Upload
mohanad11
View
223
Download
0
Embed Size (px)
Citation preview
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 1/49
Pathology of the Thyroid
Gland
SMS 2023BY
Dr. Mohanad
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 2/49
Diseases of the Thyroid
Gland
• Congenital diseases
• Inflammation
• Functional abnormality• Diffuse and Multinodular goiters
• Neoplasia
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 3/49
Thyroid Neoplasms
I. Primary Tumours
• Epithelial
• Malignant Lymphomas
• Mesenchymal tumours
II. Metastatic Tumours
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 4/49
Solitary thyroid nodule
• Papillary carcinoma
• Follicular carcinoma
• Medullary carcinoma
• Follicular adenoma
• Hyperplastic (dominant) nodule
• Metastatic neoplasms
• FINE NEEDLE ASPIRATION CYTOLOGY
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 5/49
Typical Presentation of
Thyroid Cancer
• Painless lump
• Normal thyroid function tests
• Found on routine examination or by the patient
• Slow growth or no growth over several months
• Most thyroid cancers present in clinically euthyroid patients
who have normal thyroid function tests.
• These tests, including those measuring thyroid stimulating
hormone (TSH), thyroxine (T4), and triiodothyronine (T3),
are measurements of the functional status of the thyroid and
provide no information on the presence or absence of
structural disease of the thyroid (eg, nodules).
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 6/49
Epithelial Thyroid Neoplasms
• Tumours of follicular cells
Benign (adenomas)
• Follicular adenoma Malignant (carcinomas)
• Follicular carcinoma (10-20%)
• Papillary carcinoma (75-85%)
• Undifferentiated (anaplastic) carcinoma (<5%)
• Tumours of C-cells
Medullary thyroid carcinoma (MTC - 5%)
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 7/49
Types of Thyroid Cancer
• Papillary (80%-85%): develops from thyroid follicle cells in 1 or
both lobes; grows slowly but can spread
• Follicular (5%-10%): common in countries with insufficient
iodine consumption; lymph node metastases are uncommon
• Medullary: develops from C-cells, can spread quickly; sporadic
and familial types
• Anaplastic: develops from existing papillary or follicularcancers; aggressive, usually fatal
• Lymphoma: develops from lymphocytes; uncommon
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 8/49
Follicular Adenoma
• Benign, encapsulated tumor showing
evidence of follicular differentiation
• Common
• Predominantly young to middle women
• Presents as solitary thyroid nodule
• Painless nodular mass, cold on isotopic scan
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 9/49
Follicular Adenoma
Solitary, Variably
sized,
encapsulated, well-circumscribed with
homogenous gray-
white to red-brown
cut-surface+/- degenerative
changes
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 10/49
• Hemorrhage
• Oedema
• Fibrosis• Calcification
• Bone formation
(ossification)• Cystic degeneration
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 11/49
Follicular Carcinoma
• Second most common form, 10-20%
• Females > Males, average age ~ 45 - 55 yr
• Rare in children
• Solitary nodule, painless, cold on isotopic scan
• Widely invasive Vs minimaly invasive• 50% 10 yr survival Vs 90%10 yr survival
• Haematogenous route is preferred mode of spread
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 12/49
Follicular Carcinoma
• Solitary round or oval
nodule
• Thick capsule• Composed of follicles
• Capsular invasion or
vascular invasion
within our outsidecapsular wall
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 13/49
• Well-formed follicles
• Poorly-formed follicles
• Cribiform area
• Trabecular formations
• Predominantly solid growth
pattern
• Cytoplasmic clear changes
• Mitotic activity & nuclear
atypia
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 14/49
Follicular Thyroid Cancer
Solid invasive tumors,
usually solitary and
encapsulated
Usually stays in the thyroid
gland, but can spread to the
bones, lungs, and central
nervous system
Usually does not spread tothe lymph nodes Follicular Thyroid
Cancer
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 15/49
Follicular Thyroid Cancer
Diagnosis and Prognosis
• Most FTCs present as an asymptomatic neck
mass
• If caught early, this type of thyroid cancer isoften curable
Tumors >3 cm have a much higher mortality rate
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 16/49
Papillary Carcinoma
• Commonest thyroid malignancy, 75-85%
• Female:Male = 2.5:1
• Mean age at onset = 20 - 40 yr
• May affect children
• Prior head & neck radiation exposure
• Indolent, slow-growing painless mass cold on
isotopic scan• Cervical lymphadenopathy may be presenting
feature
