International Journal of Gynecological Pathology 34:293–297, Lippincott Williams & Wilkins, Baltimore r 2015 International Society of Gynecological Pathologists
Case Report
Ovarian Strumal Carcinoid Containing Appendiceal-Type Mucinous Tumor Patterns Presenting as Pseudomyxoma Peritonei Enoe Quin˜onez, M.D., Maolly Schuldt, M.D., Juan A. Retamero, and Francisco F. Nogales, M.D., Ph.D.
M.D.,
Summary: We report for the first time a case of ovarian strumal carcinoid containing both trabecular carcinoid and mucinous glands lined by both goblet and neuroendocrine cells and a low-grade mucinous neoplasm that presented clinically as pseudomyxoma peritonei in the absence of appendiceal lesion in a 58-yr-old woman. Histologically, there were both a tall columnar cell epithelial component lacking neuroendocrine cells, showing the scalloped contours and subepithelial clefts of lowgrade appendiceal-type neoplasms and a mixed goblet cell neuroendocrine element. Characteristically, both reproduced appendiceal neoplastic phenotypes in a teratoid fashion. In addition, we present previously unreported oncocytic and mucinous changes in the thyroideal components of strumal carcinoid. This case represents a rare instance of pseudomyxoma peritonei of primary ovarian origin and is an example of multiple somatic teratoid endodermal differentiations of the different sections of the embryonal gut: foregut represented by thyroid, midgut by both mucinous appendiceal components, and hindgut by trabecular carcinoid. Key Words: Ovary—Strumal carcinoid— Pseudomyxoma peritonei—Struma ovarii—Mucinous neoplasms—Appendix.
We report for the first time a case of strumal carcinoid containing both trabecular carcinoid and mixed goblet cell neuroendocrine pattern and an appendiceal-type low-grade mucinous neoplasm that presented clinically as pseudomyxoma peritonei in the absence of appendiceal lesion. In addition, we present previously unreported oncocytic and mucinous changes in its thyroideal (strumal) components.
Strumal carcinoid (1) is a rare ovarian germ cell tumor where both thyroid and neuroendocrine differentiations coexist. The latter are represented by various growth patterns of carcinoid, usually trabecular (1), less often insular, and only rarely mucinous carcinoid types (2). Pseudomyxoma peritonei usually originates from primary mucinous tumors arising in the vermiform appendix (3,4). More infrequently, it can appear associated to primary mucinous ovarian neoplasms that often have a germ cell, teratoid origin.
CLINICAL HISTORY A 58-yr-old woman presented with a 2 month history of increasing abdominal pain, distension, and weight loss. On examination, she had marked ascites. An abundant amount of yellow mucinous fluid was obtained from a peritoneal tap. Magnetic resonance imaging revealed the presence of a large cystic ovarian mass. Surgical findings showed an intact large multicystic mass
From the Department of Pathology, Facultad de Medicina, San Cecilio University of Granada Hospital, Granada, Spain. The authors declare no conflict of interest. Address correspondence and reprint requests to Francisco F. Nogales, MD, PhD, Department of Pathology, Facultad de Medicina, San Cecilio University of Granada Hospital, Av de Madrid 11, Granada 18012, Spain. E-mail: [email protected].
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DOI: 10.1097/PGP.0000000000000138
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adherent to pelvic organs which coexisted with an abundant mucinous ascites. Total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, and appendectomy were performed. Five months after surgery, the patient is alive and well and currently under observation.
MATERIALS AND METHODS The tumor was thoroughly sampled and 30 tissue blocks were obtained. Paraffin-embedded tissue was available for H&E sections and immunohistochemistry. The following prediluted antibodies were used: thyroid transcription factor 1 (TTF-1) (clone 8G7G3/ 1; Dako, Denmark), chromogranin A (polyclonal; Dako), CDX2 (clone DAK-CDX2; Dako), villin (clone CWWB1; Master Diagnostica, Granada, Spain), CK20 (clone Ks20.8; Dako), CK7 (clone
OV-TL 12/30; Dako), glypican 3 (GPC3) (clone SP 86; Master Diagnostica), and a-fetoprotein (polyclonal; Dako).
