Thyroid gland
Papillary thyroid carcinoma
Rare variants
Warthin-like

Editorial Board Member: Andrey Bychkov, M.D., Ph.D.
Editor-in-Chief: Debra Zynger, M.D.
Shipra Agarwal, M.D.

Topic Completed: 6 August 2020

Minor changes: 23 September 2020

Copyright: 2003-2020, PathologyOutlines.com, Inc.

PubMed Search: Warthin-like variant thyroid

Shipra Agarwal, M.D.
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Cite this page: Agarwal S. Warthin-like. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/thyroidwarthin.html. Accessed September 29th, 2020.
Definition / general
  • Rare histological variant of papillary thyroid carcinoma (PTC), having favorable prognosis
  • Characterized by papillae lined by large oncocytic cells with nuclear features of PTC and prominent lymphoplasmacytic infiltrate within the papillary cores
  • Proposed by Apel et al. in 1995 (Am J Surg Pathol 1995;19:810)
Essential features
  • Histopathologically mimics Warthin tumor of salivary glands, i.e. the lining oncocytic epithelial cells and the abundant lymphoid stroma
  • Commonly associated with lymphocytic / Hashimoto thyroiditis
Terminology
  • Papillary carcinoma, Warthin-like variant
  • Microscopically resembles Warthin tumor of salivary glands, hence the name
ICD coding
  • ICD-O: 8260/3 - Papillary carcinoma of thyroid
  • ICD-10: C73 - Malignant neoplasm of thyroid gland
Epidemiology
Sites
  • Either lobe or isthmus of thyroid gland
Clinical features
Diagnosis
  • Diagnostic workup is similar to any thyroid mass / nodule
    • Ultrasound with fine needle aspiration cytology (FNAC)
    • CT scan may be useful to evaluate extrathyroidal extension and lymph node metastases
  • Final diagnosis is rendered on histopathological examination of resected tumor
    • Accurate diagnosis of Warthin-like variant may not be possible on FNAC; however, preoperative recognition of Warthin-like PTC does not influence treatment decisions
Radiology description
  • Sonography:
    • Solid, wider than tall and hypoechoic nodules (Med Ultrason 2019;21:152, Endocr J 2016;63:329)
    • Margins: smooth / irregular / microlobulated
    • Less commonly, punctate echogenic foci; taller than wide shape; cystic component
    • American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) category 4 or 5 (Med Ultrason 2019;21:152)
    • Color Doppler ultrasound: little or no internal vascularity
    • Thyroid parenchyma: heterogeneous echogenicity, indicative of diffuse thyroiditis
Radiology images

Images hosted on other servers:
Ultrasound Ultrasound Ultrasound Ultrasound

Ultrasound

Prognostic factors
Case reports
Treatment
  • Based on American Thyroid Association guidelines (Thyroid 2016;26:1)
  • Also based on National Comprehensive Cancer Network guidelines (J Natl Compr Canc Netw 2018;16:1429)
  • Usually surgical excision, such as lobectomy or total thyroidectomy with or without neck dissection
Gross description
  • Usually solitary nodule, well circumscribed, unencapsulated and limited to the thyroid gland
  • Solid, red-brown to tan or gray-white, 3 - 50 mm (Case Rep Oncol Med 2012;2012:689291)
  • Variable cystic change, hemorrhagic areas, calcification
  • Background thyroid parenchyma: pale yellow to tan, variable nodularity (consistent with Hashimoto thyroiditis)
Gross images

