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E-JCRT CORRESPONDENCE
Year : 2015  |  Volume : 11  |  Issue : 3  |  Page : 652

Unusual presentation of Warthin variant of Papillary thyroid carcinoma with lymph nodal metastases in a patient of Graves' disease


Department of Nuclear Medicine and PET CT, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Cochin, Kerala, India

Date of Web Publication9-Oct-2015

Correspondence Address:
Palaniswamy Shanmuga Sundaram
Department of Nuclear Medicine and PET CT, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Cochin, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.138041

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 > Abstract 

Warthin-like Papillary thyroid carcinoma (WPTC) is a rare variant of papillary carcinoma of thyroid, PTC which derives its name by closely resembling Warthin's tumor of salivary gland. Hallmark histological feature of this variant is papillary folding lined by oncocytic neoplastic cells with clear nuclei and nuclear pseudoinclusions, accompanied by prominent lymphocytic infiltrate in the papillary stalks. It is thought to be one of those differentiated thyroid cancers with favorable prognosis. We report a case of Graves' disease with a cold nodule harboring WPTC with initial presentation of lymph nodal metastases. It is important to identify this peculiar variant of PTC as 5 to 10% of them undergo dedifferentiation and 30% have the lymph nodal metastases and extra thyroidal extension.

Keywords: Cold nodule in thyroid, Graves′ disease, iodine avid thyroid carcinoma, thyroid carcinoma, warthin tumor like variant


How to cite this article:
Padma S, Sundaram PS, Arun B R. Unusual presentation of Warthin variant of Papillary thyroid carcinoma with lymph nodal metastases in a patient of Graves' disease. J Can Res Ther 2015;11:652

How to cite this URL:
Padma S, Sundaram PS, Arun B R. Unusual presentation of Warthin variant of Papillary thyroid carcinoma with lymph nodal metastases in a patient of Graves' disease. J Can Res Ther [serial online] 2015 [cited 2019 Nov 14];11:652. Available from: http://www.cancerjournal.net/text.asp?2015/11/3/652/138041


 > Introduction Top


Warthin-like papillary thyroid carcinoma (WPTC) derives its name from Warthin's tumor of salivary glands as it bears a close morphological resemblance. [1] This variant of papillary ca thyroid was first described in 1995 by Apel et al. [2] Fine needle aspiration cytology and histological examination pose a diagnostic challenge to pathologists as it can mimic a florid chronic thyroiditis. [1],[3] Other possibilities include Hürthle cell tumors, tall cell and oncocytic variants of PTC, and, lastly, oncocytic variant of medullary carcinoma. Here, a simple 99m Technetium pertechnetate thyroid scan can be used to differentiate chronic thyroiditis from a space-occupying lesion in the thyroid gland as expected in thyroid malignancies. Hallmark histological features of WPTC are papillary infoldings lined by oncocytic neoplastic cells with clear cell nuclei and nuclear pseudoinclusions, accompanied by prominent lymphocytic infiltrate in the papillary stalks. [1] We report the first case of a Graves' disease patient with a solitary thyroid cold nodule which proved histologically to be a WPTC and associated lymph nodal metastases. It is important to identify this peculiar variant of PTC as 5 to 10% of them undergo dedifferentiation and 30% have the lymph nodal metastases and extra thyroidal extension.


 > Case report Top


A 21-year-old female with recent evidence of thyrotoxicosis was referred to our department for a 99mTc pertechnetate thyroid scintigraphy. 5 millicurie of 99mTc pertechnetate was injected intravenously and 20 minutes later, high-resolution static images of anterior neck were acquired using a dual-head variable angle Gamma camera. Scintigraphic findings revealed Graves' disease with a solitary cold nodule in left mid and lower pole (arrow) [Figure 1]. An ultrasound-guided FNAC examination was suggested from the above mentioned cold nodule in left lobe to rule out an underlying malignancy as 10% of such non-functioning nodules may harbor malignancy.
Figure 1: 99m Tc pertechnetate thyroid scintigraphy confirming Graves' disease with a solitary cold nodule in left mid and lower pole of thyroid gland (arrow)

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Ultrasound examination of neck revealed a solitary left lobe thyroid nodule with bilateral cervical lymphadenopathy. FNAC showed highly cellular smears with cells arranged in cohesive clusters and papillaroid fragments. Many nuclear pseudoinclusions, plasmacytoid cells were also noted. The amount of colloid in the cells was scanty. Morphological findings resembled PTC in the background of suspicious thyroiditis.

Patient underwent total thyroidectomy and cervical nodal dissection. Histopathological examination [Figure 2] showed a fairly well-circumscribed gray white firm granular lesion (measuring 1.5 × 1.5 × 1.5 cm) in the lower and mid pole junction of left lobe. Tumor was confined within the thyroid capsule and was 0.3cm away from the capsule. Sections from the left lobe showed a neoplasm comprising of cells arranged in papillary pattern. Individual cells had round to oval nuclei with abundant eosinophilic cytoplasm. Papillary cores showed lymphoid infiltrates. Nuclear clearing was seen. One of the two lymphnodes showed metastasis. The final histological diagnosis was WPTC involving left lobe [Figure 2]. Post total thyroidectomy, patient was taken up for a diagnostic (WBI) whole body I-131 scintigraphy (74 MBq) and was treated successfully with high-dose I 131 residual thyroid ablation (370 MBq). Post-therapy WBI scan showed I-131 uptake in residual thyroid tissue with no evidence of any distant metastases [Figure 3].
Figure 2: Histopathological examination of left lobe of thyroid gland showing a neoplasm comprising of cells arranged in papillary pattern. Individual cells had round to oval nuclei with abundant eosinophilic cytoplasm. Papillary cores showed lymphoid infiltrates. Nuclear clearing was seen. One of the two ymphnodes showed metastasis. Low-power histological section showed the neoplasm arranged in papillary pattern with stroma showing dense lymphoid infiltrate. High-power image shows the oncocytic nature of the lining cells, nuclear clearing, and occasional grooves clearly confirming the diagnosis of WPTC

