|Year : 2014 | Volume
| Issue : 3 | Page : 176-178
Follicular variant of papillary thyroid carcinoma in a Struma ovary: Report of a rare case
Anindya Adhikari, Subhalakhshmi Mukhopadhyay, Suprio Roy Chowdhury, Prasenjit Bar
Department of Pathology, Medical College, Kolkata, West Bengal, India
|Date of Web Publication||7-Oct-2014|
Basudevpur, Banipur, Sankrail, Howrah - 711 304, West Bengal
Source of Support: None, Conflict of Interest: None
Malignant struma ovarii is a very rare neoplasm and constitute 0.1-0.3% of all ovarian teratoma. Herein, we report a case of follicular variant of papillary carcinoma in a struma ovarii (SO) of left side in a young female of 21 years, presented with a tubo-ovarian (T-O) mass of diameter of 8 cm. Ultrasonography revealed, slightly bulky uterus and a large cystic T-O mass in left side. Total abdominal hysterectomy with left sided salpingo-oophorectomy was done. Histopathological examination revealed multiple thyroid follicles lined by cells having optically clear, overlapping nuclei with inconspicuous nucleoli. Some nuclei showed nuclear grooves also. No papillary structures were seen. Immunohistochemically, the tumor was positive for thyroid transcription factor (TTF). Both functionally and architecturally, thyroid gland was absolutely normal. Neither postoperative radiotherapy nor adjuvant chemotherapy was given, and the patient has remained disease free 6 months postoperatively.
Keywords: Papillary carcinoma, struma ovarii, thyroid
|How to cite this article:|
Adhikari A, Mukhopadhyay S, Chowdhury SR, Bar P. Follicular variant of papillary thyroid carcinoma in a Struma ovary: Report of a rare case. Saudi J Health Sci 2014;3:176-8
|How to cite this URL:|
Adhikari A, Mukhopadhyay S, Chowdhury SR, Bar P. Follicular variant of papillary thyroid carcinoma in a Struma ovary: Report of a rare case. Saudi J Health Sci [serial online] 2014 [cited 2023 Mar 22];3:176-8. Available from: https://www.saudijhealthsci.org/text.asp?2014/3/3/176/142339
| Introduction|| |
Struma ovarii (SO) belongs to the group of monodermic and highly specific teratomas and comprises less than 5% of mature teratomas.  More than 50% of the tumor should consist of thyroid tissue before it is designated as a SO.  Though, the vast majority of SO are benign (95%),  it may turn into malignancy too. Papillary carcinoma is most common in malignant SO.
Our case is a follicular variant of papillary carcinoma in a SO.
| Case report|| |
A 21-year-old female presented with complaints of gradually increasing distension and discomfort of lower abdomen, intermittent spotting for last 3 months. The patient was cachectic and had severe pallor. There was no swelling in neck. Abdominal palpation could not reveal any mass except mild left iliac fossa tenderness. Vaginal examination disclosed slightly bulky uterus and a large left tubo-ovarian mass, which was tender on movement. Right adnexa, fornices and pouch of Douglas were clear.
Ultrasonography (USG) of whole abdomen showed slightly bulky uterus and a left sided cystic T-O mass measuring 8 cm in diameter. There was no collection of fluid in abdominal or pelvic cavity. Total abdominal hysterectomy with left sided salpingo-oophorectomy was done.
Grossly, uterus was slightly bulky. Along with attached small tube (3 cms), there was a cystic T-O mass measuring 8 × 7.5 × 3 cm and weighing 200 grams. Outer surface of the cyst was smooth, lobulated and thickened in some places. On cut-section, it was a multi locular cyst with smooth and slightly hemorrhagic inner surface, colloid material was seen inside. A small solid area measuring 2.5 × 2.5 cm was noted. No normal ovarian tissue could be identified [Figure 1].
|Figure 1: Gross appearance of cut section of T-O mass showing colloid material|
Click here to view
Histological examination of the T-O mass showed multiple large dilated thyroid follicles having eosinophilia colloid with scalloped edges. The lining cells had optically clear, overlapping nuclei with inconspicuous nucleoli. Some nuclei showed grooves also. No papillary structure was seen. Based on morphology, a diagnosis given was that of a follicular variant of papillary carcinoma in SO [Figure 2]. Immunohistochemically, nature of the lining cells were confirmed by thyroid transcription factor (TTF)-1 positivity. There was no enlargement of thyroid gland in neck, serum free triiodothyronine FT3, free thyroxine FT4, thyroid stimulating hormone (TSH) was normal and USG thyroid was also normal. No postoperative therapy was given. The 6 months follow-up period was uneventful.
|Figure 2: Histopathological picture showing follicular variant of papillary thyroid carcinoma (H and E, x400)|
Click here to view
| Case discussion|| |
SO is a teratoma in which thyroid tissue predominates. Though it is mostly benign, thyroid tissue of struma may demonstrate the same spectrum of pathological changes as in the normal thyroid including malignant changes.
