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CORRESPONDENCE
Year : 2013  |  Volume : 9  |  Issue : 1  |  Page : 119-121

Tall cell variant of papillary carcinoma arising from strumaovarii: A rare case report


Department of Pathology, Indira Gandhi Medical College, Shimla, India

Date of Web Publication10-Apr-2013

Correspondence Address:
Kavita Mardi
Department of Pathology, Indira Gandhi Medical College, Shimla
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.110390

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 > Abstract 

Struma ovarii is the presence of thyroid tissue as the major cellular component in an ovarian tumour. Papillary carcinoma in strumaovarii is exceptionally rare. A tall cell variant of papillary carcinoma arising from a strumaovarii has not been reported so far. We present a case of a 40-year-old female with a tall cell variant of papillary carcinoma arising in strumaovarii.

Keywords: Papillary carcinoma, strumaovarii, tall cell variant, thyroid


How to cite this article:
Mardi K, Gupta N. Tall cell variant of papillary carcinoma arising from strumaovarii: A rare case report. J Can Res Ther 2013;9:119-21

How to cite this URL:
Mardi K, Gupta N. Tall cell variant of papillary carcinoma arising from strumaovarii: A rare case report. J Can Res Ther [serial online] 2013 [cited 2019 Sep 15];9:119-21. Available from: http://www.cancerjournal.net/text.asp?2013/9/1/119/110390


 > Introduction Top


Struma ovarii is diagnosed when thyroid tissue is the predominant element (>50%) of an ovarian tumor. Approximately 5-10% of ovarian tumors are malignant, with papillary carcinoma and follicular carcinoma as the most common histological types. To the best of our knowledge, a tall cell variant of papillary carcinoma arising from strumaovarii has not been reported so far. Due to the rarity of the disease, there is still no consensus on its treatment. This report describes a rare case of strumaovarii with a tall cell variant of papillary thyroid carcinoma and reviews the management of this rare tumor.


 > Case Report Top


A 40-year-old woman presented with pain in the right iliac fossa which continued for the last 6months. This non-radiating pain was gradual atonset and moderate in intensity. Abdominal examination revealed a single, firm, fixed, and non-tender mass measuring 12 cm × 10 cm at the umbilical region. Computed tomography of the mass scan demonstrated that the right ovary contained a large cystic mass of 17 cm × 16 cm × 15 cm with an enhancing soft tissue of 3.7 cm × 1.7 cm in its lateral wall. Therefore, a radiological diagnosis of dermoid cyst was made. The cystic mass at the right ovary was removed by laparotomy and the specimen was sent for histopathological examination. Gross examination showed a smooth-walled cyst which measured 11 cm × 10 cm × 7 cm in size and which was filled with pultaceous material and hair. The cyst wall included a 4 cm × 3 cm wide focus of thickening which was homogenously grey white in color [Figure 1]. Microscopic examination indicated that the cyst was lined by keratinizing stratified squamous epithelium along with skin appendages. Subepithelial tissue consisted of smooth muscle bundles and gastric glands. In addition, the tumor cells were arranged as follicles, trabecules, and papillary projections, which were lined by single to stratified layers of cuboidal or columnar cells with abundant granular eosinophilic cytoplasm [Figure 2] and [Figure 3]. These tumor cells had clear, enlarged, round, or elongated nuclei with nuclear overlapping, frequent nuclear grooving, and intranuclear inclusions. Moreover, these tumor cells were immunohistochemically positive for thyroglobulin. Consequently, a histopathological diagnosis of the tall cell variant of papillary carcinoma arising in mature cystic teratoma (malignant strumaovarii) was made.The postoperative period was uneventful and up to 6 months after surgery there was no evidence of any recurrence.
Figure 1: Gross specimen showing a solid area in the wall of a dermoid cyst

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Figure 2: Photomicrograph showing stratified squamous epithelial lining of a dermoid cyst as well as papillary carcinoma (H and E,10×)

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Figure 3: Higher magnification showing tall cell variant of papillary carcinoma (H and E, 40×)