RESULTS The large ovarian tumor measured 18 13 11 cm and on cut section it had a variegated appearance with solid firm white-yellow areas interspersed with numerous cystic spaces that contained dense whiteyellow mucus. Separate specimens from the peritoneum were composed of a similar adherent mucous substance. On cut section, the resected appendix, presented only fecal but not mucinous contents, which were, however, present adherent to its serosal surface. Histologically, the tumor revealed the presence of thyroid tissue in a 70% proportion that merged with
FIG. 1. Low power of strumal carcinoid (A) showing thyroid (both sides) and trabecular carcinoid (center) and an appendiceal-type lowgrade neoplasm (arrow). Higher magnification of coexisting thyroid and carcinoid (B). Thyroid transcription factor 1 is positive in thyroid tissue but negative in the trabecular carcinoid (C). Chromogranin has an inverse expression (D).
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STRUMAL CARCINOID AND PSEUDOMYXOMA trabecular carcinoid (Figs. 1A, B). Thyroid follicular epithelia expressed TTF-1 (Fig. 1C) and thyroglobulin which were absent in the carcinoid ribbons. Conversely, chromogranin A was expressed in carcinoid but not in the thyroid epithelium (Fig. 1D). CDX2 failed to stain the carcinoid component. Furthermore, practically in every tissue block there was an admixture of 2 additional elements: (1) Narrow glands lined by CK20+ and CDX2+, however, TTF-1 – , thyroglobulin-negative, and CK7 – goblet cells, and abundant chromograninpositive neuroendocrine cells similar to those found in mucinous carcinoid pattern. The glands also had a basophilic mucinous secretion that ruptured into the abundant fibromatous stroma, forming the mucin lakes of pseudomyxoma ovarii (Figs. 2A, B). Stromal mucin granulomas, however, were not found.
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(2) Large mucinous cysts lined by a benign, tall cylindrical, CDX2+ and CK20+, but CK7 – , mucinous epithelium (Fig. 1A) that showed scalloped epithelial contours and subepithelial clefts (Fig. 2B). Pseudomyxoma was prominent in the peritoneal samples that include the omentum, presenting with dissecting masses of mucin (Fig. 2C), which also involved the hypervascular serosal surface of an otherwise normal appendix (Fig. 2D). The thyroid tissue component showed remarkable changes. Although most of it had usual histology with neither atypia, nor papillae or optically clear nuclei, there were isolated areas where a granular, eosinophilic, oncocytic (Hu¨rtle cell) metaplasia was evident (Fig. 3A). Other areas exhibited follicles with narrow lumina containing a basophilic mucinous material (Fig. 3B). Their TTF-1, thyroglobulin-positive follicu-
FIG. 2. Mucinous component of strumal carcinoid. Glands with mixed goblet cell neuroendocrine cells are surrounded by stromal mucin lakes (A). Strumal carcinoid with areas of appendiceal-type low-grade neoplasm (right) showing scalloping and subepithelial clefts (B). Pseudomyxoma peritonei (C) with acellular mucin pools in the serosa of an unremarkable appendix (D).
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FIG. 3. Oncocytic (A) and mucinous (B) changes in thyroid tissue of strumal carcinoid.
lar epithelium was devoid of goblet cells but revealed a strong villin expression that was absent in both areas of normal thyroid tissue and in trabecular carcinoid. GPC3 and a-fetoprotein were not expressed in any areas of the tumor. DISCUSSION Strumal carcinoid does not occur in the eutopic thyroid and is unique to the ovary, being different from medullary carcinoma of the thyroid (5). Although strumal carcinoid is nearly always associated with benign behavior, its neuroendocrine component may rarely metastasize (6). Moreover, in only 1 documented instance (7), strumal carcinoid had a malignant mucinous component that, however, was not associated with pseudomyxoma peritonei. The present case is the first report to exemplify the association between ovarian strumal carcinoid, mucinous tumors, and pseudomyxoma peritonei. Int J Gynecol Pathol Vol. 34, No. 3, May 2015
