World Journal of Medical and
Surgical Case Reports
Case Report
Open Access
Insular Thyroid Microcarcinoma with Precedent
Adenopathy – Peculiar Subset of Malignant Tumor
Mihai Radu Diaconescu1, Mihai Glod1, Mirela Grigorovici1, Smaranda Diaconescu2
IVst Surgical Clinic, "Gr T Popa" University of Medicine and Pharmacy Iasi, 700507, Romania
V Pediatric Clinic, “St Maria” Children’s Emergency Hospital; 62, Vasile Lupu str, Iasi 700309
1
2 th
This is an Open Access article distributed under the terms of the Creative Commons Attribution License
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Background: A case report of a patient with insular thyroid carcinoma, a poorly differentiated
subtype of thyroid tumor with intermediate aggressiveness and prognosis between welldifferentiated and anaplastic thyroid malignant lesions is presented.
Case Report: A 59 year old man with an apparent isolated huge lateral cervical adenopathy was
directed to our clinic. The thyroid and other cervical structures were clinically inapparent and
also could not be identified by imaging methods. Fine-needle aspiration biopsy showed
aggregates of small, monomorphic cells with scant cytoplasm, round nuclei with granular
chromatin and rare mitosis oriented the diagnosis towards a follicular thyroid carcinoma
metastasis.
While intraoperatively completing the selective cervical dissection, a solitary centrolobar
micronodule (5 mm) was identified and a total thyroidectomy was done. Microscopy showed
neoplastic cells arranged in nests (insulae) separated by hyaline stroma, with grooved nuclei,
rare mitosis and necrotic areas diagnostic for insular carcinoma. Complementary radioiodine
therapy allowed a stable cure at 36 months follow-up.
Discussion: Appearance of these tumors with rapid evolution in which only precocious diagnosis
(although not always possible) orienting the patient towards radical surgery completed by 131 I
therapy, both assuring in 1/3 of cases a real chance of cure, to the poorly differentiated thyroid
carcinomas is underlined.
Conclusion: Together with the rarity of this subtype of thyroid neoplasia, must be mentioned
the precedency of the cervical adenopathy to the primary subclinical microcarcinoma and also
the efficacy of the association between radical surgery with 131 I radiation.
Key Words: insular thyroid microcarcinoma, fine needle-biopsy, prognosis, total thyroidectomy.
Address for Correspondence and reprint request to:
Smaranda Diaconescu MD, Vth Pediatric Clinic “St
Maria” Children’s Emergency Hospital; 62, Vasile Lupu
str,Iasi 700309, Tel 0232212532, E mail:
[email protected]
Background
Thyroid carcinomas include a lot of
tumors with raised incidence/prevalence (the
most frequent malignant lesion of the
endocrine system) with a broad diversity of
the clinical and evolutionary aspects of the
biologic behavior deriving from their extreme
histological polymorphism. Natural history and
©2013 Diaconescu S et al., Licensee Narain
Publishers Pvt. Ltd. (NPPL)
Submitted: February 17 2013; Accepted: March 29
2013; Published: April 01 2013;
15 www.npplweb.com/wjmscr/content/2/4 World J Med Surg Case Rep 2013;2:15‐20 Diaconescu S et al. Figure 2: Ultrasound of the lateral cervical
adenopathy
Case report
CC a 59-year old male whose chief
complaint is a huge right cervical
conglomerate of lymph nodes appearing one
year ago. Personal patient’s history revealed a
nodal biopsy on the same side performed 15
years ago but with benign histology. Physical
examination revealed a right sided 3x5 cm
firm, painless but fixed conglomerate of
lymph nodes. (Fig 1) There is no significant
another adenopathy and the thyroid gland is
not papable. The general clinical condition is
good without evidence of any physical or
metabolic and endocrine disturbances.
Excepting a discrete anemia (Ht= 39%), the
standard laboratory tests including TSH and
T4 measurements were in normal range.
Cervical ultrasonography demonstrate a hypo
echoic huge irregular mass including multiple
more or less distinct solid, heterogeneous
images of 1-2 cm in diameter, related to the
middle and inferior cervical node groups. The
thyroid gland is also heterogeneous but with
normal contour and dimensions (Fig 2).
Thyroid scan reveals similar characters but
without cold areas.
Fine needle aspiration biopsy showed
aggregates
of
monomorphic,
isolated,
clustered or overlapping cells with indistinct
limits, reduced cytoplasm, round nuclei and
rare mitosis, situated in a scanty fibrovascular
Figure 1: Right laterocervical adenopathy
the consecutive post-therapeutic evolution
principally depend upon the evolutionary
stage and the cytomorphologic features of the
lesions [1, 2].
