pathology of the thyroid

7/27/2019 Pathology of the Thyroid

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PATHOLOGYof the

THYROID

Dr. Mudjiwijono HE, MS, SpPA

Lab. Patologi AnatomiFKUB/RSSA


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THYROID PATHOLOGY1. Inflammation (thyroiditis)

1.Hashimoto thyroiditis2. Granulomatous (de Quervains) thyroiditis

3. Subacute lymphocytic thyroiditis

2. Hyperplasia

1. Goiter (Diffuse / Multinodular Goiter)

2. Graves disease

3. Neoplasm

1. Benign :Follicular adenoma

2. Malignant : Carcinoma

1.Papillary carcinoma2.Follicular carcinoma

3.Anaplastic (undifferentiated) carcinoma

4.Medullary carcinoma


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THYROIDITIS :HASHIMOTO THYROIDITIS

Etiology : autoimmune Incidence : > 45 - 65 y.o.

Female >> male (10 : 1 to 20 : 1)

Macros :

- >, diffuse, firm, intact caps, well defined- CS : pale, yellowish gray,

vaguely/distinctly nodular

Micros :

- Lymphocytic infiltration, germinal centers (+)

- Plasma cells, histiocytes, multinucleated giant

cells (+)

- Atrophic follicle, interstitial fibrosis


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Clinic : Thyroid > symmetric, diffuse, pain (-)

Initially : mild hyperthyroidism hypothyroidism

Sometimes :

Very firm, sudden enlargement,severe pressure symptom confused with Ca


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SUBACUTE THYROIDITIS

(Granulomatous thyroiditis; De Quervains thyroiditis) Freq : < Hashimoto thyroiditis

Incidence : > 40 -50 y.o.

Female > male (4 : 1)

Etiology : ? (initially with viral inf.) Macros :

- >, unilateral / bilateral, rubberyfirm

- Intact caps, little/no adherence to

the surrounding structures- CS : yellowish white


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Micros :- First : PMN infiltration, microabscesses (+)

lymphocytes, macrophages, plasma cells,multinucleated giant cells (+)(granulomatous inflammation)

late stage : fibrosis (+)

Clinic :- Thyroid >, pain (+)- First : hyperthyroidism : in 2 - 6 weeks

(with/without tx )- T4 dan T3 , TSH - 6 - 8 weeks, thyroid functionN


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SUBACUTE LYMPHOCYTIC THYROIDITIS More common in children Female > male Autoimmun Macros : thyroid N / slight > Micros :

- Lymphocytic infiltration, germinal center (+) Clinic :

- Pain (-)- Hyperthyroidism (transient) N- Some px :

hyperthyroidism hypothyroidismN


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HYPERPLASIAGOITER The most common thyroid disease Forms :

- Diffuse non toxic (simple) goiter

- Multinodular goiter

- Endemik / Sporadik

Etiology and pathogenesis :

- Impairment of thyroid hormone synthesis,largely caused by iodine deficiency

TSH ,hypertrophy and hyperplasia

follicular cells thyroid >


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Endemic goiter :* Goiter >10% population

* Etiology :

1. Low iodine content in soil, water, food(Andes,Himalaya)

2. Goitrogen (cabbage, cauliflower, radish, cassava)

Sporadic goiter : < endemic goiter* > female, peak : puberty / young adult

* Etiology :

- Goitrogen- Genetic


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SIMPLE GOITER (Colloid goiter)Thyroid >, nodule (-)Morphology :

* Hyperplastic phase :- Thyroid > diffuse, symmetric, rarely >100 - 150 gm- Follicle ep : columnar, dense papillary projection- Colloid >/ filled with colloid- CS : brownies, translucent- Micros : follicles epithelium flatened /cuboid

Clinic : Thyroid >, euthyroid


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MULTINODULAR GOITERSimple goiterrepeated hyperplasia and involution

multinodular goiter(nodular hyperplasia,adenomatoid goiter, adenomatous hyperplasia)

Macros :

- Thyroid > asymmetric, multilobulated, >2000 gm- Sometimes : substernal (intrathoracicgoiter)

- CS : irregular nodule, filled with colloid, brownies

and gelatinous

- Hemorrhage, fibrosis, calcification, and cystic

degeneration


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Micros :

- Distended follicles flattened epithelium,

hyperplastic follicles cuboid epithelium- Follicular hyperplasia (+)

- Irregular septae, hemorrhagic area and calcification

Clinic :- Thyroid >, usually euthyroid

sometimes toxic multinodular goiter

- Airway obstruction, dysphagia, large vascular

compression in cervical / upper thoracal (superior

vena cava syndrome)

