KCP 748 고려대학교 구로병원 전공의 이은정

Clinical Information Patient Identification: Chief Complain: M/58 Incidental found left thyroid mass

Thyroid Function Test Laboratory Finding TSH 2.12 uIU/ml T3 130 ng/dL Free T4 1.00 ng/dL 10-8-09: urine metanephrine 24 hrs 0.884 mg/day, VMA 4.59 mg/day (normal) TSH(0-4) fT3 1.78-0.89 T3 78-182

Thyroid Sonography Thyroid는 양쪽다 noral sized gladnsㄱ로 homogeneous echocity를 보이고 vascularity를 보이고 있지 않았음. Isthmus에 0.983ㅌ0.729 irregular hypoechoic nodule을 FNA시행하였고 왼쪽에 0.358 츠 small hypoechoic nodule이 있었음. 2010-07-30 13:08 ASPIRATION NECK SONO : US-GUIDED FNA FOR THYROID NODULE: After informed consent, we performed US-guided FNA for 1.3 cm-sized hypoechoic septated nodule in the isthmic portion of left thyroid gland. During FNA, patient was tolerable. No immediate complication. No visible metastatic neck node. Left thyroid의 isthmic portion에 약 1x0.7cm의 irregular hypoechoic nodule

FNA Cytology Loose sheets and clusters of granular cells with abundant cytoplasm and indistinct borders, eccentric round, spindle shaped nuclei with inconscipcuous nucleoli GCT같은 경우 cohesive group/ single cell둘다 보이게 되는데 granular cytoplasm을 갖고 있고 granules은 주로 aggregate을 만든다. Medullay carcinoma: ill defined cytoplasmic membrane, plentiful finely granular eosinophilic cytoplasm. Central nucleus, 8u in diameter, speckled chromatin pattern: nucloeli prominent.

FNA cytology Medullary carcinoma에서 보일수 있는 finely granular cytoplasm을 갖고 있고 round, polygonal or spindle cells in nests, cords or follicles, defined by sharply outlined fibrous bands; tumor cells have granular cytoplasm and uniform round/oval nuclei with punctate chromatin; stroma has amyloid deposits from calcitonin, prominent vascularity with glomeruloid configuration or long cords of vessels (Am J Surg Pathol 1995;19:642), highly cellular, syncytial arrangement of plasmacytoid (eccentric nuclei, uni- or binucleated), spindle and polygonal cells, cells have abundant cytoplasm, occasionally pink azurophilic granules and intranuclear inclusions, amyloid present occasionally (Am J Clin Pathol 1984;82:552)

FNA cytology Prominent cytoplasm, spindle cell shaped, cuboidal, prominent nuclei. Medullary carcinoma에서 보일수 있는 finely granular cytoplasm을 갖고 있고 핵은 pleomorphic하지 않고 eosinophilia는 심하지 않습니다. Granular cell tumor도 granular하고 oncocytic change를 보일 수 있는데 benign은 대부분 cohesive grup으로 clumped together하는 경우가 많고 cytoplasmic edge가 indistinct하다. Naked nuclei, abundant granular material이 prominent하다.

Cytology Finding Spindle cells with Plasmacytoid cells Granular cytoplasm Indistict cell border Fine chromatin Prominent or inconspicuous nucleoli Plasmacytoid cells Clusters of follicular cells with oncocytic change

Differential Diagnosis Sheets of follicles composed of large, eosinophilic Hurthle cells with granular cytoplasm Hurthle cell neoplasm Medullary carcinoma Abundant eosinophilic or clear cytoplasm with formation of typical honeycomb patten Parathyroid tumor

Cytology Diagnosis Suspicious for malignancy Suspicious for medullary carcinoma

Calcitonin <1.0 pg/mL

Thyroid Scan Tc-99m Tc-99m pertechnetate를 정맥주사하고 갑상선 영상을 얻었음. 좌우엽의 크기와 방사능 섭취양상 모두 정상소견임.

