Thyroid No Surgery: Beware of the Hurthle Cell Diagnosis that sends you to unnecessary thyroid surgery.

Thyroid No Surgery: Beware of the Hurthle Cell HC Diagnosis that sends you to unnecessary thyroid surgery.

Dr.Guttler’s comments:

1. The scary diagnosis after a FNA is the presence of Hurthle Cells in a nodule in the thyroid gland.
2. The description of HCs on FNAB reports may cause significant concern to the clinician; however, placing the finding in the appropriate clinical context may alleviate some anxiety.
3. Over the 40 years doing FNAs the common mistake is to call any presence of HC possible HCN neoplasm.
4. This causes the physician to send the patient the surgeon to do a lobectomy or total. surgery.
5. Not every aspirate containing HCs is or should be considered equivalent to an HCN neoplasm. This will result in unnecessary surgery in patients with benign disease.
6. There are many benign thyroid lesions associated with HCs or HC change.
7. Before sending the patient to surgery ask for a second opinion by a skilled thyroidologist or cytopathologist to tell the difference between HC in benign disease from true HCN neoplasm.
8. The diagnosis of HC carcinoma, a form of follicular carcinoma relies on histopathologic scrutiny and evidence of capsular and/or vascular invasion or metastasis to lymph nodes or distant organs.
9. Genetic markers have recently been used help determine if the HC lesion is likely cancer.
10. Once it is determine it is a HCN neoplasm, and because of the inability to determine the benign or malignant nature of HCN neoplasms based on cytology alone, a surgical approach is warranted usually a lobectomy.
11. More specifically, the HC is a large (10–15 μ), polygonal cell with distinct cell borders, abundant eosinophilic finely granular cytoplasm, a large hyperchromatic round to oval nucleus, and a prominent nucleolus.
12. Non-HC oncocytic follicular cells contain eosinophilic cytoplasm, which is generally nongranular, in contrast to the granular cytoplasm of true HCs. They are slightly larger than a normal follicular cell and are commonly seen on FNAB results from nodular goiters and dominant hyperplastic or adenomatous nodules.
13. HCs may be found in a wide variety of conditions affecting the thyroid gland; they are not specific to any particular pathology.
14. They are commonly found in older individuals, those who have undergone thyroid irradiation, and patients with long-standing nodular goiters, Graves’ disease, and CLT.
15. Classic definition of Hashimoto’s disease calls for the triad of lymphocytes, plasma cells, and HCs.
16. Reflecting the apparent need for cells to accumulate significant numbers of mitochondria over a prolonged period of time, HC metaplasia is rarely seen in the juvenile form of CLT.
17. HCs are also seen in neoplastic diseases of the thyroid, both benign and malignant, including HCA, HCC, variants of PTC, and the oncocytic variant of MTC.
18. FNAB aspirates of non-neoplastic lesions are often comprised of HCs, benign follicular cells without oncocytic change, and colloid, as in the case of nodular goiter, or of HCs, aggregates of lymphocytes and dendritic cells, and benign follicular cells, as seen in CLT.
19.  High degree of intraobserver variability in the interpretation of thyroid specimens. Liberal use second opinions at the discretion of the overseeing cytopathologist or at the request of the treating clinician may be warranted.
20. HCs may be found in lesions across the spectrum of thyroid disease. The significance of HCs in thyroid pathology is currently uncertain. Although surgery may not always be mandatory when an FNAB specimen contains HCs, a clear concern is that of missing a malignant lesion by abstaining from surgery [6]. Although the mere presence of HCs or HC change in an FNAB smear should not immediately trigger clinical worry and perhaps an unnecessary surgical referral, clinical context and an appreciation for the variety of findings associated with oncocytes may help guide the clinician to appropriate clinical follow-up.
21. Always get an opinion from experts before undergoing surgery with a FNA that has HC  that they call possible HC Neoplasm.
22. Contact me at 310-393-8860 or thyroid.manager@thyroid.com
23. Dr.G.