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Quiz Case
2022
:19;
13
doi:
10.25259/Cytojournal_23_2020

Plasmacytoid cells in a thyroid aspirate – Look before you leap

Department of Pathology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India
Corresponding author: Mona Agnihotri, Department of Pathology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India. mona.agnihotri2@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Agnihotri M, Naik L, Kothari K, Kharat J. Plasmacytoid cells in a thyroid aspirate – Look before you leap. CytoJournal 2022;19:13.

HTML of this article is available FREE at: https://dx.doi.org/10.25259/Cytojournal_23_2020

CASE HISTORY

A 60-year-old female with hypothyroidism under treatment presented with neck swelling for 2 months. Ultrasonography showed bulky right thyroid lobe (6.4 × 4.2 × 3.1 cm) with multiple heterogeneous nodules and microcalcification and with multiple necrotic cervical lymph nodes. Fine-needle aspiration (FNA) of the largest thyroid nodule (3 × 3 × 2 cm) is shown in Figure 1.

Figure 1:: (a) Right thyroid FNA. Cellular smear showing predominantly discohesive plasmacytoid cells of variable sizes (Giemsa stain, ×400). (b) Few binucleate and multinucleate cells present. Background shows a few scattered lymphoglandular bodies (Giemsa stain, ×600). (c) Cells have eccentric nuclei with finely stippled chromatin and moderate amount of cytoplasm (Papanicolaou stain, ×400). (d) Discohesive plasmacytoid cells. (Giemsa stain, ×1000).

What is your interpretation?

  1. Hurthle cell neoplasm

  2. Non-Hodgkin’s lymphoma

  3. Medullary carcinoma

  4. Metastatic carcinoma

Answer

The correct answer is b. Non-Hodgkin’s lymphoma.

Thyroid FNA smears were highly cellular, showing predominantly discohesive plasmacytoid cells of variable sizes [Figure 1a]. Also seen were binucleate and multinucleate cells [Figure 1b]. The cells had eccentric nuclei with finely stippled chromatin and moderate amount of cytoplasm [Figure 1c]. Lymph node aspirate also showed similar cytomorpholological features. The location, that is, mass in the thyroid, along with the above cytologic features led to a high suspicion of diagnosis of medullary thyroid carcinoma (MTC, plasmacytoid type) with lymph node metastasis. Serum calcitonin was advised. The calcitonin level was found to be less than 2 pg/ml. On review of the slides, it was observed that the background had scattered lymphoglandular bodies (LGBs). One Pap stained slide was then destained for immunocytochemistry (ICC) and the cells showed strong immunoreactivity for leukocyte common antigen (LCA) (CD45) [Figure 2]. The possibility of non-Hodgkin lymphoma (NHL) with plasmacytic differentiation was highly considered. In the meanwhile, a lymph node biopsy was also done for further workup. The cells showed immunoreactivity for LCA, cluster designation (CD)79a, CD10, BCL2, and EMA and non-immunoreactivity for calcitonin, CD138, CD56, CD3, CD20, CD30, CD23, and anaplastic lymphoma kinase (ALK1). The proliferative index (MIB1) was 40%. The final diagnosis of high-grade non-Hodgkin B-cell lymphoma with plasmacytic differentiation was rendered.

Figure 2:: Cells expressing LCA immunoreactivity (ICC, ×400).

ADDITIONAL QUIZ QUESTIONS

Q1. Which immunochemistry panel will best help in the diagnosis?

  1. Calcitonin, synaptophysin, chromogranin

  2. Calcitonin, LCA, CD138

  3. LCA, synaptophysin, CK

  4. Thyroglobulin, chromogranin, calcitonin.

Q2. All the following are features of medullary thyroid carcinoma except

  1. Dispersed tumor cells

  2. Eccentric nuclei

  3. Stippled chromatin

  4. Blue cytoplasmic granules on MGG.

Q3. Lymphoglandular bodies are derived from:

  1. Nuclear remnants

  2. Stain precipitation

  3. Cytoplasmic fragments

  4. Immunoglobulin.

Answers of additional Quiz Questions

Q1.b; Q2.d; Q3.c.