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Figure 3: Post therapy whole body I-131 scintigraphy in dual-intensity showing I-131 uptake in residual thyroid tissue with no evidence of any distant metastases

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 > Discussion Top


Thyroid nodules in Graves' disease patients are frequently encountered in clinical practice but they raise concern about coexistent thyroid malignancy and need to be investigated. Incidence of malignancy in cold nodule of Graves' disease varies from 15 to 17%. [4],[5] The main diagnostic criterion for diagnosis of WPTC is the detection of the typical nuclear features like optically clear nuclei, nuclear grooves, and intranuclear pseudoinclusions as in conventional PTC. The cores of the papillae contain a brisk infiltrate of lymphocytes and plasma cells. Owing to oncocytic cytoplasm of the tumor cells, these tumors may resemble papillary Hürthle cell lesions such as oncocytic papillary hyperplastic nodule and papillary Hürthle cell carcinoma. [6] It is well known from molecular studies that both WPTC and conventional PTC share the same BRAF and RET mutations. Understanding the molecular behavior of this variant of PTC is important as this reflects on the management and prognosis of these patients. Rarely these tumors undergo dedifferentiation and thus need long-term follow up. Conflicting reports exist on the incidence of BRAF and RET mutations in these tumors. [7] Trovisco et al. [8] identified BRAF mutations in 75% of Warthin-like PTCs vs 46% of usual-type PTCs. In contrast though, Sargent et al. [9] observed BRAF mutations only rarely in a variety of papillary carcinomas arising in a background of chronic lymphocytic thyroiditis and not in Warthin variant.


 > Conclusion Top


We emphasize that this variant of PTC should be histologically identified, biopsied and subjected to larger sampling as they may be associated with a locoregional spread and may have a dedifferentiated component. Like all PTCs, this subtype is also iodine avid and thus can be successfully treated with high-dose I-131 therapy unlike the other aggressive variants of thyroid carcinoma which may not be iodine avid. However, whether WTPC should be considered as a distinct clinicopathologic entity or not and whether it still holds a favorable prognosis is a matter of continuing debate.

 
 > References Top

1.
Amico P, Lanzafame S, Li Destri G, Greco P, Caltabiano R, Vecchio GM, et al. Warthin tumor-like papillary thyroid carcinoma with a minor dedifferentiated component: Report of a case with clinicopathologic considerations. Case Rep Med 2010; 495281.doi: 10.1155/2010/495281.  Back to cited text no. 1
    
2.
Papillary Hürthle cell carcinoma with lymphocytic stroma: "Warthin-like tumor" of the thyroid. Am J Surg Pathol 1995;19:810-4.  Back to cited text no. 2
    
3.
Mai KT, Thomas J, Yazdi HM, Commons AS, Lamba M, Stinson AW. Pathologic study and clinical significance of Hürthle cell papillary thyroid carcinoma. Appl Immunohistochem Mol Morphol 2004;12 (4):329-337.  Back to cited text no. 3
    
4.
Tor-Sriwong P, Rechaipichikul W, Ratanaanekchai T, sombooporn C, Chainansamit S. Prevalence of malignancy in Graves′ disease with cold nodule in Srinagarind Hospital. Srinagarind Med J 2013;28(Suppl):545-550.  Back to cited text no. 4
    
5.
Kraimps JL, Bouin-Pineau MH, Mathonnet M, De Calan L, Ronceray J, Visset J, et al. Multicentre study of thyroid nodules in patients with Graves′ disease. Br J Surg 2000;87:1111-3.  Back to cited text no. 5
    
6.
Ludvíková M, Ryska A, Korabecná M, Rydlová M, Michal M. Oncocytic papillary carcinoma with lymphoid stroma (Warthin-like tumor) of the thyroid: A distinct entity with favourable prognosis. Histopathology 2001;39:17-24.  Back to cited text no. 6
    
7.
D′Antonio A, De Chiara A, Santoro M, Chiappetta G, Losito NS. Losito.Warthin-like tumour of the thyroid gland: RET/PTC expression indicates it is a variant of papillary carcinoma. Histopathology 2000;36:493-8.  Back to cited text no. 7
    
8.
Trovisco V, Vieira de Castro I, Soares P, Máximo V, Silva P, Magalhães J. BRAF mutations are associated with some histological types of papillary thyroid carcinoma. J Pathol 2004;202:247-51.  Back to cited text no. 8
    
9.
Sargent R, LiVolsi V, Murphy J, Mantha G, Hunt JL. BRAF mutation is unusual in chronic lymphocytic thyroiditis-associated papillary thyroid carcinomas and absent in non-neoplastic nuclear atypia of thyroiditis. Endocr Pathol 2006 Fall; 17:235-41.  Back to cited text no. 9
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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