tiroid biologi

7/28/2019 tiroid biologi

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ThyroidCytopathology

and Its

Histopathological Bases

Doc. MUDr. Jaroslava Dukov,CSc,FIAC

Inst. of Pathol. 1st Med. Faculty, Charles Univ. & Chair of Pathol. Inst. of Postgraduate Studies,

Prague, Czech Rep.


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Thyroid Gland

- embryology and fetal endocrinology

mouth epithelium, end of the 1st iu.monthductus thyreoglosus

lateral pharynx ultimobranchial bodiesC- bb.

parathyroid glands

fetal secretion starts in 12 weeks

effect on GROWTH

effect on DIFFERENTIATION


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Thyroid Gland - anatomy

Weight in adults 15-20g

over60g(7g in a neonate)struma

lobus dexter ismus a lobus pyramidalis

lobus sinister

aberant, accesory, ectopic gland

(polyclonality should help to tell from ca)


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Thyroid Gland - ectopic tissue

Parasitic thyroid nodule

Rosai (1990) - mediastinum

Assi (1996) - laterally in the neck

Shimizu et al. (1999) - onlyforlaterally on

the neck localised thyroid tissue without anyrelation to the lymph nodes


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Main Tasks

in the Thyroid Cytology

reduction of the unnecessary surgery diagnosis & follow-up of subclinical

inflammation

EARLY DIAGNOSIS of NEOPLASMS


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Thyroid Cytology

getting sample

needle 0.6-0.8mm

min. 2 punctionsaspiration

nonaspiration reduction of the blood content

cyst: evacuate and aspirate with thesecond punction the periphery

fluid: whole volume for cytology


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Thyroid Cytology - processing

Fixation

air dried

etanol / spray

(cytospin)

CYTOBLOCK

Staining:

MGG, HE

polychrom

all histo

imunocytoTGB,calcitonin,

parathormon


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Thyroid Cytology

- diagnostic groups (n20 000)

10,8

58,2

19,3

3,6

8,1 nondiag.

goitre

inflammation

benign tumor

tumor susp./malignant


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Main Tasks

in the Thyroid Histology

diagnosis of all lesions

in malignancies pTNM


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Processing of Thyroid Resecate

orientation

division lobus dx.

isthmus (+lobus pyramidalis) lobus sin.

cutting in cca 3mm thick lamellae

revision and extensive/completeblocking of the encapsulated nodulesperiphery

any suspicious focus for histology


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Benign Thyroid Nodule 1.

Histological

diagnosis

adenomatous

goitre

macrofollicular

adenoma

Cytologic features low cellularity

colloid background

phragments ofmacrofollicules

tct regular small orslightly enlarged

small and middle size

bare nucleioncocytes esp. in

elderly people


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Histological

diagnosis

adenomatoid

goitre

macrofollicular

adenoma

with regressive

changes


colloid background

phragments ofmacrofollicules

tct regular small orslightly enlarged

small and middle sizebare nuclei

pigmentedmacrophages

oncocytes esp. inelderly people


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Histologicaldiagnosismicromacrofollicular

goitre

micromacrofollicular

adenoma

cystic transformation(often with signs of older

haemorrhage)


regresively changed

erythrocytes and colloid

macrophages(abundant, pigmented) thyreocytes small or

slightly enlarged

scatterred groups

may be damaged

may be absent


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Folicular Neoplasia

(proliferating microfollicular lesion)

Histological

diagnosis

microfollicular

adenoma

follicular

carcinoma

Cytological features

highly cellular smears few colloid microfollicular

formations thyreocytes regular,

small or slightlyenlarged bare nuclei regressive changes:

mostly absent


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ThyreoiditisNON-SPECIFIC purulent non-specific granulomatose de Quervain lymphocytic (Hashimoto)

hypertrofic

atrofic focal

invasive sclerosing Riedel

SPECIFIC tbc syfilis sarcoidosis


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Non-Specific Granulomatose

Thyreoiditis de Quervain (1904)

Synonyma: Giant cell

Subacute non-purulent Clin.features: Oedema, pain, eufunction,

may be also silent

Histol. features: dispersegranulomaswith giant cells

Course: spontaneous healing by 2-4weeks


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Thyreoiditis lymphoplasmocellularis Hashimoto - HT

Hashimoto, H.:Zur Kenntniss der lymphomatsen

Vernderung der Schilddrse

(struma lymphomatosa)