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 17/49
Papillary Carcinoma
• Variable size (microscopic
to several cm)
• Solid or cystic• Infiltrative or encapsulated
• Solitary or multicentric
(20%)
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 18/49
Papillary Thyroid Cancer
Characteristics
Unencapsulated tumor nodule with ill-defined margins
Tumor typically firm and solid
May present as nodal enlargement
Commonly metastasizes to neck and mediastinal lymphnodes
40% to 60% in adults and 90% in children
<5% of patients have distant metastases at time of
diagnosis
Lung is most common site
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 19/49
Papillary Carcinoma
• Papillae or follicles
• Psammoma bodies
• NUCLEAR
FEATURES***
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 20/49
Papillary Carcinoma
Nuclear Features
Optically clear (groundglass, Orphan Annie
nuclei)
Nuclear
pseudoinclusions or
nuclear grooves
Nuclear
microfilaments
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 21/49
This illustrative cell group shows cardinal features of papillary
carcinoma: nuclear grooves and pseudoinclusion
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 22/49
Lymph node with metastasis of papillary thyroid carcinoma
(middle/bottom of image)
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 23/49
Papillary Carcinoma
Prognosis
Excellent but following factors play importantrole: Age and sex
Size
Multicentricity
Extra-thyroid extension
Distant metastasis Total encapsulation, pushing margin of growth
& cystic change
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 24/49
Anaplastic Carcinoma
• Rare; < 5% of thyroid carcinomas
• Highly malignant and generally fatal < 1yr.
• Elderly ≈ 65 yrs; females slightly > males
• Rapidly enlarging bulky neck mass
• Dysphagia, dyspnoea, hoarseness
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 25/49
Anaplastic Carcinoma
Large, firm, necrotic mass
Frequently replaces entire thyroid glandExtends into adjacent soft tissue, trachea
and oesophagus
Highly anaplastic cell on histology with: Giant, spindle,small or mix cell population
Foci of papillary or follicular differentiation
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 26/49
Anaplastic Carcinoma
• Cellular pleomorphism
• +/- multinucleated giantcells
• High mitotic activity
• Necrosis
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 27/49
Anaplastic Carcinoma
• Cellular variants
Squamoid
Spindle clee
Giant cell *Paucicellular
• 1. Neutrophilic infiltration
• 2. Prominent vascularization
• 3. Cartilaginous/osseous metaplasia
• Patterns of growth
Fascicular
Storiform
Palisading at the necrotic edges
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 28/49
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 29/49
Medullary Thyroid Carcinoma
(MTC)
• Malignant tumour of thyroid C cells
producing cacitonin
• 5 % of all thyroid malignancies
• Sporadic (80%)
• Rest in the setting of MEN IIA or B or as
familial without associated MEN syndrome
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 30/49
Medullary Thyroid Carcinoma
(MTC)
Sporadic MTC
Middle-aged adults Female:male = 1.3:1
Unilateral involvement of gland
+/- cervical lymph node metastases Indolent course with 60-70% 5-yr survival after
thyroidectomy
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 31/49
Multiple Endocrine Neoplasia
Types IIA & IIB
• Germ-line mutation in Ret protooncogene on
chromosome 10q11.2
• MEN IIA: MTC, phaeochromocytoma,
parathyroid adenoma or hyperplasia
• MEN IIB: MTC, phaeochromocytoma, mucosal
ganglioneuromas, Marfanoid habitus, other
skeletal abnormalities
C
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 32/49
Medullary Thyroid Carcinoma
(MTC)
Associated with MEN IIA
Younger patients in twenties
Multicentric and bilateral Slow growing
Associated with MEN IIB
Even younger patients in teens Aggressive with early metastasis
Poor prognosis
M d ll Th id C
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 33/49
Medullary Thyroid Cancer
Metastases
• Cervical lymph node metastases occur early
• Tumors >1.5 cm are likely to metastasize, often to
bone, lungs, liver, and the central nervous system
• Metastases usually contain calcitonin and stain for
amyloid
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 34/49
Gross:(MTC)
• solid, firm & non-encapsulated
but well circumscribed
• Continuous fibrous capsule (rare)• Located in the midportion of upper half of
the gland
• Corresponding to a greater concentration of C-cells
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 35/49
Medullary carcinoma of the thyroid
(MTC) is a distinct thyroid carcinoma
that originates in the parafollicular C
cells of the thyroid gland.
These C cells produce calcitonin.
