscope 84: 1748-1755, 1974.
Request reprints from:
Dr. Toyoharu Yoshida, Nagato Hospital, 85 Higashifukagawa, Nagato, Yamaguchi, Japan