Received: February 8, 2014; Accepted: June 7, 2014

AbstractHashimoto’s thyroiditis, the most common autoimmune thyroid disease, is due to

destruction of the thyroid gland by autoantibodies. Various types of thyroid malignanciesmay arise in Hashimoto’s thyroiditis. Follicular carcinomas, papillary carcinomas,lymphomas, medullary carcinomas and hurthle cell neoplasms may develop inHashimoto’s thyroiditis. We present a rare case report of a 35-year-old female whopresented with hypothyroidism of a two-year duration. A diagnosis of Hashimoto’sthyroiditis was made for which she was under treatment. Due to the recent increase insize of the thyroid, a fine needle aspiration cytology was done. A preoperative diagnosisof Hurthle cell neoplasm was made based on fine needle aspiration cytology findings.The total thyroidectomy specimen revealed Hashimoto’s thyroiditis with synchronouspapillary carcinoma and Hurthle cell carcinoma, which is a very rare occurrence.

Keywords: Papillary carcinoma, Thyroid, Hashimoto’s thyroiditis

IntroductionCancer of thyroid is the most

common endocrine carcinoma.Papillary carcinoma of the thyroidis reported as the seventh mostcommon cancer among women. Theassociation of Hashimoto’s thyroiditiswith thyroid malignancy is welldocumented in the literature.Although much less when comparedto follicular and papillary carcinomas,Hurthle cell tumors may also arise ina background of Hashimoto’sthyroiditis. Papillary and Hurthle cellcarcinoma are usually reported to

occur as separate neoplasms, whenthey occur in Hashimoto’s thyroiditis.However the co-existence of bothtogether is a very rare finding. Thisis a case report of simultaneousexistence of Hurthle cell carcinomaand papillary carcinoma in a patientwith Hashimoto’s thyroiditis.

Case ReportA 35-year-old female presented

with a swelling in the front of herneck which gradually increased insize over the past one year. Therewas no associated pain, hoarseness or

♦Corresponding Author: K.F. Magdalene, MDKodiyil House, Avittathur P.O.,Thrissur, 680683, Kerala, IndiaTel: 9496373192

Email: magdalenekf@gmail.com

Case ReportMiddle East Journal of Cancer; October 2014; 5(4): 221-224

Synchronous Hurthle Cell Carcinoma andPapillary Carcinoma in a Patient with

Hashimoto’s Thyroiditis: A Rare Case ReportNarayanan O. Navya, Kanapilly F. Magdalene♦, Gopinath P. Satheesh

Department of Pathology, Sree Narayana Institute of Medical Sciences, Chalaka, Kerala, India

loss of weight. She was diagnosed withHashimoto’s thyroiditis two years previous andwas under treatment for hypothyroidism.

Clinical examination showed a swollen thyroidthat measured 8×4cm. The swelling was firm inconsistency, moved on deglutition, non-tenderand non-pulsatile. Thyroid function tests showedelevated TSH (58.58 mIU/L). An iodine uptakestudy indicated the possibility of thyroiditis. A fineneedle aspiration cytology (FNAC) wasperformed. The smears showed microfollicularclusters with cells that had abundant eosinophiliccytoplasm and nuclei with mild anisonucleosis(Figure 1). The background showed a fewlymphocytes and scant colloid. A diagnosis ofHurthle cell neoplasm was considered. Excisionand histopathological examination was advised.

The patient underwent a total thyroidectomy.The gross specimen showed a thyroid thatmeasured 100×50×45 mm and weighed 350g.One lobe was enlarged and measured 60×50×40mm, the cut surface of which revealed anencapsulated grey tan nodular tumor(50×45×40mm) with firm to hard consistency.Adjacent to this was another granular area (8×8mm) with tiny papillary protrusions (Figure 2).The remainder of the thyroid showed a firm meaty,lobulated appearance with hemorrhagic areas.

The histopathology of the encapsulatedneoplasm showed cells with abundant granular,

eosinophilic cytoplasm (Hurthle cells). A follicular,trabecular and solid pattern of arrangement wasnoted (Figure 3). The tumor showed minimalinvasion of the capsule and limited vascularinvasion. The nuclear features typical of papillarycarcinoma and psammoma bodies were not presentin the entire tumor.

Sections from the adjacent granular areashowed another neoplasm with complex papillaehaving dense fibro vascular cores covered bysingle to multiple layers of cuboidal epithelialcells. Cells that lined the papillae showed opticallyclear ground glass nuclei and intranuclear grooves(Figure 4). A few concentric calcified psammomabodies were noted.

