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Presented by Dr. Justin Bishop and prepared by Dr. Jason Kern
60 year old woman with a thyroid nodule
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1. Question
60 year old woman with a thyroid nodule
Correct
Answer: Papillary thyroid carcinoma, columnar cell variant
Description/Discussion:
The tumor consists of a proliferation of papilla and villous structures, with foci of necrosis. The cytologic features of classic papillary thyroid carcinoma are not well developed. Rather, the nuclei are hyperchromatic and pseudostratified, highly reminiscent of colorectal carcinoma. Immunohistochemistry shows that the tumor is diffusely postiive for CDX-2, as well as TTF-1, PAX8, and thyroglobulin (not shown).The columnar variant of papillary carcinoma occurs in adults, with a wide age range, as 1 or more thyroid nodules, often with evidence of regionally metastastic disease on presentation. While its cells are “tall,” it is distinguished from the tall cell variant of PTC by its characteristically hyperchromatic and pseudostratified tumor nuclei, closely resembling colorectal adenoma/carcinoma. Moreover, the columnar variant is sometimes positive for CDX-2 as seen here, which may result in mistaking it for a metastasis. Helpfully, this variant is consistently positive for the usual markers of PTC, PAX8, TTF-1, and thyroglobulin. The columnar variant of PTC appears to be more aggressive than conventional papillary carcinoma, with higher rates of extrathyroidal extension, metastatic disease, and death (although recent studies indicate that well encapsulated examples may be more indolent).
Incorrect
Answer: Papillary thyroid carcinoma, columnar cell variant
Description/Discussion:
The tumor consists of a proliferation of papilla and villous structures, with foci of necrosis. The cytologic features of classic papillary thyroid carcinoma are not well developed. Rather, the nuclei are hyperchromatic and pseudostratified, highly reminiscent of colorectal carcinoma. Immunohistochemistry shows that the tumor is diffusely postiive for CDX-2, as well as TTF-1, PAX8, and thyroglobulin (not shown).The columnar variant of papillary carcinoma occurs in adults, with a wide age range, as 1 or more thyroid nodules, often with evidence of regionally metastastic disease on presentation. While its cells are “tall,” it is distinguished from the tall cell variant of PTC by its characteristically hyperchromatic and pseudostratified tumor nuclei, closely resembling colorectal adenoma/carcinoma. Moreover, the columnar variant is sometimes positive for CDX-2 as seen here, which may result in mistaking it for a metastasis. Helpfully, this variant is consistently positive for the usual markers of PTC, PAX8, TTF-1, and thyroglobulin. The columnar variant of PTC appears to be more aggressive than conventional papillary carcinoma, with higher rates of extrathyroidal extension, metastatic disease, and death (although recent studies indicate that well encapsulated examples may be more indolent).
