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1 갑상선의 Poorly Differentiated (Insular) Carcinoma Insular Carcinoma: An Aggressive Subtype of Differentiated Thyroid Neoplasms Seok-Jin Nam, M.D., Sang-Dal Lee, M.D., Hal-lin Park, M.D., Young-Ryun Oh, M.D. 1 and Jung-Hyun Yang, M.D. Purpose: Insular carcinoma is a rare subtype of thyroid cancer which was first described by Carcangiu in Its aggressiveness is intermediate between well differentiated and anaplastic thyroid carcinoma. But its origin, clinical features and prognosis are not yet clearly understood. We wanted to evaluate the clinical features, histologic characteristics and prognosis of insular thyroid carcinoma. Methods: We studied 4 cases of insular thyroid carcinoma treated in Samsung Medical Center from March 1996 to April Age, sex, clinical features, treatment, pathology and follow up findings were reviewed, retrospectively. Results: All patients were female and the mean age was 44 years. Three of all patients complained of anterior neck mass and one patient complained of low back pain and paresthesia of the right thigh. Two patients had metastatic bone lesions at the time of diagnosis. Preoperative fine needle aspiration cytology diagnosed follicular neoplasm in 2 cases and papillary carcinoma in 1. We performed total or completion total thyroidectomy and radioactive iodine therapy in 3 cases and radioactive iodine therapy alone in one. Extrathyroidal invasion, vascular invasion and multicentricity were noted in two cases. All four patients showed recurrence or distant metastasis in follow up over a period of 10 to 31 months and 2 of them died of distant metastasis during this follow up period. Conclusion: Insular carcinoma is a special type of thyroid carcinoma with aggressive clinical course. Recurrence and extrathyroidal involvements are common and the prognosis is poorer than other well differentiated thyroid carcinomas. (Korean J Endocrine Surg 2001;1: ) Key Words: Thyroid neoplasm, Insular carcinoma Departments of General Surgery and 1 Diagnostic Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

2 남석진 외 갑상선의 Poorly Differentiated (Insular) Carcinoma 109 ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ 결 과 환자는 모두 여성이었으며 연령은 51, 50, 47, 28세로 평 균 44세였다. 환자의 주 증상은 3예의 경우 전 경부의 종 물을 호소하였고 1예에서는 요통과 양측 하지의 통증 및 마비를 주소로 하였다. 전 경부 종물을 호소한 경우 중 1 예는 27년 전 병명미상으로 우엽 절제술을 시행받고 20년 전 재차 좌엽 절제술을 받은 후 이번에 또 다시 경부 종물 이 발생하여 내원한 예로 갑상선 암의 재발과 함께 진단 당시 폐전이 및 골전이가 동반 관찰되었다. 또한 요통을 호소한 증례 3의 경우도 요추부 및 우측 요골 부위에 골 전이가 관찰되었다. 전 경부 종물을 호소한 젊은 여성의 경우(증례 4)는 내원 전 이미 두 차례에 걸쳐 조직 형태 불명의 갑상선암으로 타 병원에서 수술을 받고 재발한 환 자로 내원 당시 남아있는 갑상선 조직에서 발생한 종물생 검상 insular carcinoma로 진단되었으며 폐전이가 관찰되어 좌측 폐 절제술 및 방사성 동위원소 치료 후 1년 뒤 골전 이 및 간전이가 발생하였다. 수술 전 시행한 세침흡입세 포검사상 2예에서는 종양세포들이 육주 또는 여포 모양으 로 배열되어 있으며 과 염색성의 핵을 가진 여포상 종양 을 진단할 수 있었으며 1예에서는 세포에서 유두상 돌출 이 관찰되고 핵에 groove가 있으며 intranuclear inclusion을 보여 유두상 암으로 진단하였다. 한편 CEA, AP 등의 종 양표식자는 정상수치를 나타내어 진단에 도움을 주지 못 하였다(Table 1). 수술을 시행한 3예의 병리조직검사상 종 양세포들은 작은 섬 모양을 이루며 배열되어 있고 혈관이 풍부하였다. 섬 모양을 이루는 세포 군집들은 고형상이거 나 부전형성 여포(abortive follicle)를 가지고 있었다(ig. 1). 종양세포들은 분화가 좋지 않고 유사분열이 빈번하였으 Table 1. Clinicopathologic features of the cases ꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚ Patient Case 1 Case 2 Case 3 Case 4 ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ Age Sex Chief LBP*, paresthesia complaints (recurred) of lower leg (recurred) Past history Lt.lobectomy (27 yr ago) otal T (6 yr ago) Rt.lobectomy (20 yr ago) Completion T (1 yr ago) CEA, AP Distant Bone, lung Bone Lung metastasis Cytology N PC N ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ * = low back pain; = thyroidectomy, = follicular neoplasm; = papillary carcinoma. a b ig. 1. Histologic finding. a) Tumor cells aggregates in insular pattern with prominent vascularity ( 40). b) Tumor cells are arranged in solid pattern and focally show abortive follicle ( 200).

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