SO is seen mainly in female in the fifth decade but rarely occur in pre-pubertal girls. The patient usually presents with non-specific abdominal symptoms like pain or abdominal distension. Rarely, patient presents with pseudo-Meigs' syndrome or abnormal vaginal bleeding or symptoms of hyperthyroidism with occasional enlargement of thyroid gland. Malignant SO is seldom diagnosed preoperatively due to the rarity of the disease itself and the even rarer complications of thyrotoxicosis.  Any type of thyroid cancer can arise in SO,  even malignant lymphoma. Papillary carcinoma is most common and has the same histologic appearance as seen in papillary carcinoma occurring primarily in the thyroid.  Follicular and micro carcinoma variants of papillary carcinoma have been described in SO  and featuring either RAS or BRAF mutation.
Papillary carcinoma grows in an infiltrative manner, usually containing well- developed papillae, and is composed of cells with large, crowded, grooved nuclei with small nucleoli. Some nuclei are clear and others contain intra nuclear cytoplasmic inclusion and the cell cytoplasm is moderate or abundant and appears dense. Case of follicular variant of papillary carcinoma in SO containing numerous intraluminal crystalloids has been reported. Most case of malignant SO designated as carcinoma on histological grounds alone and never spreads beyond ovary.  Rarely, (5%) malignant SO metastasize.  Metastases have been described locally to peritoneum, omentum, contralateral ovary or to distant sites like lymph node, liver, bone, lung. These appear best treated by hysterectomy, bilateral salpingo-oophorectomy, thyroidectomy and radio iodine administration.  Follow-up examinations of patients with thyroid-type carcinoma include assessment of thyroglobulin levels and Iodine-131 scanning, the same procedures used in the case of thyroid carcinoma. 
| Conclusion|| |
Our case shows follicular variant of papillary carcinoma in a unilateral SO in a young patient which is a rare tumor. Clinical presentation as malignant condition was a remarkable and also very unusual finding. It is important to be aware of the fact that SO may contain malignant thyroid tissue, which is needed to be diagnosed correctly for proper decision regarding follow-up or management.
| Acknowledgment|| |
Department of Gynaecology, Medical college, Kolkata for co-operation regarding patient's informations.
| References|| |
|1.||Mandic A, Tesic M, Rajovic J, Vujkov T, Zivalijevic M, Mihajlovic O. Ovarian teratomas: Struma ovarii. Arch Oncol 2001;9:189-91. |
|2.||Russell P, Painter DM. The pathological assessment of ovarian neoplasms V: The germ cell tumours. Pathology 1982;14:47-72. |
|3.||Alvarez DM, Lee V, Bhatt S, Dogra VS. Struma ovarii with papillary thyroid carcinoma. J Clin Imaging Sci 2011;1:44. |
|4.||Matsuda K, Maehama T, Kanazawa K. Malignant struma ovarii with thyrotoxicosis. Gynecol Oncol 2001;82:575-7. |
|5.||Zaloudek CF. Tumors of the female genital tract. In: Fletcher CD, editor. Diagnostic Histopathology of Tumors. China: Elsevier Limited. 3 rd ed. 2007. |
|6.||Devaney K, Snyder R, Norris HJ, Tavassoli FA. Proliferative and histologically malignant struma ovarii: A clinicopathologic study of 54 cases. Int J Gynecol Pathol 1993;12:333-43. |
|7.||Boutross-Tadross O, Saleh R, Asa SL. Follicular variant of papillary thyroid carcinoma arising in struma ovarii. Endocr Pathol 2007;18:182-6. |
|8.||Yücesoy G, Cakiroglu Y, Muezzinoglu B, Besnili B, Yucesoy I. Malignant struma ovarii: A case report. J Korean Med Sci 2010;25:327-9. |
|9.||DeSimone CP, Lele SM, Modesitt SC. Malignant struma ovarii: A case report and analysis of cases reported in the literature with focus on survival and I131 therapy. Gynecol Oncol 2003;89:543-8. |
|10.||Soto Moreno A, Venegas EM, Rodriguez JR, Sánchez F, Robles MJ, Martinez MA, et al. Thyroid carcinoma on an ovarian teratoma: A case report and review of literature. Gynecol Endocrinol 2002;16:207-11. |
[Figure 1], [Figure 2]