Case Studies

CBLPath's team of cytopathologists utilizes the latest technologies, including special stains, to aid in achieving definitive diagnoses.

Case Study 1

A 65 year old woman with a prior history of breast cancer and colon cancer is being followed with serum CEA measurements. The CEA has been steadily rising. An "incidental" 1.5 cm nodule of the right mid thyroid is palpated and FNA is performed.
Cytopathology
Direct smears show sheets of dyscohesive epithelial elements on a background of fresh blood without colloid, cyst content or inflammation. No follicular organization is evident, nor is papillary structure present. At high magnification there is moderate pleomorpism with isolated neoplastic giant cells and a conspicuous spindle cell population. Most cells are polygonal, often with eccentric nuclei. The nuclear chromatin pattern is variable. Scattered cells have partial optical clarity and chromatin grooves are also present. A few cells with nuclear inclusions are identified. Immunocytochemical study using direct smears shows strong positive cytoplasmic calcitonin stain.
Diagnosis
Positive for malignant cells - Medullary Carcinoma of the thyroid. Follow-up: Serum calcitonin measurement is 1196. Pre-op evaluation does not indicate any syndrome, and family members have no related problems. Based on the pre-operative diagnosis, a single operation is performed. Ten years later, the patient is free of disease.

Case Study 2

A 74 year old woman who had a total thyroidectomy for malignancy about 20 years previously and a nephrectomy for renal cortical adenocarcinoma about 3 years previously presents with hypercalcemia. A 1cm. nodule is identified in the thyroid bed, and sono-guided FNA is performed.
Cytopathology
Direct smears from 4 needle passes include occasional clusters of epithelial cells on a background of fresh blood. Similar clusters are present in combined cytoconcentrates of the needle rinse and corresponding cell block sections. The cells are uniform and polygonal with microfollicular structure. Cell junctions are generally preserved. Some of the cells have a moderate amount of granular eosinophilic cytoplasm, and others are "clear" cell types. At high magnification the nuclei are uniform, small and round without chromatin atypia. Small chromocenters are noted, but no macronucleoli are seen. Immunohistochemistry using cell block material is negative for thyroglobulin and TTF-1, but strongly positive for parathyroid hormone.
Diagnosis
Significant findings present - Parathyroid Neoplasm (Favor Adenoma).
Follow-up
Pre-operative evaluation shows no evidence of metastatic disease related to the thyroid or kidney; curative surgery confirms the diagnosis of parathyroid adenoma.

Case Study 3

A 56 year old Asian woman presents with a long history of multinodular goiter; sonography confirms multiple solid and cystic nodules. The largest nodule is located in the isthmus and measures 1.5 cm. The patient is referred to radiology for FNA of the dominant nodule.
Cytopathology
The background is mainly fresh blood, but includes some dense colloid. Monolayer crowded clusters of atypical cells are identified; atypia is characterized by uniform moderate nuclear enlargement with increased N/C ratio, and a variety of nuclear membrane defects. Eosinophilic nucleoli are apposed to partial and complete chromatin grooves. Focal chromatin clearing is present; however, optical clarity and nuclear inclusions are not seen. No papillary structure is identified including cytoconcentrates and cell block sections. CK-19 immunostain is strongly positive.
Diagnosis
Suspicious findings present - Suspect Papillary Carcinoma of the thyroid (Possibly Follicular Variant).
Follow-up
Partial thyroidectomy was performed; surgical pathology diagnosis included several colloid-rich adenomatous nodules, including one with a single 0.3 cm. focus of follicular variant, papillary carcinoma.

Case Study 4

A 46 year old woman underwent drainage of a solitary 1.0 cm. left thyroid cyst. About 0.5 cc. of "airplane glue" material is aspirated and submitted for cytology.
Cytopathology
The background includes abundant dense colloid substance throughout. Scattered small clusters of partly degenerated follicular epithelial cells are present. Several large complex fibro-epithelial tissue particles are identified; at low magnification papillary contours are evident. At high magnification, epithelial cells are palisaded at the periphery of the particles to produce a "community border." However, the nuclei are characterized by ordinary degenerative changes without specific chromatin atypia. CK-19 immunostain is completely negative.
Diagnosis
No malignant cells identified - Colloid Nodule (With Pseudopapillary Change).
Follow-up
Clinical/radiologic follow-up is ongoing. At one year after FNA, follow-up remains entirely negative.