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Chadha P, Kamboj M, Pasricha S, Arora V, Yadav V, Gupta M, Mehta A. Spindle epithelial tumor with thymus-like elements (SETTLE): a diagnostic challenge with distinct therapeutic implication; case report. Diagn Pathol 2024; 19:108. [PMID: 39138528 PMCID: PMC11321057 DOI: 10.1186/s13000-024-01527-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 07/13/2024] [Indexed: 08/15/2024] Open
Abstract
Spindle epithelial tumor with thymus-like elements (SETTLE) is a rare malignant neoplasm of the thyroid gland which is believed to arise from intrathyroidal thymic tissue. It predominantly affects young adults and children presenting with a thyroid mass of variable duration and rarely occurs in adults. It has a high overall survival with a tendency for delayed metastasis. SETTLE is a biphasic lobulated tumor composed of spindle shaped cells along with glandular formations seen on histopathological examination. Despite its typical morphology it is commonly misdiagnosed on histopathology due to its rarity and overlapping morphology with other close mimics such as a carcinoma, synovial sarcoma and thymoma. Herein we report such a case occurring in a middle aged female presenting with a neck mass. She had an initial diagnosis of metastatic poorly differentiated squamous cell carcinoma possibly with an orophayngeal primary in view of co expression of CK, p40 and p16 on immunohistochemistry. The patient underwent surgical resection with modified neck dissection. On review at our hospital it was diagnosed as SETTLE and she remains disease free after a follow-up period of 1 year. Diligent histopathological examination espoused with a judicious panel of IHC markers in conjunction with clinicoradiological findings forms the mainstay of diagnosis. Diffuse and strong p16 immunoexpression has not been documented or evaluated in literature so far, and needs to be explored for its diagnostic utility in this rare entity.
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Affiliation(s)
- Prerna Chadha
- Histopathology and Cytopathology, Department of Laboratory and Transfusion Services, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, 110085, India
| | - Meenakshi Kamboj
- Histopathology and Cytopathology, Department of Laboratory and Transfusion Services, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, 110085, India
| | - Sunil Pasricha
- Histopathology and Cytopathology, Department of Laboratory and Transfusion Services, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, 110085, India.
| | - Vikas Arora
- Head and Neck Oncosurgery, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, 110085, India
| | - Vishal Yadav
- Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, 110085, India
| | - Manoj Gupta
- Nuclear Medicine Department, Rajiv Gandhi Cancer Institute And Research Centre, Delhi, 110085, India
| | - Anurag Mehta
- Department of Laboratory and Transfusion Services, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, 110085, India
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Bernardo P, Messias H, Nogueira R, Lopes B, Gomes P. Spindle epithelial tumor with thymus-like element (SETTLE)-Report of a rare thyroid carcinoma. Clin Case Rep 2024; 12:e9300. [PMID: 39130807 PMCID: PMC11316011 DOI: 10.1002/ccr3.9300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 07/23/2024] [Accepted: 07/27/2024] [Indexed: 08/13/2024] Open
Abstract
Spindle epithelial tumor with thymus-like element should be included in the differential diagnosis of thyroid gland cancers, particularly in medullary carcinoma, younger patients and indolent clinical presentation, because it may influence treatment and prognosis.
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Affiliation(s)
| | - Henrique Messias
- Head and Neck Surgery DepartmentInstituto Português de Oncologia de Lisboa Francisco GentilLisbonPortugal
- Division of Clinical and Surgical SciencesUniversity of EdinburghEdinburghUK
| | - Ricardo Nogueira
- Head and Neck Surgery DepartmentInstituto Português de Oncologia de Lisboa Francisco GentilLisbonPortugal
| | - Brazão Lopes
- Pathological Anatomy DepartmentInstituto Português de Oncologia de Lisboa Francisco GentilLisbonPortugal
| | - Pedro Gomes
- Head and Neck Surgery DepartmentInstituto Português de Oncologia de Lisboa Francisco GentilLisbonPortugal
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Arshia A, Balikani L, Booth CN. Cytomorphology of monomorphic spindle epithelial tumor with thymus-like elements: A case with local recurrence after subtotal resection. Diagn Cytopathol 2024; 52:E134-E144. [PMID: 38520309 DOI: 10.1002/dc.25301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/01/2024] [Indexed: 03/25/2024]
Abstract
Spindle epithelial tumor with thymus-like elements (SETTLE) is a rare biphasic thyroid tumor with low malignant potential that has a distinct morphology. Despite fine needle aspiration (FNA) being a common method for evaluating thyroid nodules and lymph nodes, there are limited cytologic descriptions of SETTLE in the literature due to its rarity. As a result, SETTLE is frequently underdiagnosed or misdiagnosed as medullary carcinoma, thymoma, teratoma, synovial sarcoma, or solitary fibrous tumor, among others. We present a case of a 28-year-old man with a history of a hemithyroidectomy diagnosed as SETTLE found to have a neck nodule along the strap muscle suspicious for recurrence 5 years post-surgery. The ultrasound-guided FNA cytology specimen of the neck nodule showed loosely cohesive, monomorphous ovoid to spindled cells with scant cytoplasm and nuclei with fine to granular chromatin. In addition, there were occasional clusters of cells with a papillary configuration. The tumor cells were associated with magenta, amorphous extracellular material. Immunocytochemical staining of the cell block material revealed that tumor cells were positive for p63, cytokeratin AE1/3, and CK8/18 and negative for TTF-1 and thyroglobulin. Overall, the morphological and immunocytochemical findings were consistent with a local recurrence of SETTLE. The subsequent left anterior strap mass excision revealed a 4 cm encapsulated tumor consistent with SETTLE. Because ofits rarity and low level of awareness, SETTLE poses a diagnostic and therapeutic challenge. We herein present the cytologic findings of monomorphic SETTLE and highlight the potential cytomorphologic and immunophenotypic pitfalls. We also highlight how tumors with high-risk features can be a therapeutic challenge.
