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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 11  |  Issue : 3  |  Page : 124-126

Infarcted papillary carcinoma of thyroid following fine needle aspiration


1 Department of Pathology, Mathikere Sampige Ramaiah Medical College, Mathikere Sampige Ramaiah Institute of Technology Post, Bangalore, Karnataka, India
2 Department of Surgery, Mathikere Sampige Ramaiah Medical College, Mathikere Sampige Ramaiah Institute of Technology Post, Bangalore, Karnataka, India

Date of Web Publication13-Aug-2014

Correspondence Address:
Muniyappa Usha
150, 9th Cross, HIG Colony, Bangalore 560 094, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-0354.138561

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  Abstract 

Fine needle aspiration (FNA) is a well-established and safe method for the rapid diagnosis of palpable thyroid lesions. Serious complications after FNA are rare, but there is also an underestimation of complications because of record, selection, and publication bias. Most common post FNA related complications are in the form of hemorrhage and pain. Very little attention has been focused on tissue related changes resulting from FNA. FNA related tissue changes will alter the reporting in successful aspirations or during histopathological examination which may create confusion in reporting and successive treatment of the patient. Increased awareness regarding these secondary changes is required for the benefit of clinician, pathologist, and most important for successful management of the patient. We report a case of papillary carcinoma of thyroid diagnosed on FNA. Subsequent histopathological examination of the resected specimen revealed a completely infarcted tumor. However, correlating the FNA history and presence of ghost outlines of papillae a final diagnosis of papillary carcinoma was given.

Keywords: Fine needle aspiration, infarction, papillary carcinoma, thyroid


How to cite this article:
Usha M, Rashmi K, Sridhar M, Aarathi RR. Infarcted papillary carcinoma of thyroid following fine needle aspiration. Thyroid Res Pract 2014;11:124-6

How to cite this URL:
Usha M, Rashmi K, Sridhar M, Aarathi RR. Infarcted papillary carcinoma of thyroid following fine needle aspiration. Thyroid Res Pract [serial online] 2014 [cited 2019 Dec 16];11:124-6. Available from: http://www.thetrp.net/text.asp?2014/11/3/124/138561


  Introduction Top


Thyroid fine needle aspiration (FNA) is the procedure of choice in the management of thyroid nodules, because of its simplicity, accuracy, and cost effectiveness. [1] Thyroid nodules are common in clinical practice and most often benign. Even though, their risk of malignancy is low, it is not negligible and it is necessary to be excluded. The introduction of FNA in clinical practice has displaced the use radionuclide thyroid scan and has almost halved the percentage of patients undergoing thyroidectomy, thereby declining unnecessary imaging, operative morbidity, mortality, and the cost of medical care. Post FNA local pain and minor hematomas are the most common clinical complications. [2] Serious complications after FNA are rare, but there is also an underestimation of complication risk because of record, selection, and publication biases. We are reporting a case of papillary thyroid carcinoma which underwent complete infarction following FNA which led to confusion while reporting the histopathology following total thyroidectomy. The aim of the study is to highlight FNA induced infarction which may obscure the nature of a cytologically diagnosed neoplasm, making histopathologic confirmation difficult.


  Case report Top


A 54-year-old female came with history of enlarging thyroid mass since 3 months for which FNA was advised. During FNA diffuse enlargement of the thyroid which was more prominent on left side was noted. On multiple aspirations, brown blood mixed fluid was obtained from which smears were made. Smears showed cells arranged in monolayered flat sheets and papillary fragments [Figure 1]a]. Individual cells showed enlarged ovoid, finely granular, and powdery chromatin with many of them showing intranuclear inclusions and grooves [Figure 1]b]. Based on cytomorphological features a diagnosis of papillary thyroid carcinoma was made following which total thyroidectomy was done. Gross examination of the specimen showed a large cyst in the left lobe measuring 2 cm across. The cyst was filled with brown blood mixed granular material. Rest of the parenchyma showed multiple small nodules filled with colloid. Entire tissue was submitted for histopathological examination. On microscopy, follicles of varying size lined by flattened epithelium and filled with colloid were seen along with large areas of coagulative necrosis. The coagulative necrosis areas showed ghost outlines of papillae [Figure 2]. There was no evidence of viable tumor. Based on this a diagnosis of colloid goiter with large areas of infarction was given. But as the diagnosis on FNA was papillary carcinoma of thyroid, the clinician was advised to follow -up the patient and evaluate the lymph node status.
Figure 1: (a) Shows cells arranged in monolayered flat sheets and papillary fragments (H and E, ×100) (b) Individual cells showed overlapping nuclei with enlarged ovoid, finely granular, and powdery chromatin and many of them showing intranuclear inclusions and grooves (H and E, ×400)

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Figure 2: Coagulative necrosis areas showed ghost outlines of papillae (H and E, ×400)

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  Discussion Top


Papillary carcinoma of thyroid is a common malignancy arising from thyroid with a very good prognosis when diagnosed early. FNA of the thyroid gland has proven to be an important and widely accepted method for patients with thyroid nodules. [1] The usefulness of FNA relates to the fact that it is easy to perform, is minimally invasive, smear evaluation is immediate, and the procedure can be repeated several times to obtain more tissue for diagnosis or special studies. When a diagnosis of malignant tumor is given, the surgeon and the patient are in a better position to discuss and plan for the next course of action, while the diagnosis of a benign lesion provides immediate relief to the patient, sparing the anxiety of waiting several days for a surgical biopsy diagnosis.