Mucinous carcinoid is an unusual (2) pattern in strumal carcinoid, where trabecular carcinoid usually predominates (1). In this case there were both areas of glands lined by goblet cells and abundant granular chromogranin positive similar to those found in mucinous carcinoid cells and yet another mucinous tall columnar cell epithelial benign component lacking neuroendocrine cells, that showed the characteristic scalloped contours and subepithelial clefts (4) of low-grade appendiceal neoplasms (3). We believe that both patterns are closely related, as it is known that mucinous carcinoid can be associated with intestinaltype mucinous tumors (8) and that both are characteristic appendiceal neoplastic phenotypes that were reproduced here in a teratoid fashion. Both intestinal mucinous borderline tumors and appendiceal-type low-grade neoplasms, as in the current case, are the mucinous neoplasms associated with pseudomyxoma peritonei. It has been shown that in the ovary, the teratoid mucinous neoplasms that reproduce the histology of appendiceal mucinous tumors are the main ones responsible for pseudomyxoma peritonei (3,9). As distinctive histologic features they have scalloped contours and subepithelial stromal clefts, whereas intestinal borderline tumors often display mucin granulomas and are surrounded by a reactive cellular stroma (4). This case represents one of the rare instances of pseudomyxoma peritonei of primary ovarian origin (9), as the great majority of cases arise from the vermiform appendix. The association we describe here of strumal carcinoid with mucinous carcinoid and low-grade intestinal neoplasm has not been previously reported and represents an example of multiple somatic teratoid endodermal differentiations of the different sections of the embryonal gut: foregut represented by thyroid, midgut by both mucinous components, and hindgut by trabecular carcinoid. In addition, it is of interest to note that the thyroid tissue component in our study also had unusual mucinous and oncocytic changes (10) that have been reported only rarely in ovarian thyroid tissue. Mucinous change is also extremely rare in eutopic thyroid neoplasms in both malignant (11) and benign (12) conditions and has not been described in struma ovarii. Its significance and relationship with other neoplastic mucinous phenotypes present in this case remains unknown. It is remarkable that the mucus-containing follicles expressed the intestinal marker villin in the epithelium. In normal thyroid tissue this protein is not expressed and in neoplasms
STRUMAL CARCINOID AND PSEUDOMYXOMA of the thyroid gland, the positivity suggests a metastatic intestinal adenocarcinoma (13).
REFERENCES 1. Robboy SJ, Scully RE. Strumal carcinoid of the ovary: an analysis of 50 cases of a distinctive tumor composed of thyroid tissue and carcinoid. Cancer 1980;46:2019–34. 2. Matias-Guiu X, Forteza J, Prat J. Mixed strumal and mucinous carcinoid tumor of the ovary. Int J Gynecol Pathol 1995;14:179–83. 3. Rouzbahman M, Chetty R. Mucinous tumours of appendix and ovary: an overview and evaluation of current practice. J Clin Pathol 2013;67:193–7. 4. Stewart CJ, Ardakani NM, Doherty DA, et al. An evaluation of the morphologic features of low-grade mucinous neoplasms of the appendix metastatic in the ovary, and comparison with primary ovarian mucinous tumors. Int J Gynecol Pathol 2014;33:1–10. 5. Stagno PA, Petras RE, Hart WR. Strumal carcinoids of the ovary. An immunohistologic and ultrastructural study. Arch Pathol Lab Med 1987;111:440–6. 6. Armes JE, Ostor AG. A case of malignant strumal carcinoid. Gynecol Oncol 1993;51:419–23.
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7. Kim SM, Choi HS, Byun JS, et al. Mucinous adenocarcinoma and strumal carcinoid tumor arising in one mature cystic teratoma of the ovary with synchronous cervical cancer. J Obstet Gynaecol Res 2003;29:28–32. 8. Baker PM, Oliva E, Young RH, et al. Ovarian mucinous carcinoids including some with a carcinomatous component: a report of 17 cases. Am J Surg Pathol 2001;25:557–68. 9. McKenney JK, Soslow RA, Longacre TA. Ovarian mature teratomas with mucinous epithelial neoplasms: morphologic heterogeneity and association with pseudomyxoma peritonei. Am J Surg Pathol 2008;32:645–55. 10. Pardo-Mindan FJ, Vazquez JJ. Malignant struma ovarii. Light and electron microscopic study. Cancer 1983;51:337–343. 11. D’Antonio A, Addesso M, De Dominicis G, et al. Mucinous carcinoma of thyroid gland. Report of a primary and a metastatic mucinous tumour from ovarian adenocarcinoma with immunohistochemical study and review of literature. Virchows Arch 2007;451:847–51. 12. Rigaud C, Peltier F, Bogomoletz WV. Mucin producing microfollicular adenoma of the thyroid. J Clin Pathol 1985;38:277–80. 13. Kim CH, Park YW, Ayala AG, et al. Colonic adenocarcinoma metastatic to the thyroid gland: a case report with immunohistochemical investigation. J Korean Med Sci 1999;14:455–9.
