Malignant solitary fibrous tumor of the thyroid gland: report of a case and review of the literature

Solitary fibrous tumors of the thyroid gland (T-SFT) are rarely described, with only 21 cases being reported in the English literatures, all showing benign clinical characteristics. We herein present a 76-year-old woman presenting with a 3-month history of rapidly enlarging neck masses and the CT showed masses with partial calcification in the right thyroid lobe. We performed right hemithyroidectomy and isthmectomy with negative margin under general anesthesia. Histologically, the masses consisted of pleomorphic spindle cells with high mitoses and collagen bands. Immunohistochemically, the tumor cells showed positive reactions for CD34, vimentin and bcl-2, then a diagnosis of malignant solitary fibrous tumor of the right thyroid was made. Six months postoperatively, the CT showed the recurrence of the thyroid tumor and the presence of many nodules of varying sizes throughout bilateral pulmonary lobes. To our knowledge, this is the first case of malignant solitary fibrous tumor of the thyroid gland (T-SFT) with local recurrence and pulmonary metastasis and T-SFT must be considered in the differential diagnosis of spindle cells lesions in the thyroid gland. Correct diagnosis of the malignant T-SFT plays an important role in choosing appropriate therapeutic strategies and long-term follow-up is also extremely essential for these patients.     

Sclerosing mucoepidermoid carcinoma with eosinophilia of thyroid gland in a male patient: a case report and literature review

Sclerosing mucoepidermoid carcinoma with eosinophilia (SMECE) was first described by Chan et al in 1991. It is characterized by nest or strands of epidermoid tumor cells with squamous differentiation, rare mucous cells, prominent sclerotic stroma, eosinophilic and lymphoplasmacytic infiltration, and a background of chronic lymphocytic thyroiditis in the non-neoplastic thyroid gland. It is important to recognize SMECE of thyroid and differentiate it from squamous cell carcinoma or other neoplasms with squamous differentiation/metaplasia. In published cases, the SMECE of thyroid gland predominantly occurs in women. We report a case of SMECE of thyroid in a 45-year-old male patient. All cases in male patients were Caucasian described in English literature, and our case is the first one in Asian.     

Immunocytochemical investigation of Langerin (CD207) is a valuable adjunct in the cytological diagnosis of Langerhans cell histiocytosis of the thyroid

Langerhans cell histiocytosis (LCH) is an uncommon disease encompassing three clinically different entities: eosinophilic granuloma, Hand-Schüller-Christian disease, and Abt-Letterer-Siewe disease. Despite usually being a multisystemic disease affecting numerous different organs, involvement of the thyroid gland is extremely rare, and only a few cases in adults have been described in the literature. Herein, we present the case of a 28-year-old male patient presenting with LCH involving the skin, the skeletal system, and the thyroid gland. Fine needle aspiration (FNA) of the thyroid was performed and showed the typical Langerhans cells (LC) with foamy cytoplasm and slender nuclei with longitudinal grooves against a background of inflammatory cells with only a few eosinophilic granulocytes. Immunocytochemically, the LC showed positive staining with antibodies against CD1a and Langerin, a recently detected glycoprotein exclusively expressed in LC. Langerin is the major protein that makes up the so-called Birbeck granules, the electronmicroscopical hallmark of LC. Since LCH involvement of the thyroid is occasionally mistaken for papillary thyroid carcinoma cells, we propose that application of Langerin in combination with CD1a is a helpful diagnostic adjunct for the correct assessment of LCH affecting the thyroid gland.     

Follicular carcinoma of the thyroid with extensive clear-cell differentiation: a potential diagnostic pitfall

Clear-cell features have been recognized in several different thyroid neoplasms. A case of thyroid follicular carcinoma with extensive clear- and Hurthle-cell features is described in a 37-yr-old white female, with cytochemical and immunohistochemical analysis. The tumor of the thyroid gland, with anterior neck soft-tissue extension, displayed clear cells on fine-needle aspiration, which were negative for thyroglobulin. The surgical specimen displayed predominately clear cells (80%), and only the nonclear-cell areas stained for thyroglobulin. Proper categorization of clear-cell lesions of the thyroid and soft tissues requires a multimodality approach, involving clinical/pathological correlation, morphological analysis, and ancillary tissue studies. Immunohistochemical stains for thyroglobulin are quite definitive in making the distinction between primary clear-cell thyroid tumors vs. metastatic clear-cell tumors. Cytologists should be aware, however, that the clear-cell areas of thyroid tumors might not stain for thyroglobulin.     

