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Clinical Problem Solving: Pathology |

Pathology Quiz Case 2

Roshan Sethi, BS; Elliott Kozin, MD; Harrison W. Lin, MD; William C. Faquin, MD, PhD; Gregory W. Randolph, MD
Arch Otolaryngol Head Neck Surg. 2012;138(11):1093. doi:10.1001/2013.jamaoto.363a 10.1001/2013.jamaoto.363b.
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A 41-year-old woman presented with a slowly enlarging right submandibular mass. Her medical history was notable for Raynaud phenomenon, fibromyalgia, and rosacea, which had been controlled with minocycline therapy for more than 1 year. She did not smoke or drink alcohol. Her family history was significant for non-Hodgkin lymphoma in her father.

Physical examination revealed a 5-cm, firm, mobile, submandibular mass, consistent with a lymph node. Thyroid examination also revealed a 1-cm right midpole nodule. Contrast-enhanced computed tomography of the neck (Figure 1) demonstrated a large, 2.5 × 1.8 × 4.0-cm, cystic lymph node in the right level II region and a 8.0 × 6.8 × 13.0-mm low-attenuation lesion in the right thyroid lobe (Figure 2). The thyroid-stimulating hormone level was measured at 2.4 μIU/mL. Fine-needle aspiration revealed the characteristic cytologic features of papillary thyroid carcinoma. Accordingly, the patient underwent a total thyroidectomy and a right modified radical neck dissection. Intraoperatively, the thyroid was noted to be grossly black in appearance. Pathologic examination showed a 1.0-cm classic subtype of papillary thyroid carcinoma. An unusual finding, however, was that the surrounding benign thyroid parenchyma contained coarse, black pigment granules within the cytoplasm of follicular cells, and the colloid within follicles was gray-purple (Figure 3). In contrast, there was no cytoplasmic pigment present in the adjacent papillary thyroid carcinoma (Figure 4).

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