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CYTOLOGY SECTION - CASE REPORT Table of Contents   
Year : 2008  |  Volume : 51  |  Issue : 1  |  Page : 91-93
Cutaneous metastasis from follicular variant of papillary thyroid carcinoma: A case diagnosed on cytology


Department of Pathology, Bankura Sammilani Medical College, Bankura, West Bengal, India

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   Abstract 

A 40-year-old woman presented with a scalp swelling. A careful clinical examination revealed a left-sided deep-seated thyroid nodule. Fine needle aspiration from both sites disclosed a microfollicular architectural pattern on Giemsa stain and pale nuclei with nuclear grooves on Papanicolaou stain, indicating the possibility of follicular variant of papillary thyroid carcinoma with metastasis to the scalp. Histologic tissue evaluation confirmed the diagnosis. Thus, a diligent search for nuclear features should be performed to enable a diagnosis of follicular variant of papillary thyroid carcinoma on cytology. This helps in patient management obviating the need for a second surgical intervention.

Keywords: Fine needle aspiration cytology, follicular variant, papillary, thyroid carcinoma

How to cite this article:
Chakraborty J, Bandyopadhyay A, Choudhuri MK, Mitra K, Guha D, Mallik MG. Cutaneous metastasis from follicular variant of papillary thyroid carcinoma: A case diagnosed on cytology. Indian J Pathol Microbiol 2008;51:91-3

How to cite this URL:
Chakraborty J, Bandyopadhyay A, Choudhuri MK, Mitra K, Guha D, Mallik MG. Cutaneous metastasis from follicular variant of papillary thyroid carcinoma: A case diagnosed on cytology. Indian J Pathol Microbiol [serial online] 2008 [cited 2020 Oct 21];51:91-3. Available from: https://www.ijpmonline.org/text.asp?2008/51/1/91/40414



   Introduction Top


Papillary thyroid carcinoma (PTC) usually manifests slow progression. Distant metastasis occurs in approximately 10% of patients, who can still survive for many years. [1] Most distant metastases appear in the lungs and bones. [1]

Deposits of PTC in the skin are distinctly uncommon.

The cytological diagnosis of classical PTC does not present a diagnostic difficulty in most cases; however, in the follicular variant of papillary thyroid carcinoma (FVPTC), the papillary architecture is absent and nuclear features are present to a variable degree. We describe a patient of FVPTC who presented with metastatic foci in the scalp.


   Case History Top


A 40-year-old female presented with a soft swelling over forehead for 1 month, measuring 1.5 cm in diameter. A careful examination of the patient revealed a left-sided deep-seated thyroid nodule, which measured 2 cm in diameter. No cervical lymphadenopathy was present. The routine hematological, biochemical and thyroid hormone profile were within normal limits except for mild anemia. Thyroid scan showed a cold nodule. X-ray chest did not reveal any opacity.

The X-ray of skull revealed the erosion of outer table. No lytic lesions were identified on the X-ray of pelvis, vertebrae and limbs. The ultrasonography of abdomen was normal.

Pathological findings

Fine Needle Aspiration Cytology (FNAC) smears from both the lesions, stained with May-Grunwald Giemsa (MGG) stain were cellular, comprising of small cells that exhibited scanty ill-defined cytoplasm, predominantly arranged in syncytial clusters with microfollicular architectural pattern [Figure - 1],[Figure - 2]. The cells had round to ovoid nuclei with mild anisokaryosis and focal nuclear overcrowding. Papanicolaou stained smears revealed pale nuclei with dusty chromatin and nuclear grooves [Figure - 3],[Figure - 4]. No intranuclear inclusions were identified. There was very little colloid in the background. Based on these features, a diagnosis of the follicular variant of papillary thyroid carcinoma (FVPTC) with metastasis to the scalp was suggested.

Total thyroidectomy was performed. Cut surface revealed multiple grayish white solid nodules, varying in size from 0.2-2 cm, the largest one showing capsular invasion. On histopathological examination there were small- to medium-sized irregular shaped follicles with no papillary structures. A small amount of hypereosinophilic and scalloped colloid was seen in some of the follicles. The cells lining the follicles contained large clear nuclei. Focal areas of insular growth pattern were seen. No stromal sclerosis or psammoma bodies were identified. No areas of tumor necrosis, prominent mitosis or marked nuclear atypia were present. The case was diagnosed as FVPTC.


   Discussion Top


Thyroid carcinoma metastatic to the skin is a rare clinical entity. [2] Dermal lesions are typically present as slowly growing erythematous or purple plaques or nodules usually on scalp, face or neck. Scalp is the most common site, which is involved in approximately two-third of cases, [2] and this may relate to local vascular factors essential for the highly complex nature of metastasis formation. [3] The rich dermal capillary network of the scalp, face and chest as well as the choroids may initially trap the tumor cell emboli from the circulation and provide the environment for the successful formation of metastatic foci. [3]

FNAC is highly accurate in diagnosing PTC but the accuracy in subtyping its variants, especially follicular, is doubtful. Architecture might play the most important and definite role in the differential diagnosis of usual type of papillary thyroid carcinoma (UTPTC) and FVPTC but it is also the most vulnerable. If the follicular structure is destroyed or sample is too small, the FVPTC is difficult to diagnose. In a study conducted by Shih et al. [4] the sensitivity and specificity of the cytological diagnosis of FVPTC was 42% and 83%, respectively, as the rate of presence of follicles in FNAC of FVPTC is not sufficiently high. However, the follicular architecture was very prominent in the present case, both at the primary and metastatic sites.