Int J Gynecol Pathol Vol. 34, No. 3, May 2015
Case Report
Ovarian Strumal Carcinoid Containing Appendiceal-Type Mucinous Tumor Patterns Presenting as Pseudomyxoma Peritonei Enoe Quin˜onez, M.D., Maolly Schuldt, M.D., Juan A. Retamero, and Francisco F. Nogales, M.D., Ph.D.
M.D.,
Summary: We report for the first time a case of ovarian strumal carcinoid containing both trabecular carcinoid and mucinous glands lined by both goblet and neuroendocrine cells and a low-grade mucinous neoplasm that presented clinically as pseudomyxoma peritonei in the absence of appendiceal lesion in a 58-yr-old woman. Histologically, there were both a tall columnar cell epithelial component lacking neuroendocrine cells, showing the scalloped contours and subepithelial clefts of lowgrade appendiceal-type neoplasms and a mixed goblet cell neuroendocrine element. Characteristically, both reproduced appendiceal neoplastic phenotypes in a teratoid fashion. In addition, we present previously unreported oncocytic and mucinous changes in the thyroideal components of strumal carcinoid. This case represents a rare instance of pseudomyxoma peritonei of primary ovarian origin and is an example of multiple somatic teratoid endodermal differentiations of the different sections of the embryonal gut: foregut represented by thyroid, midgut by both mucinous appendiceal components, and hindgut by trabecular carcinoid. Key Words: Ovary—Strumal carcinoid— Pseudomyxoma peritonei—Struma ovarii—Mucinous neoplasms—Appendix.
We report for the first time a case of strumal carcinoid containing both trabecular carcinoid and mixed goblet cell neuroendocrine pattern and an appendiceal-type low-grade mucinous neoplasm that presented clinically as pseudomyxoma peritonei in the absence of appendiceal lesion. In addition, we present previously unreported oncocytic and mucinous changes in its thyroideal (strumal) components.
Strumal carcinoid (1) is a rare ovarian germ cell tumor where both thyroid and neuroendocrine differentiations coexist. The latter are represented by various growth patterns of carcinoid, usually trabecular (1), less often insular, and only rarely mucinous carcinoid types (2). Pseudomyxoma peritonei usually originates from primary mucinous tumors arising in the vermiform appendix (3,4). More infrequently, it can appear associated to primary mucinous ovarian neoplasms that often have a germ cell, teratoid origin.
CLINICAL HISTORY A 58-yr-old woman presented with a 2 month history of increasing abdominal pain, distension, and weight loss. On examination, she had marked ascites. An abundant amount of yellow mucinous fluid was obtained from a peritoneal tap. Magnetic resonance imaging revealed the presence of a large cystic ovarian mass. Surgical findings showed an intact large multicystic mass
From the Department of Pathology, Facultad de Medicina, San Cecilio University of Granada Hospital, Granada, Spain. The authors declare no conflict of interest. Address correspondence and reprint requests to Francisco F. Nogales, MD, PhD, Department of Pathology, Facultad de Medicina, San Cecilio University of Granada Hospital, Av de Madrid 11, Granada 18012, Spain. E-mail: [email protected].
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DOI: 10.1097/PGP.0000000000000138
E. QUIN˜ONEZ ET AL.
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adherent to pelvic organs which coexisted with an abundant mucinous ascites. Total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, and appendectomy were performed. Five months after surgery, the patient is alive and well and currently under observation.
MATERIALS AND METHODS The tumor was thoroughly sampled and 30 tissue blocks were obtained. Paraffin-embedded tissue was available for H&E sections and immunohistochemistry. The following prediluted antibodies were used: thyroid transcription factor 1 (TTF-1) (clone 8G7G3/ 1; Dako, Denmark), chromogranin A (polyclonal; Dako), CDX2 (clone DAK-CDX2; Dako), villin (clone CWWB1; Master Diagnostica, Granada, Spain), CK20 (clone Ks20.8; Dako), CK7 (clone
OV-TL 12/30; Dako), glypican 3 (GPC3) (clone SP 86; Master Diagnostica), and a-fetoprotein (polyclonal; Dako).
