Endocr Pathol (2015) 26:232–238 DOI 10.1007/s12022-015-9380-9
Thyroid Paraganglioma: BNaked^ Nuclei as a Clue to Diagnosis on Imprint Cytology Mana Taweevisit 1 & Wasakorn Bunyayothin 2 & Paul Scott Thorner 1,3
Published online: 27 June 2015 # Springer Science+Business Media New York 2015
Abstract A cytologic diagnosis of paraganglioma of the thyroid is difficult to make because the thyroid gland is an unusual location for such a tumor and the cytologic findings overlap with other benign and malignant thyroid tumors. We report the case of a 28-year-old female presenting with a solitary mass of the right thyroid gland. A diagnosis of paraganglioma was made on the resected specimen. At the time of tumor resection, imprint cytology was performed. The imprint was hypercellular with cohesive sheets of round cells showing anisokaryosis and anisocytosis. Moreover, there was a second cell type consisting of oval nuclei with dispersed nuclear chromatin present within the sheets and separate as Bnaked^ nuclei. By immunohistochemistry, the cohesive round cells were positive for chromogranin A, indicating chief cells. The naked nuclei were positive for S-100 protein, indicating sustentacular cells. To the best our knowledge, this is the first case report describing naked nuclei as a cytologic feature of paraganglioma. Identification of sustentacular cells provides a clue for the cytologic diagnosis of paraganglioma.
Keywords Paraganglioma . Thyroid gland . Cytology . Immunohistochemistry * Mana Taweevisit [email protected] 1
Department of Pathology, Faculty of Medicine, Chulalongkorn University, 1873 King Rama IV Street, Pathumwan, Bangkok 10330, Thailand
2
Department of Anatomical Pathology, Ministry of Public Health, Chonburi Hospital, 69 Sukhumvit Road, Baan Suan Muang, Chonburi 20000, Thailand
3
Department of Pathology and Laboratory Medicine, Hospital for Sick Children and University of Toronto, Toronto, ON M5G1X8, Canada
Introduction Paragangliomas are uncommon slow-growing, neuroendocrine tumors arising from extra-adrenal paraganglia of the autonomic nervous system [1–3]. These tumors can be found from the skull base to the pelvic floor in locations that correspond to the embryologic migration routes of neural crest tissue. Paragangliomas of sympathetic ganglia are often found along the prevertebral and paravertebral sympathetic chains, whereas those of parasympathetic origin occurs primarily in the head and neck region, in particular at the bifurcation of the common carotid artery (carotid body paraganglioma or chemodectoma) and in the middle ear (jugulotympanic paraganglioma). There are occasional reports of paragangliomas occurring adjacent to or inside of the thyroid gland [4–23]. Thyroid paraganglioma was first described in 1974 [24] and was believed to be a subset of laryngeal paraganglioma. Anatomically, there are bilateral superior and inferior laryngeal paraganglia. It is postulated that paragangliomas arising from inferior laryngeal paraganglia can grow downwardly and ultimately come to reside lateral to the thyroid gland or within the thyroid capsule. Alternatively, in comparison with the superior laryngeal paraganglia that are more consistent in their location, inferior laryngeal paraganglia can be found anywhere along the course of the recurrent laryngeal nerve and may sometimes be situated within the thyroid itself [16, 18, 21]. Fine needle aspiration (FNA) is used commonly for the initial workup of thyroid lesions. Because thyroid paragangliomas are uncommon and can be biochemically silent, they are not likely to be considered in the diagnosis of most thyroid nodules, and aspiration findings may be mistinterpreted as other benign and malignant thyroid neoplasms. We report a case of a thyroid paraganglioma that demonstrated the cytologic feature of oval Bnaked^ nuclei.
Endocr Pathol (2015) 26:232–238
233
These cells were confirmed to be sustentacular cells by S-100 protein immunostaining. To our knowledge, this feature has not been previously recognized and may help provide a clue on FNA for the diagnosis of a paraganglioma.
characterized by spindle-shaped nuclei with scanty cytoplasm. These latter cells showed nuclear and cytoplasmic positivity by S-100 protein immunostaining (Fig. 1d). The remaining thyroid tissue appeared normal.