Insular thyroid carcinoma (ITC) is a rare
mentioned but aggressive subtype of thyroid
neoplasm situated in an intermediate position
between the highly differentiated follicular
and papillary carcinomas with good prognosis
and the undifferentiated (anaplastic) cancers
which are almost uniformly lethal. Actually
ITC is framed together with trabecular and
solid tumors in the poorly differentiated
subgroup of thyroid cancers representing 46% of all the malignant lesions of this gland.
The lesion is characterized by accelerated
tumoral growth and extra nodal invasion,
precocious nodal and distant metastasis,
frequent recurrences and an overall mortality
of 60-85% [3].
An uncommon case of ITC with precessive
lateral cervical lymphadenopathy (pTxN2M0),
with presence of follicular features at FNAB,
and also with a 5 mm 0 impalpable thyroid
nodule discovered intraoperatively, all of
them leading to the diagnosis, is presented.
16 www.npplweb.com/wjmscr/content/2/4 World J Med Surg Case Rep 2013;2:15‐20 Insular thyroid microcarcinoma Figure 3: ITC: FNAB aspect.
Figure 4: ITC: Histologic characteristic
aspect low magnification.
stroma leading to the diagnosis of follicular
thyroid carcinoma metastasis.
During operation a selective neck lymph
node dissection with en block extirpation of
the IInd and IVth node groups along with
internal jugular vein, accessory spinal nerve
and sternocleidomastoid muscle conservation
was done.
The thyroid had a normal volume with
discrete lobulated surface but a firm,
unencapsulated,
grey-white
solitary
centrolobar nodule of 5 mm 0 was discovered
at palpation. After the main vascular pedicles
interception a standard total thyroidectomy
was done. The entire surgical specimen
weighted 60 g.
Microscopic sections both in the lateral
cervical nodes and in the thyroid nodule
showed the presence of round and oval
“monotonous” cells, with scant cytoplasm and
regular nuclei with granular chromatin and
mitosis, disposed in follicles and “insular
groups” separated by fibrovascular stroma
(Fig 4). Intravascular tumor emboli and
necrotic areas were also identified. The rest
of the gland showed inequal colloid-filled or
atrophic areas, thyroid follicles, stromal
reaction, hyalinization, hemorrhagic zones but
without another neoplasic focus. Final
diagnosis: insular thyroid carcinoma.
Immediate postoperative course was
uneventful and after 5 weeks rh TSH
(recombinant
human
thyrotropin)
was
administered and a dose of 100 mCi 131 I
17 was given. Afterwards the patient received
thyroid
hormone
suppressive
therapy.
Periodic clinical, biological and imaging followup at 1-3 years did not reveal recurrences or
metastasis.
Discussion
Initially described by Langhans (1907) as
“wuchernde struma” (proliferative struma)
and later by Sakamoto (1983) as a poorly
differentiated thyroid carcinomatous entity,
the insular thyroid carcinoma is defined by
Carcangiu (1984) as a distinct variant of
glandular neoplasia characterised by presence
of solid nests –“insulae” of little uniform
tumoral cells, constituting a variable number
of follicles containing thyroglobulin [4, 5, 6].
Adjoining moderate mitotic activity,
capsular and vascular invasion and necrotic
foci made together a peritheliomatous
structure. Later ITC was added assimilated to
the “aggressive” thyroid carcinomas of
follicular origin subgroup which includes
trabecular, insular and solid lesions with an
intermediary behavior and prognosis between
epithelial (papillary and folliculary) and
anaplasic (undifferentiated) cancers. Some
authors underlined the peculiarities of the
insular lesions i.e. intense cellularity, presence
of atypias, increased number of mitosis and
necrotic areas but especially of the accelerate
rhythm of growth while other experts also
www.npplweb.com/wjmscr/content/2/4 World J Med Surg Case Rep 2013;2:15‐20 dimercaptosuccinic) showed evidence of the
hypofixant or cold areas and established the
macroscopic tumoral features remaining
important in the diagnosis of metastatic
deposits and in the post therapeutic
monitoring. I-131 whole-body scan remains a
prime line investigation [15, 16].
Computer tomography and magnetic
resonance imaging defines the volume but
especially the limits and extension of the
tumor (mediastinum, thorax).
18F-Fluorodeoxiglucose positron emission
tomography (FDG-PET) only or associated
with CT or/and magnetic resonance imaging,
reveals the prevailing character of the less
differentiated lesions positive to FDG, being
useful in precise preoperative staging and
post therapeutic restaging and follow-up of
the ITC [5, 15].
