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Presented by William Westra, M.D. and prepared by Walter Klein, M.D.
Case 3: 53 year-old man with an enlarging cystic mass in the midline of the neck.
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1. Question
Week 150: Case 3
53 year-old man with an enlarging cystic mass in the midline of the neck./images/klein/090103case3fig1.jpg
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/images/klein/090103case3fig4.jpgCorrect
Answer: Thyroglossal duct cyst
Histology: The cyst is lined by ciliated columnar epithelium. Its wall is fibrotic without a significant inflammatory component. Within the fibrotic wall are irregular aggregates of epithelium forming follicular structures filled with a pink colloid-like material. The cells lining the follicles are uniform without nuclear enlargement or irregularities.
Discussion: The thyroglossal duct – the embryologic connection between the foramen cecum at the base of the tongue and the thyroid gland – normally undergoes atrophy during post-fetal life. In some instances, the duct persists and enlarges resulting in a thyroglossal duct cyst. Keeping with the path of embryologic descent, the thyroglossal duct cyst is consistently located in the midline of the neck. Thus, location is key to its distinction from other cystic neck lesions. For example, the branchial cleft cyst is located laterally in the neck along a line that extends from the tragus to the clavicle alone the anterior border of the sternocleidomastoid muscle.
The presence of thyroid tissue in the wall of the cyst is helpful in the histologic recognition of thyroglossal duct cyst, but this is not a consistent finding. Only about half of thyroglossal duct cysts harbor thyroid tissue. In most instances, this thyroid tissue has a normal appearance, but it can undergo nodular hyperplasia and, rarely, malignant transformation. About 1.5% of thyroglossal duct remnants harbor well differentiated thyroid carcinoma, the vast majority of these being papillary thyroid carcinoma. The criteria used to diagnose these carcinomas are the same as those applied to lesions arising in the thyroid gland. In the present case, the cytoarchitectural features of papillary thyroid cancer were not present.
Thyroglossal duct cysts are surgically removed using the “Sistrunk” procedure, where the entire tract is resected from the foramen cecum to and including the hyoid bone. The purpose of this extended operation is to minimize the risk of cyst recurrence. The procedure is generally adequate even when the incidental carcinomas is detected.
Incorrect
Answer: Thyroglossal duct cyst
Histology: The cyst is lined by ciliated columnar epithelium. Its wall is fibrotic without a significant inflammatory component. Within the fibrotic wall are irregular aggregates of epithelium forming follicular structures filled with a pink colloid-like material. The cells lining the follicles are uniform without nuclear enlargement or irregularities.
Discussion: The thyroglossal duct – the embryologic connection between the foramen cecum at the base of the tongue and the thyroid gland – normally undergoes atrophy during post-fetal life. In some instances, the duct persists and enlarges resulting in a thyroglossal duct cyst. Keeping with the path of embryologic descent, the thyroglossal duct cyst is consistently located in the midline of the neck. Thus, location is key to its distinction from other cystic neck lesions. For example, the branchial cleft cyst is located laterally in the neck along a line that extends from the tragus to the clavicle alone the anterior border of the sternocleidomastoid muscle.
The presence of thyroid tissue in the wall of the cyst is helpful in the histologic recognition of thyroglossal duct cyst, but this is not a consistent finding. Only about half of thyroglossal duct cysts harbor thyroid tissue. In most instances, this thyroid tissue has a normal appearance, but it can undergo nodular hyperplasia and, rarely, malignant transformation. About 1.5% of thyroglossal duct remnants harbor well differentiated thyroid carcinoma, the vast majority of these being papillary thyroid carcinoma. The criteria used to diagnose these carcinomas are the same as those applied to lesions arising in the thyroid gland. In the present case, the cytoarchitectural features of papillary thyroid cancer were not present.
Thyroglossal duct cysts are surgically removed using the “Sistrunk” procedure, where the entire tract is resected from the foramen cecum to and including the hyoid bone. The purpose of this extended operation is to minimize the risk of cyst recurrence. The procedure is generally adequate even when the incidental carcinomas is detected.