Case Report
Cytology
A 28-year-old female presented with a neck mass of 2 years duration. The patient denied any underlying medical illness as well as symptoms of palpitation, weakness, and weight loss. Examination of her neck showed a mass in the right lobe of the thyroid gland. Her vital signs included a heart rate of 112 and blood pressure of 117/80 mmHg. Thyroid function tests were normal (serum total T3=88.7 ng/dl, free T4=1.19 ng/dl, and TSH=0.901 mU/ml). An ultrasound study revealed a solitary heterogeneous mass in the right lobe; the left lobe was unremarkable. The clinical impression was a nodular goiter, and the patient was treated by Eltroxin 1.5 mg orally once a day. Four months later, the mass had increased in size. Malignancy could not be clinically excluded, and the decision was made to resect the mass. A right lobectomy of the thyroid gland was performed. During operation, the right recurrent laryngeal nerve could not be preserved due to fibrous tissue adhering to the mass. An intraoperative frozen section on the mass was interpreted as suspicious for a follicular neoplasm, and a total thyroidectomy was carried out. Two months postoperatively, the patient experienced mild hoarseness due to right vocal cord paralysis. Thyroid function tests were compatible with hypothyroidism, with serum free T3 of 5.16 pg/ml (normal, 1.60–4.00 pg/ml), free T4 of
Thyroid Paraganglioma: BNaked^ Nuclei as a Clue to Diagnosis on Imprint Cytology Mana Taweevisit 1 & Wasakorn Bunyayothin 2 & Paul Scott Thorner 1,3
Published online: 27 June 2015 # Springer Science+Business Media New York 2015
Abstract A cytologic diagnosis of paraganglioma of the thyroid is difficult to make because the thyroid gland is an unusual location for such a tumor and the cytologic findings overlap with other benign and malignant thyroid tumors. We report the case of a 28-year-old female presenting with a solitary mass of the right thyroid gland. A diagnosis of paraganglioma was made on the resected specimen. At the time of tumor resection, imprint cytology was performed. The imprint was hypercellular with cohesive sheets of round cells showing anisokaryosis and anisocytosis. Moreover, there was a second cell type consisting of oval nuclei with dispersed nuclear chromatin present within the sheets and separate as Bnaked^ nuclei. By immunohistochemistry, the cohesive round cells were positive for chromogranin A, indicating chief cells. The naked nuclei were positive for S-100 protein, indicating sustentacular cells. To the best our knowledge, this is the first case report describing naked nuclei as a cytologic feature of paraganglioma. Identification of sustentacular cells provides a clue for the cytologic diagnosis of paraganglioma.
Keywords Paraganglioma . Thyroid gland . Cytology . Immunohistochemistry * Mana Taweevisit [email protected] 1
Department of Pathology, Faculty of Medicine, Chulalongkorn University, 1873 King Rama IV Street, Pathumwan, Bangkok 10330, Thailand
2
Department of Anatomical Pathology, Ministry of Public Health, Chonburi Hospital, 69 Sukhumvit Road, Baan Suan Muang, Chonburi 20000, Thailand
3
Department of Pathology and Laboratory Medicine, Hospital for Sick Children and University of Toronto, Toronto, ON M5G1X8, Canada
Introduction Paragangliomas are uncommon slow-growing, neuroendocrine tumors arising from extra-adrenal paraganglia of the autonomic nervous system [1–3]. These tumors can be found from the skull base to the pelvic floor in locations that correspond to the embryologic migration routes of neural crest tissue. Paragangliomas of sympathetic ganglia are often found along the prevertebral and paravertebral sympathetic chains, whereas those of parasympathetic origin occurs primarily in the head and neck region, in particular at the bifurcation of the common carotid artery (carotid body paraganglioma or chemodectoma) and in the middle ear (jugulotympanic paraganglioma). There are occasional reports of paragangliomas occurring adjacent to or inside of the thyroid gland [4–23]. Thyroid paraganglioma was first described in 1974 [24] and was believed to be a subset of laryngeal paraganglioma. Anatomically, there are bilateral superior and inferior laryngeal paraganglia. It is postulated that paragangliomas arising from inferior laryngeal paraganglia can grow downwardly and ultimately come to reside lateral to the thyroid gland or within the thyroid capsule. Alternatively, in comparison with the superior laryngeal paraganglia that are more consistent in their location, inferior laryngeal paraganglia can be found anywhere along the course of the recurrent laryngeal nerve and may sometimes be situated within the thyroid itself [16, 18, 21]. Fine needle aspiration (FNA) is used commonly for the initial workup of thyroid lesions. Because thyroid paragangliomas are uncommon and can be biochemically silent, they are not likely to be considered in the diagnosis of most thyroid nodules, and aspiration findings may be mistinterpreted as other benign and malignant thyroid neoplasms. We report a case of a thyroid paraganglioma that demonstrated the cytologic feature of oval Bnaked^ nuclei.
Endocr Pathol (2015) 26:232–238
233
These cells were confirmed to be sustentacular cells by S-100 protein immunostaining. To our knowledge, this feature has not been previously recognized and may help provide a clue on FNA for the diagnosis of a paraganglioma.
characterized by spindle-shaped nuclei with scanty cytoplasm. These latter cells showed nuclear and cytoplasmic positivity by S-100 protein immunostaining (Fig. 1d). The remaining thyroid tissue appeared normal.
Case Report
Cytology
A 28-year-old female presented with a neck mass of 2 years duration. The patient denied any underlying medical illness as well as symptoms of palpitation, weakness, and weight loss. Examination of her neck showed a mass in the right lobe of the thyroid gland. Her vital signs included a heart rate of 112 and blood pressure of 117/80 mmHg. Thyroid function tests were normal (serum total T3=88.7 ng/dl, free T4=1.19 ng/dl, and TSH=0.901 mU/ml). An ultrasound study revealed a solitary heterogeneous mass in the right lobe; the left lobe was unremarkable. The clinical impression was a nodular goiter, and the patient was treated by Eltroxin 1.5 mg orally once a day. Four months later, the mass had increased in size. Malignancy could not be clinically excluded, and the decision was made to resect the mass. A right lobectomy of the thyroid gland was performed. During operation, the right recurrent laryngeal nerve could not be preserved due to fibrous tissue adhering to the mass. An intraoperative frozen section on the mass was interpreted as suspicious for a follicular neoplasm, and a total thyroidectomy was carried out. Two months postoperatively, the patient experienced mild hoarseness due to right vocal cord paralysis. Thyroid function tests were compatible with hypothyroidism, with serum free T3 of 5.16 pg/ml (normal, 1.60–4.00 pg/ml), free T4 of
