Presentation
Left vocal cord palsy.
Patient Data
Hypoattenuating ill-defined mass measuring 2.0 x 1.8 x 2.3 cm located at the posterior aspect of the left thyroid lobe mid pole which is inseparable from the left thyroid lobe itself and extends into the left tracheo-esophageal groove. Separate 1.4 cm hypoattenuating nodule in the lower pole of the left thyroid lobe. The right thyroid lobe is unremarkable. Enlarged heterogeneous lymph node comprising cystic and calcified components measuring 1.9 x 1.3 cm in the level III/IV on the left, with smaller rounded but heterogeneous 8 mm level IV lymph node seen just beneath this. Left-sided vocal cord palsy.
Small non-calcified subpleural nodule measuring 4.4 mm in the posterior segment of the right lower lobe. The lungs and pleural spaces are otherwise clear.
The lesion on the left lobe was confirmed by ultrasound, as well as the suspicious lymph node, and FNA was performed in both.
Case Discussion
This case illustrates left vocal cord palsy caused by a thyroid malignancy probably infiltrating the left laryngeal recurrent nerve in its ascending path.
MICROSCOPIC DESCRIPTION: 1. The smears contain numerous pigmented macrophages and scattered cohesive sheets of epithelioid cells showing enlarged round nuclei, prominent nucleoli and dense, well-defined cytoplasm. The background contains abundant proteinaceous material. The cytological features favor a benign thyroid cyst, however a cystic neoplasm can not be entirely excluded. Additionally the paucity of background lymphocytes suggests that a lymph node has not been sampled. 2. The hypercellular smears contain atypical follicular epithelial cells presenting in sheets and papillary-like clusters showing round-to-oval nuclei with grooves and intranuclear pseudoinclusions. Globules of colloid and multinucleated giant cells are present in the background.
DIAGNOSIS: 1. FNA "Lymph Node": Inconclusive. 2. FNA Thyroid: Papillary thyroid carcinoma.
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