BRIEF REPORT

Clinically, a mass in the thyroid and the presence of discohesive plasmacytoid cells in a background containing amyloid/amyloid-like material on cytology smears leads to a diagnosis MTC as it is the most common carcinoma associated with the above two features among thyroid malignancies.[1] These features can, however, also be seen in other rare thyroid neoplasms such as plasma cell neoplasm and NHLs with plasma cell differentiation.[2] It is important to look for other supporting cytomorphological features that are often reported in MTC, like red cytoplasmic granules (88%), neuroendocrine type salt and pepper or stippled nuclear chromatin (65%), binucleated and multinucleated cells (70%), cytoplasmic “triangular” tails (58%), and amyloid.[3] Amyloid should be confirmed by Congo-red stain and serum calcitonin levels must be advised.

The presence of LGBs, cartwheel chromatin pattern, and Dutcher bodies can indicate malignant lymphoma and plasmacytoma.[4] The monomorphic appearance, granular cytoplasm, intranuclear inclusions, and eccentric nucleus of MTC cells can mimic Hürthle cell neoplasm and Hurthle cell variant of papillary thyroid carcinoma (PTC).[5] The finely textured chromatin, prominent macronucleoli, and blue cytoplasmic granules on Romanowsky stains correctly identify Hürthle cell neoplasm.[5] The presence of characteristic nuclear features of PTC, dense cytoplasm, and positive immunoreactivity for thyroglobulin distinguishes it from MTC. Rarely metastatic tumor, particularly melanoma warrants consideration but the presence of pigment and macronucleoli helps in the diagnosis. Serum calcitonin and immunochemistry for calcitonin, thyroglobulin, LCA, CD 138, and HMB 45 are of great help for confirmation and in avoiding the diagnostic dilemmas.

SUMMARY

The diagnosis of lymphomas with plasmacytic morphology in the thyroid can be overlooked and misinterpreted as MTC due to rarity and overlapping cytomorphologic features. Clinical correlation, precise study of the cytological features, and carefully screening the thyroid smears for LGBs in the background are crucial to avoid misdiagnosis, before instituting a definitive therapy.

COMPETING INTEREST STATEMENT BY ALL AUTHORS

The authors declare that they have no competing interest.

AUTHORSHIP STATEMENT BY ALL AUTHORS

MA carried out cytological evaluation and reference work and drafted the manuscript. LN carried out the cytological evaluation and clinico-pathological co-relation. KK conceived the study, edited the manuscript and formatted the questions. JK helped to draft the manuscript and perform ICC. All authors read and approved the final manuscript.

ETHICS STATEMENT BY ALL AUTHORS

This study was conducted with approval.

LIST OF ABBREVIATIONS (In alphabetic order)

ALK-Anaplastic lymphoma kinase

FNA-Fine-needle aspiration

ICC-Immunocytochemistry

LCA-Leukocyte common antigen

LGB-Lymphoglandular bodies

MTC-Medullary thyroid carcinoma

NHL-non-Hodgkin lymphomas

PTC- Papillary thyroid carcinoma.

EDITORIAL/PEER-REVIEW STATEMENT

To ensure the integrity and highest quality of CytoJournal publications, the review process of this manuscript was conducted under a double-blind model (authors are blinded for reviewers and vice versa) through automatic online system.

References

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  3. , , , , , . Medullary carcinoma of the thyroid. Accuracy of diagnosis by fine-needle aspiration cytology. Cancer (Cancer Cytopathol). 1998;84:295-302.
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  5. , , . Cytologic diagnosis of medullary carcinoma of the thyroid gland. Diagn Cytopathol. 2000;22:351-8.
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