RESULTS The large ovarian tumor measured 18 13 11 cm and on cut section it had a variegated appearance with solid firm white-yellow areas interspersed with numerous cystic spaces that contained dense whiteyellow mucus. Separate specimens from the peritoneum were composed of a similar adherent mucous substance. On cut section, the resected appendix, presented only fecal but not mucinous contents, which were, however, present adherent to its serosal surface. Histologically, the tumor revealed the presence of thyroid tissue in a 70% proportion that merged with
FIG. 1. Low power of strumal carcinoid (A) showing thyroid (both sides) and trabecular carcinoid (center) and an appendiceal-type lowgrade neoplasm (arrow). Higher magnification of coexisting thyroid and carcinoid (B). Thyroid transcription factor 1 is positive in thyroid tissue but negative in the trabecular carcinoid (C). Chromogranin has an inverse expression (D).
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STRUMAL CARCINOID AND PSEUDOMYXOMA trabecular carcinoid (Figs. 1A, B). Thyroid follicular epithelia expressed TTF-1 (Fig. 1C) and thyroglobulin which were absent in the carcinoid ribbons. Conversely, chromogranin A was expressed in carcinoid but not in the thyroid epithelium (Fig. 1D). CDX2 failed to stain the carcinoid component. Furthermore, practically in every tissue block there was an admixture of 2 additional elements: (1) Narrow glands lined by CK20+ and CDX2+, however, TTF-1 – , thyroglobulin-negative, and CK7 – goblet cells, and abundant chromograninpositive neuroendocrine cells similar to those found in mucinous carcinoid pattern. The glands also had a basophilic mucinous secretion that ruptured into the abundant fibromatous stroma, forming the mucin lakes of pseudomyxoma ovarii (Figs. 2A, B). Stromal mucin granulomas, however, were not found.
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(2) Large mucinous cysts lined by a benign, tall cylindrical, CDX2+ and CK20+, but CK7 – , mucinous epithelium (Fig. 1A) that showed scalloped epithelial contours and subepithelial clefts (Fig. 2B). Pseudomyxoma was prominent in the peritoneal samples that include the omentum, presenting with dissecting masses of mucin (Fig. 2C), which also involved the hypervascular serosal surface of an otherwise normal appendix (Fig. 2D). The thyroid tissue component showed remarkable changes. Although most of it had usual histology with neither atypia, nor papillae or optically clear nuclei, there were isolated areas where a granular, eosinophilic, oncocytic (Hu¨rtle cell) metaplasia was evident (Fig. 3A). Other areas exhibited follicles with narrow lumina containing a basophilic mucinous material (Fig. 3B). Their TTF-1, thyroglobulin-positive follicu-
FIG. 2. Mucinous component of strumal carcinoid. Glands with mixed goblet cell neuroendocrine cells are surrounded by stromal mucin lakes (A). Strumal carcinoid with areas of appendiceal-type low-grade neoplasm (right) showing scalloping and subepithelial clefts (B). Pseudomyxoma peritonei (C) with acellular mucin pools in the serosa of an unremarkable appendix (D).
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FIG. 3. Oncocytic (A) and mucinous (B) changes in thyroid tissue of strumal carcinoid.
lar epithelium was devoid of goblet cells but revealed a strong villin expression that was absent in both areas of normal thyroid tissue and in trabecular carcinoid. GPC3 and a-fetoprotein were not expressed in any areas of the tumor. DISCUSSION Strumal carcinoid does not occur in the eutopic thyroid and is unique to the ovary, being different from medullary carcinoma of the thyroid (5). Although strumal carcinoid is nearly always associated with benign behavior, its neuroendocrine component may rarely metastasize (6). Moreover, in only 1 documented instance (7), strumal carcinoid had a malignant mucinous component that, however, was not associated with pseudomyxoma peritonei. The present case is the first report to exemplify the association between ovarian strumal carcinoid, mucinous tumors, and pseudomyxoma peritonei. Int J Gynecol Pathol Vol. 34, No. 3, May 2015
