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Agoaspirato di nodulo tiroideo in un uomo di 52 anni / Fine needle aspiration cytology of a thyroid nodule in a 52 years-old man

Giorgio Gherardi

Servizio di Anatomia e Istologia Patologica
Ospedale Fatebenefratelli e Oftalmico
Milano

Italia
Comentado en:
PATOLOGIA
PATOCITO
FOROPAT
 Historia Clínica
Agoaspirato di nodulo tiroideo in un uomo di 52 anni. Il nodulo è localizzato nel polo inferiore del lobo tiroideo destro, misura circa cm 2.5 di diametro ed è facilmente palpabile; il paziente è eutiroideo e gode apparentemente di buona salute.

Fine-needle aspiration biopsy of a thyroid nodule in a 52 years-old man. The nodule is located in the lower pole of right thyroid lobe, it measures about 2.5 cm in its greatest diameter and is easily palpable; the patient is euthyroid and apparently in good health.
 Iconografía
Imagen de Agoaspirato di nodulo tiroideo in un uomo di 52 anni / Fine needle aspiration cytology of a thyroid nodule in a 52 years-old man
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Imagen de Agoaspirato di nodulo tiroideo in un uomo di 52 anni / Fine needle aspiration cytology of a thyroid nodule in a 52 years-old man
Zoom
Imagen de Agoaspirato di nodulo tiroideo in un uomo di 52 anni / Fine needle aspiration cytology of a thyroid nodule in a 52 years-old man
Zoom
Imagen de Agoaspirato di nodulo tiroideo in un uomo di 52 anni / Fine needle aspiration cytology of a thyroid nodule in a 52 years-old man
Zoom
Imagen de Agoaspirato di nodulo tiroideo in un uomo di 52 anni / Fine needle aspiration cytology of a thyroid nodule in a 52 years-old man
Zoom
 Comentarios

 

El 5/9/2004 22:56, Ricardo Drut dijo:

Papillary carcinoma would be too easy and it does not fit with the age of the patient.

Medullary carcinoma appears the favorite. There appears to be some extracellular material (amyloid?) in the last figure. Notice that not all the naked nnuclei are lymphocytes! Some exhibit the same pattern as the epithelial cells!

Anyway, there are indeed some lymphocytes there. Why?

 

El 6/9/2004 4:28, Luis Muñoz Fernández dijo:

Me llaman la ayención dos aspectos:

1.-Es un aspirado muy celular, lo que apunta hacia un proceso neoplásico.

2.-Las células epiteliales tienen núcleo excéntrico, lo que les confiere aspecto "plasmocitoide". Este dato se describe como un rasgo que se observa en las biopsias por aspiración de los carcinomas medulares.

Por tanto, mi diagnóstico es carcinoma medular.

 

El 6/9/2004 10:32, Maurizio Ferretti dijo:

In questo interessante caso l'abbondante materiale è costituito da cellule in gruppi con struttura lassa o disaggregate, con ampio citoplasma finemente granulare e nuclei rotondeggianti, polidimensionali, ipercromici con cromatina uniformemente distribuita ed occasionali nucleoli. Le cellule disperse nello sfondo come nuclei nudi mi sembrano essere simili a quelle in aggregati, solo che hanno perso il citoplasma durante la manovra di striscio. In alcune cellule sono presenti inclusi intranucleari.

Tale quadro, meritevole di approfondimento diagnostico anche istologico mediante nodulectomia, mi suggerisce un carcinoma midollare della tiroide.

cari saluti a tutti

Maurizio Ferretti

 

El 6/9/2004 12:40, Clóvis Klock dijo:

Medullary Carcinoma

Saludos

Clóvis

 

El 6/9/2004 15:20, Celso Chassot dijo:

Carcinoma medular.

Celso Chassot - São Paulo - Brasil

 

El 6/9/2004 20:58, Shashidhar dijo:

Medullary carcinoma.

 

El 6/9/2004 21:06, Víctor Linares dijo:

Me parece que es un carcinoma Medular

Unj abrazo a todos

 

El 7/9/2004 8:50, Julián José Ahijado González dijo:

CARCINOMA MEDULAR DE TIROIDES. UN SALUDO A TOD@S

 

El 7/9/2004 11:32, David Cubero dijo:

Llama la atención la cohesión de los grupos epiteliales, otro posible diagnóstico sería un adenoma trabecular hialinizante. En espera de la exeresis.

Saludos David.

 

El 7/9/2004 16:44, Dan Pankowsky dijo:

Saludos a todos de Nashville.

