Endocr Pathol (2018) 29:9–14
DOI 10.1007/s12022-017-9491-6
Synchronous and Metastatic Papillary and Follicular Thyroid
Carcinomas with Unique Molecular Signatures
Vincent Cracolici 1 & Ibro Mujacic 2 & Sabah Kadri 2 & Mir Alikhan 1 & Nifang Niu 2 &
Jeremy P. Segal 2 & Lauren E. Rosen 1 & David H. Sarne 3 & Adam Morgan 4 &
Samy Desouky 4 & Nicole A. Cipriani 1
Published online: 14 July 2017
# Springer Science+Business Media, LLC 2017
Abstract Despite the relatively high prevalence of thyroid
cancer, the occurrence of multiple synchronous, distinct sub-
types of primary thyroid carcinoma is uncommon. The inci-
dental finding of papillary thyroid microcarcinoma in a gland
with a biologically relevant follicular or medullary carcinoma
is more frequent than the synchronous occurrence of multiple
clinically significant carcinomas. We report a case of synchro-
nous papillary and follicular thyroid carcinomas metastatic to
lymph node and bone, respectively. Next generation sequenc-
ing showed BRAF V600E mutation in the primary papillary
carcinoma and NRAS Q61R mutation in the primary follicular
carcinoma and bony metastasis. To our knowledge, this is the
first reported case of synchronous and metastatic primary pap-
illary and follicular carcinomas, and the first report of syn-
chronous BRAF V600E mutated papillary and NRAS mutated
follicular carcinoma.
Keywords Metastatic thyroid carcinoma . Synchronous
thyroid carcinomas . Follicular thyroid carcinoma . Papillary
thyroid carcinoma . Molecular signatures of thyroid carcinoma
* Vincent Cracolici
vincent.cracolici@uchospitals.edu
1
Department of Pathology, The University of Chicago Medical
Center, 5841 South Maryland Ave, Chicago, IL 60637, USA
2
Division of Molecular Pathology, Department of Pathology, The
University of Chicago Medical Center, 5841 South Maryland Ave,
Chicago, IL 60637, USA
3
Section of Endocrinology, Department of Medicine, The University
of Chicago Medical Center, 5841 South Maryland Ave,
Chicago, IL 60637, USA
4
Department of Pathology, St. Mary’s Hospital, 700 South Park St,
Madison, WI 53715, USA
Background
Thyroid carcinomas account for approximately 4% of new can-
cer cases in the United States, with papillary carcinoma (PTC)
as the most common subtype, followed by follicular carcinoma
(FTC) [1]. Synchronous occurrence of well-differentiated thy-
roid carcinomas has been reported, most frequently papillary
and medullary, either as Bcollision^ tumors in the same lobe, or
as synchronous primaries that are geographically separated
[2–5]. Occasional synchronous papillary, medullary, and follic-
ular carcinomas have been reported [6–8], as well as synchro-
nous PTC and FTC [9–11]. Furthermore, the prevalence of
metastatic disease in thyroid carcinoma is as high as 43% in
PTC [12] and 22% in FTC [13]. However, to our knowledge,
synchronous metastatic PTC and FTC have not been reported.
We present a case of synchronous PTC and FTC in a patient
with metastasis of both components, and confirm the molecular
genetic differences of each carcinoma by next generation se-
quencing. The presence of synchronous papillary and follicular
carcinoma is rare, especially those that are larger than 1 cm and
biologically significant. To our knowledge, this is the first re-
port of synchronous and metastatic papillary and follicular car-
cinomas, as well as the first to demonstrate molecular genetic
differences in synchronous carcinomas.
Case Presentation
A 63-year-old euthyroid female with a history of Type 1 dia-
betes mellitus, hypercholesterolemia, hypertension, and
nephrolithiasis presented with flank pain. Although she did
not have a personal history of thyroid disease, her family
history was notable for maternal thyroidectomy for an uncer-
tain indication and two sisters with hypothyroidism. She had
no radiation exposure and no known genetic predisposition to
10 Endocr Pathol (2018) 29:9–14