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 > Discussion Top


Struma ovarii is a rare ovarian tumor defined by the presence of thyroid tissue comprising more than 50% of the overall mass. Struma ovarii refers to approximately 1% of all ovarian tumors. Most commonly, they occur as part of a teratoma, but may occasionally be encountered with serous or mucinous cystadenomas. The thyroid tissue in strumaovarii can be affected by a variety of pathologies which would otherwise influence the native thyroid gland. Malignant transformation of strumaovariioccurs rarely [1] and thyroid-type papillary carcinoma arising from thyroid tissue in mature cystic teratoma of the ovary is extremely rare. [1],[2] The criteria for the histopathologic diagnosis of malignant strumaovarii have varied over time;thus, widely accepted criteria for diagnosis of a thyroid-type carcinoma arising in strumaovarii have to be established as soon as possible.Currently, the guidelines for diagnosis of primary thyroid carcinoma are usually adopted for the diagnosis of thyroid-type carcinoma arising in strumaovarii. [3],[4] Strict criteria are required for the diagnosis of thyroid-type carcinoma because proliferative changes, including areas of densely packed follicles or pseudopapillary formations in strumaovarii may be confused with malignancy. [3] The appearance of colloid in strumaovarii can help the diagnosis. Several thyroid-type carcinomas have been described in strumaovarii such as papillary carcinoma, including the follicular variant, follicular carcinoma, anaplastic carcinoma, [5] and medullary carcinoma. [6] A preoperative diagnosis of strumaovarii can be stated in only 5% to 8% of the cases with hyperthyroidism. [7] A solid-cystic, teratoma-like ovarian tumor with a well-vascularized solid component on color Doppler ultrasound may be observed by ultrasonography. The same mass may be visualized as a multilocular ovarian tumor with a strongly enhancing solid component by computed tomography or magnetic resonance imaging. The diagnosis of thyroid-type carcinoma arising in strumaovarii largely depends on the recognition of its characteristic microscopic features with hematoxylin-eosin-stained sections. The nuclear features, such as overlapping, ground-glass nuclei with nuclear grooves, and intranuclear inclusions, are important for the diagnosis of papillary thyroid carcinoma. Morphological features and biological behavior (e.g., vascular invasion, metastasis) should be considered simultaneously. Thyroid-type carcinoma arising in strumaovarii may mimic other primary ovarian tumors, such as granulosa cell tumor, Brenner tumor, papillary serous cystadenoma, or cystadenocarcinoma. Distinction from these primary ovarian tumors, especially papillary serous cystadenocarcinoma, is of great significance because misdiagnosis may lead to suboptimal treatment of the patient. Just like the thyroid-type carcinoma arising in strumaovarii, a granulosa tumor or a Brenner tumor can be a component of mature cystic teratoma and may have a microfollicular or pseudotubular appearance with grooved nuclei, which may simulate follicular carcinoma or papillary thyroid carcinoma with a follicularvariant. The papillary appearance and the presence of psammoma bodies in ovarian papillary serous cystadenoma or cystadenocarcinoma may mimic thyroid-type papillary carcinoma. However, the correct diagnosis can be made by the cytological features of the neoplastic cells and the presence of typical thyroid follicles in most of the cases. Furthermore, the combination of immunohistochemistry staining with thyroglobulin, TTF-1, inhibin, WT1 (Wilms tumor 1), and CA 125 will help differentiate these ovarian primary tumors from thyroid-type carcinoma. [8] Metastatic cervical thyroid carcinoma of the ovary is extraordinarily uncommon which may occur many years after the primary cervical carcinoma and which may histologically resemble primary thyroid-type carcinoma arising in strumaovarii. [9] A detailed clinical history and examination can be instrumental in establishing the correct diagnosis. The tall cell variant has been described as an aggressive variant of papillary carcinoma. World Health Organization defines this neoplasm as being composed of tall cells with height at least twice its width, eosinophilic cytoplasm, and basally oriented nuclei. Also characteristic nuclear features of papillary thyroid carcinoma should be present. There is still no consensus on the management of patients with thyroid-type carcinoma arising in strumaovarii. Surgical treatment ranges from total abdominal hysterectomy, plus bilateral salpingo-oophorectomy with omentectomy, to conservative surgery, involving unilateral oophorectomy or strumectomy (cystectomy). Adjuvant therapy may refer to external radiotherapy, chemotherapy, and the suppression of thyroid functions. [7]

 
 > References Top

1.Lataifeh I, Abdel-Hadi M, Morcos B, Sughayer M, Barahmeh S. Papillary thyroid carcinoma arising from mature cystic teratoma of the ovary. J Obstet Gynaecol 2010;30:884-6.  Back to cited text no. 1
    
2.Tanaka H, Sakakura Y, Kobayashi T, Yoshida K, Asakura T, Taniguchi H. A case of thyroid-type papillary carcinoma derived from ovarian mature cystic teratoma, resected by laparoscopic surgery. Asian J Endosc Surg 2011;4:86-9.  Back to cited text no. 2
    
3.Devaney K, Snyder R, Norris HJ, Tavassoli FA. Proliferative and histologically malignant strumaovarii: aclinicopathologic study of 54 cases. Int J Gynecol Pathol 1993;12:333-43.  Back to cited text no. 3
    
4.Boutross-Tadross O, Saleh R, Asa SL. Follicular variant papillary thyroid carcinoma arising in strumaovarii. Endocr Pathol 2007;18:182-6.  Back to cited text no. 4
    
5.Makni SK, Bahri I, Ellouze S, Mnif H, Ayadi L, Ghariani M. Malignant strumaovarii:a case report. J Gynecol Obstet Biol Reprod (Paris) 2005;34:815-8.  Back to cited text no. 5
    
6.Shamanna RK, Lee MW, Gaba AR. Struma ovarii with a focus of medullary thyroid carcinoma. Arch Pathol Lab Med 2008;132:1510.  Back to cited text no. 6
    
7.Makani S, Kim W, Gaba AR. Struma Ovarii with a focus of papillary thyroid cancer: A case report and review of the literature. Gynecol Oncol 2004;94:835-9.  Back to cited text no. 7
    
8.Mc Cluggage WG, Young RH. Immunohistochemistry as a diagnostic aid in the evaluation of ovarian tumors. Semin Diagn Pathol 2005;22:30-2.  Back to cited text no. 8
    
9.Young RH, Jackson A, Wells M. Ovarian metastasis from thyroid carcinoma 12 years after partial thyroidectomy mimicking strumaovarii: Report of a case. Int J Gynecol Pathol 1994;13:181-5.  Back to cited text no. 9
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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