Diffuse Sclerosing Variant Of Papillary Thyroid Carcinoma: A Pitfall In Clinicopathological Diagnosis

Öz

Diffuse sclerosing variant is an uncommon variant of papillary thyroid carcinoma. The biological behavior and prognostic outcome of this variant are still controversial. The aim of this report is to analyse the features of this entity. A 32-year-old male patient who presented with the complaint of palpitations was diagnosed with hyperthyroidism by clinical evaluation. Hyperechoic heterogeneous microcalcifications were detected in the right lobe on ultrasound radiography. Fine needle aspiration was performed from the right lobe and the lymph node. Abundant psammomatous calcification and follicular epithelial cell groups that suggest the nuclear properties of papillary carcinoma were observed. It was reported as malignant cytology. Bilateral total thyroidectomy was planned. In the macroscopic evaluation, irregularly limited nodule-like area, the largest size of which was about 35 millimeters, was noticed in the right lobe. Histopathological examination revealed a diffuse-widespread lymphocytic infiltration and intense psammomatous calcification, which holds the entire lobe. Micropapillary groups showing nuclear properties of papillary carcinoma were observed, especially in areas rich in connective tissue, with marked dilated lymphatic and lymphatic-like spaces. Very few areas had typical papillary carcinoma features. With the current findings, the case was diagnosed with diffuse sclerosing variant papillary thyroid carcinoma. The patient is healthy for 15 months after the treatment. Although the papillary carcinoma of the thyroid generally has a good prognosis, the diffuse sclerosing variant has an aggressive course and poor prognosis. The correct identification of this variant, which can cause differential diagnosis problems with benign thyroid lesions both cytopathologically and histopathologically, is very important in terms of appropriate treatment

Anahtar Kelimeler

• Thyroid
• papillary carcinoma
• diffuse sclerosing variant
• clinicopathological diagnosis

Tiroid Papiller Karsinom Diffüz Sklerozan Varyant: Klinikopatolojik Tanıda Tuzak

Öz

Papiller tiroid karsinomu, diffüz sklerozan varyant (PTK-DSV) papiller tiroid karsinomunun nadir bir varyantıdır. Bu varyantın biyolojik davranışı ve prognostik önemi hala tartışmalıdır. Bu olgu sunumunun amacı, bu antitenin özelliklerini analiz etmektir. Çarpıntı şikayeti ile başvuran 32 yaşında erkek hastada klinik değerlendirme ile hipertiroidi saptandı. Ultrason grafisinde, sağ lobta hiperekoik heterojen yapıda mikrokalsifikasyonlar saptandı. Sağ lobtan ve lenf nodundan ince iğne aspirasyon sitolojisi (İİAS) yapıldı. Zeminde bol psammomatöz kalsifikasyon ve arada papiller karsinomun nükleer özelliklerini düşündüren follikül epitel hücre grupları izlendi. Malign sitoloji olarak raporlandı. Bilateral total tiroidektomi yapılması planlandı. Makroskopik değerlendirmede sağ lobda, en büyük boyutu yaklaşık 35 milimetre olan düzensiz sınırlı nodül benzeri alan dikkati çekti. Histopatolojik incelemede tüm lobu diffüz-yaygın şekilde tutan lenfositik infiltrasyon ve yoğun psammomatöz kalsifikasyon içeren görünüm vardı. Özellikle bağ dokudan zengin alanlarda belirgin dilate lenfatik ve lenfatik benzeri boşluklar içinde papiller karsinom nükleer özelliklerini gösteren mikropapiller yapıda gruplar görüldü. Çok az alanda tipik papiller karsinom özellikleri belirgindi. Mevcut bulgular ile olgu PTK-DSV varyant tanısı aldı. Tedavi sonrası 15 aydır sağ ve sağlıklıdır. Tiroidin papiller karsinomu genelde iyi prognozlu olsa da, diffüz sklerozan varyantı agresif seyirli ve kötü prognozludur. Hem sitopatolojik hem de histopatolojik olarak benign tiroid lezyonları ile ayırıcı tanı sorunu yaratabilen bu varyantın doğru tanımlaması uygun tedavi açısından çok önemlidir.