tumor development. CT and subsequent MRI identified a 7-
cm mass centered on the left 11th rib with destruction of the
lateral T11 vertebral body and extension into the epidural
space, causing displacement of the spinal cord. Core needle
biopsy of the spinal lesion showed small colloid-filled folli-
cles with monotonous round to oval nuclei. Cells were posi-
tive for TTF-1 and thyroglobulin and negative for calcitonin
and BRAF, and a diagnosis of metastatic thyroid carcinoma
was made. She was treated with external beam radiotherapy to
the metastatic lesion, followed by total thyroidectomy with
central neck dissection 1 month later.
The entire thyroid gland was submitted for histologic eval-
uation. It showed a 1.7-cm tumor in the left lobe with irregular
borders and an invasive growth pattern. It was composed of
well-developed papillae lined by large cells with eosinophilic
cytoplasm and irregular, wrinkled nuclei with chromatin clear-
ing and intranuclear cytoplasmic pseudoinclusions (Fig. 1a,
b). A single lymph node in the central neck contained a 1-
mm focus of metastatic carcinoma with papillary growth,
abundant eosinophilic cytoplasm, and pseudoinclusions (Fig.
2c, d). These foci were considered papillary thyroid carcino-
ma. There was also a 1.1-cm tumor in the right lobe composed
of an encapsulated proliferation of cells arranged entirely in
follicles with scant clear to amphophilic cytoplasm and round,
regular nuclei without atypia. Scattered foci of capsular inva-
sion were present, as well as abundant central necrosis (Fig.
2a–d). One mitotic figure was identified per ten high power
fields, although the necrosis effaced much of the tumor
cellularity. Definite angioinvasion was not identified. This le-
sion was considered follicular thyroid carcinoma.
Following thyroidectomy, she was treated briefly with
levatinib, but it was discontinued after seizures likely secondary
to reversible posterior leukoencephalopathy syndrome.
Another round of radiation was given to the spine for pain,
and the persistent thoracic rib/vertebral lesion was resected
5 months after thyroidectomy. The spinal lesion showed histo-
logic features similar to prior core biopsy, namely small colloid-
filled follicles with round, bland nuclei and scant cytoplasm
(Fig. 2e, f). The spinal lesion was favored to represent a metas-
tasis from the primary right lobe follicular carcinoma. Two
months later, PET scan revealed additional lesions in the liver,
sacrum, and T12 vertebra. The hepatic lesion was resected,
radiation was given to the bony lesions, and radioactive iodine
therapy was administered. Approximately one and a half years
following original diagnosis, the patient is alive with disease.
Molecular Testing
Next generation sequencing of the primary left lobe PTC,
primary right lobe FTC, and spinal metastasis was performed
using the targeted hybrid capture 1213 gene UCM-OncoPlus
panel [14]. In brief, genomic DNA was isolated from macro-
dissected tumor-enriched FFPE tissue using the QIAamp
DNA FFPE Tissue Kit (Qiagen, Valencia, CA) according to
manufacturer’s instructions. Following extraction, DNA was

Fig. 1 Papillary thyroid

carcinoma. A low power image of
the 1.7-cm left lobe carcinoma
showing invasive borders and
intratumoral fibrosis (a). At
higher power (b), well-defined
papillary projections are apparent
and are lined by large cells with
eosinophilic cytoplasm and
nuclear atypia including
wrinkling, chromatin clearing,
and pseudoinclusions (inset). A
lymph node from the central neck
(c) with a 1-mm focus of
metastatic papillary thyroid
carcinoma. At higher power (d),
nuclei show enlargement,
grooves, and multiple crisp
eosinophilic intranuclear
cytoplasmic pseudoinclusions.
These features are identical to
those seen in the primary
papillary thyroid carcinoma
Endocr Pathol (2018) 29:9–14 11

Fig. 2 Follicular thyroid

carcinoma. A low power image of
the 1.1-cm right lobe carcinoma
showing a relatively well-
circumscribed neoplasm with a
thick peripheral capsule (a).
Broad, irregular tongues of
invasion into and through the
capsule are apparent (b). Tumor
approaches but does not invade
vessels. Neoplastic cells are
arranged in follicles (c), with
abundant geographic necrosis in
the center of the tumor, manifest
as ghost follicles. Fine needle
aspiration biopsy was not
performed in this patient.
Therefore, necrosis is considered
true tumor necrosis. At higher
power (d), cells have scant
cytoplasm and round, regular
nuclei characteristic of follicular
thyroid carcinoma. Metastatic
carcinoma (e) to thoracic
vertebral bone demonstrates
follicular architecture and bland
cytologic features (f) identical to
the primary follicular thyroid
carcinoma