Mucinous carcinoid is an unusual (2) pattern in strumal carcinoid, where trabecular carcinoid usually predominates (1). In this case there were both areas of glands lined by goblet cells and abundant granular chromogranin positive similar to those found in mucinous carcinoid cells and yet another mucinous tall columnar cell epithelial benign component lacking neuroendocrine cells, that showed the characteristic scalloped contours and subepithelial clefts (4) of low-grade appendiceal neoplasms (3). We believe that both patterns are closely related, as it is known that mucinous carcinoid can be associated with intestinaltype mucinous tumors (8) and that both are characteristic appendiceal neoplastic phenotypes that were reproduced here in a teratoid fashion. Both intestinal mucinous borderline tumors and appendiceal-type low-grade neoplasms, as in the current case, are the mucinous neoplasms associated with pseudomyxoma peritonei. It has been shown that in the ovary, the teratoid mucinous neoplasms that reproduce the histology of appendiceal mucinous tumors are the main ones responsible for pseudomyxoma peritonei (3,9). As distinctive histologic features they have scalloped contours and subepithelial stromal clefts, whereas intestinal borderline tumors often display mucin granulomas and are surrounded by a reactive cellular stroma (4). This case represents one of the rare instances of pseudomyxoma peritonei of primary ovarian origin (9), as the great majority of cases arise from the vermiform appendix. The association we describe here of strumal carcinoid with mucinous carcinoid and low-grade intestinal neoplasm has not been previously reported and represents an example of multiple somatic teratoid endodermal differentiations of the different sections of the embryonal gut: foregut represented by thyroid, midgut by both mucinous components, and hindgut by trabecular carcinoid. In addition, it is of interest to note that the thyroid tissue component in our study also had unusual mucinous and oncocytic changes (10) that have been reported only rarely in ovarian thyroid tissue. Mucinous change is also extremely rare in eutopic thyroid neoplasms in both malignant (11) and benign (12) conditions and has not been described in struma ovarii. Its significance and relationship with other neoplastic mucinous phenotypes present in this case remains unknown. It is remarkable that the mucus-containing follicles expressed the intestinal marker villin in the epithelium. In normal thyroid tissue this protein is not expressed and in neoplasms
STRUMAL CARCINOID AND PSEUDOMYXOMA of the thyroid gland, the positivity suggests a metastatic intestinal adenocarcinoma (13).
REFERENCES 1. Robboy SJ, Scully RE. Strumal carcinoid of the ovary: an analysis of 50 cases of a distinctive tumor composed of thyroid tissue and carcinoid. Cancer 1980;46:2019–34. 2. Matias-Guiu X, Forteza J, Prat J. Mixed strumal and mucinous carcinoid tumor of the ovary. Int J Gynecol Pathol 1995;14:179–83. 3. Rouzbahman M, Chetty R. Mucinous tumours of appendix and ovary: an overview and evaluation of current practice. J Clin Pathol 2013;67:193–7. 4. Stewart CJ, Ardakani NM, Doherty DA, et al. An evaluation of the morphologic features of low-grade mucinous neoplasms of the appendix metastatic in the ovary, and comparison with primary ovarian mucinous tumors. Int J Gynecol Pathol 2014;33:1–10. 5. Stagno PA, Petras RE, Hart WR. Strumal carcinoids of the ovary. An immunohistologic and ultrastructural study. Arch Pathol Lab Med 1987;111:440–6. 6. Armes JE, Ostor AG. A case of malignant strumal carcinoid. Gynecol Oncol 1993;51:419–23.
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7. Kim SM, Choi HS, Byun JS, et al. Mucinous adenocarcinoma and strumal carcinoid tumor arising in one mature cystic teratoma of the ovary with synchronous cervical cancer. J Obstet Gynaecol Res 2003;29:28–32. 8. Baker PM, Oliva E, Young RH, et al. Ovarian mucinous carcinoids including some with a carcinomatous component: a report of 17 cases. Am J Surg Pathol 2001;25:557–68. 9. McKenney JK, Soslow RA, Longacre TA. Ovarian mature teratomas with mucinous epithelial neoplasms: morphologic heterogeneity and association with pseudomyxoma peritonei. Am J Surg Pathol 2008;32:645–55. 10. Pardo-Mindan FJ, Vazquez JJ. Malignant struma ovarii. Light and electron microscopic study. Cancer 1983;51:337–343. 11. D’Antonio A, Addesso M, De Dominicis G, et al. Mucinous carcinoma of thyroid gland. Report of a primary and a metastatic mucinous tumour from ovarian adenocarcinoma with immunohistochemical study and review of literature. Virchows Arch 2007;451:847–51. 12. Rigaud C, Peltier F, Bogomoletz WV. Mucin producing microfollicular adenoma of the thyroid. J Clin Pathol 1985;38:277–80. 13. Kim CH, Park YW, Ayala AG, et al. Colonic adenocarcinoma metastatic to the thyroid gland: a case report with immunohistochemical investigation. J Korean Med Sci 1999;14:455–9.
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