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CASE REPORT  
Year : 2015  |  Volume : 58  |  Issue : 3  |  Page : 348-350
Diffuse lipomatosis of the thyroid gland with papillary microcarcinoma: Report of a rare entity


1 Department of Pathology, RDT Hospital, Bathalapalli, Andhra Pradesh, India
2 Pathology Department, Vimta Laboratory, Hyderabad, Telangana, India
3 Department of Minimal Access Surgery, RDT Hospital, Bathalapalli, Andhra Pradesh, India

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Date of Web Publication14-Aug-2015
 

   Abstract 

Presence of lobules of adipose tissue either focally or diffusely is very rare in the thyroid gland. Fat accumulation can be macroscopic or microscopic. Focal infiltrates of fat have been reported in conditions such as adenolipoma, intrathyroid lipoma, and encapsulated papillary carcinoma. Diffuse lipomatosis has been reported in conditions such as amyloid goitre, heterotopic fat nests, thyrolipoma and liposarcoma. The exact mechanism of fat accumulation is not known although there are many theories postulated. Investigations such as ultrasound, computed tomography scan, and magnetic resonance imaging can detect the presence of macroscopic fat in the thyroid gland. Accurate diagnosis of the type of fat accumulation is necessary because tumorous and nontumorous conditions fall into the differential diagnosis. Only nine cases of papillary carcinoma associated with lipomatosis of thyroid are reported so far. We report possibly the first case of diffuse lipomatosis of the thyroid gland with a focus of papillary microcarcinoma.

Keywords: Lipomatosis, papillary microcarcinoma, thyroid gland

How to cite this article:
Nandyala HS, Madapuram S, Yadav M, Katamala SK. Diffuse lipomatosis of the thyroid gland with papillary microcarcinoma: Report of a rare entity. Indian J Pathol Microbiol 2015;58:348-50

How to cite this URL:
Nandyala HS, Madapuram S, Yadav M, Katamala SK. Diffuse lipomatosis of the thyroid gland with papillary microcarcinoma: Report of a rare entity. Indian J Pathol Microbiol [serial online] 2015 [cited 2020 Feb 29];58:348-50. Available from: http://www.ijpmonline.org/text.asp?2015/58/3/348/162890



   Introduction Top


Fat-containing lesions of the thyroid are seen as lesions containing macroscopic mature fat or lesions rich in microscopic intracellular fat vacuoles, or lesions that are referred to as clear cell or lipid-rich neoplasms. [1] Diffuse lipomatosis of the thyroid gland is an extremely rare lesion, first reported by Dhayagude in 1942. [2] Normal thyroid may have a scanty amount of fat immediately adjacent to the capsule and along the fibrous tissue septa, but do not have fat intermixed with the follicles. Rarely, a small amount of fat around the blood vessels in the subcapsular area of the anterior portion can be seen. [1],[3] Lipomatosis is characterized by diffuse fatty infiltration into the thyroid stroma without any evidence of encapsulation. Many tumorous and nontumorous conditions of thyroid have been reported to be associated with diffuse lipomatosis. The exact mechanism of lipomatosis is still debated though there are some theories to explain the presence of fat in the thyroid gland. [4],[5] Correct diagnosis of these tumorous or nontumourous conditions is essential for the better management. There are only nine case reports of papillary carcinoma of the thyroid gland associated with lipomatosis. We are presenting the first case of papillary microcarcinoma associated with diffuse lipomatosis of the thyroid gland.


   Case Report Top


A 37-year-old male presented to the outpatient department of surgery in May 2013 with the complaints of painful midline swelling in the neck of 8 months duration. This patient is a known case of adenocarcinoma of the ascending colon for which he underwent right side hemicolectomy and complete course of chemotherapy in 2010. During the follow-up, he was diagnosed to have pulmonary tuberculosis and hypertrophic cardiomyopathy. He had taken the complete course of treatment for pulmonary tuberculosis in 2012. The present clinical examination did not reveal any significant findings. Fine-needle aspiration cytology (FNAC) of the neck swelling was suggestive of nodular goitre with adipocytes in the background. Total thyroidectomy was done, and the specimen was sent to the laboratory for pathological evaluation.

Gross examination of the specimen revealed an encapsulated greyish brown oval mass of size 5 cm × 11 cm × 15 cm. Cut surface showed yellowish, greasy lobular areas with tiny foci of cystic spaces and hemorrhages [Figure 1].
Figure 1: Thyroidectomy specimen which shows yellowish grey lobular areas with tiny foci of hemorrhages and cystic change


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Microscopic examination of the tissue revealed thyroid tissue almost totally replaced by mature adipocytes with normal or slightly distended follicles scattered in between [Figure 2]. One small focus of a lobule of thyroid follicles showing papillary projections was noted. The cells covering these papillary projections were round to oval with the ground glass nucleus. Overlapping of these cells was observed [Figure 3] and [Figure 4]. Psammoma bodies were not seen. Immunohistochemistry of this papillary area revealed positive thyroid transcription factor-1, thyroglobulin and focal positivity of cytokeratin confirming the diagnosis of papillary carcinoma.
Figure 2: Low power view of single or small groups of follicles surrounded by adipocytes (H and E, ´20)


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Figure 3: Low power view showing a cluster of follicles surrounded by adipocytes and a focus of papillary carcinoma (H and E, ´20)


