THYROID PTHYROID P

ELLEN GREENEBASSOCIATE PROFESSOR O

P&S Ph 30Phone: 30

eg39@colu

PATHOLOGYPATHOLOGY

BAUM, MD MPHOF CLINICAL PATHOLOGY

’7705 671905-6719

umbia.edu

DEFINITDEFINIT• GOITER: enlarged• GOITER: enlarged

• EUTHYROID: norm

• NONTOXIC: thyroidy

TOXIC h perf nctio• TOXIC: hyperfunctio

TIONSTIONSthyroidthyroid

mal thyroid function

d not hyperfunctionaly

onal th roidonal thyroid

GRAVES’GRAVES DIFFUSE TO

MOST COMMON CAUS

HYPERTHYHYPERTHY

GROSS:GROSS:• DIFFUSELY ENLARG• UP TO 3-4X NORMA• SURGERY RARE• SURGERY RARE

DISEASEDISEASEOXIC GOITERSE OF

YROIDISMYROIDISM

GEDAL (normal 10-35gm)

GRAVES’GRAVES’ MICROSCOPIC:Hyperplasia of follicular

– New follicles forme

– Scalloping of colloid

L h id ll i filt– Lymphoid cell infilt

• ?source of abno

DISEASEDISEASE

lining cells

ed; tall, columnar cells

d

t ttrates

rmal autoantibodies

HASHIMOTO’SHASHIMOTO S• May be found

incidentally– incidentally– visible neck mass– compressing trachea o

• GROSS:• Usually enlarged up toUsua y e a ged up o• Usually symmetrical, d

if nodular suspect neo– if nodular, suspect neo

• Light tan or gray• L-thyroxine therapy m

S THYROIDITISS THYROIDITIS

or esophagus

o 2-3Xo 3diffuse & firmoplasmoplasm

may shrink gland

HASHIMOTO’SLymphocytic thyr

MICROSCOPIC:• LYMPHOCYTES &• LYMPHOCYTES & • HURTHLE CELLS = O

– Abundant pink cytoppink = acidophilic =– pink = acidophilic =

– Electron Microscopy • numerous mitocho

S THYROIDITISoiditis with oxyphilia

plasma cellsplasma cellsOxyphilic cellsplasmeosinophiliceosinophilic

ndria

NONTOXIC NODNONTOXIC NOD“NTN

• Common: – 4-7% adults in US have pp– usually asymptomatic but – most are MULTINODULA– may have only one palpab

• clinical concern to ruclinical concern to ru• do ultrasound to dete• do needle aspirate or• do needle aspirate or

DULAR GOITERDULAR GOITERNG”

alpable nodular goiterp gmay cause compression

ARble nodulele out neoplasmle out neoplasm

ect other nodulescore bx to diagnose NTNGcore bx to diagnose NTNG

NONTOXIC NODNONTOXIC NOD“NTN

• GROSS:>1 round, well de

li t i dglistening nodusizes within nors es t othyroid tissue.

DULAR GOITERDULAR GOITERNG”

emarcated, tan l f i blules of variable

rmal red-brown a ed b o

NONTOXIC NODNONTOXIC NOD“NT

• MICROSCOPIC:F lli l–Follicles • VARYING SIZEVARYING SIZE• filled with COLL• lined by cuboid

–Zones of FIBROSZones of FIBROS

DULAR GOITERDULAR GOITERTNG”

ES, usually largeES, usually largeLOIDdal cellsSIS & HEMORRHAGESIS & HEMORRHAGE

THYROID NTHYROID N• BENIGN:

G OSS• GROSS:Nodule–Nodule •well enc•soliddeep ta•deep-ta

EOPLASMSEOPLASMSADENOMA

capsulated p

anan

THYROID NTHYROID NH t di ti i• How to distinguisADENOMA from CADENOMA from C–Search for invas

blood vessels–Examine entire

lcapsule

EOPLASMSEOPLASMSh F lli lsh Follicular

CARCINOMA?CARCINOMA?sion of capsule or p

nodule, especially

THYROID CATHYROID CA

1. PAPILLARY: 70-80%2. FOLLICULAR: 10-20%3. MEDULLARY: 5%4 ANAPLASTIC: 1-3%4. ANAPLASTIC: 1-3%

ARCINOMAARCINOMA

70

80

3 4%% 50

60

70Papillary

Follicular

23 4

%% 20

30

40Medullary

U diff1%

0

10

20 Undiff.1

PAPILLARY CPAPILLARY C• 70 80% of thyroid c• 70-80% of thyroid c• GROSS: most ofte

BUT…MICRO: most often• MICRO: most often–if opposite lobe is

another focus wilof casesof cases

CARCINOMACARCINOMAcarcinomascarcinomasn solitary……...

n multifocaln multifocals serially sectioned, yll be found in 50-75%

PAPILLARY CPAPILLARY C

GROSS:

