Thyroid Cytopathology and Its Histopathological Bases - PowerPoint PPT Presentation

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Thyroid Cytopathology and Its Histopathological Bases

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Title: Na e zku enosti s HT Author: MUDr J. Du kov CSc,MIAC Last modified by: Jaroslava Du kov Created Date: 5/15/1998 11:31:40 AM Document presentation format – PowerPoint PPT presentation

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Title: Thyroid Cytopathology and Its Histopathological Bases


1
ThyroidCytopathology and ItsHistopathological
Bases
  • Doc. MUDr. Jaroslava Dušková,CSc,FIAC
  • Inst. of Pathol. 1st Med. Faculty, Charles Univ.
    Chair of Pathol. Inst. of Postgraduate Studies,
  • Prague, Czech Rep.

2
Thyroid Gland - embryology and fetal
endocrinology
  • mouth epithelium, end of the 1st iu.
    month? ductus thyreoglosus
  • lateral pharynx
  • ultimobranchial bodies ? C- bb.
  • parathyroid glands
  • fetal secretion starts in 12 weeks
  • effect on GROWTH
  • effect on DIFFERENTIATION

3
Thyroid Gland - anatomy
  • Weight in adults 15-20g
  • over 60g (7g in a neonate) struma
  • lobus dexter
  • ismus a lobus pyramidalis
  • lobus sinister
  • aberant, accesory, ectopic gland
  • (polyclonality should help to tell from ca)

4
Thyroid Gland - ectopic tissue
  • Parasitic thyroid nodule
  • Rosai (1990) - mediastinum
  • Assi (1996) - laterally in the neck
  • Shimizu et al. (1999) - only for laterally on
    the neck localised thyroid tissue without any
    relation to the lymph nodes

5
Main Tasks in the Thyroid Cytology
  • reduction of the unnecessary surgery
  • diagnosis follow-up of subclinical
    inflammation
  • EARLY DIAGNOSIS of NEOPLASMS

6
Thyroid Cytology getting sample
  • needle 0.6-0.8mm
  • min. 2 punctions
  • aspiration
  • nonaspiration reduction of the blood content
  • cyst evacuate and aspirate with the second
    punction the periphery
  • fluid whole volume for cytology

7
Thyroid Cytology - processing
  • Staining
  • MGG, HE
  • polychrom
  • all histo
  • imunocyto
  • TGB,calcitonin, parathormon
  • Fixation
  • air dried
  • etanol / spray
  • (cytospin)
  • CYTOBLOCK

8
Thyroid Cytology - diagnostic groups
(n?20 000)
9
Main Tasks in the Thyroid Histology
  • diagnosis of all lesions
  • in malignancies pTNM

10
Processing of Thyroid Resecate
  • orientation
  • division
  • lobus dx.
  • isthmus (lobus pyramidalis)
  • lobus sin.
  • cutting in cca 3mm thick lamellae
  • revision and extensive/complete blocking of the
    encapsulated nodules periphery
  • any suspicious focus for histology

11
Benign Thyroid Nodule 1.
  • Histological diagnosis
  • adenomatous goitre
  • macrofollicularadenoma
  • Cytologic features
  • low cellularity
  • colloid background
  • phragments of macrofollicules
  • tct regular small or slightly enlarged
  • small and middle size bare nuclei
  • oncocytes esp. in elderly people

12
Benign Thyroid Nodule 2.
  • Histological diagnosis
  • adenomatoid goitre
  • macrofollicular adenoma
  • with regressive changes
  • Cytologic features
  • low cellularity
  • colloid background
  • phragments of macrofollicules
  • tct regular small or slightly enlarged
  • small and middle size bare nuclei
  • pigmented macrophages
  • oncocytes esp. in elderly people

13
Benign Thyroid Nodule 3.
  • Histological diagnosis
  • micromacrofollicular goitre
  • micromacrofollicular adenoma
  • cystic transformation (often with signs of older
    haemorrhage)
  • Cytologic features
  • low cellularity
  • regresively changed erythrocytes and colloid
  • macrophages
  • (abundant, pigmented)
  • thyreocytes small or slightly enlarged
  • scatterred groups
  • may be damaged
  • may be absent