Neck CT Exophytic thyroid tumor, DDx perithyroidal nodule 2010-08-20 16:42 NECK CT [CE,3D] : NECK CT: Left thyroid gland의 isthmic portion에 약 1cm 크기의 capsule 밖으로 나온 nodule 있으며 이 nodule은 tracheal wall과 abutting 하고 있음. Abnormal LNs는 보이지 않음. IMP) Exophytic thyroid tumor, DDx perithyroid nodule.

Total Thyroidectomy (B)RLN; preserved (B)Parathyroid gland; preserved Frozen biopsy -> Isthmus tumor; R/O Granular cell tumor Parathyroid gland Freshly received specimen labeled as "Lt" consists of a left lobe of thyroid gland with attached adipose tissue, measuring 3.5x3x1.5cm and weighing 10gm. The external surface is grossly unremarkable. On serial section, the cut surface of thyroid gland is grossly unremarkable. On serial section of adipose tissue, the cut surface shows a ill-demarcated whitish mass, measuring 1.1x0.9x1.3cm. A well demarcated nodule is noted at the upper pole, measuring 0.5x0.5cm across. Sections from adipose tissue mass is embedded inn block Fs1A and Fs1B.(Touch)(강영란) (PHOTO, IC) FDx ; Soft tissue, perithyroidal, excision; Defer, R/O granular cell tumor Thyroid gland, left, lobectomy; No pathologic diagnosis Parathyroid gland, left, incidental biopsy; No pathoogic diagnosis BKS Permanent sections are embedded in block X1A to X1D. The specimen labeled as "Rt" consists of right thyroid gland, measuring 3.8x3x2cm and weighing 8gm. On serial section, the cut surface is grossly unremarkable. After fixation, multisected and representative sections are embedded in block A and B. 【확인결과】 Thyroid gland, total thyroidectomy; Parathyroid gland, left, incidental parathyroidectomy; No pathologic diagnosis(x1) Note) The results of immunohistochemical staining for tumor cells(X1A); S-100 : +ve Calretinin : -ve Chromogranin : -ve Synaptophysin : -ve Calcitonin : -ve CEA : -ve

Adipose tissue에 위치한 1cm 가량의 mass는 ill demarcated mass로 thyroid invasion 없고 내부에 fibrous 한 septation을 동반하고 있습니다.

Granular cell: granular, acdiophilic cytoplasm with abundant lysosomes on ultrastructure. Prominent basal lamina and intracytoplasmic filament 20x

S-100 protein CD68 Caletinin CEA

Chromogranin-A Synaptophysin Calcitonin PTH

Final diagnosis Granular cell tumor 1.3x1.1x0.9cm Soft tissue perithryoidal without thyroid invasion

1926년으 abrikossoff가 lingual GCT를 발견하였고 striated muscle fiber과 비슷하게 생겨서 myogenic origin이라 생각하여 myoblastoma라고 불리기도 했습니다. 하지만 GCT와 nerve의 close association, perineural distribution, immunophenotype이 neural origin과 유사하여 neural lesion이라 생각되어지고 있습니다. Granular cell tumor은 전신에서 다 발견되는데 이중 multiple origin을 갖고 있는 경우도 많이 있습니다. 이중 cervical portion 60%(73 intraluminal, 17% extra); tracheobronchial tree에 localize되기 때문에 midline neck nodule로 보일수 있고 thryoid disease를 mimic할수 있습니다. Thyroid mass로 존해나는 경우 주로 asymptomatic, painless mass로 보이게 됩니다. 현제 thryoid origin GCT는 case report 10개 미만이 있습니다.

Granular cell tumor Medullary Carcinoma Smaller N/C Small, round, uniform, spindle nuclei Background granular debris and naked nuclei More coarsely grayish granular Large epithelial cells Background amyloid Scattered giant cells Faintly granular

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