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