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Difficulty: EasyPathology and Biopsy Interpretation

A 48-year-old woman is referred to an endocrinologist after her primary care physician palpated a lump in her neck during a routine physical examination. She is asymptomatic and denies dysphagia, hoarseness, or weight changes. Her thyroid-stimulating hormone (TSH) level is within normal limits. A neck ultrasound demonstrates a 2.5-cm, solid, hypoechoic nodule with irregular margins and microcalcifications in the right lobe of the thyroid gland. A fine-needle aspiration (FNA) biopsy of the nodule is performed. The cytopathology report describes 'high cellularity with large, overlapping epithelial cells demonstrating optically clear nucleoplasm, prominent nuclear grooves, intranuclear pseudoinclusions, and scattered concentric laminated calcifications.'

Which of the following is the most likely diagnosis based on this cytopathologic interpretation?

  1. A
    Anaplastic thyroid carcinoma
  2. Papillary thyroid carcinomaAnswer
  3. C
    Medullary thyroid carcinoma
  4. D
    Follicular thyroid carcinoma
  5. E
    Hashimoto thyroiditis

Answer

The correct diagnosis is papillary thyroid carcinoma.
The correct answer is papillary thyroid carcinoma because the cytopathologic findings described are highly characteristic and pathognomonic for this disease. The diagnosis is heavily dependent on specific nuclear features: 'optically clear nucleoplasm' (often referred to as 'Orphan Annie eye' nuclei), prominent nuclear grooves, intranuclear pseudoinclusions, and 'concentric laminated calcifications' (psammoma bodies).

Step-by-Step Solution

1
Evaluate the clinical presentation and initial imaging.
A 48-year-old euthyroid woman presents with an asymptomatic 2.5-cm solid, hypoechoic thyroid nodule with irregular margins and microcalcifications.
These ultrasound features are highly suspicious for a primary thyroid malignancy, indicating the need for a fine-needle aspiration (FNA) biopsy.
2
Analyze the fine-needle aspiration (FNA) cytopathology report.
The report highlights optically clear nucleoplasm ('Orphan Annie eye' nuclei), nuclear grooves, intranuclear pseudoinclusions, and concentric laminated calcifications.
Cytopathology relies heavily on distinct cellular features to differentiate between benign and malignant thyroid conditions.
3
Correlate the cytopathologic findings with the appropriate diagnosis.
The described nuclear features and the presence of psammoma bodies (concentric laminated calcifications) are classic and pathognomonic findings for papillary thyroid carcinoma.
Accurate interpretation of these pathognomonic biopsy features establishes the definitive diagnosis and guides subsequent surgical management.

Key Concept

The classic cytopathologic features of papillary thyroid carcinoma include large epithelial cells with optically clear nucleoplasm ('Orphan Annie eye' nuclei), prominent longitudinal nuclear grooves, intranuclear pseudoinclusions, and the presence of psammoma bodies.
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Topics

Pathology and Biopsy Interpretation

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