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Presented by William Westra, M.D. and prepared by Lynette S. Nichols, M.D.
Case 1: 33 year-old woman with a thyroid nodule
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1. Question
Week 140: Case 1
33 year-old woman with a thyroid noduleimages/Lyn’s/w-1a.jpg
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images/Lyn’s/w-1e.jpgCorrect
Answer: Hyalinizing trabecular neoplasm
Histology: On cut surface, the thyroid gland harbors a 2 cm round circumscribed nodule that is tan to yellow in color. Microscopically, the nodule is circumscribed but non-encapsulated. The tumor cells grow in clusters and trabeculae that are interspersed with dense hyaline material. Rare stromal calcifications are present. The tumor cells are elongated and have abundant pink granular cytoplasm. Their nuclei are oval with perinucleolar vacuoles, acidophilic inclusions and longitudinal grooves. Elsewhere in the gland, multiple foci of papillary microcarcinomas are identified (not shown).
Discussion: Hyalinizing trabecular adenoma was first described by Carney in 1987. Its distinguishing morphologic features are its prominent trabecular growth pattern and its striking intra- and extra-cellular hyalinization.
The HTA is notable for ways in which it overlaps with papillary thyroid carcinoma (PTC) – morphologically, biologically, and clinically. Morphologically, HTA has nuclei with exaggerated features of PTC including elongation, inclusions, pallor and grooves. Stromal calcifications resembling psammoma bodies are also frequently noted. Biologically, HTAs have been shown to harbor some of the same genetic mutations as PTC (i.e. ret oncogene translocations). HTAs often arise in thyroid glands that harbor foci of PTA, and sometimes there may even be a direct association between HTA and conventional PTC. Clinically, there have been some reports of locally invasive and even metastasizing HTAs. Because of this overlap, some pathologists argue that the HTA is best classified as hyalinizing trabecular neoplasm – a diagnostic term that leaves some room for uncertainty regarding potential malignant behavior.
The tern hyalinizing trabecular neoplasm is best reserved for those circumscribed tumors that do not locally infiltrative and do not demonstrate overt features of PTC. Conversely, those lesions that show infiltrative tumor growth and/or foci of more conventional PTC should be considered PTCs. While paraganglioma and medullary carcinoma often enter the differential diagnosis of a nested tumor of the thyroid gland, these entities are easily excluded with immunohistochemical stains.
Incorrect
Answer: Hyalinizing trabecular neoplasm
Histology: On cut surface, the thyroid gland harbors a 2 cm round circumscribed nodule that is tan to yellow in color. Microscopically, the nodule is circumscribed but non-encapsulated. The tumor cells grow in clusters and trabeculae that are interspersed with dense hyaline material. Rare stromal calcifications are present. The tumor cells are elongated and have abundant pink granular cytoplasm. Their nuclei are oval with perinucleolar vacuoles, acidophilic inclusions and longitudinal grooves. Elsewhere in the gland, multiple foci of papillary microcarcinomas are identified (not shown).
Discussion: Hyalinizing trabecular adenoma was first described by Carney in 1987. Its distinguishing morphologic features are its prominent trabecular growth pattern and its striking intra- and extra-cellular hyalinization.
The HTA is notable for ways in which it overlaps with papillary thyroid carcinoma (PTC) – morphologically, biologically, and clinically. Morphologically, HTA has nuclei with exaggerated features of PTC including elongation, inclusions, pallor and grooves. Stromal calcifications resembling psammoma bodies are also frequently noted. Biologically, HTAs have been shown to harbor some of the same genetic mutations as PTC (i.e. ret oncogene translocations). HTAs often arise in thyroid glands that harbor foci of PTA, and sometimes there may even be a direct association between HTA and conventional PTC. Clinically, there have been some reports of locally invasive and even metastasizing HTAs. Because of this overlap, some pathologists argue that the HTA is best classified as hyalinizing trabecular neoplasm – a diagnostic term that leaves some room for uncertainty regarding potential malignant behavior.
The tern hyalinizing trabecular neoplasm is best reserved for those circumscribed tumors that do not locally infiltrative and do not demonstrate overt features of PTC. Conversely, those lesions that show infiltrative tumor growth and/or foci of more conventional PTC should be considered PTCs. While paraganglioma and medullary carcinoma often enter the differential diagnosis of a nested tumor of the thyroid gland, these entities are easily excluded with immunohistochemical stains.
