|Year : 2013 | Volume
| Issue : 1 | Page : 82-83
Follicular carcinoma in a 9-year-old child: A case report and review of literature
Babina Sarangthem1, Gayatri Devi Pukhrambam1, Barindra Sharma2, Durlav Chandra Sarma1
1 Department of Pathology, Regional Institute of Medical Sciences, Imphal, Manipur, India
2 Department of Immunohaematology and Blood Transfusion, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Web Publication||17-Aug-2013|
Gayatri Devi Pukhrambam
Departments of Pathology, Regional Institute of Medical Sciences, Imphal - 795 004, Manipur
Source of Support: None, Conflict of Interest: None
Thyroid cancer is rare in children and is mostly of the papillary carcinoma histologically. Follicular carcinoma constitutes 10-20% of all primary thyroid cancers with the age peak at the fourth and fifth decades. Iodine deficiency appears to be the main contributing factor for follicular carcinoma because iodine supplementation to the diet has been associated with a decline in the incidence of this tumor in iodine-deficient areas. A 9-year-old female patient who was under treatment for hypothyroidism presented with a single thyroid nodule, which on fine needle aspiration cytology, a cytologic diagnosis of follicular neoplasm was made. A histological diagnosis of minimally invasive follicular carcinoma was done after subtotal thyroidectomy. This case was presented with review of the literature.
Keywords: Follicular carcinoma, Hypothyroidism, Iodine deficiency, Papillary carcinoma
|How to cite this article:|
Sarangthem B, Pukhrambam GD, Sharma B, Sarma DC. Follicular carcinoma in a 9-year-old child: A case report and review of literature. J Med Soc 2013;27:82-3
|How to cite this URL:|
Sarangthem B, Pukhrambam GD, Sharma B, Sarma DC. Follicular carcinoma in a 9-year-old child: A case report and review of literature. J Med Soc [serial online] 2013 [cited 2020 Sep 20];27:82-3. Available from: http://www.jmedsoc.org/text.asp?2013/27/1/82/116657
| Introduction|| |
Follicular carcinoma of the thyroid is rare in children. It comprises 10-20% of all primary thyroid cancers with female predominance with a peak age in the fourth and fifth decades. Iodine deficiency appears to be the main contributing factor. Thyroid cancer in children is biologically more aggressive than in adults with more frequent extra thyroid extension. 
A 9-year-old female patient who was undergoing treatment for hypothyroidism presented with a single thyroid nodule. A cytologic diagnosis of follicular neoplasm was made on fine needle aspiration cytology (FNAC) followed by a histologic diagnosis of minimally invasive follicular carcinoma. Rarity of this malignancy in children and being the first case detected at this age in our institute prompted us to report with review of the literature.
| Case Report|| |
A 9-year-old female patient presented with a solitary thyroid nodule of 3 cm × 3 cm size; well circumscribed, firm and non-tender. There was no lymphadenopathy and no organomegaly. Hematological, biochemical and urine examinations were within the normal limits. Electrocardiogram and X-ray chest were normal. Serum T 3 was 0.5 nmol/L (normal range 0.9-2.5 nmol/L), T 4 was 40 nmol/L (N.R. 60-120 nmol/L) and TSH 8 uIU/ml (0.3-6.8 uIU/ml). She was undergoing treatment for hypothyroidism at a district hospital for the last 3 months and the thyroid swelling was increasing in size. FNAC was carried out on 17/02/2004. Cytological findings revealed increased cellularity with a tendency to follicle formation, scanty colloid, and occasional atypical cells with prominent nucleoli suggesting follicular neoplasm [Figure 1]. Subtotal thyroidectomy was done. Grossly a single, greyish white, well-capsulated, and solid tissue of 3.5 cm × 3 cm × 3 cm was identified with normal thyroid tissue. Histological examination showed increased cellularity with the follicular arrangement, cellular atypia and some cells with prominent nucleoli, along with focal Hurthle cell metaplasia. Evidence of capsular and vascular invasion was also noted [Figure 2]. Diagnosis of minimally invasive follicular carcinoma was made, based on the criteria of Fletcher. 
