Contributed by Deborah Marks, MD and Jennifer Hunt, MD
Published on line in February, 2005
This is a female in her 20s with past medical history significant for bipolar disorder and asthma. In August, the patient was admitted to a psychiatric hospital for treatment of bipolar disorder. She was on several different psychiatric medications including lithium. In October, the patient began to feel fatigued and noticed some weight gain. Thyroid function tests were performed which showed that the patient was hypothyroid with a TSH= 110.2, free thyroxine index= 0.9, and total T3= 0.41. The patient also had a palpable mass in the right lobe of the thyroid. A thyroid ultrasound was performed which showed diffuse enlargement of the entire gland as well as multiple microcalcifications. Both thyroid lobes were biopsied. Based on those results, the patient was scheduled for a lobectomy/ possible total thyroidectomy.
The cell block from the FNA of the left lobe showed lymphocytes as well as abundant epithelial cells (Fig. 1A). Some of these epithelial cells had nuclear grooves (Fig. 1B). The FNA of the right lobe showed abundant lymphocytes (Figs. 1C and 1D).
A thyroidectomy was performed. A touch prep done during intraoperative consult showed atypical epithelial cells with grooved nuclei (Fig. 2).
Both lobes of the thyroid showed diffuse infiltration by abnormal cells (Fig. 3). These cells are enlarged with ground glass nuclei, also known as "Orphan Annie Eyed" nuclei (Fig. 4). The shape of the nuclei is irregular and many have nuclear grooves (Fig. 5). There are numerous psammoma bodies scattered throughout both lobes (Figs. 6 and 7 ) Lymphocytes are also present throughout the gland (Figs. 8 and 9). A total of five lymph nodes were removed which showed the same abnormal cells that were in the thyroid (Figs. 10, 11 and 12).
The lymphocytes are CD3, CD43, and L26 positive (Figs. 13, 14 and 15). There are also macrophages within the follicles which are staining positive for CD68 (Fig. 16).