I agree with medullary carcinoma. Is there a cell block for an amyloid stain?

 

El 8/9/2004 17:09, Giorgio Gherardi dijo:

Dear friends,

to stimulate the discussion on this case I wish to tell you that the serum calcitonin and CEA values are within normal values. Additional suggestions are encouraged.

Un caro saluto a tutti

 

El 8/9/2004 19:12, Romualdo Lins Filho e Gustavo Sales Barbosa dijo:

Estimados Dr. Gherardi e demais colegas do foro

Como Dr. Ricardo Drut já chamou à atenção, parece que há linfócitos de permeio. Além disso, na foto 4, parece haver uma acentuada granularidade no fundo do esfregaço. A foto 1 mostra numerosos grupamentos de células epiteliais, um padrão muito incomum em carcinomas medulares, que geralmente mostram células isoladas não associadas a linfócitos.

Pensamos em um nódulo de céluas oxifílicas, provavelmente não neoplásico, associado a uma tireoidite de Hashimoto.

Abraços

Romualdo e Gustavo

Caruaru

Brasil

 

El 9/9/2004 8:19, Bayardo Flores dijo:

La localización del nódulo en el polo inferior no es la esperada para un Carcinoma Medular y si las células del fondo son en verdad linfocitos, esta posibilidad se aleja aun más. Aunque los caracteres nucleares del Carcinoma Papilar no son muy evidentes, me atrevería de todos modos a proponer la posibilidad de un "Wartin-like Tumor", a diferenciar de un nódulo de la variante oxífila de la Tiroiditis de Hashimoto.

Saludos

Bayardo

 

El 9/9/2004 12:37, MAURIZIO SPINELLI dijo:

Escludendo una Tiroidite di Hashimoto nodulare asintomatica, potrebbe trattarsi di un nodulo/adenoma ossifilo di paratiroide.

Un caro saluto

Maurizio Spinelli-Milano

Hacer un comentario a este caso
 Diagnóstico
INTRATHYROID PARATHYROID CARCINOMA
 Comentario del Autor
This report illustrates a case of intrathyroid parathyroid carcinoma that masqueraded as a thyroid primary tumor both cytologically and clinically. The patient was first seen by an orthopedic doctor for evaluation of a back pain of increasing intensity. X-rays studies of the vertebral column and a laboratory blood test work-up followed. On physical examination a thyroid nodule was also palpated and the patient was seen by an endocrinologist. Ultrasound evaluation documented a solid, hypo-echoic nodule in the lower third of the left lobe of thyroid gland which was readily examined by FNA biopsy.
On microscopic evaluation of the aspirate our first impression was that of a medullary thyroid carcinoma (MTC) but the following cytologic features seemed not to fit with the diagnosis: uniform cell size and lack of significant cellular pleomorphism; complexity of cellular arrangement with frequent three-dimensional tight clusters and tendency to cell aggregation; abundant monomorphic naked nuclei; concomitant presence of both oncocytoid and clear cells; lack of spindled or triangular cells. Moreover, the tumor was located in the lower thyroid pole, which is unusual for MTC.
In fact, the above cytologic features suggested a parathyroid lesion as an alternative diagnosis. Laboratory data which were made available soon after FNA biopsy sampling showed a calcemia of 16.1 mg/dL, (n.v. 8.4-10.5), a phosphoremia of 2.27 mg/dL (n.v. 2.5-4.5) and signs of slight renal insufficiency. These findings were consistent with a condition of hyperparathyroidism and strongly supported the above contention. Our FNA cytologic diagnosis was “parathyroid tumor, uncertain if benign or malignant”. Preoperative values of serum PTH were 2002 pg/ml (normal value 8.0-76.0). The patient underwent right hemithyroidectomy with isthmus resection.
Histology of surgical specimen demonstrated a well circumscribed and encapsulated intrathyroid nodule Foto_6; microscopically, the architecture of tumor growth was either solid structureless, or multinodular, or trabecular with thick fibrous bands incompletely dividing the tumor. The tumor consisted of a population of medium sized polygonal oxyphilic and transitional oxyphylic parathyroid cells Foto_7 with occasional mitotic figures. Immunostaining for PTH was positive Foto_8. There were occasional necrotic areas. Foci of capsular disruption and pericapsular invasion into thyroid parenchyma in addition to intravascular tumor growth Foto_9 and minimal foci of extrathyroid invasion were also seen. These latter findings demonstrated the malignant nature of the tumor.
It is well known in the Literature that the distinction of parathyroid from thyroid cells in FNA samples can be challenging, and incorrect identification of parathyroid as thyroid lesions has been reported in a significant proportion of cases in the largest published series 1 2 3 4 5 6. Potential trap is due to the finding in parathyroid lesions of aggregation patterns and cellular features, including intranuclear holes (cytoplasmic inclusions) 7, which overlap with those seen in thyroid follicular lesions 2 5 6 or Hurthle cell neoplasms 5 6, or papillary carcinoma 6 7. If the tumor exhibits a clear cell cytology it can be confused with a primary clear cell carcinoma of the thyroid. Naked nuclei can be misinterpreted as lymphocytes and suggest the diagnosis of lymphocytic thyroiditis 8. Finally, as in the present case, plasmacytoid or oncocytoid cellular morphology and intranuclear holes can simulate the FNA cytological picture of medullary thyroid carcinoma 6 9.
I want to thank all the colleagues for their comments and congratulate my friend M. Spinelli for making the correct suggestion.
Imagen de Agoaspirato di nodulo tiroideo in un uomo di 52 anni / Fine needle aspiration cytology of a thyroid nodule in a 52 years-old man
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Well circumscribed and encapsulated intrathyroid nodule.
Imagen de Agoaspirato di nodulo tiroideo in un uomo di 52 anni / Fine needle aspiration cytology of a thyroid nodule in a 52 years-old man
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The tumor consisted of a population of medium sized polygonal oxyphilic and transitional oxyphylic parathyroid cells.
Imagen de Agoaspirato di nodulo tiroideo in un uomo di 52 anni / Fine needle aspiration cytology of a thyroid nodule in a 52 years-old man
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Immunohistochemical expression for parathyroid hormone.
Imagen de Agoaspirato di nodulo tiroideo in un uomo di 52 anni / Fine needle aspiration cytology of a thyroid nodule in a 52 years-old man
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Intravascular tumor growth.
 Bibliografía
1. Bondeson L, Bondeson AG, Nissborg A, Thompson NW
Cytopathological variables in parathyroid lesions: a study based on 1,600 cases of hyperparathyroidism.
Diagn Cytopathol. 1997 Jun;16(6):476-482.