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Affiliation(s)
- Asma Arshia
- Department of Pathology and Laboratory Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Lame Balikani
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Christine N Booth
- Department of Pathology, RJT-Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Nagarjun BR, Mehta S, Gandhi J, Trivedi P, Rathod P. When to settle for SETTLE! A lesson learned from our cases. Thyroid Res 2024; 17:6. [PMID: 38438897 PMCID: PMC10913219 DOI: 10.1186/s13044-023-00189-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 12/27/2023] [Indexed: 03/06/2024] Open
Abstract
Spindle epithelial tumor with thymic like elements (SETTLE) is a biphasic tumor composed of epithelial and spindle cell components. It is an uncommon indolent tumor arising in the thyroid gland and most commonly affects the children and young adults. This entity is mostly overlooked because of its rarity and diagnostic difficulty on morphology. We discuss two cases of SETTLE with varied presentation, diagnostic challenges and lessons learnt from them.SETTLE should be considered as a differential especially when dealing with a thyroid lesion in young and adolescent. The article discusses the histologic details and common mimickers to be borne in mind aiding in arrival at the final diagnosis on biopsy specimens.
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Affiliation(s)
| | - Shailee Mehta
- Gujarat Cancer Research Institute (GCRI), Ahmedabad, Gujarat, India.
| | - Jahnavi Gandhi
- Gujarat Cancer Research Institute (GCRI), Ahmedabad, Gujarat, India
| | - Priti Trivedi
- Gujarat Cancer Research Institute (GCRI), Ahmedabad, Gujarat, India
| | - Priyank Rathod
- Gujarat Cancer Research Institute (GCRI), Ahmedabad, Gujarat, India
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Lu D, Zhang Y, Zhao R, Zhou E, Xue X, Li C, Huang S, Chen X. Spindle Epithelial Tumor With Thymus-Like Differentiation of Thyroid (SETTLE): A Case Report and Literature Review. EAR, NOSE & THROAT JOURNAL 2023:1455613231171826. [PMID: 37247430 DOI: 10.1177/01455613231171826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
Spindle epithelial tumor with thymus-like differentiation of thyroid (SETTLE) is very rare neoplasm with 2 cellular forms, epithelial cell and spindle cell, and most reported cases have been in young people. An 11-year-old boy presented with painless swelling of the right neck lasting for more than 2 months. A tumor size measuring approximately 3 × 3 cm was resected, and intraoperative frozen pathology suggested a spindle cell tumor, which was confirmed as SETTLE by immunohistochemical staining and external hospital consultation. The immunohistochemical staining profile of the resected tumor tissue was as follows: cytokeratin (CK) (+), smooth muscle actin (weak+), vimentin (+), CK7 (focal+), B-cell lymphoma 2 (partial+), CD99 (-), calcitonin (+), galectin-3 (+), CK19 (+), and Ki-67 (10%+). Ultrasound at 1-year postoperative follow-up revealed no local recurrence of the lesion or lymph node metastasis in the thyroid gland. We summarized the disease characteristics of SETTLE among 6 cases reported to date and found that SETTLE is associated with a good prognosis and low postoperative recurrence rate. Thus, for this type of malignant thyroid tumor, diagnosis depends mainly on postoperative pathology and immunohistochemical staining and simple surgical resection is recommended.