|Figure 1: Photomicrograph of fine needle aspiration cytology smear showing increased cellularity with follicle formation and scanty colloid (MGG, ×400)|
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|Figure 2: Photomicrograph of histology section showing vascular invasion (tumor plug lined by endothelium) inside the capsule (H and E, ×100)|
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| Discussion|| |
Thyroid carcinoma is rare in children and is mostly of the papillary histological type. Follicular carcinoma shares with papillary carcinoma the same predilection for females; however, it occurs on an average in patients, who are a decade older with the main mode of spread being hematogenous rather than lymphatic.  Depending on the degree of invasiveness, follicular carcinoma has been subdivided into a minimally invasive and widely invasive type. , The mean age for minimally invasive type is between 48 years and 55 years for the widely invasive type.  Iodine deficiency appears to be the main contributing factor. Other factors include pre-existing adenoma, dyshormonogenesis, irradiation, and Cowden disease.  The tumor is more likely to be functional and secretory than the papillary type.  The present case was also under treatment for hypothyroidism for the last 3 months.
When the follicular variant of papillary carcinoma, Hurthle cell carcinoma, poorly differentiated (insular) carcinoma and rare mixed medullary-follicular carcinoma are excluded, follicular carcinoma becomes a relatively rare neoplasm whose identification largely depends on the presence of invasion of the capsule, blood vessels or adjacent thyroid.  There is a decreasing trend in the incidence of this tumor probably because of iodine supplementation in the diet. The incidence of ras point mutation has been found to be much higher for follicular carcinoma than papillary carcinoma (53% vs. 17%) suggesting that this difference may be related to the known differences in epidemiology, pathology, and clinical behavior between the two tumors.  Recently, a genetic abnormality, t (2:3) (q 13; q 25) has been detected resulting in the PAX8-PPAR gamma one fusion and found that the follicular carcinomas with PPAR gamma rearrangement tend to have vascular invasion and solid/nested histology. 
The diagnosis of follicular carcinoma is not made cytologically because cytomorphology alone is not reliable criteria of malignancy. Thus, histological evaluation is always required to look for invasion.
Metastases are common in the widely invasive type, occur in fewer than 5% of minimally invasive tumors with vascular invasion and develop in fewer than 1% of the tumors with capsular invasion only.  There was no evidence of metastasis in the present case. Adverse prognostic indicators are younger age at discovery and presence of distant metastasis. In conclusion, the present case highlights the association of hypothyroidism with follicular carcinoma and the importance of critical examination of solitary thyroid nodule even in a child.
| References|| |
|1.||Fletcher CD, editor. Diagnostic Histopathology of Tumors. 3 rd ed., Vol. 2. Philadelphia: Elsevier Health Science; 2007. p. 997-1079. |
|2.||Evans HL, Vassilopoulou-Sellin R. Follicular and Hurthle cell carcinomas of the thyroid: A comparative study. Am J Surg Pathol 1998;22:1512-20.2. |
|3.||Franssila KO, Ackerman LV, Brown CL, Hedinger CE. Follicular carcinoma. Semin Diagn Pathol 1985;2:101-22.3. |
|4.||Oyama T, Suzuki T, Hara F, Iino Y, Ishida T, Sakamoto A, et al. N-ras mutation of thyroid tumor with special reference to the follicular type. Pathol Int 1995;45:45-50. |
|5.||Kroll TG, Sarraf P, Pecciarini L, Chen CJ, Mueller E, Spiegelman BM, et al. PAX8-PPAR gamma1 fusion oncogene in human thyroid carcinoma corrected. Science 2000;289:1357-60. |
|6.||Lang W, Choritz H, Hundeshagen H. Risk factors in follicular thyroid carcinomas. A retrospective follow-up study covering a 14-year period with emphasis on morphological findings. Am J Surg Pathol 1986;10:246-55. |
[Figure 1], [Figure 2]