Follicular carcinoma of the thyroid with extensive clear-cell differentiation: a potential diagnostic pitfall

Clear-cell features have been recognized in several different thyroid neoplasms. A case of thyroid follicular carcinoma with extensive clear- and Hurthle-cell features is described in a 37-yr-old white female, with cytochemical and immunohistochemical analysis. The tumor of the thyroid gland, with anterior neck soft-tissue extension, displayed clear cells on fine-needle aspiration, which were negative for thyroglobulin. The surgical specimen displayed predominately clear cells (80%), and only the nonclear-cell areas stained for thyroblobulin. Proper categorization of clear-cell lesions of the thyroid and soft tissues requires a multimodality approach, involving clinical/pathological correlation, morphological analysis, and ancillary tissue studies. Immunohistochemical stains for thyroglobulin are quite definitive in making the distinction between primary clear-cell thyroid tumors vs. metastatic clear-cell tumors. Cytologists should be aware, however, that the clear-cell areas of thyroid tumors might not stain for thyroglobulin.     

Isolated Langerhans cell histiocytosis of the thyroid: a report of two cases with nuclear imaging-pathologic correlation

We describe two cases of isolated langerhans cell histiocytosis (LCH) of the thyroid gland, one of which was found in conjunction with an incidental papillary carcinoma. The first case was that of a 43-year-old man who presented with a 1- to 2-cm nodule within the left lobe of the thyroid. Fine-needle aspiration cytology revealed atypical cells with convoluted nuclei in a background of eosinophils and lymphocytes. The findings prompted a recommendation for excision secondary to the high suspicion of a hematologic malignancy. Histologic sections demonstrated LCH in association with a small focus of papillary carcinoma. The second case involved a 43-year-old woman who presented with a 1.8-cm nodule within the right lobe of the thyroid. Fine-needle aspiration in this case demonstrated abundant hemosiderin-laden macrophages, occasional lymphocytes, and a single benign sheet of follicular cells. No eosinophils were seen; however, a single group of atypical histiocytic cells with cleaved nuclei was noted. The nodule was subsequently resected. Histologic examination demonstrated LCH in association with follicular nodular hyperplasia with cystic degeneration. Immunohistochemical studies were performed in both cases, revealing CD1a and S100 immunoreactivity in the Langerhans' cells. Although LCH may occur as a manifestation of systemic disease, its occurrence as an isolated finding in the thyroid is rare. Its occurrence in association with papillary carcinoma of the thyroid is even more uncommon. We present two cases of isolated LCH of the thyroid, one of which was found in association with papillary carcinoma of the thyroid. The cytologic, histologic, immunohistochemical, and radiologic features are described in each case. The ultrastructural findings from the first case are also presented.     

Plasma cell granuloma of the thyroid gland: a challenging diagnostic problem

This study reports a case of plasma cell granuloma of the thyroid gland in a 47-year-old woman, presenting with a right subhyoid mass and a previous diagnosis of Hashimoto thyroiditis dating back to 1988, which was made on a subtotal thyroidectomy. Plasma cell granuloma preferentially involves the lung, with only 18 cases of thyroid gland involvement having been reported to date in the English literature. Thyroid plasma cell granuloma preferentially affects women and classically shows a prominent plasma cell infiltrate embedded in a variable degree of fibrous stroma: only 2 of the reported cases exhibited the morphologic features of inflammatory myofibroblastic tumor. These morphologic features may raise problems in the differential diagnosis with other plasma cell-rich disorders, including infectious diseases and auto(dys)immune conditions, including the recently described "IgG4-related sclerosing disease." In view of these considerations, a contemporary diagnostic approach to thyroid plasma cell granuloma is therefore discussed here.     

Malignant T-cell lymphoma of the thyroid gland associated with Hashimoto's thyroiditis

Reported herein is a rare case of malignant T-cell lymphoma of the thyroid gland that developed in a 71-year-old woman with a past history of chronic thyroiditis. The chief complaints were rapidly growing neck mass, weight loss and hoarseness. Presence of abnormal lymphoid cells in the peripheral blood, and an increase in anti-microsome antibodies and anti-thyroglobulin antibodies were found on preoperative laboratory tests. A diagnosis of suspicious malignant lymphoma of the thyroid gland accompanied by Hashimoto's thyroiditis was made, and a total thyroidectomy was performed. Histological examination revealed diffuse small lymphocytic infiltration in the thyroid gland associated with Hashimoto's thyroiditis. Immunohistochemical examination showed that the small lymphocytes were positive for T-cell markers with CD4 predominance. Southern blot analysis of tumor specimens revealed a monoclonal T-cell receptor gene rearrangement. Peripheral T-cell lymphoma was diagnosed. No adjuvant therapy was performed because of the tumor stage and its subtype. The patient is well with no recurrence or metastasis 25 months after the surgical removal of the thyroid. The present case suggests that Hashimoto's thyroiditis might play an important role in the carcinogenesis of thyroid lymphoma not only of B-cell lineage but also of T-cell lineage.     