Indirect laryngoscopy and fiber optic
examination of the upper respiratory tract are
mandatory to discover the eventually RN
involvement (present in 25% of cases) or
local invasion. However the great majority of
these tumors are diagnosed only by
postoperative paraffin examination.
The consensus meeting held in Turin
(2006) proposed uniform criteria for the
diagnostic of ITC:
included the columnar and tall cell cancers in
this subgroup [7, 8].
From the clinical point of view the
majority of these tumors developed as
solitary
or
multiple
thyroid
nodules,
sometimes on a preexistent goiter, having a
female predominance: report F/M ♀/♂ - 2.12.5/1 and a mean age of 50-55 years. ITC
have a rapid invasive evolution both locally
reaching great dimensions (5-10 cm) and
causing compressive complications such as
dysphonia or Horner syndrome and also extra
thyroid metastasis of the lymph nodes or
distant sites (lung, bone, liver), present in
20% of cases at the initial examination
putting them in high-risk lesions in
accordance with De Groot, AMES or MACIS
scores at the moment of diagnosis [9, 10,
11]. Medium and genetic factors as gene p53
(the molecular marker of the tumor
dedifferentiation) mutations, detected in 2030% of cases and also N-RAS and BRAF
genes alterations can be incriminated for their
prognostic stratification [12]. The diagnosis of
ITC can be difficult, the gold standard being
histology completed by ancillary studies as
immunohistochemistry
and
molecular
techniques [3, 9].
FNAB is delusive evidencing subtle
modifications leading often to a erroneous
initial diagnosis of follicular carcinoma as in
our observation. Cellular smears composed of
monomorphic groups of small cells disposed
in large layers or clusters, with high N/C ratio,
frequent mitotic activity and presence of
necrotic or cellular debris are suggestive for
ITC [13, 14].
Ultrasound is a descriptive but not a
diagnostic investigation for assessing the
dimensions and tumoral invasion, the
eventual adenopathy (as in our observation),
the often predominant hypoechogeous,
solid/homogeneous aspect, but the absence
of halo or cystic modifications. Ultrasound is
also used to guide needle biopsy [3, 4].
131 I scintigraphy (radioiodine uptake is
increased in 75% of ITC), Tc-99 MIBI
(methoxisobutilisonitril) or DMSA (acid
18 Diaconescu S et al. 




Solid, trabecular or “insular” growth
pattern;
The absence of papillary carcinoma’s
characteristics;
Existence of “complicated” nuclei with
greater mitotic activity and tumoral
necrosis [2].
The rest of microscopic description
traced with the one of our observation.
Electronic microscopy showed an
abundant cytoplasm, endoplasmic
reticulum, numerous mitochondria and
free ribosoms [13, 14, 15].
We must also remember the “focal” ITC
coexisting with zones of papillary, folliculary
or even anaplastic carcinoma and also the
dedifferentiation of some initially less
www.npplweb.com/wjmscr/content/2/4 World J Med Surg Case Rep 2013;2:15‐20 aggressive lesions. The mainstay ITC therapy
is total thyroidectomy with lateral and even
central neck dissection followed by high dose
radioiodine administration, efficacious in
distant metastases present in 1/3 of
observations [16, 17, 18].
the thyroid gland: an aggressive subset of
differentiated thyroid neoplasms. Surgery
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[2]. Sobrino-Simoes M Arbores-Saavedra J, Tallini
G, Santoro M, Volante M, Pilotti S et al: “Poorly
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[3]. Kazaure HS, Roman SA, Sosa JA: Insular
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[4]. Langhans T: Uber des epithelialen form der
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[5]. Sakamoto A, Kasai N, Sugano H: Poorly
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[6]. Carcangiu ML, Zampi G, Rosai J: Poorly
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Conclusion
Our case exemplify a rare described
epithelial thyroid tumor (about 200 cases in
literature) characterized by intermediate
aggressiveness between the cancers of
follicular origin and anaplastic tumors,
advanced stage at presentation with a rapidly
invasive behavior, accelerated local and
general dissemination, local recurrences and
poor
prognosis.
Atypical
debut
with
precessive adenopathy, lacking goiter and the
presence of follicular features at the FNAB,
determined diagnosis difficulties, this one
been established only after the paraffin
examination. Radical surgical treatment
completed by radioiodine ablation can assure
however the cure or prolonged survival in a
variable percentage of cases as in our patient.
Author’s Contribution
MRD: Conceived and drafted the manuscript,
performed surgery.
MG: Literature research.
MG: Pathology.
SD: Essentially involved in manuscript
drafting.
Conflict of Interest
There is not personal and financial conflict
of interest.
Ethical considerations
The authors obtained the patient's
consent foe the publication on this paper.
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Surgical Case Reports
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