14
Folicular Neoplasia (proliferating
microfollicular lesion)
  • Histological diagnosis
  • microfollicular adenoma
  • follicular carcinoma
  • Cytological features
  • highly cellular smears
  • few colloid
  • microfollicular formations
  • thyreocytes regular, small or slightly enlarged
  • bare nuclei
  • regressive changes
  • mostly absent

15
Thyreoiditis
  • NON-SPECIFIC
  • purulent
  • non-specific granulomatose de Quervain
  • lymphocytic (Hashimoto)
  • hypertrofic
  • atrofic
  • focal
  • invasive sclerosing Riedel
  • SPECIFIC
  • tbc
  • syfilis
  • sarcoidosis

16
Non-Specific Granulomatose Thyreoiditis de
Quervain (1904)
  • Synonyma Giant cell
  • Subacute non-purulent
  • Clin.features Oedema, pain,
    eufunction, may be also silent
  • Histol. features disperse granulomas
  • with giant cells
  • Course spontaneous healing by 2-4
    weeks

17
Thyreoiditis lymphoplasmocellularis Hashimoto -
HTHashimoto, H.
  • Zur Kenntniss der lymphomatösen Veränderung der
    Schilddrüse
  • (struma lymphomatosa)
  • Arch.f. klin. Chir. 97, 1912, 219

18
Original Description of HT (4
cases)
  • Micro - inflammation
  • diffuse
  • lymphoplasmocellular
  • follicules
  • ONCOCYTES
  • Macro - goitre
  • diffuse
  • parenchymatous
  • firm elastic
  • gray- yellowish

19
Etiopatogenesis of HT
  • Etiology unclear - viri ?
  • Patogenesis
  • dysregulation of T lymphocytes
  • IL-1? expression Fas molecules on the surface
  • of thyreocytes (they have FasL) ?
    activation of apoptosis
  • Activity CD44 proteoglycan influencing
    migration and lymphocyte proliferation, and
    metastasing

20
Course of HT
  • a) progressive
  • oncocytic transformation loss of
    thyreocytes
  • transformation to a lymph- node-with-ca-
    meta image
  • hyperfunction folowed by
    hypofunction

21
Course of HT
  • b) regressive
  • loss of parenchyma,
  • fibrosis
  • hypofunction

22
Course of HT
  • c) neoplasia
  • carcinoma
  • lymphoma (mostly B - MALT)

23
Oncocytic Tumours
  • adenoma
  • architecture follicular, trabecular
  • cellular atypiae without predictive value
    for biological behaviour
  • more risky in case of solid architecture
  • EXCLUDE
  • ANGIOINVASION, CAPSULOINVASION

24
Oncocytic Tumours
  • carcinoma
  • oncopapillary (may lack ground glass nuclei ?
  • oncofollicular
  • must exhibit
  • ANGIOINVASION and/or
  • CAPSULOINVASION (all capsule thickness
    with extracapsular expansion)

25
Oncocytic Tumours - cytology
  • blood colloid background, often siderophages
  • groups of oncocytes
  • well delineated and stained cytoplasm
  • sometimes dark blue cytoplasmic granules
  • irregular large nucleus, excentric, binucleation
  • solitary cherry red nucleolus
  • anisocytosis, anisokaryosis may be striking
  • no signs of inflammation in the background
  • no inflammatory cells in the oncocytic groups

26
HT - differential diagnosis
  • HT versus HT lymphoma
  • HT versus HT carcinoma
  • oncocytic
  • papillary
  • medullary

27
Thyroid Malignant Lymphomas
  • less than 2 of primary thyroid malignancies
  • most in women with HT
  • clinically rapid growth, often hypofunction
  • mostly B (MALT) with lymphoepiteliod lesion
    features
  • LG i HG
  • dif dg. HT
  • in case of uncertainty dg. excision

28
Summary
  • interpretation of cytology in some patients
    with HT may be very difficult
  • correlation with clinical course especially
    important (rapid growth, nodule formation)
  • extensive histology investigation of resecates
    with HT proves coincidence with latent
    malignancies in the inflammatory background

