Although controversial, mixed follicular-parafollicular cell carcinomas do occur (253); these rare monomorphous tumours are composed of cells showing dual differentiation (254,255). Composite tumors are composed of two intermixed well differentiated components, one showing thyroglobulin immunoreactivity and either papillary or follicular architecture and cytology, the other with calcitonin and CEA immunopositivity (81,256). The diagnosis of a mixed or composite tumor can be convincing only in cases where metastatic disease is identified, since the identification of thyroglobulin and calcitonin in a primary intrathyroidal tumor may represent the identification of a typical medullary thyroid carcinoma with trapped nontumorous elements containing thyroglobulin, or phagocytosis of thyroglobulin by medullary carcinoma cells. Moreover, the two tumours may occur separately in the same gland and metastasise together to a regional node (257,258).
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