MTC has a genetic association with
multiple endocrine neoplasia (MEN)
type 2A an
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 36/49
Medullary Thyroid Carcinoma (MTC)
• Histology same for
sporadic & familial
• Solid, lobular or
insular growth
patterns
• Tumour cells round,
polygonal or spindle-shaped
• Amyloid deposits in
many cases
M d ll Th id C i
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 37/49
Medullary Thyroid Carcinoma
(MTC)
• Medium sized nucleus
• Highly vascular
stroma
• Hyalinized collagen
Coarse calcification
• Amyloid deposits stain
orange-red withCongo Red stain
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 38/49
Hürthle Cell Cancer
• A variant of follicular
cancer that tends to be
aggressive
• Represents about 3% to 5%
of all types of thyroid cancer
High power magnification
Hü thl C ll C
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 39/49
Hürthle Cell Cancer
Prognosis
• May be benign or malignant, based on
demonstration of vascular or capsular
invasion
• Malignancies tend to have a worse
prognosis than other follicular tumors and
rarely respond to 131I therapy
• Tend to be locally invasive
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 40/49
Hürthle cell carcinoma expanding right IJV lumen, with adjacent smallertumour mass. Note cells with uniform round nuclei and abundant granular
cytoplasm (haematoxylin and eosin × 200).
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 41/49
Primary Thyroid Lymphoma
• A rare type of thyroid
cancer
Affects fewer than 1 in 2
million people
• Constitutes 5% of thyroid
malignanciesLarge Cell Lymphoma of the
Thyroid
• Patients may have a history of diffuse goiter (probably theresult of an autoimmune thyroiditis) that suddenly increases in
size, and often diagnosed because of symptoms of airway
obstruction.
• pain, hoarseness, dysphagia, dyspnea,
P i Th id L h
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 42/49
Primary Thyroid Lymphoma
Characteristics and Diagnosis
• Develops in the setting of pre-existing
lymphocytic thyroiditis
• Often diagnosed because of airway obstruction
symptoms
• Tumors are firm, fleshy, and usually pale
•The tumors usually appear as rapidly enlarging massesthat develop over a period of time ranging from several
days to a few weeks.
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 43/49
GrossCut surface
Solid white with fish flesh appearance
MicroscopicMostly diffuse large cell type
Sclerosis (focally prominent)Immunoblastic lymphomaLow grade lymphomas
small/intermediate cellsDiffuse / follicular pattern
Packing of follicular lumina of
lymphoma
Prognosis of Thyroid
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 44/49
Prognosis of Thyroid
Carcinomas
Papillary Best prognosis
Follicular
Medullary
Anaplastic Worst prognosis
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 45/49
Secondary Tumours
• Direct extensions from: larynx, pharynx,
oesophagus etc.
• Metastasis from:renal cell carcinoma, large intestinal
carcinoma, malignant melanoma, lung
carcinoma, breast carcinoma etc.
T t t f Th id C
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 46/49
Treatment of Thyroid Cancer
Summary
• Papillary and follicular thyroid cancer
Generally excellent prognosis
Risk for recurrence for as long as 30 years
• Initial management Surgery and radioactive iodine
LT4 suppressive therapy
• Follow-up Physical examination
Radioactive iodine scans
Serum Tg
TSH and T4
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 47/49
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 48/49
Q-1-A 39-year-old woman presented with a large solid, firm nodules,
painless swelling in her neck. The enlargement had been a gradualprocess over 2 years. She had no other symptoms and felt generally
well. On examination, her thyroid was diffusively enlarged and had a
rubbery consistency. There were no signs of thyrotoxicosis or of thyroid
failure.
Thyroid function tests showed that she was euthyroid; T3 was 1.2nmol/l
(NR 0.8-2.4), T4 was 12nmol/l (NR 9-23) and TSH was 6.3mU/l (NR
0.4-5mU/l). However, her serum contained high titre antibodies to
thyroid peroxidase (1/64000; 4000iu/ml).
A biopsy revealed thyroid tissue within the mediastinal lymph node.A. What is the most likely diagnosis is?
B. Describe the histological lesion.
C. Mention the most common factor related to the development of the
disease.
8/3/2019 Lect 5 Thyroid Tumor
http://slidepdf.com/reader/full/lect-5-thyroid-tumor 49/49
Q-2-A-Subacute (granulomatous) thyroiditis or de quervian
thyroiditis.
B-Subacute painless lymphocytic (painless or silent) thyroiditis.