Arch.f. klin. Chir. 97, 1912, 219


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Original Description of HT

(4 cases)

Macro - goitre

diffuse

parenchymatous

firm elasticgray- yellowish

Micro - inflammation

diffuse

lymphoplasmocellular

folliculesONCOCYTES


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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

ofapoptosis

Activity: CD44 proteoglycan influencingmigration and lymphocyte proliferation, andmetastasing


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Course of HT

a) progressive

oncocytic transformation

loss of thyreocytes

transformation to a lymph-

node-with-ca- meta image

hyperfunction folowed by

hypofunction


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Course of HT

b) regressive

loss of parenchyma,

fibrosis

hypofunction


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Course of HT

c) neoplasia

carcinoma

lymphoma (mostly B - MALT)


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Oncocytic Tumours

adenoma

architecture follicular, trabecular

cellular atypiae without predictive valuefor biological behaviour

more risky in case of solid architecture

EXCLUDE

ANGIOINVASION, CAPSULOINVASION


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Oncocytic Tumours

carcinoma

oncopapillary (may lack ground glass nuclei ?

oncofollicularmust exhibit

ANGIOINVASION and/or

CAPSULOINVASION (all capsulethickness with extracapsular expansion)


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Oncocytic Tumours- cytology

blood & colloid background, oftensiderophages

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


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HT - differential diagnosis

HT versus HT + lymphoma

HT versus HT + carcinoma

oncocyticpapillarymedullary


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ThyroidMalignant Lymphomas

less than 2% of primary thyroidmalignancies

most in women withHT

clinically rapid growth, often hypofunction

mostly B (MALT) with lymphoepiteliodlesion features

LG i HG

dif dg. HT

in case of uncertainty dg. excision


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Summary:

interpretation of cytology in some patientswith 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


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Papillary Carcinoma

- histological variants WHO (2004)

microcarcinoma

(encapsulated)

follicular

macrofollicular

diff. sclerosing

oxyphil cell

clear cell

tall cell

columnar cell

solid

cribriform

with desmopl.stroma (hyal. trabecular ca)

with focal insular component

with squamous ormucoepidermoid ca

with spindle and giantcell ca

combined papillary andmedullary ca


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Papillary Carcinoma


general highly cellular smears

few colloid

waxy colloid, may beabsent

architecture

phragments of papillae groups trabecular

microfollicular syncytial formations

squamous metaplasia

psammomata

NUCLEI

enlarged non - circular

overlapping

grooves pseudoinclusions


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Medullary Carcinoma

origin fom C-cells

clinical forms :

(parafollicular)

sporadic familiar

MEN 2a

MEN 2b


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Medullary Carcinoma

familiar forms

MEN 2a

medullary ca

parathyr. adenoma

pheochromocytoma

MEN 2b

MEDULLARY CA

marfanoid habitus

mucous neuromas

pheochromocytoma

parathyr. adenoma -


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Medullary Carcinoma

Histological

diagnosis

architecturemay mimicany 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


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Medullary Carcinoma

Cytological

types large cell small cell

fusocellular

plasmocytoid


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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)


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highly malignant neoplasm of the old age withrapid progression

origin:

non diag. differentiated ca

hyperplastic goitre

chronic inflammation without preceeding goitre

Undifferentiated Carcinoma

(anaplastic)


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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!


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blood background without colloid

isolated and grouped atypical cells

fusiform polygonal giant

striking anisocytosis, anisokaryosis

HYPERCHROMATIC NUCLEI

squamous metaplasia


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Mixed Medullary-Follicular

Carcinomamixture 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


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Other Types

ofPrimaryThyroid Carcinomas

epidermoid

mucoepidermoid

mixed follicular and mucoepidermoid


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Metastases to theThyroid

kidney

lung

breast

others


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Pitfalls in Thyroid FNAB

combined diagnoses

repair

medullary ca

rare tumours


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The Unified Approach to

Breast Fine NeedleAspiration Biopsy.

A synopsis.

Acta Cytol., 1996, 40, 6, 1120-6

Applicable to the Thyroid FNAB


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Triple test in Thyroid FNAB

clinical symptoms and info

(+laboratory data)ultrasonography

cytology (FNAB)


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What to do?

Listen

to the patients

history

and clin. info BUT


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Considermaterial

limitations bothquantitative and

qualitative


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evaluate

what ISon the slide


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If uncertainty

considering malignancy presencepersists

forASK


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extensive

histological

investigation

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