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Affiliation(s)
- Dan Lu
- Postgraduate Training Base at Shanghai Gongli Hospital, Ningxia Medical University, Shanghai, China
| | - Yi Zhang
- Postgraduate Training Base at Shanghai Gongli Hospital, Ningxia Medical University, Shanghai, China
| | - Runyu Zhao
- Postgraduate Training Base at Shanghai Gongli Hospital, Ningxia Medical University, Shanghai, China
| | - Enhui Zhou
- Postgraduate Training Base at Shanghai Gongli Hospital, Ningxia Medical University, Shanghai, China
| | - Xiaocheng Xue
- Postgraduate Training Base at Shanghai Gongli Hospital, Ningxia Medical University, Shanghai, China
| | - Can Li
- Postgraduate Training Base at Shanghai Gongli Hospital, Ningxia Medical University, Shanghai, China
| | - Shuixian Huang
- Postgraduate Training Base at Shanghai Gongli Hospital, Ningxia Medical University, Shanghai, China
| | - Xiaoping Chen
- Postgraduate Training Base at Shanghai Gongli Hospital, Ningxia Medical University, Shanghai, China
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Kathamuthu K, Janardan C, Ramkumar S, Agarwal L, Al-Brahim N, Eldein Ahmed M, Jayamani J. Spindle Epithelial Tumor With Thymus-Like Differentiation (SETTLE) Misdiagnosed as Papillary Thyroid Carcinoma: A Case Report. Cureus 2022; 14:e31574. [DOI: 10.7759/cureus.31574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2022] [Indexed: 11/17/2022] Open
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Manukyan I, DeBrito P, Rossi CT, Russo PA, Sidawy M. Spindle epithelial tumor with thymus-like differentiation in fine needle aspiration of thyroid gland: Report of two cases. Diagn Cytopathol 2021; 50:E54-E58. [PMID: 34636490 DOI: 10.1002/dc.24886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/03/2021] [Accepted: 10/04/2021] [Indexed: 11/05/2022]
Abstract
Spindle epithelial tumor with thymus-like differentiation (SETTLE) is a rare, malignant tumor of the thyroid gland that typically affects young males and has a propensity for late metastasis. With fine needle aspiration (FNA) being a primary tool for diagnosis of thyroid lesions, there are rare reports of cytological features of SETTLE on FNA since its initial characterization 30 years ago . Here we report two cases of SETTLE, involving 9-year-old and 15-year-old male patients. Both patients underwent US-guided FNA with a subsequent resection confirming the diagnosis of SETTLE. In the first patient the thymic origin of the tumor was suspected on FNA, but the diagnosis of SETTLE was established only after resection. Five years later, this patient presented with an enlarged ipsilateral cervical lymph node. Needle biopsy confirmed it to be a metastatic tumor compatible with SETTLE. In the second patient the diagnosis of SETTLE was suggested on FNA. Cytology of the thyroid gland nodule on FNA from both patients showed loosely cohesive and single spindle-shaped epithelial cells associated with metachromatic stroma. The differential diagnosis of spindle cell lesions of the thyroid should include SETTLE based on characteristic morphological features, after more common entities of thyroid gland such as medullary carcinoma are excluded.
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Affiliation(s)
- Irena Manukyan
- Department of Pathology, MedStar Georgetown University Hospital, Washington, D.C., USA.,Department of Personalized Genomic Medicine, Columbia University Medical Center, New York, New York, USA
| | - Pedro DeBrito
- Department of Pathology, MedStar Georgetown University Hospital, Washington, D.C., USA
| | - Christopher T Rossi
- Department of Pathology, Children's National Medical Center, Washington, D.C., USA
| | - Pierre A Russo
- Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mary Sidawy
- Department of Pathology, MedStar Georgetown University Hospital, Washington, D.C., USA
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Adegun OK, Proctor I, Falzon M, Pomplun S. Spindle cell tumour with thymus-like differentiation (SETTLE) on fine needle aspiration cytology: A case report highlighting diagnostic pitfalls. Diagn Cytopathol 2021; 49:E325-E328. [PMID: 33794064 DOI: 10.1002/dc.24744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 11/11/2022]
Abstract
A 7-year-old girl presented with a painless neck swelling localised near the left lobe of the thyroid gland, which was initially investigated by fine needle aspiration cytology. This raised a differential diagnosis of medullary thyroid carcinoma and small round blue cell tumour. Only after several additional clinical investigations and a total thyroidectomy was a definitive diagnosis of spindle cell tumour with thymus-like differentiation (SETTLE) reached. This case report highlights how contemporaneous clinical and investigation findings made arriving at a definitive diagnosis challenging, contributed to diagnostic delay, and ultimately influenced choice of treatment.
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Affiliation(s)
- Oluyori K Adegun
- Department of Cellular Pathology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ian Proctor
- Department of Cellular Pathology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mary Falzon
- Department of Cellular Pathology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Sabine Pomplun
- Department of Cellular Pathology, University College London Hospitals NHS Foundation Trust, London, UK
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