Question: A 24-year-old woman was referred to our hospital because of thyroid nodules. Physical examination revealed a painless nodule in the right lobe of the thyroid but no abnormal findings in the abdomen. The patient has no remarkable past history and laboratory studies, including blood count, chemistry, and thyroid function tests, were all within normal limits. Computed tomography revealed 2 thyroid tumors (Figure A) and fine needle aspiration from the right tumor suggested undifferentiated carcinoma. The patient underwent total thyroidectomy, which disclosed that both nodules were cancers with identical and unique histologic findings. They were composed of cribriform, morular, and papillary growth patterns (Figure B–D). Immunohistochemistry showed cytoplasmic and nuclear accumulation of beta-catenin (Figure E). The final diagnosis was cribriform-morular variant, a rare subtype of papillary thyroid carcinoma.View Large Image Figure ViewerDownload Hi-res image Download (PPT) What is a possible underlying gastrointestinal disease in this case? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Patients with familial adenomatous polyposis (FAP) are at risk for extracolonic malignancies, including duodenal ampullary cancer, neurologic tumors, and papillary thyroid cancer. Approximately 1%–2% of FAP patients develop thyroid carcinoma, which is observed almost exclusively in young, female patients (male:female ratio, 1:20).1Groen E.J. Roos A. Muntinghe F.L. et al.Extra-intestinal manifestations of familial adenomatous polyposis.Ann Surg Oncol. 2008; 15: 2439-2450Crossref PubMed Scopus (174) Google Scholar The diagnosis of thyroid cancer precedes polyposis in one third of FAP cases.2Tomoda C. Miyauchi A. Uruno T. et al.Cribriform-morular variant of papillary thyroid carcinoma: clue to early detection of familial adenomatous polyposis-associated colon cancer.World J Surg. 2004; 28: 886-889Crossref PubMed Scopus (78) Google Scholar Thyroid cancer in FAP is often multiple and shows the unique histology known as cribriform-morular variant (CMV) of papillary carcinoma.2Tomoda C. Miyauchi A. Uruno T. et al.Cribriform-morular variant of papillary thyroid carcinoma: clue to early detection of familial adenomatous polyposis-associated colon cancer.World J Surg. 2004; 28: 886-889Crossref PubMed Scopus (78) Google Scholar CMV accounts for only 0.1%–0.2% of all papillary thyroid carcinoma, whereas >50% of CMV is associated with FAP.2Tomoda C. Miyauchi A. Uruno T. et al.Cribriform-morular variant of papillary thyroid carcinoma: clue to early detection of familial adenomatous polyposis-associated colon cancer.World J Surg. 2004; 28: 886-889Crossref PubMed Scopus (78) Google Scholar The histologic feature of CMV is a mixture of cribriform, morular, trabecular, and papillary growth pattern. Immunohistochemically, CMV invariably demonstrates aberrant nuclear and cytoplasmic accumulation of beta-catenin, which is not observed in other types of thyroid cancer.3Kurihara K. Shimizu S. Chong J.M. et al.Nuclear localization of immunoreactive β-catenin is specific to familial adenomatous polyposis in papillary thyroid carcinoma.Jpn J Cancer Res. 2000; 91: 1100-1102Crossref PubMed Scopus (34) Google Scholar In this case, the pathologic findings of thyroid cancer suggested underlying FAP, although the patient did not complain any polyposis-associated symptoms. Colonoscopy after thyroidectomy revealed hundreds of colorectal polyps (Figure F) without colorectal cancer. Polypectomy was performed for large polyps, all of which were low-grade tubular adenoma. The patient's father has also suffered from FAP and underwent total colectomy at the age of 35, although she did not know this until the diagnosis of her FAP. Germline mutation analysis by direct sequence revealed a nonsense mutation of APC exon 7.
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