CHRISMED Journal of Health and Research

CASE REPORT
Year
: 2020  |  Volume : 7  |  Issue : 1  |  Page : 71--73

Fine-needle aspiration cytology-induced infarction of thyroid nodule hampers diagnosis


Khushboo Dewan, Poonam Rani, Arti Khatri, Kusum Gupta, Ashish K Mandal 
 Department of Pathology, Dr. Baba Saheb Ambedkar Medical College and Hospital, Delhi, India

Correspondence Address:
Poonam Rani
Department of Pathology, Dr. Baba Saheb Ambedkar Medical College and Hospital, Rohini, Delhi
India

Abstract

Fine-needle aspiration cytology (FNAC) is a useful procedure for the investigation of thyroid swellings. It is a safe and minimally invasive procedure but is accompanied by its own set of complications. Infarction of the parent tissue post-FNAC has been reported in the lymph node, salivary gland, and breast but is a rare phenomenon in the thyroid. We present a case of a 34-year-old female with a solitary thyroid nodule. FNAC smears were hypercellular and showed numerous Hurthle cells suggesting a possibility of Hurthle cell neoplasm. Hemithyroidectomy performed 1 month thereafter showed extensive necrosis and hemorrhage with only few atypical follicular epithelial cells and Hurthle cells at the periphery. The near-total infarction and paucity of viable cells made it extremely difficult to make a histopathological diagnosis. The case highlights the need for extensive sampling and thorough examination of the periphery for any viable foci on histopathology along with cytologic-histologic correlation in such cases.



How to cite this article:
Dewan K, Rani P, Khatri A, Gupta K, Mandal AK. Fine-needle aspiration cytology-induced infarction of thyroid nodule hampers diagnosis.CHRISMED J Health Res 2020;7:71-73


How to cite this URL:
Dewan K, Rani P, Khatri A, Gupta K, Mandal AK. Fine-needle aspiration cytology-induced infarction of thyroid nodule hampers diagnosis. CHRISMED J Health Res [serial online] 2020 [cited 2020 Aug 10 ];7:71-73
Available from: http://www.cjhr.org/text.asp?2020/7/1/71/286884


Full Text



 Introduction



Fine-needle aspiration cytology (FNAC) is routinely used for the investigation of thyroid swellings. The Bethesda System for Reporting Thyroid Cytopathology gives guidelines in deciding the diagnostic category and further management of the patient.[1] About 60% of thyroid nodules are classified cytologically as benign, whereas around 10% are malignant. Remaining 30% are of indeterminate nature.[2] Patients reported as thyroid neoplasms or suspicious for malignancy on FNAC are advised surgical excision. The FNAC procedure comes with its own set of complications. Infarction of the thyroid tissue is an uncommon but known complication of FNAC.[3],[4] If the subsequent histopathological examination of the lesion only reveals infarcted tissue, it becomes difficult for a pathologist to make a diagnosis. In such a setting, a thorough histopathological examination of the periphery of the lesion and cytologic-histologic correlation are extremely important for the diagnosis. We report a case signed out as Hurthle cell neoplasm on FNAC and the histopathological examination of which revealed complete infarction of the tumor nodule.

 Case Details



A 34-year-old female patient presented to the outpatient department with a complaint of anterior neck swelling for 2-month duration. On examination, a firm, 3-cm solitary nodule was present in the right lobe of thyroid. Ultrasonogram showed a well-demarcated nodule without capsular invasion and areas of infarction. No cervical lymphadenopathy was present. Thyroid function tests yielded normal results. FNAC was done in a single setting from two different sites in the thyroid nodule using one pass each time and without aspiration. FNAC showed hypercellular smears with the presence of numerous clusters and sheets of Hurthle cells adherent to capillaries in a background of numerous hemosiderin-laden macrophages [Figure 1]a and [Figure 1]b. The Hurthle cells showed minimal pleomorphism with abundant dense cytoplasm, uniform nuclei with indistinct nucleoli. No lymphoid cells were seen. No intranuclear inclusions were seen. Thus, a diagnosis of Hurthle cell neoplasm (Category IV of The Bethesda System of Reporting Thyroid Cytopathology – suspicious for follicular neoplasm) was signed out.{Figure 1}

The patient underwent right hemithyroidectomy 1 month after FNAC. Gross examination of the resection specimen revealed a well-circumscribed solitary nodule measuring 3 cm showing hemorrhage on cut-section. Multiple sections from the nodule showed large areas of coagulative necrosis and hemorrhage [Figure 1]c. The peripheral rim of the nodule also showed fibrosis and granulation tissue. Few collections of atypical follicular epithelial cells and Hurthle cells were entrapped in the granulation tissue [Figure 1]d. Hemosiderin-laden macrophages, foreign-body giant cells, and calcification were seen at multiple foci within the nodule [Figure 1]e. Suspicious foci of capsular invasion by Hurthle cells were also noted [Figure 1]f. No vascular invasion was seen.

