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CASE REPORT
Year : 2012  |  Volume : 9  |  Issue : 2  |  Page : 58-59

Amyloid tumor of thyroid, amyloid goiter: A case report with a stress on importance of preoperative diagnosis


1 Department of Pathology, Aarupadai Veedu Medical College and Hospital, Kirumampakkam, Pondicherry, India
2 Deparment of Pathology, Vydehi Institute of Medical Sciences and Research Centre, White field, Bangalore, India

Date of Web Publication12-May-2012

Correspondence Address:
B J Naveen Kumar
Department of Pathology, Aarupadai Veedu Medical College and Hospital, Cuddalore Road, Kirumampakkam, Pondicherry 607 402
India
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DOI: 10.4103/0973-0354.96053

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  Abstract 

Although involvement of the thyroid gland by amyloid is a relatively common phenomenon, clinically significant enlargement of the thyroid owing to amyloid deposition is an extremely rare occurrence. Deposition of amyloid is commonly found in the kidneys, spleen, liver, lymph nodes, nerves, skin, heart, gastrointestinal tract, lungs, and blood vessels. We present a rare case of amyloid deposition in thyroid, leading to amyloid goiter which is still rarer.

Keywords: Amyloid goiter, amyloid, thyroid gland


How to cite this article:
Naveen Kumar B J, Santosh K V. Amyloid tumor of thyroid, amyloid goiter: A case report with a stress on importance of preoperative diagnosis. Thyroid Res Pract 2012;9:58-9

How to cite this URL:
Naveen Kumar B J, Santosh K V. Amyloid tumor of thyroid, amyloid goiter: A case report with a stress on importance of preoperative diagnosis. Thyroid Res Pract [serial online] 2012 [cited 2014 Jul 28];9:58-9. Available from: http://www.thetrp.net/text.asp?2012/9/2/58/96053


  Introduction Top


Amyloid goiter can be defined as the presence of amyloid within the thyroid gland in such quantities as to produce a clinically apparent enlargement of the gland. This unusual entity was first described in 1858 by Beckman, and in 1904 by Eiselberg, who advanced the name "amyloid goiter." Focal microscopic deposition of amyloid within the thyroid gland might be seen in systemic secondary amyloidosis, medullary thyroid carcinoma, and less frequently, in primary amyloidosis. Clinically detectable thyroid enlargement from amyloid infiltration is rare, and most cases are not diagnosed prior to surgery. [1]


  Case Report Top


A 36-year-old man presented with complaints of a gradually increasing swelling in front of the neck and generalized body swelling for 2 years, pain in the swelling and change in voice since 6 months, with history of breathlessness on lying down. Examination revealed an average built adult male with mild pallor. A 15 × 5 cm 2 mass involving both the lobes of thyroid was palpable in the neck.

Investigations showed hemoglobin of 9.6 g and TLC 4590/mm 3 . ESR 5 mm/h and thyroid profile within normal limits. FNA done outside was reported as colloid goiter.

The patient was taken up for surgical removal of the tumor subsequently. The gross specimen consisted of thyroidectomy specimen with large lobe measuring 10 × 6 × 3 cm 3 and smaller lobe measuring 8 × 5 × 2 cm 3 . Cut section revealed lobular gray white area almost replacing the thyroid tissue, with normal thyroid tissue made out only in the periphery. Microscopy shows diffuse infiltration of thyroid gland by amorphous eosinophilic material. Thyroid follicles of various sizes are seen widely separated by amorphous material [Figure 1]. Congo red staining display apple green birefringence on polarized microscopy [Figure 2]. Diagnosis of amyloid tumor of thyroid, amyloid goiter was made.
Figure 1: Thyroid follicles of various sizes are seen widely separated by amorphous material

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Figure 2: Congo red staining display apple green birefringence on polarized microscopy

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  Discussion Top


Amyloid is found in the thyroid in three different settings. The most common of these is the amyloid in the stroma of medullary carcinoma. Amyloid goiter is a tumefactive mass of amyloid associated with a foreign body giant cell response and with adipose tissue. It is associated with systemic amyloidosis. Another complication of systemic amyloidosis is amyloid deposition in the thyroid stroma and in glandular and periglandular blood vessels. [2]

Amyloid goiter is very rare, without a known gender predilection. A condition characterized by either focal or diffuse infiltration of the thyroid by amyloid. [3],[4] Patients usually identify a palpable mass. If symptomatic, may cause dysphagia, dyspnea, and hoarseness. Patients are usually euthyroid. Hypothyroidism may occur.

