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Presented by Risa Mann, M.D. and prepared by Angelique W. Levi, M.D.
Case 3: 45 year-old female with a neck mass
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1. Question
Week 17: Case 3
45 year-old female with a neck mass
Correct
Answer: Lymphocytic thyroiditis and papillary carcinoma of the thyroid, follicular variant
Histology: The thyroid shows a rather dense infiltrate of lymphocytes associated with prominent germinal center formation. The germinal centers appear reactive in nature. Within the thyroid parenchyma there are some cells which are larger in appearance with abundant pink cytoplasm and enlarged nuclei. These cells have features which are typical of Hurthle cells. Although the thyroid gland has a vague nodularity, there is one well-circumscribed nodule which appears distinctly different from the remainder of the thyroid. The colloid within this nodule is dense and pink in color also referred to as “bubble gum pink” in appearance. The nuclei of the cells within the tumor are round and have clear chromatin. The nuclei of the cells within the nodule are larger than the nuclei of the thyroid follicular cells outside of the nodule. In some areas the nuclei appear somewhat crowded and overlapping, and occasional nuclear grooves are observed.
Discussion: The thyroiditis in this case is typical of Hashimoto’s thyroiditis in that it has a multifocal dense lymphocytic infiltrate, Hurthle cells, and reactive germinal centers. The presence of reactive germinal centers and Hurthle cells is helpful in recognizing this as Hashimoto’s and helps to distinguish the lymphocytic infiltrate from a low grade or aggressive non-Hodgkin’s lymphoma. The nodule associated with this lesion has all the features typical of papillary thyroid cancer which include the “bubble gum pink” colloid, and the enlargement of the nuclei with clearing of the chromatin. In addition, in some areas the nuclei overlap and occasional nuclear grooves are observed. These features help one to distinguish this nodule from a follicular carcinoma, which would have different nuclear features. Also, vascular invasion would have to be demonstrated in order to establish the diagnosis of follicular carcinoma. Patients with Hashimoto’s thyroiditis do have an increased incidence of papillary carcinoma.
Incorrect
Answer: Lymphocytic thyroiditis and papillary carcinoma of the thyroid, follicular variant
Histology: The thyroid shows a rather dense infiltrate of lymphocytes associated with prominent germinal center formation. The germinal centers appear reactive in nature. Within the thyroid parenchyma there are some cells which are larger in appearance with abundant pink cytoplasm and enlarged nuclei. These cells have features which are typical of Hurthle cells. Although the thyroid gland has a vague nodularity, there is one well-circumscribed nodule which appears distinctly different from the remainder of the thyroid. The colloid within this nodule is dense and pink in color also referred to as “bubble gum pink” in appearance. The nuclei of the cells within the tumor are round and have clear chromatin. The nuclei of the cells within the nodule are larger than the nuclei of the thyroid follicular cells outside of the nodule. In some areas the nuclei appear somewhat crowded and overlapping, and occasional nuclear grooves are observed.
Discussion: The thyroiditis in this case is typical of Hashimoto’s thyroiditis in that it has a multifocal dense lymphocytic infiltrate, Hurthle cells, and reactive germinal centers. The presence of reactive germinal centers and Hurthle cells is helpful in recognizing this as Hashimoto’s and helps to distinguish the lymphocytic infiltrate from a low grade or aggressive non-Hodgkin’s lymphoma. The nodule associated with this lesion has all the features typical of papillary thyroid cancer which include the “bubble gum pink” colloid, and the enlargement of the nuclei with clearing of the chromatin. In addition, in some areas the nuclei overlap and occasional nuclear grooves are observed. These features help one to distinguish this nodule from a follicular carcinoma, which would have different nuclear features. Also, vascular invasion would have to be demonstrated in order to establish the diagnosis of follicular carcinoma. Patients with Hashimoto’s thyroiditis do have an increased incidence of papillary carcinoma.