Anahtar Kelimeler

• Tiroid, papiller karsinom, diffüz sklerozan varyant, klinikopatolojik tanı
• Tiroid
• papiller karsinom
• diffüz sklerozan varyant
• klinikopatolojik tanı

Kaynakça

1. Chow S-M, Chan J, Law S, Tang D, Ho C-M, Cheung W-Y, et al. Diffuse sclerosing variant of papillary thyroid carcinoma-clinical features and outcome. Eur J Surg Oncol 2003; 29(5): 446-9.
2. Vuong HG, Kondo T, Pham TQ, Oishi N, Mochizuki K, Nakazawa T, et al. Prognostic significance of diffuse sclerosing variant papillary thyroid carcinoma: a systematic review and meta-analysis. Eur J Endocrinol 2017; 176(4): 433-41.
3. Pillai S, Gopalan V, Smith RA, Lam AK-Y. Diffuse sclerosing variant of papillary thyroid carcinoma an update of its clinicopathological features and molecular biology. Crit Rev Oncol Hematol 2015; 94(1): 64-73.
4. Carcangiu ML, Bianchi S. Diffuse sclerosing variant of papillary thyroid carcinoma. Clinicopathologic study of 15 cases. Am J Surg Pathol 1989; 13(12): 1041-9.
5. Takagi N, Hirokawa M, Nobuoka Y, Higuchi M, Kuma S, Miyauchi A. Diffuse sclerosing variant of papillary thyroid carcinoma: a study of fine needle aspiration cytology in 20 patients. Cytopathology 2014; 25(3): 199-204.
6. Bongiovanni M, Triponez F, McKee TA, Kumar N, Matthes T, Meyer P. Fine‐needle aspiration of the diffuse sclerosing variant of papillary thyroid carcinoma masked by florid lymphocytic thyroiditis; a potential pitfall: a case report and review of the literature. Diagn Cytopathol 2009; 37(9): 671-5.
7. Vickery JA, Carcangiu ML, Johannessen JV, Sobrinho-Simoes M, editors. Papillary carcinoma. Semin Diagn Pathol 1985; 2(2): 90-100.
8. Mc Elvanna K, Mc Cusker G, Stirling I. Diffuse sclerosing variant of papillary thyroid carcinoma–a rare cause of goitre in a young patient. The Ulster Medical Journal 2007; 76(2): 113.

9. Walsh J, Griffin TP, Ryan CB, Fitzgibbon J, Sheahan P, Murphy MS. A Case Report Demonstrating How the Clinical Presentation of the Diffuse Sclerosing Variant of Papillary Thyroid Carcinoma Can Mimic Benign Riedel’s Thyroiditis. Case Reports in Endocrinology 2015; Volume 2015, Article ID 686085, 3 pages.
10. Kubo T, Kikuchi N, Shiina S, Torigoe T, Iwaki H. Occult carcinoma confirmed to be a diffuse sclerosing variant of papillary thyroid carcinoma with unusual immunohistochemical features: A pitfall of clinicopathological diagnosis. Auris Nasus Larynx 2019; 22; S0385-8146(19)30444-4.
11. Imamura Y, Kasahara Y, Fukuda M. Multiple brain metastases from a diffuse sclerosing variant of papillary carcinoma of the thyroid. Endocr Pathol 2000; 11(1): 97-108.
12. Caruso G, Tabarri B, Lucchi I, Tison V. Fine needle aspiration cytology in a case of diffuse sclerosing carcinoma of the thyroid. Acta Cytol 1990; 34(3): 352-4.
13. Odashiro DN, Nguyen GK. Diffuse sclerosing variant papillary carcinoma of the thyroid: Report of four cases with fine‐needle aspirations. Diagn Cytopathol 2006; 34(3): 247-9.
14. Akaishi J, Sugino K, Kameyama K, Masaki C, Matsuzu K, Suzuki A, et all. Clinicopathologic features and outcomes in patients with diffuse sclerosing variant of papillary thyroid carcinoma. World J Surg 2015; 39: 1728-35.
15. Regalbuto C, Malandrino P, Tumminia A, Le Moli R, Vigneri R, Pezzino V. A diffuse sclerosing variant of papillary thyroid carcinoma: clinical and pathologic features and outcomes of 34 consecutive cases. Thyroid 2011; 21: 383-9.
16. Albareda M, Puig-Domingo M, Wengrowicz S, Soldevila J, Matias- Guiu X, Caballero A, et all. Clinical forms of presentation and evolution of diffuse sclerosing variant of papillary carcinoma and insular variant of follicular carcinoma of the thyroid. Thyroid 1998; 8: 385-91.
17. Kazaure HS, Roman SA, Sosa JA. Aggressive variants of papillary thyroid cancer: incidence, characteristics and predictors of survival among 43,738 patients. Ann of Surg Oncol 2012; 19: 1874-1880.