cytology of the thyroid gland - ausl...
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Cytology of the Cytology of the thyroid glandthyroid gland
A R kA. Ryska
The Fingerland Department of Pathology,Hradec Králové, Czech Republic
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StainingStainingStainingStaining
no definite recommendation no definite recommendation 3 optionsp 1. Papanicolaou – excellent nuclear features
x wet fixation neededx wet fixation needed 2. May-Grünwald-Giemsa – drying out at
room temperature, less nuclear details, better cytoplasmic features and otherbetter cytoplasmic features and other structures
3. haematoxylin-eosin
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E al ationE al ationEvaluationEvaluation
all smears, whole area (periphery!!!) morphologic features in context – synthesis ofmorphologic features in context synthesis of
information CAVE! - under- or overdiagnosis based on a single CAVE! - under- or overdiagnosis based on a single
morphologic detaill li i th l i ti i t! close clinico-pathologic cooperation is a must!
limitations of the method - FNAC is not supposed to replace histology
second opinion, ancilliary techniquesp , y q
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Criteria of aCriteria of adedequacyquacyCriteria of aCriteria of adedequacyquacy
variable at different institutions 5-6 cell groups, 10-15 follicular cells each 5 6 cell groups, 10 15 follicular cells each 10 cell groups, 20 follicular cells each counting of cells = limited evaluation "benign structures only amount of material benign structures only, amount of material
is limited" repeat the aspiration
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TheThe BethesdaBethesda s stems stemTheThe BethesdaBethesda systemsystem
unified terminology categories I – VIcategories I VI simplification of the message to a clinician
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NonNon diagnostic smearsdiagnostic smearsNonNon--diagnostic smearsdiagnostic smears
missing small nodule abnormal structure of the lesion (cystic abnormal structure of the lesion (cystic,
highly vascularized or regressively changed nodules)
di ti i ti 1 6 21% non-diagnostic aspirations 1,6 - 21% cases
our current series 6,6%
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Hyperplastic goiterHyperplastic goiterHyperplastic goiterHyperplastic goiter
any enlargement, variable etiology diffuse goiter (homogenous, no nodular diffuse goiter (homogenous, no nodular
rearrangement) h ld ll l d ff children – virtually always diffuse goiter
variable proliferative activity variable proliferative activity selection of populations with different
f t ti t tifeatures, somatic mutations hyperplastic nodules – nodular goiterype p ast c odu es odu a go te
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Colloid goiterColloid goiter difdiffusefuse and nodularand nodularColloid goiter Colloid goiter -- difdiffusefuse and nodularand nodular
variable cellularity of smears abundant colloid, mosaic pattern hyperfunction - anisokaryosis, vacuolization of
cytoplasm, "lace-like margin"cytoplasm, lace like margin macrofollicular – large flat fragments and sheets
non t anspa ent tiss e f agments non-transparent tissue-fragments regressive change – nuclear shrinkage, vacuoles,
granules of hemosiderin siderophages, foamy histiocytes, cholesterol crystalsp g y y y
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SubaSubacutecute tthhyroiditiyroiditissSubaSubacutecute tthhyroiditiyroiditiss((de Quervainde Quervain))
viral etiology, heredity (antigen HLA-gy, y ( gB35)f ll i i f i follows acute respiratory infection
may be unilateral (single lobe) may be unilateral (single lobe) solitary nodule!y
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CytologicCytologic featuresfeaturesCytologic Cytologic featuresfeatures
moderate cellularity cellular debris, small amounts of colloid, cellular debris, small amounts of colloid,
regressive changes of follicular cellsl h h l d h lymphocytes, neutrophils and macrophages
epitelioid cells - „wavy" nuclei epitelioid cells „wavy nuclei granulomas multinucleated giant cells (reaction to colloid) not specific for subacute thyroiditis !!! not specific for subacute thyroiditis !!!
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AutoimmuneAutoimmune thyroiditisthyroiditisAutoimmuneAutoimmune thyroiditisthyroiditis
ThyroiditisThyroiditis Clin.courseClin.course Characteristic featuresCharacteristic featureswith goiter chronic goiter, lymphoid infiltrate, oncocytic
(Hashimoto) chronic transformation of follicular cells, fibrosisatrophic (primary hypothyroidism) chronic atrophy, fibrosishypothyroidism)
juvenile chronic lymphocytic infiltrate
focal lymphocytic self-limited present in 20% of goiters at autopsy
post-partum t i t small goiter, lymphocytic infiltratepost partum transient small goiter, lymphocytic infiltrate
silent transient small goiter, lymphocytic infiltrate
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HashimotoHashimoto tthhyroiditiyroiditissHashimotoHashimoto tthhyroiditiyroiditiss
goiter, variable size and character small changes of thyroid size (fast
progression - susp of malignancy)progression susp. of malignancy) clinical symptoms of hypothyroidism US - hypoechoic, inhomogenous
t tstructure
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DifDiffusefuse toxictoxic goitergoiterDifDiffusefuse toxic toxic goitergoiter(Graves(Graves--Basedow Basedow diseasedisease))(( ))
most frequent cause of thyroid hyperfunction most frequent cause of thyroid hyperfunction organ specific autoimmune disorder
t tib di i t TSH t autoantibodies against TSH receptor thyroid growth + increased production of T3, T4 indication for FNAC = nodule 40% of GB goitersg Ca in 3,5% of GB goiters probability of malignancy of nodule = 11% probability of malignancy of nodule = 11%
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CytologicCytologic featuresfeaturesCytologic Cytologic featuresfeatures
high cellularity minimal amount of colloid minimal amount of colloid follicular cells in small and middle-sized
groups, moderate cohesivity marginal vacuoles at periphery background with small amount of background with small amount of
mature lymphocytes
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PapilPapillalarryy ccarcinomarcinomaaPapilPapillalarryy ccarcinomarcinomaa
t f t th id li most frequent thyroid malignancy (65-80%)(65 80%)
derived from follicular cells tumor papillae and/or specific nuclear
f tfeatures F:M = 2-3:1 any age F:M = 2 3:1, any age microCa more frequrent in males !