quantified using the Qubit fluorometric assay (Thermo Fisher
Scientific, Foster City, CA) and further assessed for quantity
and quality using a quantitative PCR assay (hgDNA
Quantitation and QC kit, KAPA Biosystems, Wilmington,
MA). Library preparation and sequencing were performed as
previously described for the UCM-OncoPlus Assay [14].
Briefly, approximately 100 ng Qubit quantified DNA was
fragmented using the Covaris S2 (Covaris, Woburn, MA).
The fragmented DNA was amplified using the KAPA HTP
Library Preparation Kit (Kapa Biosystems) along with a set
of patient-specific indexes (Roche, Indianapolis, IN). The
pooled library was captured using a custom SeqCap EZ cap-
ture panel (Roche) featuring a collection xGen
LockdownProbes (IDT, Coralville, IA) for 1213 genes. The

Table 1 Allele frequencies of mutations in carcinomas by location and type

Tumor type and site Percent tumor BRAF V600E RAS Q61R MSH2 R382H WRN K1087E
in tested sample Allele frequency Allele frequency allele frequency allele frequency
(%) (%) (%) (%) (%)

Papillary carcinoma, left thyroid lobe 60 27.3 0 47.7 39.2

Follicular carcinoma, right thyroid lobe 50 0 19 51.4 40.1
Follicular carcinoma, spine 90 0 45.3 44.2 37.8
12 Endocr Pathol (2018) 29:9–14

morphology not reported

morphology not reported
Liver and brain metastases,

Lung and liver metastases,

pooled captured library was sequenced on the Illumina HiSeq
2500 system (Illumina, San Diego, CA) in rapid run mode
(2 × 101 bp paired-end sequencing). Somatic mutation calling

None reported

None reported
None reported

None reported
was performed across all 1213 genes using the bioinformatics
Metastases

pipeline described in [14].

The primary left lobe PTC harbored a BRAF V600E muta-
tion. The primary right lobe FTC and the spinal metastasis
both had identical NRAS Q61R mutations, confirming the
impression of spinal metastasis from primary FTC. The lymph
Two medullary thyroid microcarcinomas
node metastasis (presumed PTC) was not tested due to small
Primary renal cell carcinoma, clear cell
Anaplastic thyroid carcinoma (7.0 cm)

BSolitary fibrous tumor^ of the kidney

(up to 0.4 cm, right and left lobes)

tumor volume. Additional definitive pathogenic mutations
were not found. Variants of uncertain significance were found
in all three lesions: MSH2 R382H and WRN K1087E, sug-
Medullary thyroid carcinoma

Medullary thyroid carcinoma

Follicular adenoma (1.7 cm)

Adenomatous nodules gesting that these may represent germline variants (Table 1).
(1.5 cm, right lobe)
(1.5 cm, left lobe)
Additional tumors

type (3.0 cm)

None reported

Discussion
(0.4 cm)

The occurrence of synchronous, distinct subtypes of

well-differentiated thyroid carcinoma is rare. We are the
first to report the presence of metastases of both PTC
and FTC with distinct histologic and molecular signa-
5.0 cm, lobe opposite papillary

tures: primary BRAF V600E mutated PTC with metasta-

Follicular thyroid carcinoma

sis to a central neck lymph node and NRAS Q61R mu-

tated follicular carcinoma with metastasis to thoracic ver-
4.1 cm, left lobe and
0.3 cm, right lobe

tebrae. In the literature, only six cases of synchronous

3.0 cm, right lobe

5.0 cm, right lobe

4.0 cm, right lobe

2.5 cm, left lobe

papillary and follicular carcinoma have been reported,

including three with additional medullary carcinoma
and one with additional undifferentiated carcinoma
Summary of reported synchronous papillary and follicular thyroid carcinomas

(Table 2) [6–11]. In these studies, metastatic disease

was either not present [6, 7, 9, 11] or present but not
examined histologically [8, 10]. In all but one patient (in
Confluent with 7.0-cm anaplastic carcinoma

which PTC was confluent with an anaplastic carcinoma),

the PTCs were incidentally found microcarcinomas. In
the three patients with medullary carcinoma, RET
germline mutation was not identified [6–8]. Sequencing
Multiple up to 1.0 cm, left lobe
Multiple up to 0.1 cm, bilateral

of the carcinomas was not performed in any study.