The rest of thyroid tissue showed denseinfiltration of the parenchyma by a lymphoplas-macytic infiltrate with germinal centers. Thethyroid follicles were atrophic and lined by Hurthlecells. A histopathological diagnosis of synchronousHurthle cell carcinoma and papillary carcinomaarising in Hashimoto’s thyroiditis was made.

Immunohistochemistry performed in theHurthle cell carcinoma was positive forthyroglobulin (Figure 5a) and TTF-1 (Figure 5b).The focal trabaecular pattern of arrangementraised the suspicion of medullary carcinoma,however immunohistochemistry with calcitoninwas negative.

The post-operative period of the patient was

222 Middle East J Cancer 2014; 5(4): 221-224

Narayanan O. Navya et al.

Figure 1. Follicular cells in a microfollicular cluster and singly. Thecells have abundant eosinophilic cytoplasm and nuclei with mildanisonucleosis (MGG; 400×).

Figure 2. Cut surface of a larger lobe with encapsulated grey tannodular tumor measuring 50×45 mm (white arrow). Note theadjacent granular tumor measuring 8×8 mm with tiny papillaryprotrusions (red arrow).

uneventful and the patient was referred to anoncology center for further treatment and hencelost for follow up.

DiscussionHashimoto’s thyroiditis is a well known cause

of hypothyroidism. Destruction of the thyroidgland in this disease is due to autoantibodieswhich include anti-TSH receptor antibody, anti-thyroglobulin and anti-thyroid peroxidaseantibody.1 Hashimoto’s thyroiditis commonlyaffects females during the fifth and sixth decades.2

A significant association of Hashimoto’sthyroiditis with papillary carcinomas is reported.The papillary carcinomas associated withHashimoto’s thyroiditis have favorable clinico-pathologic characteristics compared with thosewithout the disease.3 The relative risk of patientswith Hashimoto’s thyroiditis developing apapillary carcinoma in the literature is 1.59.4 Dueto this increased risk, patients may be carefullymonitored for the development of papillarycarcinoma.

Hurthle cell tumors represent less than 5% ofall thyroid tumors.5 These tumors show morethan 75% of Hurthle cells6 which aremitochondria-rich, thyroglobulin producingfollicular epithelial cells. Hurthle cells have alarge size, well-defined cell borders, and abundantamount of granular acidophilic cytoplasm, large

nucleus and prominent nucleolus. Other names forHurthle cells are Askanazy cells or oxyphil cells.7These cells are seen in large numbers of benignconditions such as nodular goiter, long standinghyperthyroidism and in Hashimoto’s thyroiditis.8

The majority of Hurthle cells tumors are benignand labeled as adenomas, but up to 40% aremalignant. Hurthle cell carcinoma is diagnosedwhen there is the presence of capsular/vascularinvasion or lymphatic spread.8 Since the Hurthlecell tumors share some similarities with folliculartumors in terms of architectural features and thedegree of invasiveness, they are now consideredto be a variant of follicular carcinoma.9 Hurthlecell carcinoma behaves in a more aggressivefashion compared to other well differentiatedthyroid neoplasms.10

Papillary carcinoma and Hurtle cell carcinomacan arise in Hashimoto’s thyroiditis as separatetumors. However the co-existence of both togetherin this disease is extremely rare. This may be thefirst case report, to the best of our knowledge, forthe synchronous occurrence of both tumors. Morestudies are required to find out the prognosis andoutcome of patients with multiple carcinomas.Though rare, various types of malignancies mayco-exist in the thyroid gland. Hence a diligentexamination of thyroidectomy specimens maybe performed to exclude synchronous occurrenceof various neoplasms.

223Middle East J Cancer 2014; 5(4): 221-224

Synchronous Hurthle Cell Carcinoma and Papillary Carcinoma in a Patient with Hashimoto’s Thyroiditis

Figure 3. Microscopy of the encapsulated neoplasm showing cellswith abundant granular, eosinophilic cytoplasm-Hurthle cells (H& E; 400×).

Figure 4. Microscopy of adjacent granular tumor with complexpapillae covered by single to multiple layers of cuboidal epithelialcells. Psammoma bodies are also noted (H & E; ×100).

Conflict of interestNo conflict of interest is declared.

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Figure 5. (a) Hurthle cell carcinoma showing positivity with thyroglobulin (IHC; 100×); (b) TTF-1 positivity in Hurthle cell carcinoma(IHC; 400×).

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