29
Papillary Carcinoma - histological variants WHO
(2004)
  • solid
  • cribriform
  • with desmopl.stroma
  • (hyal. trabecular ca)
  • with focal insular component
  • with squamous or mucoepidermoid ca
  • with spindle and giant cell ca
  • combined papillary and medullary ca
  • microcarcinoma
  • (encapsulated)
  • follicular
  • macrofollicular
  • diff. sclerosing
  • oxyphil cell
  • clear cell
  • tall cell
  • columnar cell

30
Papillary Carcinoma
  • Cytological features
  • general
  • highly cellular smears
  • few colloid
  • waxy colloid, may be absent
  • architecture
  • phragments of papillae
  • groups trabecular
  • microfollicular
  • syncytial formations
  • squamous metaplasia
  • psammomata
  • NUCLEI
  • enlarged
  • non - circular
  • overlapping
  • grooves
  • pseudoinclusions

31
Medullary Carcinoma
  • origin fom C-cells
  • clinical forms
  • (parafollicular)
  • sporadic
  • familiar
  • MEN 2a
  • MEN 2b

32
Medullary Carcinoma familiar forms
  • MEN 2a
  • medullary ca
  • parathyr. adenoma
  • pheochromocytoma
  • MEN 2b
  • MEDULLARY CA
  • marfanoid habitus
  • mucous neuromas
  • pheochromocytoma
  • parathyr. adenoma -

33
Medullary Carcinoma
  • Histological diagnosis
  • architecture may mimic any other
  • thyroid ca!!!
  • (WHO 1988)
  • Calcitonine
  • amyloid -
  • argyrophilia

VARIANTS WHO 2004 papillary, glandular-
tubular, giant cell, spindle cell, small cell,
paraganglioma-like, oncocytic , clear cell,
angiosarcoma-like, squamous cell, melanin
producing, amphicrine
34
Medullary Carcinoma
  • large cell
  • small cell
  • fusocellular
  • plasmocytoid
  • Cytological types

35
Medullary Carcinoma
  • Cytological features
  • blood background
  • colloid absent (amyloid -)
  • groups of cells
  • oncocytoid (granules rose!)
  • plasmocytoid
  • fusocellular
  • small round cells
  • HYPERCHROMATIC NUCLEI
  • (overlapping, oval or spindle shaped)

36
Undifferentiated Carcinoma (anaplastic)
  • highly malignant neoplasm of the old age with
    rapid progression
  • origin
  • non diag. differentiated ca
  • hyperplastic goitre
  • chronic inflammation
  • without preceeding goitre

37
Undifferentiated Carcinoma
  • Histological variants (often combined)
  • fusocellular
  • small cell (?) exclude lymphoma!
  • giant cell (monstrous cells)
  • squamous metaplasia
  • composed
  • lmsa, rmsa,osa, chsa, hae, MFH,
  • classify as carcinoma!

38
Undifferentiated Carcinoma
  • Cytological features
  • blood background without colloid
  • isolated and grouped atypical cells
  • fusiform
  • polygonal
  • giant
  • striking anisocytosis, anisokaryosis
  • HYPERCHROMATIC NUCLEI
  • squamous metaplasia

39
Mixed Medullary-Follicular Carcinoma
  • mixture of structures
  • both components in metastases
  • provable even without meta (differentiation,
    ihch, ISH, PCR
  • co-expression of TGB and Calcitonine)

Two own cases published in Acta Cytol 2003 47
(1)71-7
40
Other Types of PrimaryThyroid Carcinomas
  • epidermoid
  • mucoepidermoid
  • mixed follicular and mucoepidermoid

41
Metastases to theThyroid
  • kidney
  • lung
  • breast
  • others

42
Pitfalls in Thyroid FNAB
  • combined diagnoses
  • repair
  • medullary ca
  • rare tumours

43
The Unified Approach to Breast Fine Needle
Aspiration Biopsy. A synopsis.
  • Acta Cytol., 1996, 40, 6, 1120-6

Applicable to the Thyroid FNAB
44
Triple test in Thyroid FNAB
  • clinical symptoms and info
  • (laboratory data)
  • ultrasonography
  • cytology (FNAB)

45
What to do?
Listen to the patients history and clin. info
BUT
46
Consider material limitations both quantitative
and qualitative
47
evaluate what IS on the slide
48
If uncertaintyconsidering malignancy presence
persists
ASK
for
49
extensive histological investigation
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