- Incidence of malignant degeneration


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GRAVES DISEASE(Basedows disease, Thyrotoxicosis, Diffuse Toxic Goiter,

Exophthalmic Goiter) Etiology :

- autoimmune (Ab againts TSH receptor)

- Thyroid-Stimulating Immunoglobulin (TSI)

- Thyrotropin-Binding Inhibitor Immunoglobulin (TBBII) HyperplasiaT3, T4

Macros :

- Thyroid >, symmetric , diffuse (mild to moderate)

- Succulent, reddish- CS : uniformly gray or red

- Long standing cases : friable, dull yellow


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Micros :

- Hyperplastic follicles, papillary involding- Lining epithelium : columnar

- Colloid : pale, finely vacuolated, rand vacuole

- Aggregates of lymphoid tissue, germinal center (+)

- Longstanding cases : mild fibrosis

Clinic :

- > young adult female, muscle weakness, weight loss,exophthalmos, irritability, tachycardia, goiter,

appetite , atrial fibrillation (+/-)


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BENIGN NEOPLASM :

FOLLICULAR ADENOMA Etiology : ?

- > : (+) hemorrhages, fibrosis,calcification and cystic degeneration


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Micros :

- Uniform follicles, intact caps- Mitosis : dysphagia- Prognosis : very good


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THYROID CARCINOMA : Rare, USA : 1.5% all Ca Usually : young adult and middle age Female > male Follicle epithelium (except medullary ca),

majority well-diff. ca

Etiology :

* Genetic* Environment

The most common : exposure to ionizing

radiation, esp. at 1st and 2nd decade of life

(after Chernobyl disaster at 1986, incidence of

papillary ca in children)

* Iodine deficiency follicular ca


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PAPILLARY CARCINOMA The most common, USA 85% thyroid ca

Present in any age group, > in 25 50 y.o.Macros :

- Most cases : solid, whitish, firm, clearly invasive

- < 10% : encapsulated

- 10% cases : cystic changes- Sometimes : papillary formation are evident to the

naked eye

Micros :

- Papillae : lining by a single/stratified cuboidal cells- Well-differentiated /anaplastic

- Nuclei : ground-glass

- Intranuclear inclusion / intranuclear groove (+)


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Clinic :

- >> asymptomatic, first manifestation :

cervical nodal metastases- Hoarse, dysphagia, cough, or dyspnea (+) : late std.

- Metastases >> lymphogen, < hematogen (>> lung)

Lab : CT Scan/ FNAB

Prognosis :- Good, 10 ysr > 95%

- 5% - 20% cases : local recurrent

- 10% - 15% cases : distant metastases

- Prognosis, depend on :- Age (>40 y.o, prognosis


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FOLLICULAR CARCINOMA 5% - 15% thyroid ca

Female > male (3 : 1)

Age > papillary ca, peak : 40 60 y.o.

Macros :

- Single nodule, encapsulated

- CS : solid, fleshy, brownish to reddish grey,sometimes translucent or (+) central fibrosis

and calcification

Micros :

- Uniform epithelial cells, create small follicles,colloid +/- = Follicular adenoma

capsular/vascular invasion ca

- Variant : Hrthle cell / oncocytic variant


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Clinic :- Slow growing, pain (-)

- Lymphogen metastases other thyroid ca, 65 y.o.

Macros : necrotic and hemorrhagic solid tumor mass

Micros :

(1) large, pleomorphic giant cells(2) spindle cells with a sarcomatous appearance

(3) mixed spindle and giant cells

Clinic :

- Rapid growing, at the time of initial detected :>> extrathyroidal extension / pulmonal metastases

- Symptom : dyspnea, dysphagia, hoarseness and cough

- Effektive Tx (-), death < 1 yr. after diagnosed


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MEDULLARY CARCINOMA Neuroendocrine Tumor ( parafollicular cell/C cell),

produce calcitonin, serotonin, ACTH, and

vasoactive intestinal peptide (VIP) 5% thyroid caMacros :

- Solitary/bilateral, multicentric nodule- > : necrosis and hemorrhage- Solid, firm, nonencapsulated, well circumscribed- CS : grey to yellowish

Micros :- Solid proliferation of round to polygonal cells of

granular amphophilic cytoplasm- Separated by a highly vascular stroma, hyalinizedcolagen and amyloid

- Pattern of growth : carcinoid like, paraganglioma like,trabecular, glandular or pseudopapillary


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Clinic :

- Dysphagia, hoarsenes- Paraneoplastic syndrome

- Diarrhoe (caused by VIP)

- Cushing syndrome (caused by ACTH)

- Calcitonin

- CEA (+)


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pathology of the thyroid

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