|Year : 2021 | Volume
| Issue : 1 | Page : 52-55
Columnar cell variant of papillary thyroid carcinoma: Report of a rare case with cytohistological findings and review of literature
Kavita Mardi1, Anish Chandran1, Kavya Raghavendra2
1 Department of Pathology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
2 Kasturba Medical College, Manipal, Karnataka, India
|Date of Submission||26-May-2021|
|Date of Decision||05-Jun-2021|
|Date of Acceptance||05-Jun-2021|
|Date of Web Publication||23-Jul-2021|
Dr. Kavita Mardi
Set No 14, Type VI Quarters, IAS Colony, Meheli, Shimla, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Columnar cell carcinoma variant is a rare aggressive variant of papillary thyroid carcinoma (PTC) with unique histological features. They represent only 0.15%–0.2% of all PTCs. It is difficult to diagnose them on fine-needle aspiration cytology as they lack the classic nuclear features of PTC. Histologically they can mimic metastatic carcinomas from colon, endometrium, and lung. However, characteristic histological features combined with immunohistochemistry (IHC) findings help in accurate diagnosis. We describe the cytological, histopathological, and IHC findings of a rare case of PTC-CCV in a 23-year-old female and review the pertinent literature. It is important to diagnose this variant of PTC accurately, as it has prognostic and therapeutic implications.
Keywords: Carcinoma, columnar variant, papillary, thyroid
|How to cite this article:|
Mardi K, Chandran A, Raghavendra K. Columnar cell variant of papillary thyroid carcinoma: Report of a rare case with cytohistological findings and review of literature. Ann Oncol Res Ther 2021;1:52-5
|How to cite this URL:|
Mardi K, Chandran A, Raghavendra K. Columnar cell variant of papillary thyroid carcinoma: Report of a rare case with cytohistological findings and review of literature. Ann Oncol Res Ther [serial online] 2021 [cited 2022 May 23];1:52-5. Available from: http://www.aort.com/text.asp?2021/1/1/52/322154
| Introduction|| |
Columnar cell carcinoma is a rare variant of papillary thyroid carcinoma (PTC-CCV), first described by Evans in 1986. It is considered an aggressive variant of PTC by the World Health Organization (WHO). It accounts for only 0.15%–0.4% of all PTCs. The aggressive nature of this variant is characterized by its association with increasing age, larger size, and extrathyroid extension at presentation. This variant lacks the characteristic nuclear features of PTC, which makes it difficult to diagnose them on fine-needle aspiration (FNA). However, this tumor has characteristic histological features and immunohistochemistry (IHC) findings that helps in its diagnosis. We herein describe cytological, histopathological, and IHC findings of a rare case of PTC-CCV in a 23-year-old female and review the pertinent literature.
| Case Report|| |
23-year-old female presented with painless swelling in the midline of neck for 3 years. On examination, the swelling was firm, nontender, 2 cm × 2 cm in size, and was moving with deglutition.
Thyroid function tests were normal. ultrasonography (USG) revealed a large hyperechoic solid nodule in the right side of isthmus measuring 1.4 cm × 2.3 cm in size [Figure 1] FNA smears were moderately cellular with clusters of follicular epithelial cells arranged predominantly in micro follicular pattern. The follicular epithelial cells showed moderately pleomorphic ovoid to elongated nuclei, nuclear overlapping, nuclear membrane irregularities, inconspicuous nucleoli, and occasional nuclear grooves. Some of the follicular cells showed fine vacuoles in the cytoplasm [Figure 2]. Intranuclear pseudoinclusions/psammoma bodies were absent. The background was clean. FNA cytology (FNAC) findings were consistent with a follicular neoplasm. Patient underwent right hemithyroidectomy, per operatively growth was identified at the isthmus. Gross examination of the specimen also revealed an irregular solid grey white growth measuring 2.2 cm × 1.2 cm in the isthmus which was reaching up to capsule and focally breaching the capsule. Microscopic examination revealed tumor cells predominantly arranged in follicular/cribriform pattern with focal papillary and trabecular pattern. The tumor cells were columnar, revealing pseudo stratification, elongated hyperchromatic nuclei, inconspicuous nucleoli, and occasional nuclear grooves [Figure 3]. Intranuclear pseudoinclusions were not seen. Focally, there were supra/sub nucleolar cytoplasmic vacuoles. Mitotic figures were rare. IHC revealed positivity for TTF-1 [Figure 4], CK7, CK19, and HBME-1. The tumor cells were negative for CD56 and CDX2. Keeping in view, the above histopathological and IHC findings, diagnosis of PTC-CCV was rendered. The tumor was invading the capsule and extending into extrathyroidal tissues.
|Figure 1: USG showing large hyper echoic solid nodule in the right side of isthmus|
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|Figure 2: Fine-needle aspiration smears revealing follicular epithelial cells with moderately pleomorphic ovoid to elongated nuclei, nuclear overlapping, nuclear membrane irregularities, inconspicuous nucleoli arranged in micro follicular pattern (Giemsa, ×40)|
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|Figure 3: Columnar tumor cells revealing pseudo stratification and elongated hyper chromatic nuclei arranged in follicular/cribriform pattern (H and E, ×40)|
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| Discussion|| |
Aggressive variants of PTC include the tall cell, diffuse sclerosing, solid, hobnail, and columnar cell variants. Among these, columnar cell variant of PTC (PTC-CCV) is the most misdiagnosed and underrecognized entity. The most common manifestation of columnar cell carcinoma is an asymptomatic enlarging neck mass. Early reports suggested a higher incidence in males, but a literature review revealed a female preponderance. The patient population is older than normal for papillary carcinoma, with a mean age of 44 years.
