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Warthin-like, a Rare Variant of Papillary Thyroid Warthin-like, a rare variant of papillary thyroid cancer
Warthin-like, una variante infrecuente del carcinoma papilar de tiroides
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"flvferrer@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "María José" "apellidos" => "García Coret" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Alberto" "apellidos" => "Ríos Agudo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Gara" "apellidos" => "Alcalá García del Río" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Ana" "apellidos" => "Villalba Segarra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Cirugía General y Digestivo, Unidad de Cirugía Endocrina, Hospital General Universitario de Valencia, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Universidad CEU Cardenal Herrera, Alfara del Patriarca, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Warthin-like, una variante infrecuente del carcinoma papilar de tiroides" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 680 "Ancho" => 905 "Tamanyo" => 151464 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0065" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Solid and papillary structures of oncocytic cells in lymphoid stroma (H&E × 10).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Papillary thyroid carcinoma (PTC) is the most common malignancy of the thyroid gland. Currently, in addition to the classic PTC variant, 14 other histopathological variants can be distinguished.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The Warthin-like variant of papillary thyroid carcinoma (PTC-WL) is rare (1.9%),<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> as only 164 cases have been described,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and there are no specific recommendations regarding its prognosis and treatment.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We present a case of the PTC-WL variant and comment on the most relevant aspects of this type of tumor given its rarity.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A 59-year-old woman with no medical history consulted for a nodule in the left thyroid lobe that was well defined, non-adherent, measured 2<span class="elsevierStyleHsp" style=""></span>cm, with no palpable lymphadenopathies. Analytically, the patient was euthyroid with elevated anti-TPO antibodies (1500<span class="elsevierStyleHsp" style=""></span>IU/mL).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Ultrasound revealed a solid, hypoechoic nodule measuring 17<span class="elsevierStyleHsp" style=""></span>mm×21<span class="elsevierStyleHsp" style=""></span>mm×16<span class="elsevierStyleHsp" style=""></span>mm with no halo, scarce intranodular vascularization and a poorly defined surface (TIRADS 4C). FNA was performed on 2 occasions, reported as Bethesda II.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Left hemithyroidectomy was indicated. The pathology study reported a PTC-WL variant measuring 2<span class="elsevierStyleHsp" style=""></span>cm, no capsular infiltration, mutated BRAF V600E biomarker and associated thyroiditis (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was reoperated with right hemithyroidectomy and prophylactic left lymph node dissection, with definitive histology of thyroiditis and no lymph node involvement.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Radioiodine (100<span class="elsevierStyleHsp" style=""></span>mCi) was administered, and after 18 months of follow-up the patient is disease-free with thyroglobulin 0.1<span class="elsevierStyleHsp" style=""></span>ng/mL and anti-thyroglobulin antibodies 0.1<span class="elsevierStyleHsp" style=""></span>IU/mL.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The PTC-WL variant mainly affects women (W:M=8:1) in the fifth decade of life.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Its name is due to the histological similarity with salivary gland tumors<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and its behavior is similar to the classic PTC variant,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> which is currently considered different from the oncocytic variant due to histological and prognostic differences.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The size is variable (0.5–6.0<span class="elsevierStyleHsp" style=""></span>cm), presentation is usually unifocal (88%) and lymph node involvement is seen in up to 45% of cases, similar to the classic variant.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> On ultrasound, they are usually seen as solid-cystic nodules.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Diagnosis by FNA biopsy is complicated because it is difficult to differentiate the lesion from the classic variant or other lesions such as thyroiditis, and the definitive diagnosis is sometimes established with the surgical specimen.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In the case described, the cytology result was Bethesda II on 2 occasions, with no diagnosis of thyroiditis or carcinoma. This established the surgical indication together with the high suspicion of malignancy on ultrasound, and the definitive diagnosis was reached based on the surgical specimen.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The histological diagnosis stands out because of a papillary structure with fibrovascular stalks infiltrated by lymphatic tissue and covered by tumor cells with oncocytic change and nuclear characteristics of papillary carcinoma. Oncocytic or Hürthle cells may be seen interspersed in the lymphatic infiltrate. The healthy parenchyma is also usually accompanied by lymphatic infiltrate.