But unfortunately very little attention has been focused on FNA related tissue changes in the literature. Mukunyadzi et al., has found that the use of very thin needle with 23 gauge leads to insignificant bleeding and minor tissue damage. [3] But potential tissue damage following FNA has been reported in few cases. Pandit and Phulpagar in 2001 published their study on worrisome histologic alterations following FNA of thyroid (WHAFFT) lesion. [4] WHAFFT was classified into acute and chronic lesions. Acute lesions comprised of hemorrhage, granulation tissue, siderophages, nuclear atypia, poorly formed granulomas, capsule distortion and infarction, necrosis thrombosis, and recanalization. Chronic lesions are hemorrhage, granulation tissue, siderophages, linear fibrosis, nuclear atypia, vascular changes-hemangioma like, angiosarcoma like papillary endothelial hyperplasia, thrombosis, and recanalization. Capsular pseudoinvasion, infarction, necrosis, metaplasia, calcification, mitosis, and vascular invasion were the other chronic lesions. [4] Tumor necrosis following FNA has been reported in various tumors in various parts of the body. Infarction of acinic cell carcinoma, [5] Warthins tumor, pleomorphic adenoma of salivary gland, fibroadenoma, and renal cell carcinoma are few cases which are reported in the literature. [1] Hurthle cell neoplasm and papillary carcinoma are few thyroid neoplasms reported in the literature which showed tumor infarction. [6],[7],[8] Batsakis et al., has classified FNA associated tissue effects into three categories: (1) Micronecrosis and hemorrhage with retention of diagnostic features, (2) macronecrosis (infarction) with deletion of diagnostic features, and (3) macronecrosis and micronecrosis with reactive proliferation of cells of the lesion and stromal cells. [9] In our case, it was macronecrosis with deletion of diagnostic features was observed. Interruption of the microvascular supply, traumatic venous thrombosis, vigorous aspiration, and compromised vascular supply from extraction of large amounts of tissue were considered the responsible factors in tissue damage following FNA. [10] Tumor necrosis creates problems in two settings. One in case of successive aspirations yielding necrotic debris which may result in false negative diagnosis, two in case of histological confirmation, and necrosis can obscure the tumor. However, despite the rarity of significant post FNA tissue changes, surgical pathologists need to be aware of such changes to avoid potential diagnostic errors in the histologic interpretation of the resected specimens.

In conclusion, FNA related tissue changes are rare but increased awareness regarding these changes is required to avoid unnecessary confusion among the pathologist, treating clinician, and the patient. The aim of this paper is to emphasize the importance of recognizing the infarction induced by preoperative FNA.

 
  References Top

1.Cobanoglu U, Ersoz S, Adamhasan F, Ozoran Y. Infarction of parotid pleomorphic adenoma following fine needle aspiration biopsy. Aegean Path J 2005;54-7.  Back to cited text no. 1
    
2.Polyzos SA, Anastasilaki AD. Clinical complications following thyroid fine-needle biopsy: A systematic review. Clin Endocrinol (Oxf) 2009;71:157-65.  Back to cited text no. 2
    
3.Mukunyadzi P, Bardales RH, Palmer HE, Stanley MW. Tissue effects of salivary gland fine-needle aspiration: Does this procedure preclude accurate histologic diagnosis? Am J Clin Pathol 2000;114:741-5.  Back to cited text no. 3
    
4.Pandit AA, Phulpagar MD. Worrisome histologic alterations following fine needle aspiration of the thyroid. Acta Cytol 2001;45:173-9.  Back to cited text no. 4
    
5.Rau AR, Pai RR, Nayak S. Infarction of acinic cell carcinoma in a patient infected with HIV: A complication of fine-needle aspiration cytology obscuring definitive diagnosis. Diagn Cytopathol 2003;29:222-4.  Back to cited text no. 5
    
6.Das DK, Janardan C, Pathan SK, George SS, Sheikh ZA. Infarction in a thyroid nodule after fine needle aspiration: Report of 2 cases with a discussion of the cause of pitfalls in the histopathologic diagnosis of papillary thyroid carcinoma. Acta Cytol 2009;53:571-5.  Back to cited text no. 6
    
7.Layfield LJ, Lones MA. Necrosis in thyroid nodules after fine needle aspiration biopsy. Report of two cases. Acta Cytol 1991;35:427-30.  Back to cited text no. 7
    
8.Pinto RG, Couto F, Mandrekar S. Infarction after fine needle aspiration. A report of four cases. Acta Cytol 1996;40:739-41.  Back to cited text no. 8
    
9.Batsakis JG, Sneige N, el-Naggar AK. Fine needle aspiration of salivary glands: Its utility and tissue effects. Ann Otol Rhinol Laryngol 1992;101:185-8.  Back to cited text no. 9
    
10.Us-Krasovec M, Golouh R, Auesperg M, Pogacnic A. Tissue damage after fine needle aspiration biopsy. Acta Cytol 1992;36:456-7.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2]



 

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