thyroid stuff cytopathology & pathology ryan orosco sept 2013

Thyroid StuffCytopathology & Pathology

Ryan OroscoSept 2013

Objective

• Understand benefits of FNA• Learn an algorithmic approach to FNA

cytopathology• Be able to name and identify key cytologic

features of papillary thyroid cancer

Benign Causes of Thyroid Nodules

• Adenomatous nodule• Colloid nodule• Follicular adenoma• Simple thyroid cyst• Graves disease• Chronic lymphocytic thyroiditis (Hashimoto’s)• Focal subacute thyroiditis• Developmental conditions

Thyroid Cytopathology, Faquin and Clark, Springer 2010

Benefits of Using FNA to Evaluate Thyroid Nodules

• Reduces number of patients requiring surgery by 50%

• Increases the yield of thyroid malignancies at thyroidectomy by 2-3x

• Decreases the cost of managing thyroid nodules by 25%

Thyroid Cytopathology, Faquin and Clark, Springer 2010

Thyroid Cytopathology, Faquin and Clark, Springer 2010

Diagnostic Categories• Nondiagnostic – occurs in 10-30% of cases• Benign – about 70% of the time

– Low false negative rate (1-3%) gives you confidence to follow non-surgically

• Malignant – about 10-20% of the time– Low false negative rate (1-3%) gives you confidence to follow non-

surgically• Suspicious for Malignancy – about 60-75% risk for malignancy

– Usually managed with total thyroidectomy given high risk

• Suspicious for Follicular Neoplasm – 10-30% risk for malignancy– Usually managed with lobectomy

• Atypia of Undetermined Significance – should be less than 10% of FNAs. Risk of malignancy 5-15%.– Usually managed with repeat FNA in 3 months

Thyroid Cytopathology, Faquin and Clark, Springer 2010

Thyroid Cytopathology, Faquin and Clark, Springer 2010

Sensitivity/specificity depends on how indeterminate specimens and suspicious groups of lesions are handled, skill of the person doing the u/s and FNA, cytopathologist expertise

False neg and false pos are usually less than 1% in most series

About 18% of pts who get a FNA are treated surgically

Sensitivity/specificity depends on how indeterminate specimens and suspicious groups of lesions are handled, skill of the person doing the u/s and FNA, cytopathologist expertise

False neg and false pos are usually less than 1% in most series

About 18% of pts who get a FNA are treated surgically

The Spectrum of Thyroid Cancer• The good: well-differentiated• The bad: poorly differentiated• The ugly: undifferentiated (anaplastic)

Thyroid Cytopathology, Faquin and Clark, Springer 2010

Thyroid Cytopathology, Faquin and Clark, Springer 2010

Cystic

Inflammatory & LymphomaInflammatory & Lymphoma

Thyroid Cytopathology, Faquin and Clark, Springer 2010

Colloid Predominant

Epithelium-PredominantEpithelium-Predominant

Epithelium-PredominantEpithelium-Predominant

Thyroid Cytopathology, Faquin and Clark, Springer 2010

Epithelium-Predominant – Hurthle cellEpithelium-Predominant – Hurthle cell

Thyroid Cytopathology, Faquin and Clark, Springer 2010

Epithelium-Predominant – PTCEpithelium-Predominant – PTCFeatures of PTC

Diagnostic:• Hypercellular• Monolayered sheets with crowding

and disorganization• Enlarged oval nuclei• Fine, evenly dispersed chromatin• Nuclear grooves• Nuclear pseudoinclusions

Associated:• Dense squamoid cytoplasm• Multinucleated giant cells• Densely staining “rope” colloid• Psammoma bodies

Features of PTC

Diagnostic:• Hypercellular• Monolayered sheets with crowding

and disorganization• Enlarged oval nuclei• Fine, evenly dispersed chromatin• Nuclear grooves• Nuclear pseudoinclusions

Associated:• Dense squamoid cytoplasm• Multinucleated giant cells• Densely staining “rope” colloid• Psammoma bodies

Thyroid Cytopathology, Faquin and Clark, Springer 2010

Epithelium-Predominant – PTCEpithelium-Predominant – PTC

Thyroid Cytopathology, Faquin and Clark, Springer 2010

Thyroid Cytopathology, Faquin and Clark, Springer 2010