Worrisome histologic alterations following fine-needle aspiration of the parathyroid

Fine-needle aspiration (FNA) is a procedure that is increasingly being performed. Artefacts occurring after FNA are reported to complicate the histological analysis of the tissue, mainly in the thyroid; WHAFFT (worrisome histologic alterations following FNA of thyroid) is well documented in the literature. The case of a male patient with hypercalcaemia who was subsequently found to have a nodule in the thyroid gland is reported here. He underwent FNA, followed by a total thyroidectomy and parathyroidectomy. The abnormality in the parathyroid gland showed worrisome histological changes that were suspicious of a malignant lesion, resembling the changes seen in the thyroid gland after FNA. Parathyroid cells were identified by a review of the previous FNA. The concept of WHAFFT, which can mimic the features of malignancy in the parathyroid gland, is therefore introduced.     

Plasma cell granuloma of the thyroid

Plasma cell infiltrates in the thyroid are rare. They may represent several processes, such as localized plasmacytoma, multiple myeloma, or plasma cell granuloma (PCG). It may be difficult to distinguish these disorders on the basis of morphologic features in sections stained with hematoxylin-eosin. All may be composed of mature plasma cells, without admixed macrophages or lymphocytes, that infiltrate the thyroid and adjacent connective tissue. The identification of the uncommon, but benign, PCG is facilitated by immunohistochemical staining to demonstrate an admixture of plasma cells with cytoplasmic kappa and lambda light chains. The polyclonal nature of the plasma cell infiltrate distinguishes PCG from neoplastic plasma cell proliferation.     

Pathology of the thyroid in severe acute respiratory syndrome

The severe acute respiratory syndrome (SARS) epidemic started in November 2002 and spread worldwide. The pathological changes in several human organs of patients with SARS have been extensively described. However, to date, little has been reported about the effects of this infection on the thyroid gland. Femoral head necrosis and low serum triiodothyronine and thyroxine levels, commonly found in patients with SARS, raise the possibility of thyroid dysfunction. We have undertaken this study to evaluate for any potential injury to the thyroid gland caused by SARS on tissue samples obtained from 5 SARS autopsies. The terminal deoxynucleotidyl transferase-mediated dUPT nick end-labeling assay was performed to identify apoptotic cells. The follicular epithelium was found to be damaged with large numbers of cells exfoliated into the follicle. The terminal deoxynucleotidyl transferase-mediated dUPT nick end-labeling assay demonstrated many cells undergoing apoptosis. Follicular architecture was altered and showed distortion, dilatation, and collapse. No distinct calcitonin-positive cells were detectable in the SARS thyroids. In conclusion, both parafollicular and follicular cells were injured. This may provide an explanation both for low serum triiodothyronine and thyroxine levels and the osteonecrosis of the femoral head associated with patients with SARS. Apoptosis may play a role in the pathogenesis of SARS associated coronavirus infection in the thyroid gland.     

Morphological study of parafollicular cells and the parathyroid gland in the house shrew (Suncus murinus).

A morphological study of parafollicular cells in the thyroid gland and parathyroid gland of the house shrew (Suncus murinus) was made. The results indicated that (1) there were two pairs of parathyroid glands which were located in the upper part of the house shrew thyroid gland, (2) the volumes of the house shrew parathyroid glands ranged from 0.014 to 0.079 mm3, (3) the number of parafollicular cells along the follicles was largest in the upper part of the thyroid lobe, while no parafollicular cells were present in the isthmus, and (4) there were about 20 parafollicular cells per 100 follicular cells and 1.519 parafollicular cells per follicle. The number of parafollicular cells per 100 follicular cells was thus about 5 times larger than that in rats and the number of parafollicular cells per follicle about 2.5 times larger than that in rats.     

Primary thyroid T-lymphoblastic lymphoma: a case report and review of the literature

Most thyroid lymphomas are B-lineage, and T-cell lymphomas are rare. Here, we report a case of primary T-cell lymphoblastic lymphoma (T-LBL) of the thyroid gland. A 15-year-old boy presented with a painless thyroid mass. Ultrasonographic examination revealed a hypoechoic thyroid nodule measuring 4.6 cm × 1.9 cm × 3.4 cm. The thyroid function and antibodies were normal. Hemithyroidectomy was performed. Intraoperative frozen section was suggestive of malignant lymphoma. Histological examination showed diffuse round to oval medium sized cells with high nuclear/cytoplasmic ratio, finely dispersed chromatin, scanty cytoplasm, and numerous mitoses. Immunohistochemical studies revealed malignant cells were positive for terminal deoxynucleotidyltransferase, CD5, CD7, CD8, CD10, CD45RO, CD99, CD79a, CD3, CD1a and Ki-67 (>40%) and negative for CD34, CD20, BCL6, CD23, BCL2, Pax5 and EBV. A diagnosis of thyroid T-LBL was made. The patient was treated by intensive chemotherapy followed by allogeneic hematopoietic stem cell transplantation and has been in event-free survival for 65 months. The patient was unique because no cases of thyroid T-LBL have been previously reported, to our knowledge. Moreover, intensive chemotherapy followed by alloHSCT might be one of the adoptive options in therapy for this aggressive disease.     