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More aggressive behaviorMore aggressive behavior tall cell PC columnar cell PC diffuse sclerosing PC
Less aggressive encapsulated PC
ill i i papillary microcarcinoma
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TypicTypicalal cytologiccytologic features offeatures of PCPCTypicTypicalal cytologic cytologic features of features of PCPC
high cellularity increased N/C ratio/ intranuclear pseudoinclusions – higher frequency
lti l t d i t ll ih t f multinucleated giant cells wihout presence of lymphoid elements
thick colloid (chewing-gum like) intranuclear grooves intranuclear grooves papillary fragments psammoma bodies
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FolFollliiccululaarr neoplasmsneoplasmsFolFollliiccululaar r neoplasmsneoplasms Hyperplastic noduleyp p Follicular adenoma
At i l f lli l d (UMP) Atypical follicular adenoma (UMP) Follicular carcinoma
- minimally invasive – without vascular i.- minimally invasive – with vascular i.minimally invasive with vascular i.- widely invasive
Follicular variant of PC Follicular variant of PC Follicular variant of medullary carcinoma Mixed tumors
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There are no reliableThere are no reliablecytologic criteriacytologic criteria,
distinguishingdistinguishingbenign and malignantbenign and malignant
follicular tumorsfollicular tumors
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FolFollliiccululaarr ccarcinomarcinomaaFolFollliiccululaar r ccarcinomarcinomaa
malignant conterpart of follicular dadenoma
more frequent in elderly and in regions more frequent in elderly and in regionswith iodine defficiency
Evrope 27% USA 10% USA 10%
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F lF lllii ll iiFolFollliiccululaar r ccarcinomarcinomaa
invasion transcapsular invasion transcapsular invasion
and/or vascular invasion
minimally invasive FC (without or with a y as e C ( t out o tvascular invasion)
id l i i FC widely invasive FC
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BiologicBiologic behaviorbehaviorBiologic Biologic behaviorbehavior
different from PC hematogenous spread, metastases intohematogenous spread, metastases into
bones, brain and lungs ras mutations ras mutations
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Cytologic Cytologic features of features of y gy gfolfollliicculularar neoplasianeoplasia
high cellularity low cohesivness of cells
microfollicular formations (rosette like) microfollicular formations (rosette-like) dense colloid in microfollicles absence of colloid in the background nuclear anisomorphy (no prognostic
significance)significance)
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Oncocytic (Hürtle cell) tumorsOncocytic (Hürtle cell) tumorsOncocytic (Hürtle cell) tumorsOncocytic (Hürtle cell) tumors
>75% of oncocytes (Askanazy, oxyphillic or Hürthle cells)
abundant mitochondriae
oncocytic adenoma oncocytic carcinoma - follicular - papillary papillary
(oncocytic variant of PC)
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Anaplastic (undifferentiated) Anaplastic (undifferentiated) p ( )p ( )carcinomacarcinoma
USA 1,7%, Germany 3,6% M:F = 1,5:1
max 7 decenium max. 7. decenium rapidly growing massp y g g extrathyroidal spread necrosis, calcifications, bone formation
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Anaplastic carcinomaAnaplastic carcinomaAnaplastic carcinomaAnaplastic carcinoma large cells, variation of size and shape, large cells, variation of size and shape,
bizzare nuclei, multinucleated cellsi i d i i i mitotic and apoptotic activity
vascular invasion vascular invasion histologic types: squamous
giant-cellspindle cellspindle-cell (sarcomatoid)
frequently mixed features
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high cellularity absence of colloid necrotic debris and neutrophills necrotic debris and neutrophills poorly cohesive cell groups large polygonal cells spindle cells spindle cells bi- or multinucleated cells
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Medullary thyroid carcinomaMedullary thyroid carcinomaMedullary thyroid carcinoma Medullary thyroid carcinoma (MTC)(MTC)
● relatively rare ( )( )● relatively rare● sporadic
hereditary syndromes (25%) - MEN 2A MEN 2B FMC● hereditary syndromes (25%) - MEN 2A, MEN 2B, FMC
● typical growth pattern x atypical manifestations
l f ll ll● unusual features small cellgiant cellsquamous cellsquamous cellamphicrinemucinouspigmentedpigmentedfollicularoncocytic
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moderately to highly cellular smears
poorly cohesive cells, absence of colloid
f t f l id (1/4 ) fragments of amyloid (1/4 cases)
round oval triangular spindle cells round, oval, triangular, spindle cells
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Thyroid lymphomasThyroid lymphomasThyroid lymphomasThyroid lymphomas
relatively rare relatively rare 2% of extranodal lymphomas
5% f ll th id li i 5% of all thyroid malignancies max. in 7. decade M:F = 3:1 thyroid enlargement, growth of nodule thyroid enlargement, growth of nodule virtually always in the background of HT non Hodgkin ML 98% B cells non-Hodgkin ML, 98% B cells high-grade transformation from MALT-
l hlymphoma
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Secondary neoplasmsSecondary neoplasmsSecondary neoplasmsSecondary neoplasms
rare (autoptic series 24%, bioptical series – significantly less)series significantly less)
direct growth (larynx, hypopharynx, h )esophagus)
hematogenous – tumor generalization hematogenous tumor generalization solitary metastasis, long time span serious diagnostic problem
renal lung breast GIT ca melanoma renal, lung, breast, GIT ca, melanoma
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