Warthin-like tumor variant of papillary thyroid carcinoma: case report and literature review

Warthin-like papillary thyroid carcinoma with immunoglobulin G4-positive plasma cells possibly related to Hashimoto's thyroiditis

Hashimoto's thyroiditis with heavy lymphoplasmacytic infiltration is a common comorbidity of immunoglobulin G4 (IgG4)-related thyroiditis and Warthin-like papillary thyroid carcinoma (WL-PTC). We hypothesized that WL-PTC may have a strong association with IgG4-related thyroiditis. To validate this hypothesis, we clinically and immunohistochemically studied 17 WL-PTC cases. Fourteen patients (82.4%) had anti-thyroglobulin antibody and were confirmed to have Hashimoto's thyroiditis through microscopic analysis. Among them, five (29.4%) had disease consistent with IgG4-related thyroiditis but did not exhibit a "storiform" pattern or obliterative phlebitis. IgG4-related diseases were not found in other organs. No cases with serum IgG4 level of >135 mg/dL were noted. A total of 94.1% of WL-PTC cases had IgG4-positive plasma cells (⁺PCs) in the stroma, and cases with rich IgG4⁺PCs were more frequently associated with Hashimoto's thyroiditis than those with poor IgG4⁺PCs. In this study, all three cases without Hashimoto's thyroiditis had poor IgG4⁺PCs, and one of them did not exhibit IgG4⁺PCs in the stroma of WL-PTC and Hashimoto's thyroiditis. Nodal metastatic lesions were seen in eight cases, all of which were not WL-PTC. As such, we should consider that the Hashimoto's disease with rich IgG4⁺PCs seen in our cases is representative of non-IgG4-related disease and not IgG4-related disease involving multiple organs. This study is the first to demonstrate the presence of IgG4⁺PCs in the stroma of WL-PTC. We concluded that the appearance of IgG4⁺PCs in the stroma of WL-PTC may be related to Hashimoto's thyroiditis with rich IgG4⁺PC.

Ultrasonographic features and clinical characteristics of Warthin-like variant of papillary thyroid carcinoma

Warthin-like variant of papillary thyroid carcinoma (WVPTC) is a rare entity recently characterized. We evaluated ultrasonographic (US) features and clinical characteristics of WVPTC. Nine patients were diagnosed with WVPTC through surgery in our institution from May 2005 to January 2015. Eight of nine patients had available preoperative US images. A retrospective review of the US and clinical characteristics was performed. WVPTC compromised of 0.06% of 14,071 PTCs surgically confirmed. A mean age of nine patients was 53.2 years (range, 32-75 years). The mean nodule size of nine WVPTCs was 0.9 cm (range, 0.5-1.5 cm). Two patients showed central nodal metastasis and one patient with conventional PTC as an index tumor underwent central and lateral neck dissection. No one showed recurrence or distant metastasis during the follow-up period (mean, 4.6 years; range, 0.6-10 years). The most common US features of WVPTCs were solid composition (62.5%), hypoechogenicity (75%), and wider-than-tall shape (100%), respectively. Four (50%) of eight nodules showed well-defined margin and three (37.5%) of them had cystic component. One of eight resembled focal thyroiditis. Three nodules were considered as probably benign with US. All nine cases demonstrated underlying heterogeneous parenchymal echogenicity and accompanied chronic lymphocytic thyroiditis in permanent sections. Thyroid function tests in all patients were normal except for one with subclinical hypothyroidism. WVPTC is an uncommon subtype of PTC and has favorable prognosis, which can be misdiagnosed as a probably benign nodule or focal thyroiditis with US. All cases are associated with heterogeneous parenchyma in the background.

Warthin-like variant of papillary thyroid carcinoma: single institution experience

BACKGROUND

Correct diagnosis of the variants of papillary thyroid carcinoma (PTC) is important because these variants differ in clinical course. The Warthin-like variant (WLV) is relatively uncommon and is recognized as not different from conventional PTC. We therefore assessed the clinicopathological features of patients with WLV of PTC who were diagnosed and treated at our institution.

METHODS

Of the 8179 patients treated for PTC at the Thyroid Cancer Center, Gangnam Severance Hospital, Yonsei University College of Medicine, between January 2007 and December 2012, 16 patients (0.2%) were pathologically diagnosed with WLV of PTC. Their clinicopathological features and post-operative follow-up for local recurrence and distant metastasis were retrospectively investigated.

RESULT

Mean patient age was 44.9 years (range: 23-61 years), with seven (44%) being younger than 45 years. Only one of the 16 patients was male (6%). Mean tumour size was 8.9 mm (range: 3-22 mm). Extrathyroidal extension was observed in seven patients (44%), associated thyroiditis in 11 (69%) and lymph node metastasis in six (38%). The mean follow-up period was 37 months (range: 13-78 months), during which none of the 16 patients experienced recurrence or metastasis. Fifteen patients (94%) had MACIS score <6, with the remaining patient having a MACIS score of 6.33.

CONCLUSION

WLV of PTC is rare, with favourable prognosis. Nevertheless, it is important to determine the histopathological features of these tumours.