2 Halbauer M, Creinko I, Brzac HT, Simonovic I
Fine needle aspiration cytology in the preoperative diagnosis of ultrasonically enlarged parathyroid glands.
Acta Cytol. 1991 Nov-Dec;35(6):728-735.

3. Tseng FY, Hsiao YL, Chang TC
Ultrasound-guided fine needle aspiration cytology of parathyroid lesions. A review of 72 cases.
Acta Cytol. 2002 Nov-Dec;46(6):1029-1036.

4. Mincione GP, Borrelli D, Cicchi P, Ipponi PL, Fiorini A
Fine needle aspiration cytology of parathyroid adenoma: a review of seven cases.
Acta Cytol. 1986 Jan-Feb;30(1):65-69.

5. Liu F, Gnepp DR, Pisharodi LR
Fine needle aspiration of parathyroid lesions.
Acta Cytol. 2004 Mar-Apr;48(2):133-136.

6. Lowhagen T, Sprenger E
Cytological presentation of thyroid tumors in aspiration biopsy smears: a review of 60 cases.
Acta Cytol. 1974 May-Jun;18(3):192-197.

7. Goellner JR, Caudill JL
Intranuclear holes (cytoplasmic pseudoinclusions) in parathyroid neoplasms, or holes happen.
Cancer. 2000 Feb 25;90(1):41-46.

8. Auger M, Charbonneau M, Huttner I
Unsuspected intrathyroidal parathyroid adenoma mimic of lymphocytic thyroiditis in fine-needle aspiration specimens-a case report.
Diagn Cytopathol. 1999 Oct;21(4):276-279.

9. Rossi ED, Mule A, Zannoni GF, Fadda G
Asymptomatic intrathyroidal parathyroid adenoma. Report of a case with a cytologic differential diagnosis including thyroid neoplasms.
Acta Cytol. 2004 May-Jun;48(3):437-440.
NOTA: Esto es un foro médico profesional, que no tiene como objetivo ofrecer consejo médico o de salud. Los mensajes enviados a este foro solicitando estos consejos, no serán atendidos. La información científica ofrecida está refrendada por las referencias y bibliografía correspondientes y de su veracidad son responsables sus autores. La participación en este Foro es gratuita.

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