Simultaneous occurrence of medullary and follicular carcinoma in the same thyroid lobe

A rare case of the simultaneous development of medullary and follicular carcinoma of the thyroid gland in a 51-year-old Japanese woman is examined. A preoperative diagnosis was made by needle aspiration cytology. Neoplastic cells of the medullary carcinoma were positive for calcitonin and carcinoembryonic antigen, whereas the tumor cells of the follicular carcinoma were negative for these substances. This case presents evidence that, in rare cases, two malignant epithelial neoplasms of different origins can occur in the same lobe of the thyroid.     

Granular Cell Tumour of the Thyroid Gland: A Case Report and Review of the Literature

Granular cell tumours of the thyroid gland are rare, with only six previously reported cases in the English literature. Current histological, immunohistochemical and electron microscopic evidence favours a neural/Schwannian relationship. A case of a granular cell tumour of the thyroid gland in a healthy 36-year-old woman is described. The tumour was found incidentally following a right thyroid lobectomy for symptoms from an asymmetric multinodular goitre. Macroscopically, the lesion resembled a papillary microcarcinoma. Microscopically, the tumour was composed of nests of epithelioid cells with abundant granular, eosinophilic cytoplasm. The nests were divided by fibrous septa and peripherally interdigitated with surrounding thyroid follicles. Immunohistochemistry helped to distinguish the lesion from other neoplasms such as Hurthle cell tumour, medullary carcinoma or metastasis, and also from a histiocytic reaction to previous fine needle aspiration. On the basis of this diagnosis, no further intervention was required, and the patient was discharged following post-operative review.     

Clear-cell follicular adenoma of ectopic thyroid in the submandibular region

A case of clear-cell follicular adenoma arising in ectopic thyroid tissue is reported. The 2.0-cm tumor arose in the submandibular region in a 29-yr-old female. The diagnosis was established on the basis of light microscopic morphology, a positive thyroglobulin immunohistology, and the presence of normal thyroid tissue surrounding the mass. Preoperative computed tomography (CT) scan, and postoperative ultrasound studies revealed a normal orthotopic thyroid gland. No additional tumors have since been detected. The patient is free of recurrent or metastatic disease 54 mo following excision of the mass. Only eight previously published reports have described ectopic thyroid tissue in the submandibular region, all but one of which lacked an orthotopic thyroid gland. In this article, we describe the pathological features of our case and review the existing literature on the subject.     

Lipid-rich cell thyroid adenoma: histopathology with comparative lipid analysis

Summary A second case of the unique lipid-rich cell thyroid adenoma is described complemented by detailed lipid analysis. New observations were made. The cytoplasm of the tumour cells contained scattered, aggregated sudanophil crystals; under polarized light the frozen, unstained sections exhibited numerous birefringent lipid crystals; electron microscopy provided further evidence that the clear cell appearance was due to intracellular lipid droplets with scanty glycogen particles. Comparative lipid analysis by thin layer chromatography and high-pressure liquid chromatography (HPLC) revealed quantitative and qualitative differences in lipid composition of tumour cells when compared with goitre cells from normal thyroid gland and subcutane fat. Qualitative differences in triglyceride composition (by HPLC) between tumour cells and subcutaneous fat indicated that the fat accumulation in the follicle cells was not a result of simple storage, but an expression of altered intracellular lipid metabolism.Preliminary results presented at the XII European Congress of Pathology, Porto, Portugal, 1989     

Metastatic breast carcinoma to parathyroid adenoma on fine needle cytology sample: report of a case

Metastases to the thyroid gland diagnosed by means of fine needle cytology or by excision have been reported in the literature. To our knowledge, metastatic neoplasms to the parathyroid gland have never been described up to now. In this article, we introduce a rare case of metastatic breast carcinoma to a parathyroid adenoma in a 56-year-old woman, which clinically simulated a left thyroid nodule. The patient had a history of left breast carcinoma; the recent discovery of a palpable mass in the left thyroid area had elicited fine needle cytology sampling for its diagnostic evaluation. The obtained cytopathological sample was cellular but limited to a single Diff-Quik-stained smear; hence, no ancillary studies could be entertained. A cytopathological diagnosis of positive for malignant cells of query metastatic breast origin was performed. The permanent histopathological examination of the surgical sample disclosed multiple small foci of metastatic high-grade carcinoma of ductal type within a somewhat atypical adenoma of the parathyroid gland. The cytopathological findings and some differential diagnostic considerations are briefly commented, as well as the deranging imaging data concerning this interesting case.