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Figure 4: High power view showing the papillae with ground glass nuclei and overlapping of cells (H and E, ´40)


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   Discussion Top


Presence of fat in the thyroid tissue or fat containing lesions of thyroid is extremely rare. Focal microscopic deposits of fat can rarely be seen in normal thyroid. Lipomatosis of the thyroid gland is usually seen in the middle-aged persons with no sex predilection. Amyloid goitre, lymphocytic thyroiditis, thyroid or parathyroid lipoma, encapsulated papillary carcinoma, liposarcoma, and adenolipoma are reported to be associated with focal or diffuse macroscopic fat deposition in the thyroid gland. [1],[5],[6] Most common lesion of thyroid to have fat is thyrolipoma. It is characterized by a well-circumscribed and encapsulated nodule composed of thyroid follicles admixed with a mature adipose tissue. Thyrolipomatosis shows diffuse infiltration of thyroid by mature adipocytes and without any evidence of encapsulation. Amyloid goitre is usually associated with systemic amyloidosis which stains intensely with crystal violet or Congo red. [7] Lymphocytic thyroiditis shows diffuse stromal infiltration of lymphocytes. The presence of intracytoplasmic glycogen favors the parathyroid tissue in case of parathyroid adenoma. Papillary carcinoma will have characteristic morphological features. Liposarcoma is an aggressive rapidly growing tumor. Clear cell adenoma with lipid-rich areas shows follicular cells with small round nuclei and abundant foamy to coarsely vacuolated cytoplasm. [6]

There are no definite set criteria to make a diagnosis of diffuse lipomatosis by FNAC. Computed tomography (CT) scan, magnetic resonance imaging and ultrasonography have been shown to be effective in the preoperative diagnosis of such fatty lesions. [8] In suspected cases, due to the softness of the gland, both FNAC and CT can confirm the diagnosis preoperatively.

Only nine cases of papillary carcinoma of the thyroid gland associated with lipomatosis are reported so far. [5],[9] Our case is probably the first case of papillary microcarcinoma associated with diffuse lipomatosis.

Etiopathogenesis of lipomatosis is still obscure. Schröder and Böcker [4] postulated that the adipose tissue may be derived from the metaplasia of the stromal fibroblasts in response to tissue hypoxia or to senile involution as demonstrated in the other organs. Chesky et al. [10] attributed the lesions to the simultaneous inclusion of fat with striated muscle in the thyroid gland during embryogenesis before the development of the thyroid capsule.

The interesting fact in our case is that the patient has been treated successfully for adenocarcinoma of the colon and pulmonary tuberculosis. He had hypertrophic cardiomyopathy. It is tempting to postulate that there might have been hypoxia during the treatment period for carcinoma colon and pulmonary tuberculosis, which could have triggered the lipomatous metaplasia of the stromal cells in the thyroid gland.

Further follow-up is definitely warranted in cases of lipomatosis of the thyroid gland because this condition is rare, the natural history of the lesion is unknown and its association with tumorous and nontumorous lesions.

 
   References Top

1.
LiVolsi VA. Unusual tumors and tumor-like conditions of the thyroid. In: LiVolsi VA, editor. Surgical Pathology of the Thyroid. Major Problems in Pathology Series. Vol. 22. Ch. 15. Philadelphia: WB Saunders; 1990. p. 323-50.  Back to cited text no. 1
    
2.
Dhayagude RG. Massive fatty infiltration in a colloid goiter. Arch Pathol 1942;33:357-60.  Back to cited text no. 2
    
3.
Gupta R, Arora R, Sharma A, Dinda AK. Diffuse lipomatosis of the thyroid gland: A pathologic curiosity. Indian J Pathol Microbiol 2009;52:215-6.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Schröder S, Böcker W. Lipomatous lesions of the thyroid gland: A review. Appl Pathol 1985;3:140-9.  Back to cited text no. 4
    
5.
Gnepp DR, Ogorzalek JM, Heffess CS. Fat-containing lesions of the thyroid gland. Am J Surg Pathol 1989;13:605-12.  Back to cited text no. 5
    
6.
Ge Y, Luna MA, Cowan DF, Truong LD, Ayala AG. Thyrolipoma and thyrolipomatosis: 5 case reports and historical review of the literature. Ann Diagn Pathol 2009;13:384-9.  Back to cited text no. 6
    
7.
Aksu AO, Ozmen MN, Oguz KK, Akinci D, Yasavun U, Firat P. Diffuse fatty infiltration of the thyroid gland in amyloidosis: Sonographic, computed tomographic, and magnetic resonance imaging findings. J Ultrasound Med 2010;29:1251-5.  Back to cited text no. 7
    
8.
Borges A, Catarino A. Case 53: Adenolipoma of the thyroid gland. Radiology 2002;225:746-50.  Back to cited text no. 8
    
9.
Bisi H, Longatto Filho A, de Camargo RY, Fernandes VS. Thyroid papillary carcinoma lipomatous type: Report of two cases. Pathologica 1993;85:761-4.  Back to cited text no. 9
    
10.
Chesky VE, Dreese WC, Hellwig CA. Adenolipomatosis of the thyroid; a new type of goiter. Surgery 1953;34:38-45.  Back to cited text no. 10
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Correspondence Address:
Dr. Hariharanadha Sarma Nandyala
Department of Pathology, RDT Hospital, Bathalapalli - 515 661, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.162890

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    Figures

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

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