Scientific letter
Warthin-like variant of thyroid papillary carcinoma
Carcinoma papilar de tiroides variante Warthin-like
Pedro Antonio Sánchez Fuentes
, Antonio Ríos, José Manuel Rodríguez
Corresponding author
Unidad de Cirugía Endocrina, Servicio de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
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En las imágenes se objetiva un parénquima tiroideo con intenso infiltrado inflamatorio crónico linfoplasmocitario (*) que desestructura los folículos tiroideos, junto a la neoplasia (**) constituida por ejes conectivos tapizados por células de citoplasmas amplios eosinófilos y núcleos con hendiduras en la membrana nuclear. El estroma circundante presenta un intenso infiltrado inflamatorio linfoplasmocitario con formación de agregados linfoides tipo centro germinal primario.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">1.4) Tinción inmunohistoquímica para citoqueratina 19. 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(1–3) Haematoxylin–eosin staining, at various magnifications ×10, ×15 and ×30, respectively. The images show a thyroid parenchyma with intense chronic lymphoplasmacytic inflammatory infiltrate (*), which disassociates the thyroid follicles, together with the neoplasm (**) consisting of connective axes lined by cells with large eosinophilic cytoplasm and nuclei with clefts in the nuclear membrane. The surrounding stroma has an intense lymphoplasmacytic inflammatory infiltrate with formation of primary germinal centre lymphoid aggregates. (4) Immunohistochemical staining for cytokeratin 19. The neoplasm (**) shown is intensely positive for cytokeratin 19, characteristic of papillary carcinoma.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The Warthin-like variant of papillary thyroid carcinoma is classified within the oncocytic variants and its prevalence is less than 2%.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Apel et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> first described it in 1995 as an oncocytic papillary carcinoma with lymphatic stroma. They proposed to call it Warthin-like thyroid tumour, due to its histological resemblance to the papillary cystadenoma lymphomatosum of the salivary gland. The scarcity of published cases makes it difficult to determine their biological behaviour.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 33-year-old woman who presented with multinodular goitre and local compressive symptoms. A grade III goitre was observed on examination. The analysis showed subclinical hypothyroidism (TSH 4.6<span class="elsevierStyleHsp" style=""></span>uUI/ml, T4 1.06<span class="elsevierStyleHsp" style=""></span>ng/dl) and autoimmune thyroiditis (anti-thyroperoxidase antibodies 2000<span class="elsevierStyleHsp" style=""></span>IU/ml). The ultrasound showed an enlarged thyroid gland, with a dominant right lobe, heterogeneous and hypoechogenic, being classified as TIRADS 2.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A total thyroidectomy due to symptomatic goitre was performed in the context of Hashimoto's thyroiditis with subclinical hypothyroidism. The histopathological study showed a Warthin-like variant papillary thyroid carcinoma of 0.3<span class="elsevierStyleHsp" style=""></span>cm, located in the left lobe, unifocal, without extrathyroidal invasion, or lymphovascular, with chronic lymphocytic thyroiditis in the rest of the parenchyma (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Curative treatment was considered, starting outpatient follow-up without radioiodine ablation treatment. After 1 year, no recurrence of the disease was observed (thyroglobulin <0.1<span class="elsevierStyleHsp" style=""></span>ng/ml).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The diagnosis of the Warthin-like variant is histological, characterized by a papillary structure covered by tumour cells with oncocytic change and papillary carcinoma nuclear features. These papillae are supported on fibrovascular stems infiltrated by lymphatic tissue. Oncocytic or Hürthle cells can be observed intertwined in the lymphatic infiltrate. In addition, they are also accompanied by lymphatic infiltrate in the rest of the healthy parenchyma.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The role of cytology is still doubtful because of the difficulty of distinguishing it from lymphocytic thyroiditis. The oncocytic variant and the high cell variant are part of the differential diagnosis. The first one is characterized by oncocytic cells with papillary carcinoma nuclear features and without lymphocytic infiltrate. It has an uncertain prognosis. And the second is characterized by elongated oncocytic cells with twice as much height as width, eccentric nucleus and lymphocytic infiltrate. Clinically, this variant behaves more aggressively.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The pathological significance of the lymphatic infiltrate remains unclear. It is unknown if its role is protective in response to the antigenic stimulus of the neoplasm, or on the contrary, represents a growth factor for the proliferation of the tumour cells. With the current evidence it is considered that the coexistence of papillary carcinoma with thyroiditis results in reduced neoplastic aggressiveness, with better long-term results than without thyroiditis.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">After having reviewed the cases described in the literature, less than 30% show extrathyroidal extension and/or lymphatic invasion. Recurrence was only reported in 3 cases<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3–5</span></a> and in 2 others it was associated with undifferentiated carcinoma, one of them being the only case of mortality associated with the Warthin-like variant (10% of tumour was undifferentiated).<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Regarding tumour behaviour, the study by Yeo et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> is the only one that compares the Warthin-like variant with the classical one, and it was found that the former is associated more with Hashimoto's thyroiditis and less with the BRAF mutation, being similar in the other variables. In the absence of other studies, the prognosis is considered similar to that of the classical variant. Consequently, treatment and follow-up is based on the current recommendations for classical papillary carcinoma. In the case reported, in addition to the histological type, its size is subcentimetric, so it was treated as a papillary microcarcinoma, which justifies not performing central lymphadenectomy or administration of ablative radioiodine therapy.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion, the identification of the histological variant in papillary thyroid carcinoma is essential for the therapeutic and follow-up approach. And in the absence of more studies, the Warthin-like variant has a behaviour similar to the classical variant.</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: Sánchez Fuentes PA, Ríos A, Rodríguez JM. Carcinoma papilar de tiroides variante Warthin-like. Med Clin (Barc). 2017;149:505–506.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2185 "Ancho" => 2917 "Tamanyo" => 1506029 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Histology of Warthin-like papillary carcinoma. (1–3) Haematoxylin–eosin staining, at various magnifications ×10, ×15 and ×30, respectively. The images show a thyroid parenchyma with intense chronic lymphoplasmacytic inflammatory infiltrate (*), which disassociates the thyroid follicles, together with the neoplasm (**) consisting of connective axes lined by cells with large eosinophilic cytoplasm and nuclei with clefts in the nuclear membrane. The surrounding stroma has an intense lymphoplasmacytic inflammatory infiltrate with formation of primary germinal centre lymphoid aggregates. (4) Immunohistochemical staining for cytokeratin 19. The neoplasm (**) shown is intensely positive for cytokeratin 19, characteristic of papillary carcinoma.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The Warthin-Like variant of papillary thyroid carcinoma: a comparison with classic type in the patients with coexisting Hashimoto's thyroiditis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.K. Yeo" 1 => "J.S. Bae" 2 => "S. Lee" 3 => "M.H. Kim" 4 => "D.J. Lim" 5 => "Y.S. 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