• GRANULAR or FIGRANULAR or FI• IRREGULAR BOR

CARCINOMACARCINOMA

RM WHITE LESIONRM WHITE LESIONRDERS

PAPILLAPAPILLAMICROMICRO:• PAPILLARY FRONPAPILLARY FRON• CUBOIDAL LINING• MOST LESIONS A

FOLLICULAR ARE• SAME BIOLOGIC

REGARDLESS OFREGARDLESS OF

ARY CAARY CA

NDSNDSG CELLS

ALSO HAVE EASBEHAVIOR

F % PAP VS FOLLF % PAP VS. FOLL

PAPILLAPAPILLANUCLEAR FEATURENUCLEAR FEATURE• GROUND GLASS• OPTICALLY CLEAR

ORPHAN ANNIE EY• ORPHAN ANNIE-EY

PSAMMOMA BODIESSMALL CONCENT–SMALL CONCENT

ARY CAARY CASS:

RYEYE

S=TRIC CONCRETIONSTRIC CONCRETIONS

PAPILLAPAPILLARELIABLY DIAG1. FINE NEEDLE A

2. CORE NEEDLE

3. FROZEN SECT

ARY CAARY CAGNOSED BY:ASPIRATION (FNA)

E BIOPSY

ION DIAGNOSIS

PAPILLAPAPILLAMETASTATIC S

LYMPHATIC TO PA• LYMPHATIC TO PA

• MULTICENTRMULTICENTR– ? MULTIPLE PRIMA

– ? MET FOCI VIA LY

CLINICAL OR SUB• CLINICAL OR SUB

ARY CAARY CASPREAD:ARATHYROIDAL LNsARATHYROIDAL LNs

RIC FOCI IN THYROIDRIC FOCI IN THYROIDARIES

YMPHATIC SPREAD

BCLINICALBCLINICAL

PAPILLAPAPILLASPREAD:SPREAD:• RARELY DIE OFRARELY DIE OF• IF DIE, USUALL,

– PULMONARY ORINVASION OF JUG– INVASION OF JUGAIRWAY

– ANAPLASTIC DIF

ARY CAARY CA

F PAPILLARY CAF PAPILLARY CALYR CEREBRAL METSGULAR CAROTID ORGULAR, CAROTID OR

FFERENTIATION

FOLLICUFOLLICU

• 10-20% OF THYR• USUALLY

–SOLITARYCOLD–COLD

–LOW RAI UPTA

ULAR CAULAR CA

OID CARCINOMAS

AKE

FOLLICUFOLLICUGROSS:GROSS:• SOLITARY• MAY HAVE CAPSUL

INVASION DISTINGUISH– INVASION DISTINGUISH

• MAY INVADE – ADJACENT THYROID– OUTSIDE THYROID & C

ADJACENT STRUCTUR

ULAR CAULAR CA

LE HES CA FROM ADENOMAHES CA FROM ADENOMA

CAUSE ADHESIONS TO RES

FOLLICUFOLLICUMICROMICRO:• SOLITARY IN O• SOLITARY IN O

• METASTATIC S

–INVADES AND–COMMON SIT

LUNGS AND• LUNGS AND

ULAR CAULAR CA

ONE LOBEONE LOBE

SPREAD:

D METS VIA VEINSTES OF METS:

BONESBONES

CHORNOBYLI 131 Radioisotope scan o

thyroid cancer and

L PROJECTof 24 year old man with lung metastases

FOLLICUFOLLICUT t tTreatment:

T t l th id t• Total thyroidect

• If metastatic to• If metastatic to

treat with hi dtreat with hi d

• 10 year survival10 year survival

ULAR CAULAR CA

ttomy (1 or 2 stages)

lung or bonelung or bone,

dose 131I to ablatedose 131I to ablate

l: 50-70%l: 50-70%

THYROID NTHYROID N• How to distingu

ADENOMA fromADENOMA from–Search for inSearch for in

or blood vess–Examine enti

especially caespecially ca

EOPLASMSEOPLASMSuish Follicular m CARCINOMA?m CARCINOMA?vasion of capsulevasion of capsule selsire nodule,

