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  Table of Contents    
CASE REPORT  
Year : 2010  |  Volume : 53  |  Issue : 2  |  Page : 337-339
Synchronous occurrence of anaplastic, follicular and papillary carcinomas with follicular adenoma in thyroid gland


1 Department of Pathology, The Mission Hospital, Durgapur; Sector C, Immon Kalyan Sarani, Durgapur - 713212, India
2 Department of Pathology, SSKM Hospital, Kolkata, India
3 Department of Histopathology; Apollo Gleneagles Hospitals, 58 Canal Circular Road, Kolkata - 700 054, India

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Date of Web Publication12-Jun-2010
 

   Abstract 

Various combinations of thyroid carcinomas have been reported including those between different cancers of follicular cell origin and those between follicular and C-cell histogenesis. Accordingly, anaplastic carcinomas have been seen to coincide with simultaneous papillary and follicular cancers. We report a case of composite anaplastic and papillary cancer on one thyroid lobe with a follicular carcinoma in the other lobe in a female patient aged 64 years. The patient also had a separate and independent follicular adenoma in the same lobe as the composite anaplastic and papillary carcinoma. The papillary carcinoma was continuous with the anaplastic carcinoma. The findings were supported by immunohistochemistry. The patient was managed by a total thyroidectomy with bilateral modified radical neck dissection followed by chemotherapy. However, she died two months after surgery. The common follicular cell origin will explain the concurrent presence of all these cancers. This could result from the dedifferentiation of a pre-existing differentiated carcinoma.

Keywords: Adenoma, anaplastic, carcinoma, follicular, papillary, thyroid

How to cite this article:
Ganguly R, Mitra S, Datta A K. Synchronous occurrence of anaplastic, follicular and papillary carcinomas with follicular adenoma in thyroid gland. Indian J Pathol Microbiol 2010;53:337-9

How to cite this URL:
Ganguly R, Mitra S, Datta A K. Synchronous occurrence of anaplastic, follicular and papillary carcinomas with follicular adenoma in thyroid gland. Indian J Pathol Microbiol [serial online] 2010 [cited 2019 Nov 21];53:337-9. Available from: http://www.ijpmonline.org/text.asp?2010/53/2/337/64328



   Introduction Top


Cases of composite thyroid carcinomas have been reported in the literature. Combinations like follicular carcinoma with papillary carcinoma are seen. Cases having medullary carcinoma with foci of a differentiated cancer of follicular cell origin (papillary/follicular) are also reported. Concomitant well-differentiated carcinomas were seen in 59% of patients with insular carcinomas and 39% of patients with anaplastic cancers. [1] We report here a case of composite papillary carcinoma and anaplastic carcinoma. The patient also had follicular carcinoma in the opposite lobe and a follicular adenoma in the same lobe.


   Case Report Top


A 64-year-old lady had a multinodulated thyroid swelling having restricted mobility on deglutition. She had respiratory difficulties and mild dysphagia. An FNA of the thyroid swelling yielded only degenerated cells in a background of necrosis. However, surgery was planned based on the clinical suspicion. A per-operative frozen section showed sheets of atypical cells, acute inflammation and necrosis. Frozen section from another part of the thyroid showed sheets of cells, which were then reported to be 'histiocytic' with a comment to wait for the permanent section report.

Total thyroidectomy was done; the larger lobe (9.5 cm x 7 cm x 3.5 cm) showed a circumscribed necrotic tumor (7 cm x 4.5 cm) and another smaller nodule (1.7 cm x 1.2 cm), separate from the necrotic tumor on serial section. The smaller lobe (8 cm x 4.5 cm x 4 cm) had a nodule measuring 5 cm x 4 cm x 3 cm with a small cystic area. In both sides the capsules were grossly intact.

The circumscribed necrotic tumor was histopathologically anaplastic carcinoma [Figure 1], with one small focus showing features of papillary [Figure 2] and [Figure 3] and another of follicular carcinoma [Figure 4]. The smaller nodule on that side was a follicular adenoma [Figure 5]. The latter did not have any connection with the ipsilateral anaplastic carcinoma and was separately and completely encapsulated without any capsular or vascular invasion. The anaplastic carcinoma was found to extend up to its capsule but not beyond. It had spindle cell morphology with areas of necrosis and inflammation. The papillary carcinoma focus had all the relevant nuclear features (Orphan Annie eyed appearance with occasional grooving and pseudo inclusions) and seemed to merge into the anaplastic component. The surrounding thyroid had nodular hyperplasia. The nodule located on the smaller lobe was consistent with follicular carcinoma [Figure 6], with more than one focus of capsular and vascular invasion. The accompanying lymph nodes found on the modified neck dissection were all negative and showed reactive hyperplasia.