The histopathology sections were then re-examined along with prior cytology smears, and a diagnosis of infarcted follicular neoplasm with Hurthle cell differentiation along with suspicious capsular invasion was reported. The patient is kept under close follow-up.

 Discussion



FNAC is a commonly used procedure as it is easy to perform after acquisition of the required skills, does not require any sophisticated equipment, is inexpensive, safe, and minimally invasive, and provides rapid results. Pain, hematoma formation, infection, and inflammatory reactions are all known and common complications of the procedure.[3] Tissue damage as a result of FNAC is commonly evident in the form of hemorrhage, siderophages, and granulation tissue.[3] Less commonly, endothelial proliferation, cystic degeneration, capsular distortion, calcification, fibrosis, and vascular thrombosis may be observed on subsequent histopathological examination and indicate tissue damage.[3],[4] Post-FNAC infarction of the parent tissue has been reported in the lymph node, salivary gland, and breast.[5],[6],[7],[8]

Post-FNAC infarction of the thyroid nodule is a rarely reported phenomenon. Its incidence post-FNAC has been reported to vary from 0% to 10%.[9],[10] A study by Us-Krasovec et al. did not report any case of infarction of the thyroid tissue as a complication of FNAC in 305 thyroidectomies studied.[9] In a review of 1150 cases of thyroidectomies, the entity was reported in 1.4% of cases.[10] Gordon et al., on the other hand, reported variable amount of infarction in the thyroid tissue when surgery was performed within 3 months of FNAC with high rate of 9.8%.[11] The infarction was extensive in half of these cases so as to create challenges in histopathologic diagnosis.[11] The present case highlights a similar difficulty in diagnosis that arose due to paucity of viable reportable tissue post-FNAC.

The incidence of this interesting phenomenon also varies with the underlying thyroid pathology. Of the 28 cases of post-FNAC infarction in thyroid neoplasms reported by Kini et al., 28 cases were Hurthle cell tumors (53%) as against eight cases of papillary carcinoma and five cases of follicular carcinoma.[12] In a review of 1150 thyroidectomies, the incidence of this phenomenon was 11.5% in Hurthle cell neoplasm.[10] In comparison, the reported incidence in papillary carcinoma thyroid is only around 0.7%. Less commonly, the entity is also reported in follicular neoplasms.[10] The present case adds up in the list of Hurthle cell neoplasms with post-FNAC infarction. An interesting observation made during literature search is the occurrence of post-FNAC infarction in neoplastic tissue only.[12],[13]

The reasons for the occurrence of this phenomenon are largely unknown. A suggested explanation is the FNAC procedure causing trauma to blood vessels which in turn leads to thrombosis and occlusion of the microvascular blood supply.[3],[4],[9],[10] The increased vascularity probably explains the much higher incidence of this entity in Hurthle cell tumors. The extraction of large amounts of tissue, associated with using larger bore needles, rigorous aspiration, and multiple passes of FNAC have all been proposed as contributing mechanisms causing this phenomenon.[3],[4],[9],[10]

This entity poses challenges for the pathologist by limiting the availability of reportable tissue. There are documented difficulties in recognizing the true nature of the lesion. The probability of missing the accurate diagnosis on histopathology becomes high in such a scenario. In most of such cases, careful analysis of the rim of viable tissue is useful and therefore necessary. Adequate sampling of the capsule and the peripheral portion of the lesion are of utmost importance during grossing. Corroboration of prior cytologic and current histopathologic findings is extremely helpful to reach a diagnosis. The post-FNAC infarction in this case posed a challenge for recognition of vascular and capsular invasion in the follicular neoplasm. The presence of capsular or vascular invasion is important for it is seen in carcinomas and is associated with aggressive behavior, local recurrence, regional lymph node, and distant metastasis of the tumor. The follicular carcinomas, therefore, require total thyroidectomy and radiation ablation. On the contrary, tumors without invasion are considered cured by lobectomy and are called adenomas. Due to the presence of suspicious capsular invasion, the patient was advised to be kept under close follow-up.

 Conclusion



Awareness about the existence of this entity is important to avoid missing a diagnosis of malignancy on histopathology. A dedicated examination of remaining viable tissue along with cytologic-histologic correlation may prove to be useful in identifying the nature of the disease.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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