Conwell, L. S.

Greer, M. L.

Perry, C. F.

Stewart, A.

University of Queensland eSpace

© Freund Publishing House Ltd., London Journal of Pediatric Endocrinology & Metabolism, 22,991-993 (2009)
IMAGES IN PEDIATRIC ENDOCRINOLOGY
Differentiated Thyroid Carcinoma Associated with
Histological Features of Hashimoto's Thyroiditis
Fig. 1: Right-sided thyroid nodule. Clinically, the nodule
arose from the right lobe of the thyroid gland,
approximately 5 cm at its largest diameter, exten-
ding across the midline inferiorly. It was smooth
and firm with no apparent retrosternal extension.
There was no palpable cervical lymphadenopathy.
Fig. 2: Ultrasonographic features of nodule in the right
lobe of the thyroid gland. The thyroid nodule
measured 5.5 cm (craniocaudal) χ 3.8 cm (trans-
verse) χ 2.1 cm (AP). It occupied the majority of the
right lobe, apart from a small area of thyroid tissue
in the superior aspect of the lobe. Peripheral and
central vascularity was prominent. It had relatively
homogeneous echotexture, apart from two promi-
nent internal foci. The first region located in the
inferolateral aspect of the right lobe was anechoic,
measuring 2.6 cm (craniocaudal) χ 1.2 cm (trans-
verse) χ 0.8 cm (AP), without internal vascularity.
The second region in the inferomedial aspect of the
right lobe was hypoechoic with respect to the sur-
rounding thyroid nodule, measuring 1.0 cm (cranio-
caudal) χ 1.5 cm (transverse) χ 0.9 cm (AP), with
minimal vascularity.
A 13 year-old girl presented with a 4-month history of an enlarging thyroid nodule (Fig. 1). She had no local
symptomatology and no features suggestive of thyroid dysfunction. The patient was clinically euthyroid.
Thyroid function tests showed borderline free thyroxine (fT4): 7.9 pmol/1 (8.4-15) and normal thyroid
stimulating hormone (TSH): 3.0 mU/1 (0.6-3.9). Anti-thyroglobulin antibodies were within the normal range:
81 U/ml (<100). Anti-thyroid peroxidase antibodies were elevated: 150 U/ml (<50). Ultrasound assessment
demonstrated marked enlargement of the right lobe of the thyroid gland by a well circumscribed cystic and
solid nodular mass lesion (Fig. 2). The left lobe, isthmus and small region of right thyroid lobe parenchyma
above the large nodular mass had heterogeneous echotexture with multiple tiny, hypoechoic and anechoic
cystic foci. There was no calcification within the thyroid gland. The patient underwent an initial right
hemithyroidectomy, and subsequently completion thyroidectomy. The macroscopic and microscopic appear-
ances of the thyroid nodule (minimally invasive follicular carcinoma) are shown in Figures 3 and 4.
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992 IMAGES IN PEDIATRIC ENDOCRINOLOGY
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Fig. 3: Macroscopic appearance of the right thyroid lobe nodule. The lesion was poorly delineated (42 nun χ 25 mm), colloid
poor with a non-uniform dark discolouration.
Fig. 4: Histology of the right thyroid lobe nodule. Minimally invasive follicular carcinoma: (a) encapsulated nodule with solid
area; (b) encapsulated nodule with area of early invasion; (c) focus of papillary carcinoma (3 χ 1.5 mm).
Fig. 5: Histology of the remainder of the thyroid lobe
and left thyroid lobe. Consistent with Hashimoto's
thyroiditis, the histological features included
lymphoid hyperplasia with reactive germinal centre
formation, destruction of thyroid follicles with
cytoplasmic clearing of the epithelial cells.
The histopathology of the remainder of the right thyroid lobe and left thyroid lobe was consistent with
Hashimoto's thyroiditis (Fig. 5). An increased immune response to thyroid cancers has been noted in
paediatric patients1. However, due to the histological features, the inflammatory changes were not thought to
be due to a local inflammatory reaction around the tumour.
Differentiated thyroid carcinoma is the most common endocrine malignancy in children. Compared with
adults, children present with more advanced disease (i.e. larger primary tumour at diagnosis and increased
frequency of neck lymph node involvement and distant metastases). Local recurrence rates are higher in
children, but the cause-specific cancer mortality is lower than in adult patients2. In other disease contexts,
chronic inflammation has been associated with neoplastic transformation3. Of 812 patients (median age 40
years with range 7-79 years) undergoing thyroid resection, patients with Hashimoto's thyroiditis were
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IMAGES IN PEDIATRIC ENDOCRINOLOGY 993
approximately three times more likely to have well-differentiated thyroid carcinoma compared to patients
without Hashimoto's thyroiditis (odds ratio 2.96; 95% CI 1.9-4.6)4. The phosphatidylinositol 3-kinase (PI3K)
cellular pathway has roles in balancing cell survival/apoptosis and the inflammatory response, with increased
activation identified in thyroid and other cancers (reviewed in 4). PI3K pathway components were highly
expressed in cells in regions of Hashimoto's thyroiditis, thyroid carcinoma associated with Hashimoto's
thyroiditis, thyroid carcinoma in isolation, but not in normal follicular cells4. This suggests a potential
common molecular mechanism between the two processes of inflammation and cancer. Others authors have
also suggested an association between these two disease processes5. These studies have inherent selection bias
as the patients were only those undergoing thyroid resection. Any causal link between Hashimoto's thyroiditis
and differentiated thyroid carcinoma requires further delineation.
Louise S. Conwell1, Mary-Louise Greer2, Anne Stewarf and Christopher F. Perry4
Departments of 'Endocrinology and Diabetes, 2Medical Imaging and 4Otolaryngology-Head & Neck Surgery, Royal Children's
Hospital and 'Department of Anatomical Pathology, Royal Brisbane and Women's Hospital, Brisbane, Australia
e-mail: Louise_Conwell@health.qld.gov.au
REFERENCES
1. Dinauer C, Francis GL. Thyroid cancer in children. Endocrinol Metab Clin North Am. 2007 Sep;36(3):779-806, vii.
2. Jarzab B, Handkiewicz-Junak D. Differentiated thyroid cancer in children and adults: same or distinct disease? Hormones
(Athens). 2007 Jul-Sep;6(3):200-9.
3. Balkwill F, Mantovani A. Inflammation and cancer: back to Virchow? Lancet. 2001 Feb 17;357(9255):539-45.
4. Larson SD, Jackson LN, Riall TS, Uchida T, Thomas RP, Qiu S, et al. Increased incidence of well-differentiated thyroid
cancer associated with Hashimoto thyroiditis and the role of the PI3k/Akt pathway. J Am Coll Surg. 2007 May;204(5):764-
73; discussion 73-5.
5. Cipolla C, Sandonato L, Graceffa G, Fricano S, Torcivia A, Vieni S, et al. Hashimoto thyroiditis coexistent with papillary
thyroid carcinoma. Am Surg. 2005 Oct;71(10):874-8.
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Differentiated thyroid carcinoma associated with histological features of Hashimoto's thyroiditis

L.S. Conwell

M.-L. Greer

A. Stewart

C.F. Perry

Crossref

Journal of Pediatric Endocrinology and Metabolism

Differentiated Thyroid Carcinoma Associated with Histological Features of Hashimoto's Thyroiditis

http://espace.library.uq.edu.au/view/UQ:223692/UQ223692_OA.pdf

Differentiated thyroid carcinoma associated with histological features of Hashimoto's thyroiditis

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