Immunohistochemistry was carried out with thyroglobulin (TG), cytokeratin (CK) and chromogranin of which only CK was positive in the anaplastic carcinoma component, whereas TG came out positive in the papillary carcinoma portions. The negativity to chromogranin ruled out any co-existent medullary carcinoma. An initial Congo red stain had also failed to demonstrate any amyloid. While the morphology was diagnostic, the immunostain results were in agreement with our diagnosis. [2]

After the total thyroidectomy and modified radical neck dissection, the patient was treated with a doxorubicin-based chemotherapy regime, but ultimately died after two months due to widespread liver and brain metastasis.


   Discussion Top


Undifferentiated or anaplastic carcinomas are highly aggressive neoplasms having three major subtypes viz. spindle cell, giant cell and squamoid or combinations thereof. [2] They are one extreme of the continuum comprising differentiated thyroid cancers at the other end and poorly differentiated or insular carcinoma in between. [3],[4] A differentiated thyroid cancer, sometimes a poorly differentiated one has been found in 39-89% of anaplastic carcinoma cases. [5],[10] According to Fletcher, [6] ploidy analyses show aneuploidy in the differentiated components in addition to the anaplastic component. The finding indicates the possibility of a common origin. Furthermore, 71% of the anaplastic tumors are said to either follow or occur simultaneously with a well-differentiated thyroid cancer. [7] Galera-Davidson et al[8] have hypothesized that the patients with differentiated thyroid cancers having aneuploidy represent a higher risk group and are probably more prone to developing anaplastic carcinoma.

Various other combinations of thyroid carcinomas are in the literature. Cupisti et al[9] have reported synchronous occurrence of follicular, papillary and medullary thyroid carcinomas in a patient. Fadare et al[10] have found diffuse glandular formations lined by columnar cells in a thyroid carcinoma with insular and anaplastic features. Also described is the existence of well-differentiated thyroid tumors sharing the clinicopathologic features of follicular and papillary carcinoma. [9]

The common, follicular cell histogenesis of anaplastic, papillary and follicular carcinomas explains the synchronicity of the first with the latter two entities in many cases. The same reason could be cited to explain the far less common occurrence of composite cancers containing a medullary component which is of C-cell histogenesis.

In the light of the preceding discussion, the concurrent presence of anaplastic carcinoma with a more differentiated carcinoma of follicular cell origin could mean

A pre-existing follicular or papillary carcinoma transforming (dedifferentiating) into an anaplastic carcinoma.

A common follicular cell giving rise to simultaneous anaplastic and more differentiated cancers.

We have reported this case because of the uniqueness in its histopathological findings and to discuss the complicated histogenesis.

 
   References Top

1.Lam KY, Lo CY, Chan KW, Wan KY. Insular and anaplastic carcinoma of the thyroid: a 45-year comparative study at a single institution and a review of the significance of p53 and p21. Ann Surg 2000;231:329-38.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Carcangiu ML, Steeper T, Zampi G, Rosai J. Anaplastic thyroid carcinoma. A study of 70 cases. Am J Clin Pathol 1985;83:135-58.  Back to cited text no. 2
[PUBMED]    
3.Carcangiu ML, Zampi G, Rosai J. Poorly differentiated ("insular") thyroid carcinoma. A reinterpretation of Langhans' "wuchernde Struma". Am J Surg Pathol 1984;8:655-68.  Back to cited text no. 3
[PUBMED]    
4.Patel KN, Shaha AR. Poorly differentiated and anaplastic thyroid cancer. Cancer Control 2006;13:119-28.  Back to cited text no. 4
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5.Castro P, Fonseca E, Magalhaes J, Sobrinho-Simoes M. Follicular, papillary, and "hybrid" carcinomas of the thyroid. Endocr Pathol 2002;13:313-20.  Back to cited text no. 5
    
6.Fletcher CD. Tumours of thyroid and parathyroid glands. In Diagnostic Histopathology of Tumours. 2nd ed. 2000. p. 959-1023.  Back to cited text no. 6
    
7.Spires JR, Schwartz MR, Miller RH. Anaplastic thyroid carcinoma. Association with differentiated thyroid cancer. Arch Otolaryngol Head Neck Surg 1988;114:40-4.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Galera-Davidson H, Bibbo M, Dytch HE, Gonzalez-Campora R, Fernandez A, Wied GL. Nuclear DNA in anaplastic thyroid carcinoma with a differentiated component. Histopathology 1987;11:715-22.  Back to cited text no. 8
    
9.Cupisti K, Raffel A, Ramp U, Wolf A, Donner A, Krausch M, Eisenberger CF, Knoefel WT. Synchronous occurrence of a follicular, papillary and medullary thyroid carcinoma in a recurrent goiter. Endocr J 2005;52:281-5.  Back to cited text no. 9
[PUBMED]  [FULLTEXT]  
10.Fadare O, Sinard JH. Glandular patterns in a thyroid carcinoma with insular and anaplastic features: a case with possible implications for the classification of thyroid carcinomas. Ann Diagn Pathol 2002;6:389-98.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
R Ganguly
Department of Pathology, The Mission Hospital, Durgapur; Sector - 2C, Immon Kalyan Sarani, Durgapur - 713212
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.64328

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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    Abstract
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