apsuleapsule

FOLLICUFOLLICUVERY DIFFICULT• VERY DIFFICULTFROZEN SECTION

– Bland tumor cel

– Subtle invasion• EASY TO DIAGNOSE• EASY TO DIAGNOSE

INVASION &/OR ANA

ULAR CAULAR CAT TO DIAGNOSE BYT TO DIAGNOSE BY N

lls

E ANY CA WITH GROSSE ANY CA WITH GROSS APLASIA AND MITOSES

MEDULLMEDULL5% OF THYROID CAR• 5% OF THYROID CAR

• ARISE from PARAFOL(“C” CELLS)– ARISE FROM NEURARISE FROM NEUR

• 75% SPORADIC • 25% FAMILIAL (+MEN

– ASSOC’D WITH RET P

LARY CALARY CARCINOMASRCINOMASLLICULAR CELLS

RAL CRESTRAL CREST

2)ROTO-ONCOGENE

MEDULLMEDULL“C” CELLS PRODUCE MA• “C” CELLS PRODUCE MA– & OTHER PP HORMON

• PRE-OP SERUM CALCITO• POST-OP SERUM CALCIT

RESIDUAL OR RECURRE• TOTAL THYROIDECTOMY• LN DISSECTION IF ENLA

NODES

LARY CALARY CAAINLY CALCITONINAINLY CALCITONINNES ie SERATONIN, ACTHONIN FOR DIAGNOSISTONIN TO DETECT ENT TUMORY

ARGED OR SUSPICIOUS

MEDULLMEDULLGROSS:• YELLOW-TAN

ILL DEFINED B• ILL-DEFINED B

• INFILTRATES A• INFILTRATES A

LARY CALARY CA

BORDERSBORDERS

ADJACENT TISSUESADJACENT TISSUES

MEDULLMEDULLMICROSCOPICMICROSCOPIC• SOLID NESTS• SOLID NESTS• ROUND TO SPIN• AMYLOID-LIKE S

–CONGO RED, PAPPLE GREENAPPLE GREEN

LARY CALARY CACC:

NDLY CELLSSTROMAPOLARIZED: N BIREFRINGENCEN BIREFRINGENCE

MEDULLMEDULLSPREAD:SPREAD:

• LYMPHATICVENOUS• VENOUS

• METS TO LUN• METS TO LUN• MULTIFOCAL• MULTIFOCAL

LARY CALARY CA

NG AND BONESNG AND BONESLL

AutosomalI h iInheri

50% affected,50% affected,

l Dominant ttance

50% unaffected 50% unaffected

Multiple Endocr• Medullary thyroid carcin

possibly only presentatPh h t (50• Pheochromocytoma (50

• Hyperparathyroidism (1MEN2B h i t d• MEN2B has associated body habitus, hypotoniaand ganglioneuromatosg gonset tumors

• Familial MTC-isolated fi

rine Neoplasia 2noma (99%)-usual and tion0%)0%)15-30%)

f t f f idfeatures of marfanoid a, mucosal neuromas, sis of the gut, earlier g ,

inding

Patient hi• Patient history

– Early age of onset– Unusual tumors– Multiple synchronous or

h l ihyperplasia– Associated medical cond

F il hi t• Family history– Should include three gen

C d f d th– Cause and age of death osecond degree relatives

– Goiter, sudden death, hyGoiter, sudden death, hy– Resolution of ambiguous

story/FHx

metachronous tumors or

ditions

nerationsf ll fi t d if iblof all first and if possible

pertension, renal stonespertension, renal stoness medical histories

Clinical ManagClinical Manag• It is standard of care b

of medullary thyroid cagenetic testing for RETM t ti iti i di• Mutation positive indivprophylactic total thyro

• Screen for pheochromsurgery (or any surgersurgery (or any surger

• Screen biochemically apheochromocytoma anp y

gement of MEN2gement of MEN2by ASCO for ALL cases yancer to undergo T proto-oncogeneid l h ld dviduals should undergo

oidectomy

ocytoma prior to thyroid ry)ry)annually for nd hyperparathyroidism yp p y

ANAPLAANAPLA• 1-3% OF THYROID

• VERY POOR PRO

(<5% SURVIVE 5

• LESS FREQUENT

ASTIC CAASTIC CAD CARCINOMAS

GNOSIS

5 YEARS)

than 40 years ago

ANAPLAANAPLACLINICALCLINICAL:

• Patients >50 years• Patients >50 years

• Old nodule begins g

–? arose in pre-exi

• ? Lower incidence resected nodules

ASTIC CAASTIC CA

oldold

to grow rapidlyg p y

isting nodule

due to more

ANAPLAANAPLACLINICAL:CLINICAL:• Rapid growthRapid growth• Invasion of adjace• Tracheostomy freq• Usually unresectab

Chemo / Radiation• Chemo / Radiation

ASTIC CAASTIC CA

nt structuresquently necessaryble

n not useful in mostn not useful in most

ANAPLAANAPLAMICROMICRO:• HIGHLY UNDIFFERHIGHLY UNDIFFER

–small cells–giant cells–spindle cellsspindle cells

• May need immunosf l h &from lymphoma & s

ASTIC CAASTIC CA

RENTIATED!!!!!RENTIATED!!!!!

stains to distinguish sarcoma

MALIGNANTMALIGNANT OF THYOF THY

• USUALLY ARIS• USUALLY ARISHASHIMOTO’SHASHIMOTO S

• RARELY PRIMA

LYMPHOMALYMPHOMAYROIDYROIDES INES IN THYROIDITISTHYROIDITIS

ARY IN THYROID

THYROGLOSSATHYROGLOSSAPERSISTENT THYROID A• PERSISTENT THYROID AMIGRATION PATH IN MIDTO LARYNX & HYOID BOTO LARYNX & HYOID BO

• RESECTED WHEN RESIDPERSISTS OR RECURSPERSISTS OR RECURS

• MICRO:– LINED BY CILIATED R

EPITHELIUM SQUAMOEPITHELIUM, SQUAMO

AL DUCT CYSTAL DUCT CYSTALONG EMBRYONALALONG EMBRYONAL DLINE NECK, ANTERIOR ONEONEDUAL TRACT / CYST

RESPIRATORY OUS OR BOTHOUS, OR BOTH