Pathological characteristics and clinical perspectives of papillary thyroid cancer: study of 714 patients

Papillary thyroid cancer belongs to most commonly diagnosed well-differentiated malignant tumor of the thyroid gland, with only minority of cases being more aggressive, recurring locoregionally and developing distant metastatic foci. The aim of this study was to determine the clinical relationship between parameters of age, gender, size of primary tumor, intraglandular dissemination and regional metastatic spread and evaluate the importance of each parameter; analyze other major aggressive factors (tumor border, thyroid capsule invasion, perivascular, perilymphatic spread) on prevalence and extent of intraglandular dissemination and relation to metastatic spread in neck. This study is a retrospective analysis of clinical and pathological data from 714 patients with papillary thyroid cancer, presented and operated at the Department of ENT/Head and Neck surgery, Sisters of Charity University Hospital, Zagreb, in the period from 1980 to 2008. All patients were operated upon with total thyroidectomy and some type of neck lymphonode dissection (paratracheal or lateral). In results, we found 46.9% tumors were aggressive; 34.7% tumors were multicentric, with foci in the contralateral lobe nearly twice as often as in the ipsilateral lobe; 27.8% were regionally metastatic, with equal distribution between paratracheal and lateral regions. In conclusion, we revealed contralateral lobe multicentricity and male gender as independent risk factors for regional metastatic dissemination. Nodular goiter has been identified as a protective parameter.

Prognostic factors of papillary and follicular carcinomas in Japan based on data of kuma hospital

There are some important prognostic factors for papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC). In this paper, clinicopathological features significantly affecting patient prognosis are described based on our data as well as others. Distant metastasis at diagnosis is the most important prognostic factor for both PTC and FTC. Other than that, preoperative and intraoperative findings are important to evaluate the biological behavior of PTC. Extrathyroid extension, large lymph-node metastasis, and extranodal tumor extension that can be evaluated preoperatively or intraoperatively are significant prognostic factors for PTC patients. In contrast, pathological findings are important not only for diagnosis of FTC, but also for the evaluation of its biological character. Grade of invasiveness (minimally or widely invasive) and degree of differentiation (well differentiated or including a poorly differentiated component) greatly affect the prognosis of FTC patients.

Warthin tumor-like papillary thyroid carcinoma with a minor dedifferentiated component: report of a case with clinicopathologic considerations

Warthin tumor-like papillary thyroid carcinoma is an uncommon variant of papillary thyroid carcinoma. We report a rare case of Warthin tumor-like variant of papillary thyroid carcinoma with a dedifferentiated component consisting of a solid tumor area composed of neoplastic cells with a spindle to tall cell morphology associated with marked nuclear pleomorphism, atypical mitoses, and foci of necrosis. Although our patient presented with a locally aggressive disease (T3 N1b Mo), she is disease-free without radioiodine therapy after a 23-month follow-up period. We emphasize that Warthin tumor-like papillary thyroid carcinoma, like other morphological variants of papillary carcinoma, may occasionally undergo dedifferentiation. As this component may be only focally detectable, we suggest an extensive sampling of all large-sized (>3 cm) papillary thyroid carcinoma. Recognition of any dedifferentiated component in a Warthin tumor-like papillary thyroid carcinoma should be reported, including its percentage, because it may reflect a more aggressive clinical course.

Prevalence and biological behaviour of variants of papillary thyroid carcinoma: experience at a single institute

AIMS

There are many variants of papillary carcinoma, and some of these variants have been reported to show biological behaviours differing from that of conventional papillary carcinoma. In this study, we present our experience regarding the prevalence and prognoses of these variants of papillary carcinoma.

METHODS

H&E sections from 1521 patients who underwent initial surgery for papillary carcinoma in Kuma Hospital between 1987 and 1995 were re-reviewed and classified into conventional papillary carcinoma and various histological variants. We investigated the biological behaviours of these lesions, including prognoses.

RESULTS

Follicular, tall cell and oncocytic variants were observed in comparably high incidences: 6.6%, 3.9%, and 1.9%, respectively. Patients with tall cell variant showed significantly worse disease-free survival (DFS) and cause-specific survival (CSS) rates than those with conventional papillary carcinoma. The prognoses of patients with follicular variant did not differ from those of patients with conventional papillary carcinoma. Patients with oncocytic variant have not shown carcinoma recurrence. Among the rare variants, which accounted for less than 1%, columnar cell carcinoma showed a worse prognosis.

CONCLUSIONS

Since patients with some variants show different clinical outcomes from those with conventional papillary carcinoma, classification of variants might be helpful to predict patient prognosis.

Cyclooxygenase-2 in normal, hyperplastic and neoplastic follicular cells of the human thyroid gland

This study was undertaken to investigate cyclooxygenase-2 (COX-2) expression in follicular cells of the human thyroid. COX-2 expression was studied immunohistochemically in a total of 174 samples. COX-2 immunoreactivity was confined to the cell cytoplasm with the nuclei remaining unlabelled. COX-2 expression was observed in five cases (17.2%) of normal follicular cells and in one case (16.6%) of solid cell nests. Follicular carcinoma expressed COX-2 more frequently than follicular adenoma (93.4% vs 21.1%) (p<or=0.001). A higher percentage of cases of papillary microcarcinomas up-regulated COX-2 in comparison with all papillary carcinomas (p<or=0.05). However, we could not establish any relationships among COX-2, patients' ages or lymph node metastases in papillary carcinomas. COX-2 expression was found in 12 (92.3%) poorly differentiated carcinomas and in 13 (92.8%) undifferentiated carcinomas. We found that COX-2 is not always useful as a marker of malignancy. Our results suggest that COX-2 plays a role in progression of all thyroid carcinomas, but in papillary carcinomas, seems more important only in the early stages. COX-2 expression in the undifferentiated carcinoma deserves special consideration due to its prognosis and to the fact that selective COX-2 inhibitors were found to enhance tumour response to radiation in some studies.