Images hosted on other servers:
Solid, gray-white

Solid, gray-white

Microscopic (histologic) description
Microscopic (histologic) images

Contributed by Andrey Bychkov, M.D., Ph.D.
Enlarged papillae

Enlarged papillae

Lymphoid follicle

Lymphoid follicle

Oncocytic epithelium

Oncocytic epithelium

Background thyroiditis

Background thyroiditis

Ki67

Ki67

Cytology description
Cytology images

Contributed by Shipra Agarwal, M.D.
Inflammatory background

Inflammatory background

Lymphocytic permeation

Lymphocytic permeation

Oncocytic cells

Oncocytic cells



Images hosted on other servers:
Liquid based cytology and conventional smear

Liquid based cytology and conventional smear

Positive stains
Negative stains
Molecular / cytogenetics description
Sample pathology report
  • Thyroid, total thyroidectomy:
    • Papillary thyroid carcinoma, Warthin-like variant, left lobe, 2.5 cm (see synoptic report)
Differential diagnosis
  • Oncocytic variant of PTC:
    • Lacks lymphoplasmacytic infiltrate in the papillary stalks
  • Tall cell variant of PTC:
    • Tumor cells have a height 2 to 3 times their width and constitute at least 30% of all tumor cells
    • Papillary stalks lack the lymphocyte rich stroma
  • Classic type PTC with focal oncocytic change:
    • Absent lymphoid stroma
    • Only focal oncocytic change
  • Classic type PTC associated with lymphocytic / Hashimoto thyroiditis:
    • Tumor cells lack oncocytic change
    • Absent lymphoplasmacytic infiltrate in papillary cores
    • May contain small areas of Warthin-like architecture (papillary cores stuffed with lymphoplasmacytic infiltrate), which is not sufficient to qualify the whole tumor as Warthin-like variant
  • Follicular neoplasm with oncocytic change:
    • Lacks well developed nuclear features of PTC; round nuclei, prominent nucleoli and rare intranuclear inclusions
    • Usually lacks papillae
    • Absent stromal lymphoplasmacytic infiltrate in stalks of papillae
  • Hashimoto thyroiditis:
    • Lacks papillae
    • Oncocytic cells of Hashimoto thyroiditis have round nuclei with a prominent single nucleolus and lack well developed nuclear features of PTC
  • Cytology:
    • Hürthle cell neoplasm:
      • Lacks papillary fragments, nuclear features of PTC and a lymphocytic background, except if associated lymphocytic thyroiditis
    • Oncocytic PTC:
      • Usually lacks lymphocytic background, except if associated with lymphocytic thyroiditis
      • Cannot be differentiated on liquid based cytology
    • Classic type PTC:
      • Lacks diffuse oncocytic change
      • Usually lacks lymphocytic background except if associated with lymphocytic thyroiditis
Board review style question #1

This thyroid tumor is named after which of the following salivary gland tumors?

  1. Lymphadenoma
  2. Oncocytic carcinoma
  3. Oncocytoma
  4. Sialadenoma papilliferum
  5. Warthin tumor
Board review answer #1
E. Warthin tumor

Warthin-like variant of papillary thyroid carcinoma is characterized on histomorphology by papillae lined by oncocytic cells and a dense lymphoplasmacytic infiltrate within the papillary cores, closely mimicking Warthin tumor of salivary gland. The latter shows oncocytic columnar cells with underlying basal cells, resting on a dense lymphoid stroma.

Comment Here

Reference: Warthin-like variant
Board review style question #2
Which of the following is typically associated with Warthin-like variant of papillary thyroid carcinoma?

  1. Favorable clinical outcome
  2. Frequent dedifferentiation
  3. Mitochondrial DNA mutations
  4. Multiple (soap bubble-like) intranuclear inclusions
  5. Tumor cells have height 2 to 3 times the width
Board review answer #2
A. Favorable clinical outcome

Warthin-like variant of papillary thyroid carcinoma (PTC) has a favorable clinical outcome and dedifferentiation is unusual. It harbours BRAFV600E mutation in 65 - 75% cases. Mitochondrial DNA mutations are characteristic of oncocytic variant of PTC. Tumor cells having height 2 to 3 times the width is a diagnostic feature of tall cell variant of PTC. Multiple soap bubble-like intranuclear inclusions are typically described in tall cell variant of PTC but can be seen in other variants like hobnail variant also.

Comment Here

Reference: Warthin-like variant
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