Many features that have been proposed to aid the cytological diagnosis of FVPTC such as colloid balls, intranuclear inclusions and ropy colloid, were absent in the present case. However, features such as rosette-like microfollicles, nuclear grooves, syncytial clusters, monolayered branched sheets and occasional multinucleate giant cells could be identified in these smears. As intranuclear inclusions are considerably less in number in FVPTC in comparison to that in UTPTC, a Papanicolaou preparation helps to identify the pale, powdery chromatin and nuclear grooves. These features are difficult to discern on MGG smears. The diagnosis of FVPTC is usually not difficult when the classic nuclear features of PTC are diffusely distributed throughout the tumor.

An interesting feature of this case is that the follicular architecture was maintained also at the metastatic site, which was helpful in the diagnosis of the lesion. This is a rare occurrence in FVPTC as usually the papillary pattern is evident at the site of metastasis. [5]

It is of significance to note that when a follicular structure is present in smears, FVPTC may be considered in the differential diagnosis of follicular neoplasm and a diligent search for the nuclear features should be performed. This can help to reduce the number of indeterminate, false positive and false negative diagnosis of FVPTC. [6]

However, if a diagnosis of follicular neoplasm instead of FVPTC is made in cases that have a paucity of appropriate nuclear features of PTC, this will affect the clinical management. Baloch et al. [7] proposed that the cytopathology reports should include the presence of cytological clues in a specimen, suggesting that a follicular lesion may represent FVPTC. This should prompt an intraoperative pathology consultation (frozen section and touch preparation) to attempt a definite diagnosis to avoid a second surgical intervention for completion thyroidectomy. [8] At times, the morphological features are equivocal, and in such cases, immunocytochemistry can play a promising role. Markers such as ret/PTC, HBME-1, CK19 and CD10 have proved to be useful adjuncts and can confirm the diagnosis in such cases. [9],[10]

Metastatic thyroid carcinoma may be a diagnostic challenge, and thus, clinical evaluations continue to play an important role. To conclude, the investigation of a flesh-colored skin nodule, particularly in the scalp area, should include the possibility of metastatic thyroid carcinoma.

 
   References Top

1.Shaha AR, Ferlito A, Rinaldo A. Distant metastases from thyroid and parathyroid cancer. ORL J Otorhinolaryngol Relat Spec 2001;63:243-9.  Back to cited text no. 1    
2.Dahl PR, Brodland DG, Goellner JR, Hay ID. Thyroid carcinoma metastatic to the skin: A cutaneous manifestation of a widely disseminated malignancy. J Am Acad Dermatol 1997;36:531-7.  Back to cited text no. 2    
3.Avram AM, Gielczyk R, Su L, Vine AK, Sisson JC. Choroidal and skin metastases from Papillary thyroid cancer: Case and a review of the literature. J Clin Endocrinol and Metabol 2004;89:5303-7.  Back to cited text no. 3    
4.Shih SR, Shun CT, Su DH, Hsiao YL, Chang TC. Follicular variant of papillary thyroid carcinoma: Diagnostic limitations of fine needle aspiration cytology. Acta Cytol 2005;49:383-6.  Back to cited text no. 4    
5.Rosai J. Thyroid gland. In : Rosai and Ackerman's Surgical Pathology. 9 th ed. St. Louis, Missouri, Mosby; 2004. p. 537.  Back to cited text no. 5    
6.Jogai S, Al-Jassar A, Temmim L, Dey P, Adesina AO, Amanguno HG. Fine needle aspiration cytology of the thyroid: A cytohistologic study with evaluation of discordant cases. Acta Cytol 2005;49:483-8.  Back to cited text no. 6    
7.Baloch ZW, Gupta PK, Yu GH, Sack MJ, LiVolsi VA. Follicular variant of papillary carcinoma: Cytologic and histologic correlation. Am J Clin Pathol 1999;111:216-22.  Back to cited text no. 7    
8.Montone KT, LiVolsi VA. Frozen section analysis of thyroidectomy specimens: Experience over a 12 year period. Pathol Case Rev 1996;2:241-5.  Back to cited text no. 8    
9.Cheung CC, Ezzat S, Freeman JL, Rosen IB, Asa SL. Immunohistochemical diagnosis of papillary thyroid carcinoma. Mod Pathol 2001;14:338-42.  Back to cited text no. 9    
10.Chueng CL, Carydis B, Essat S, Bedard YC, Asa SL. Analysis of ret/PTC gene rearrangements refines the fine needle aspiration diagnosis of thyroid cancer. J Clin Endocrinol Metab 2001;86:2187-90.  Back to cited text no. 10    

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Correspondence Address:
Jayati Chakraborty
J-26, Nabadarsha, Birati, Kolkata - 700 134, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.40414

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    Figures

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

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    Abstract
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