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Nodal metastases from head and neck primary cancer presenting as a parapharyngeal space mass are rare. This paper reports two cases of papillary thyroid carcinoma metastatic to the parapharyngeal space. This finding can be related to Rouviere's description of a direct lymphatic pathway from the posterior surface of the superior thyroid lobe to the lateral retropharyngeal nodes. Metastatic thyroid cancer should be considered in the differential diagnosis of a parapharyngeal space mass.

To assess the potential value of cytokeratins (CK) 8,18,19 as tumor markers for thyroid diseases, a study was performed comparing serum CK 8,18,19 levels in patients affected from thyroid carcinoma, adenoma, other benign thyroid diseases and healthy volunteers as controls. One hundred cases (65 patients and 35 controls) were examined. Thirty patients had thyroid carcinoma (18 papillary--PTC, 8 follicular--FTC, 4 medullary--MTC), 19 non-toxic goiter, 10 thyroid adenoma, 6 chronic thyroiditis and 35 healthy volunteers as controls. These controls were matched by age and sex. The mean value of CK in benign thyroid diseases (46.1 U/L) was significantly higher (p<0.02) than that in healthy controls (29.6 U/L). The mean value of CK in carcinomas (68.1 U/L) was significantly higher than that in healthy controls (p<0.01) and benign thyroid diseases patients (p<0.05). The positive rate of CK in thyroid carcinomas was 28.1%, while in benign thyroid diseases was 17.8%. The CK sensitivity for thyroid carcinomas was 28.1%, with a specificity of 80% and accuracy of 70.4%. In PTC patients the mean CK value was not significantly higher than in the benign diseases' group and in healthy subjects. No evident correlation between CK levels and tumor mass was found. In FTC patients the mean value was significantly higher than in the benign diseases' group and in healthy subjects. Large tumors showed the highest levels, while small tumor values were similar to the control ones. In MTC patients the mean value was significantly higher than in the benign diseases' group and in healthy subjects, with the highest peaks in large tumors and metastatic tumors. The detection of increased values in thyroid carcinomas with high metastatic potential (FTC and MTC) seems to confirm the role of these antigens in predicting the malignancy's degree of the neoplasm. These findings, if confirmed in larger series, could play an important role in assessing the CK 8,18,19 serum level as a real prognostic factor. Further repeated serum determinations after total thyroidectomy might indicate the role of CK 8,18,19 as serum markers predicting the risk of metastases.

A case of functioning plurifocal papillary carcinoma causing a clinical condition of hyperthyroidism is presented. Histologically, the carcinoma presented a dominant macrofocal nodule of an approximately 5 cm diameter, surrounded by chronic thyroiditis. Its occurrence in a patient under 20 years of age within a hot area in the thyroid bed and the lack of histological findings of hyperplastic tissue led the authors to consider this a rare case of hyperfunctioning differentiated thyroid carcinoma, and not a pure association of hyperthyroidism and carcinoma. Autonomously functioning thyroid nodules that are differentiated carcinomas are extremely rare with only 18 such cases reported in literature. While in the past it was commonly believed that a hot nodule is unlikely to be malignant, the possibility of an hyperfunctioning carcinoma should not be overlooked.

In papillary thyroid carcinoma lymphnode metastases at presentation do not seem to adversely affect survival, but do increase the risk of loco-regional tumor recurrence. The value of systematic versus selective lymphadenectomy is far less standardized, whereas the role of postoperative radioiodine in preventing either nodal recurrence or cancer death remains controversial. Clinical data of 36 N+ patients with papillary thyroid carcinoma who had undergone from 1990 to 1996 ipsilateral or bilateral neck dissection were retrospectively reviewed, to analyse the value of systematic lymphadenectomy. In our series of 50 extensive lymph node dissections (levels 2-6), the number of metastases in each specimen (mean value: 5) and the incidence of multiple level metastases (36%) were high. In 37.5% of the metastases at level 6 and in 11.1% at level 4, coexisting nodal involvement at level 2 was observed, without metastasization at intermediate levels. Multiple levels metastases and skip metastases were present in at least one third of the patients and could be excised only performing a complete dissection of the levels 2-6. Extra-capsular spread was found in 56% of the specimens. In 64.3% of these cases a functional neck dissection was performed. A modified radical or radical neck dissection was carried out in the other 35.7% of the cases. These patients received modified radical neck dissection (functional dissection with sacrifice of internal jugular vein) in 60% of the cases and radical neck dissection in the other 40%. In papillary thyroid carcinoma extensive lymphnode dissection at presentation has been stated to offer no advantage versus selective lymphadenectomy, causing increased morbidity. However, experienced surgeons report a low incidence (less than 5%) of accessory spinal nerve and cervical plexus permanent sequelae after functional neck dissection. In our opinion, patients with cervical lymph node metastases require a complete loco-regional neck dissection. Systematic lymphadenectomy, performed by lateral neck plus upper anterior mediastinal dissection, can yield a high disease-free survival. Moreover, this can limit the overall radio-iodine therapeutic dose and the risk of de-differentiation of recurrent tumor to the anaplastic type in patients with a long-term and near normal life-span.

This paper report a case of autonomously functioning thyroid nodule, firstly occurred in a 13 years old women, complicated 9 years later by hyperthyroidism, with no response to thyreostatic treatment, hystologically diagnosed as papillary carcinoma, in a thyroid gland affected by Hashimoto's thyroiditis, with cervical bilateral lymph node metastasis. In literature the rate of coexisting hyperthyroidism, chronic thyroiditis and differentiated carcinoma is low; thus thyroid malignancies are very rare in young people. In this patient the large autonomously functioning nodule was entirely made of neoplastic tissue, while in the remaining thyroid there was no evidence of adenomatous tissue. Moreover, thyreostatic treatment failed in controlling hyperthyroidism. The Authors consider these facts as indirect evidences that this is a rare case of hyperfunctioning differentiated thyroid carcinoma.