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Proper diagnosis is important since the prognosis and treatment may be different for each histological variant. The differential diagnosis will be mainly with Hürthle cell carcinoma, as well as the tall cell and oncocytic variants of papillary carcinoma.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The PTC-WL variant is associated with Hashimoto's thyroiditis in 80% of cases.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Some authors consider this a good prognostic factor since the tumor is less aggressive and survival is higher when this association exists.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In the case described, this association was found in the surgical specimen, but not in the preoperative cytological study.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The BRAF (proto-oncogene B-raf) V600E mutation presented by the patient has been implicated in the pathogenesis of papillary thyroid carcinoma,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> being detected in more than 80% of patients with the classic PTC variant<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and up to 65% of patients with the PTC-WL variant.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Since there are few published cases, the prognosis and treatment are not clear. Based on the bibliography consulted, it appears to be a carcinoma with a good prognosis similar to the classic PTC variant, so the prognosis and treatment of the PTC-WL variant are currently considered the same. However, published studies include few cases, with short follow-up times and poorly documented histopathological and clinical characteristics.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Regarding tumor behavior, the study by Yeo et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> is the only article that compares the PTC-WL and classic variants, finding that the former is associated more with Hashimoto's thyroiditis and less with the BRAF V600E mutation, with similar demographic, clinical and pathological characteristics, especially when associated with Hashimoto's thyroiditis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The BRAF V600E mutation has been associated with a worse prognosis, associated with more extensive disease and a higher recurrence rate.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Therefore, we decided to use prophylactic central homolateral node dissection in the case described. However, Yeo et al. did not find a correlation between the BRAF mutation and the clinical–pathological characteristics among patients with the PTC-WL variant.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The medical literature has reported lymphatic involvement in up to 45% of cases,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> 3 cases of recurrence (1.8%)<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,9</span></a> and 2 cases (1.2%) associated with undifferentiated areas, one of which progressed to anaplastic disease, distant metastasis and death within 18 months of surgery.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The patient described presented an association with Hashimoto's thyroiditis and BRAF V600E mutation. After excellent response to treatment, she is currently disease-free.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Villalba Ferrer F, García Coret MJ, Ríos Agudo A, Alcalá García del Río G, Villalba Segarra A. Warthin-like, una variante infrecuente del carcinoma papilar de tiroides. Cir Esp. 2020;98:637–638.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 680 "Ancho" => 905 "Tamanyo" => 151464 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0065" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Solid and papillary structures of oncocytic cells in lymphoid stroma (H&E × 10).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 680 "Ancho" => 905 "Tamanyo" => 249455 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0070" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Papillae of oncocytic type cells with lymphoid stroma; two optically empty nuclei are observed as in the classical variant (H&E × 40).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "WHO classification of tumours of endocrine organs" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R.V. 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| Year/Month | Html | Total | |
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| 2024 November | 13 | 0 | 13 |
| 2024 October | 58 | 38 | 96 |
| 2024 September | 70 | 6 | 76 |
| 2024 August | 76 | 18 | 94 |
| 2024 July | 67 | 4 | 71 |
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| 2024 April | 47 | 6 | 53 |
| 2024 March | 71 | 7 | 78 |
| 2024 February | 97 | 2 | 99 |
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| 2023 December | 94 | 12 | 106 |
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| 2023 October | 107 | 1 | 108 |
| 2023 September | 71 | 4 | 75 |
| 2023 August | 75 | 5 | 80 |
| 2023 July | 86 | 4 | 90 |
| 2023 June | 78 | 8 | 86 |
| 2023 May | 101 | 4 | 105 |
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| 2022 December | 49 | 7 | 56 |
| 2022 November | 81 | 14 | 95 |
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| 2022 July | 23 | 14 | 37 |
| 2022 June | 40 | 11 | 51 |
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| 2022 February | 33 | 14 | 47 |
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| 2021 August | 1 | 0 | 1 |
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