Two up to 0.3 cm, right lobe
Papillary thyroid carcinoma

In our patient, the histologic features of the primary and

metastatic carcinomas were sufficiently distinct to facilitate
0.3 cm, right lobe

histologic diagnosis of PTC versus FTC. The primary PTC

0.6 cm, isthmus

contained well-developed branching papillae lined by large

cells with abundant eosinophilic cytoplasm and enlarged,
overlapping nuclei with irregular contours, grooves, and
pseudoinclusions. Identical architectural and cytologic fea-
tures were present in the lymph node metastasis. Conversely,
the primary and metastatic FTC were both composed entirely
Ganguly et al., 2010 [10]

of small follicles with scant amphophilic to clear cytoplasm

Plauche et al., 2013 [11]
Cupisti et al., 2005 [8]

Mazeh et al., 2015 [7]

Verdi et al., 2013 [6]

and round nuclei without significant enlargement, nuclear

Ma et al., 2014 [9]

membrane irregularities, or clearing. Occasional nuclear vac-

uoles secondary to processing artifact were present. This
Author, year

artefactual nuclear change represents a pitfall in the diagnosis

Table 2

of follicular lesions of thyroid and may lead to diagnosis by

some pathologists as invasive, encapsulated follicular variant
Endocr Pathol (2018) 29:9–14
of PTC. This variant is a RAS-driven neoplasm considered to
be better classified as FTC in light of the biologic and genetic
similarities between these two tumors [15]. In our case, al-
though the FTC was small (1.1 cm), it showed extensive cen-
tral necrosis with ghost follicles and multiple foci of capsular
invasion. The presence of only capsular invasion in the ab-
sence of angioinvasion may be compatible with so-called
Bminimally invasive^ FTC; however, the presence of tumor
necrosis in follicular neoplasms has been suggested as an in-
dicator of aggressive behavior and worsened prognosis in
well-differentiated thyroid carcinomas [16]. In this case, the
necrosis represented true tumor necrosis rather than post-
biopsy infarction, as the patient did not undergo previous thy-
roid FNA.
Both carcinomas demonstrate mutations characteristic
of classic, well-differentiated papillary and follicular thy-
roid carcinomas. BRAF mutations are present in approx-
imately 50% of papillary thyroid carcinomas, and, when
present, are nearly always the V600E polymorphism
[17]. RAS gene mutations are present in follicular neo-
plasms, including in 40–50% of follicular thyroid carci-
nomas, follicular adenomas, and non-invasive follicular
thyroid neoplasms with papillary-like nuclear features,
or NIFT-P [17]. Both the BRAF and the NRAS mutations
alter the MAPK pathway of cellular proliferation and
suggest a possible overlapping molecular pathophysiolo-
gy of these two tumors following the inciting genetic
aberration [17]. Germline mutational testing was not per-
formed on our patient. Cowden or Bannayan-Riley-
Ruvalcaba syndromes could be considered in patients
with multiple papillary and follicular neoplasms.
Specifically, multiple microfollicular adenomas in the
presence of chronic thyroiditis is the most common find-
ing [18–20], however, our patient had only had a single
additional 0.9-cm macrofollicular adenomatous nodule
and lacked chronic thyroiditis. Additionally, she did not
have any other clinical features of PTEN-hamartoma
syndromes.
The geographic isolation of the two carcinomas in this
patient (opposite lobes) as well as unique BRAF and RAS
mutations argues for two distinct instances of oncogene-
sis, rather than a Bmixed^ or Bhybrid^ carcinoma. In
addition, the BRAF-driven PTC and RAS-driven FTC
demonstrate metastatic distribution patterns expected for
these two different subtypes: follicular carcinoma more
frequently metastasizes hematogenously to the lungs,
bones, and liver, while papillary carcinoma generally me-
tastasizes lymphatically to cervical lymph nodes, with
distant metastases being less common [21]. Rare meta-
static sites include kidneys, soft tissue, and adrenal, with
follicular carcinomas being over-represented in metasta-
ses to the meninges and eyes [22]. In patients presenting
with metastatic disease, the presence of extrapulmonary
13
metastasis and follicular histology is associated with 50%
disease-specific 5-year survival, compared to 70% with
papillary histology [23]. In this patient, confirming the
metastatic carcinoma as follicular rather than papillary in
origin portends a worse prognosis. In summary, the oc-
currence of synchronous and metastatic PTC and FTC is
extremely rare, but, in this case, can be proven morpho-
logically and genetically to represent two independent
clonal events with genetics and behaviors unique to the
morphologic subtype.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Ethics Approval For this type of study, formal consent is not required.
This article does not contain any studies with human participants or an-
imals performed by any of the authors.
Informed Consent Informed consent was obtained from all individual
participants in this study.
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