Commonly in patients with amyloid goiter, the enlargement of the gland is relatively rapid, occurring in weeks to several months, but in our case the onset was insidious in nature.

It occurs over a wide age range from adolescents (especially with juvenile rheumatoid arthritis or familial  Mediterranean fever More Details) to elderly with hematolymphoid neoplasia. The majority of cases are associated with secondary amyloidosis. [5] It occurs in approximately 80% of patients with secondary amyloidosis and in up to 50% of patients with primary amyloidosis. [6] The main differential diagnosis of amyloid goiter is with amyloid rich medullary carcinoma, which shows diagnostic malignant neuroendocrine tumor cells. [7]

Amyloid tumors are rare masses that may occur in the heart, generally the atria. [8]

A conclusive diagnosis rests on identifying the characteristic apple-green dichroism with the Congo red stain. Amyloid is metachromatic with crystal violet. Electron microscopy is rarely necessary for diagnosis, but shows masses of nonbranching filaments ranging in size from 50 to 150 Å. Immunohistochemically most cases are positive for amyloid AA, while cases associated with plasma cell dyscrasia may be positive for amyloid AL. [5]

In cases of amyloid goiter, amyloid material is commonly seen infiltrating the parenchyma, distorting the normal tissue architecture and eliciting a variable degree of foreign body giant-cell reaction with associated moderate to severe, often focal lymphocytic thyroiditis. Other histologic features occurring in amyloid goiter include large foci of fatty metaplasia, and, rarely, squamous metaplasia. [9]

In the presented case there was no foreign body type reaction or fat cell metaplasia in the thyroid interstitium.

Although no effective medical treatment exists for either forms of amyloid, confirmation of type by immunohistochemical techniques is important, since patients with secondary amyloidosis tend to have a better prognosis than those suffering from primary amyloidosis. [9]

 
  References Top

1.Yildiz L, Kefeli M, Kose B, Baris S. Amyloid goiter: Two cases and a review of the literature. Ann Saudi Med 2009;29:138-41.  Back to cited text no. 1
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2.Mills SE. In: Steenberg's Diagnostic Surgical Pathology. 4 th ed., vol. 1. Philadelphia: Lippincott Willams and Wilkins; 2004. p. 563.  Back to cited text no. 2
    
3.Cibas ES, Ducatman BS. In: Cytology- diagnostic principles and clinical correlates. 2 nd ed. Philadelphia: Saunders; 2003. p. 253.  Back to cited text no. 3
    
4.Kanoh T, Shimada H, Uchino H, Matsumura K. Amyloid goiter with hypothyroidism. Arch Pathol Lab Med 1989;113:542-4.  Back to cited text no. 4
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5.Lester D, Thompson R, Goldblum JR. In: Endocrine Pathology. Philadelphia, US: Churchill Livingstone; 2006. p. 46-8.  Back to cited text no. 5
    
6.Kapila K, Verma K. Amyloid goiter in fine needle aspirates. Acta Cytol 1993;37:257-8.  Back to cited text no. 6
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7.Pilch BZ. In: Head and Neck Surgical Pathology. Philadelphia: Lippincott Willams and Wilkins; 2001. p. 689-90.  Back to cited text no. 7
    
8.Silverburg SG. In: Principles and practice of surgical pathology and Cytopathology. 4 th ed., vol. 1. Philadelphia, US: Churchill Livingstone; 2006. p. 1066.  Back to cited text no. 8
    
9.Villamil CF, Massimi G, D'Avella J, Cole SR. Amyloid goiter with parathyroid involvement: A case report and review of the literature. Arch Pathol Lab Med 2000;124:281-3.  Back to cited text no. 9
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