A sixty-six year-old, non hypertensive, non diabetic, heavy alcoholic male who was a known smoker for 20 years, presented with a rapid enlargement in the anterior lower part of the neck along with gradual swelling of upper chest (sternal area) which developed within 3 weeks (Figure 1).
At presentation, he reported easy fatigability and generalized weakness. He also had anorexia but minimum difficulty in deglutition of solid food for the last week along with hoarseness of voice. He mentioned weight loss during the last one month. The patient did not have any symptom of hypothyroidism, hyperthyroidism or upper respiratory symptoms due to external compression. He had no previous history of long term medicine intake, pulmonary tuberculosis, contact with a TB patient or any surgical interventions. Bowel and bladder habits were normal. He was alert, conscious and co-operative. On physical examination, he had a firm goiter associated with enlarged firm and fixed cervical lymph nodes. He had both sided enlarged supraclavicular lymph nodes (2.5cmx2.5cm) which were firm and non tender. Left lobe of thyroid was enlarged, lobulated and firm. There was a hard, non tender mass over manubrium of sternum with a size of 8cmx5cm, fixed to skin and underlying bone. Breath sounds were normal over both sides. His blood reports: Hb 12 g/dl, total leukocyte count 12,500, fasting blood sugar 101, urea 33 mg%, creatinine 0.80 mg%, serum sodium 136 mEq/L, potassium 4.42 mEq/L, LDH 447 U, total bilirubin 0.17, SGPT 25 U, SGOT 13 U, ALP 68 U, total protein 6.9 gm/dl, albumin 3.0 gm/dl, and globulin 3.9 gm/dl. Tests of thyroid function were within the normal range. No feature of upper airway obstruction was noted. Thyroid and cervical ultrasound examination revealed enlargement of the left lobe of thyroid with a heterogeneous and hypoechogenic pattern and a focal lesion. Fine needle aspiration cytology (FNAC) was performed from the thyroid (Figure 2), pre-sternal mass (Figure 3) and the abnormal lymph nodes (Figure 4) and metastatic squamous cell carcinoma was found. Cytological samples did not reveal characteristics of thyroid-derived malignant neoplasms. Immunostaining was negative for thyroglobulin, calcitonin, TTF1, K 5-6, and CK20. Computed tomography (CT) scan of the neck (Figure 5) and chest revealed a left thyroid lobe mass and destruction of the sternum resulting in a prominent swelling in front of the chest. There was no evidence of a lung cancer. Upper gastrointestinal endoscopy demonstrated one ulcerative growth at thirty cm distance from the incisor teeth involving full circumference of mucosa suggestive of a malignant neoplasm. Biopsy from the ulcer showed squamous cell carcinoma (Figure 6). Vocal cord examination revealed diminished movement of left vocal cord. He had increasing weight loss, dysphagia, poor appetite, and difficulty maintaining his caloric needs. As surgical debulking was not possible, external beam radiation therapy of the neck and upper mediastinum was planned along with combination chemotherapy. Unfortunately, the general condition of the patient deteriorated quickly, and the patient died before definitive therapy can be instituted.