The histological, architectural, and cytological diagnostic criteria for the diagnosis of PTC-CCV as defined by the WHO classification, includes neoplastic follicular cells with pseudostratified, hyperchromatic nuclei with eosinophilic-to-clear cytoplasm and supranuclear, and/or subnuclear cytoplasmic vacuoles that resembles secretory-type endometrium. The cells can be arranged in a variety of architectural patterns that includes papillary, follicular, trabecular, cribriform, complex glandular, and/or solid. Thus histologically, this variant is distinguished from conventional PTC by its elongated (”columnar”) cells and prominent nuclear pseudostratification. Although columnar cell carcinomas often display papillary architecture, they infrequently exhibit the classic nuclear features (nuclear clearing, grooves, and inclusions) of conventional PTC. Rather, the cytology of this particular PTC variant can resemble columnar epithelia of the endometrium or intestinal tract. There is no clear consensus regarding the minimal percentage of columnar cells that confers a diagnosis of PTC-CCV, with reported cases varying from 30% to 80%.
As the typical features of PTC are absent on cytology, the diagnosis of PTC-CCV by FNA can be challenging. Jayaram reported cytological findings in a case of PTC-CCV. He found tall columnar cells in monolayered, three-dimensional, acinar, and occasional papillary clusters. Nuclei were oval or elongated and monomorphic. Nuclear pseudostratification, resembling that seen in respiratory epithelial cells, was present in some of the cell clusters. Nuclear grooves and intranuclear cytoplasmic inclusions were not seen in his case. Bongiovanni et al. studied total of 11 surgical specimens of PTC-CCV with corresponding preoperative cytology in an attempt to characterize the cytological features of PTC-CCV. They concluded that hypercellular smears with papillary structures covered by cells with pseudostratified nuclei that show a paucity of nuclear pseudoinclusions and grooves should alert the cytopathologist to the possibility of this diagnosis. Our case lacked papillary fragments, pseudostratified nuclei, or nuclear pseudoinclusions, because of which diagnosis was not possible on FNAC.
The differential diagnosis of columnar cell carcinoma includes a tall-cell variant of thyroid papillary carcinoma (TCV-TPC), carcinoid tumor, and metastatic carcinoma, particularly from adenocarcinoma of the colon, lung, or endometrium.,,,,, In contrast to TCV-TPC, neoplastic cells of columnar cell carcinoma have nonoxyphilic cytoplasm and pseudostratified nuclei that lack the classic nuclear features of papillary carcinoma. An additional pathologic feature of columnar cell carcinoma is subnuclear or supranuclear vacuolization similar to that of secretory endometrium., Carcinoid tumor shows neuroendocrine differentiation, as manifested by chromogranin activity, while thyroid columnar cell carcinoma lacks this differentiation. Carcinoembryonic antigen immunohistochemistry is helpful in distinguishing columnar cell carcinoma from metastatic carcinoma of the colon and endometrium because columnar cell carcinoma is negative for this antibody.,, Thyroglobulin is not used because it may not be reactive or focal positive as columnar cell carcinoma is less differentiated than the usual types of papillary carcinoma.
Miriam et al. evaluated CDX2 expression in CCV-PTC and in a thyroid tissue microarray composed of various benign and malignant thyroid lesions. CDX2 expression was identified in six (55%) of 11 cases of CCV-PTC, but not in any other benign and malignant thyroid lesions. They concluded that CDX2 is selectively expressed in CCV-PTC and can be used in distinguishing it from other variants of PTC with overlapping morphologic features.
Chen et al. studied BRAFV600E expression in a series of nine cases and detected them in 33% of cases, a comparable finding to its overall prevalence in well-differentiated PTCs. This finding provides the genetic basis for columnar cell carcinoma as a distinct variant of PTC.
Various studies show that PTC-CCV has a fast growth rate and a high incidence of recurrence, and this type of tumors is associated with local invasion and early lymph node metastasis., However, the prognosis of PTC-CCV remains controversial, because the encapsulated form has a more favorable outcome with indolent clinical process, which shows relatively slow growth and low incidence of recurrence or metastasis.,,
The presence or absence of extrathyroidal invasion represents the most important parameter in predicting the behavior of these tumors. Tumors confined to the thyroid gland are associated with an excellent prognosis and can be managed conservatively (less than total thyroidectomy with or without radioactive iodine therapy) whereas tumors that invade beyond the thyroid capsule with extension into perithyroidal soft tissues behave more aggressively, necessitating more aggressive management (total thyroidectomy with supplemental radioactive iodine therapy), and evaluation for disseminated visceral disease. Our patient showed extrathyroidal invasion. However, there was no evidence of visceral metastasis. In a study conducted by Jiang et al., it was concluded that CCV has a worse prognosis than classic PTC and treatment with external beam radiotherapy and radioactive implants should be conducted carefully in these patients. Wang et al. conducted a study to investigate the CCPTC prognosis using the surveillance, epidemiology, and end results database. Their study also revealed that the cancer-specific and all-cause mortality rates were higher for CCV-PTC than for Classic PTC. Our patient has received radioactive iodine therapy after right hemithyroidectomy and is alive after 6 months of therapy without recurrence and metastasis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]