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Presented by Justin A. Bishop, M.D. and prepared by Sarah Karram, M.D.
Case 2: 75 year old woman with a thyroid nodule.
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1. Question
Week 583: Case 2
75 year old woman with a thyroid nodule.images/Karram/case2_1.jpg
images/Karram/case2_2.jpg
images/Karram/case2_3.jpgCorrect
Answer: Papillary carcinoma, Warthin-like variant
Histology: The tumor consists of a proliferation of oncocytic cells lining a lymphocyte rich stroma. The tumor cells exhibit severe cytologic atypia in the form of nuclear enlargment and dyspolarization with chromatin clearing and nuclear psedoinclusions. The broad papillae with a prominent lymphoid stroma, oncocytic cells, and focally a “bilayered” appearance are reminiscent of Warthin tumor, a benign salivary gland neoplasm.
Discussion: Warthin-like variant of papillary carcinoma is rare, and commonly occurs in elderly women with Hashimoto thyroiditis. It is important to distinguish from the tall cell variant because while tall cell papillary carcinoma is aggressive, Warthin like variant appears to be indolent in its clinical behavior. Both tumor types contain “tall” (i.e., cells at least 2-3X taller than they are wide), eosinophilic cells, but the tall cell variant typically lacks the lymphoid stroma and the two-cell layer appearance, and has thinner, more delicate papillae.
Incorrect
Answer: Papillary carcinoma, Warthin-like variant
Histology: The tumor consists of a proliferation of oncocytic cells lining a lymphocyte rich stroma. The tumor cells exhibit severe cytologic atypia in the form of nuclear enlargment and dyspolarization with chromatin clearing and nuclear psedoinclusions. The broad papillae with a prominent lymphoid stroma, oncocytic cells, and focally a “bilayered” appearance are reminiscent of Warthin tumor, a benign salivary gland neoplasm.
Discussion: Warthin-like variant of papillary carcinoma is rare, and commonly occurs in elderly women with Hashimoto thyroiditis. It is important to distinguish from the tall cell variant because while tall cell papillary carcinoma is aggressive, Warthin like variant appears to be indolent in its clinical behavior. Both tumor types contain “tall” (i.e., cells at least 2-3X taller than they are wide), eosinophilic cells, but the tall cell variant typically lacks the lymphoid stroma and the two-cell layer appearance, and has thinner, more delicate papillae.
