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Case Reports
. 2020;61(1):219-226.
doi: 10.47162/RJME.61.1.24.

Clear cell change in follicular adenoma of the thyroid. A diagnostic challenge

José Fernando Val-Bernal  1 , María Martino
Affiliations
Case Reports

Clear cell change in follicular adenoma of the thyroid. A diagnostic challenge

José Fernando Val-Bernal et al. Rom J Morphol Embryol. 2020.

Abstract

Clear cells in thyroid neoplasms can take two main forms: balloon-shaped and signet-ring cells. Balloon-shaped cell change in follicular adenoma is rare. A review of the literature has revealed only 20 previously published cases. We report herein a new case in the right thyroid lobe of a 45-year-old man. The clinicopathological data of the 21 cases including our paper have revealed that the ages of the patients ranged from 22-70 years, with a mean of 41.6 years. There was a clear predominance in women (M:F, 1:6). The most frequent location was in either of both lobes (81.8%), rarely affecting the isthmus. One case was observed in an ectopic thyroid in the submandibular region. The size ranged from 0.7-5.5 cm (mean 2.9 cm). The type of surgical intervention where this data was reported it was lobectomy for 10 (55.5%) cases, thyroidectomy for six (33.3%) cases, and simple excision for two (11.1%) cases. In one patient, the lobectomy was accompanied by cervical lymph node dissection. No cases recurred or extended outside the thyroid. The main differential diagnoses include intrathyroidal clear cell tumor of parathyroid origin, clear cell carcinoma of follicular, oncocytic, papillary, medullary or undifferentiated (anaplastic) origin, paraganglioma, metastatic clear cell carcinoma, especially of renal origin, metastatic balloon cell melanoma, and clear large-cell lymphoma. A thyroid lesion showing clear cell change constitutes a diagnostic challenge in cytological and biopsy diagnosis. Careful observation of the routine techniques along with the aid of an adequate immunohistochemical panel is essential to reach a correct biopsy diagnosis.

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Conflict of interest statement

The authors declare that they have no conflict of interests.

Figures

Figure 1
Figure 1
Fine-needle aspiration cytology. First study: (A) Groups and microfollicles of clear balloon-shaped cells showing abundant fine vesicles in their cytoplasm. Second study: (B) A cluster and a microfollicle of clear balloon-shaped cells can be seen – nuclei are round with a visible nucleolus; (C) A microfollicle is displaying a central lumen – there is slight anisokaryosis. Papanicolaou (Pap) staining: (A–C) ×400
Figure 2
Figure 2
Total thyroidectomy. The right lower lobe contains a 2 cm diameter, solid, pale tan, nodular lesion
Figure 3
Figure 3
Histopathology of the follicular adenoma with clear cell change: (A) Well-circumscribed lesion with a thin smooth capsule of fibrous connective tissue; (B) Trabeculae and solid nests of clear balloon-shaped cells containing fine vesicles – many nuclei are central, hyperchromatic and show a single nucleolus. Hematoxylin–Eosin (HE) staining: (A and B) ×400
Figure 4
Figure 4
Architecture of the follicular adenoma with clear cell-change: (A) Microfollicular architecture, structures with a central lumen are surrounded by clear cells – scant amount of colloid shows pale eosinophilic staining; (B) Central lumina are occupied by PAS-positive colloid – the PAS staining accentuates the cytoplasmic granularity produced by the confluence of fine cytoplasmic vesicles. Hematoxylin–Eosin (HE) staining: (A) ×400. Periodic Acid–Schiff (PAS) staining: (B) ×400
Figure 5
Figure 5
IHC reactivity of the follicular adenoma with clear cell change. The clear balloon-shaped cells show positivity for pan-CK AE1/AE3 (A, ×200), TGB (B, ×400), PAX8 (C, ×400), and TTF-1 (D, ×400). IHC: Immunohistochemical; Pan-CK: Pan-cytokeratin; TGB: Thyroglobulin; PAX8: Paired box gene 8 protein; TTF-1: Thyroid transcription factor-1
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