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Presented by William Westra, M.D. and prepared by Lynette S. Nichols, M.D.
Case 5: 68 year-old female with hypothyroidism and a nodule in the neck
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1. Question
Week 140: Case 5
68 year-old female with hypothyroidism and a nodule in the neck/images/Lyn’s/w-5a.jpg
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/images/Lyn’s/w-5d.jpgCorrect
Answer: Hashimoto’s thyroiditis, fibrosing variant
Histology: The specimen consisted of a discrete oval nodule measuring 2 cm. Microscopically, the background is comprised of lymphoid tissue with reactive germinal center formations, and bands of dense fibrosis. In some areas, the lymphoid tissue surrounds a cystic space lined by flattened squamous epithelium. Scattered throughout the specimen are nests of squamous cells. These cells do not exhibit any significant cytologic atypia. By immunohistochemistry, they are immunoreactive for TTF-1 and thyroglobulin.
Discussion: One may not easily appreciate a lymphocytic thyroiditis when dealing with the fibrosing variant of Hashimoto’s thyroidities. Even the fundamental recognition of thyroid tissue is obscured when there is destruction of thyroid architecture, marked atrophy of thyroid follicles with replacement by dense fibrosis, and prominent squamous metaplasia of any remaining follicular epithelium. These changes are particularly treacherous when they are encountered in a so-called parasitic thyroid nodule (i.e. anatomic separation of a hyperplastic nodule from the thyroid gland). In these instances, they may easily be misinterpreting metastatic squamous cell carcinoma or metastatic thyroid carcinoma to a regional lymph node. Immunohistochemistry (TTF-1 and thyroglobulin) is quite useful in confirming the true thyroidal nature of the squamous epithelium. A clinical history of hypothyroidism, and similar histologic findings throughout the thyroid gland will also help point to the inflammatory nature of the process.
Incorrect
Answer: Hashimoto’s thyroiditis, fibrosing variant
Histology: The specimen consisted of a discrete oval nodule measuring 2 cm. Microscopically, the background is comprised of lymphoid tissue with reactive germinal center formations, and bands of dense fibrosis. In some areas, the lymphoid tissue surrounds a cystic space lined by flattened squamous epithelium. Scattered throughout the specimen are nests of squamous cells. These cells do not exhibit any significant cytologic atypia. By immunohistochemistry, they are immunoreactive for TTF-1 and thyroglobulin.
Discussion: One may not easily appreciate a lymphocytic thyroiditis when dealing with the fibrosing variant of Hashimoto’s thyroidities. Even the fundamental recognition of thyroid tissue is obscured when there is destruction of thyroid architecture, marked atrophy of thyroid follicles with replacement by dense fibrosis, and prominent squamous metaplasia of any remaining follicular epithelium. These changes are particularly treacherous when they are encountered in a so-called parasitic thyroid nodule (i.e. anatomic separation of a hyperplastic nodule from the thyroid gland). In these instances, they may easily be misinterpreting metastatic squamous cell carcinoma or metastatic thyroid carcinoma to a regional lymph node. Immunohistochemistry (TTF-1 and thyroglobulin) is quite useful in confirming the true thyroidal nature of the squamous epithelium. A clinical history of hypothyroidism, and similar histologic findings throughout the thyroid gland will also help point to the inflammatory nature of the process.
