PMC3905161_01
Cytological and histological aspects of the nodule. (A) Thyroid fine needle aspiration (Papanicolaou, magnitude 600 X). A high power field showing a cluster of neoplastic cells in a necrotic background. (B) Thyroid core biopsy (hematoxilin and eosin, magnitude 400 X): thyroid tissue infiltrated by poorly differentiated adenocarcinoma (arrows). (C) Thyroid core biopsy (CK19, magnitude 200 X): Strong cytoplasmic positivity in neoplastic cells. (D) Thyroid core biopsy (TTF-1, magnitude 200 X): nuclear positivity in follicular cells.
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F1
Cytological analysis of the lesion was defined as malignancy (Figure 1A) according to the Bethesda System for reporting thyroid cytopathology and the patient was referred for possible thyroidectomy. On microscopic examination, histological sections revealed a pseudoglandular proliferation of atypical epithelial cells embedded in a fibrous stroma with atrophic thyroid follicles (Figure 1B). Furthermore, on immunohistochemical findings, thyrocytes showed immunoreactivity for thyroid transcription factor-1 (TTF-1) in spite of negativity in the neoplastic cells (Figure 1D).
Thyroid ultrasound with contrast enhancement and biopsy. Longitudinal view of the right lobe of the thyroid gland performed with linear probe (7.5-14 Mhz) in conventional ultrasound (panel A, D) and after contrast enhancement ultrasound (panel B,C). Panel A shows a hypoechoic lesion of the right lobe of the thyroid gland. The yellow arrow indicates a metastatic lymph node located close to the upper pole of the right lobe. Panel B shows the hypovascular aspect of the nodule and lymph node after contrast injection. The enhancement is located only in the peripheral part both of nodule and lymph node as well. Panel C shows the enhancement in the venous phase which is still located only in the peripheral part of the nodule, except for the presence of small tiny vessels located also in the central part. Panel D show the path of the needle inserted inside of the nodule.
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F2
A thyroid hypoechoic mass of 30 mm in the maximum longitudinal size was detected in the right lobe of the gland, associated with round and enlarged lymph nodes in laterocervical part of the neck, especially on the right side. After conventional US, a contrast enhancement US (CPS, Siemens, Mountain View, California; Sonovue, Bracco, Italy) focused to the thyroid gland and lymph node was performed (Figure 2).
CT scan of the body. In panel A and B the yellow arrows indicate the big mass of the right lobe of the thyroid gland. In panel C the yellow arrow indicates one of the multiple secondary liver lesions. In panel D the yellow arrow indicates the pancreatic cancer located in the body with dilatation of the pancreatic duct.
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F3
A contrast CT scan demonstrated an enlargement of the pancreatic body with a 22 mm hypodense lesion with ill-defined margins, dilatation of the pancreatic duct, diffuse retroperitoneal, paraaortic and cervical lymphadenopathy and secondary lesions in the liver (1-4.2 cm) (Figure 3).