THYROID NEOPLASM

Dr. M. Abrar Barakzai

Assistant Professor Pathology
Alfaisal University, College of Medicine
Riyadh, Saudi Arabia
 Thyroid Neoplasms
Most neoplasms present as nodules ( small / large – benign /
malignant )

 Nodules are common!

 4 times more common in female than male

 Solitary nodules are mostly benign 10:1

 So, the chance of becoming malignant is 1/10

 Thyroid carcinoma is uncommon.

 If there is a carcinoma ( malignancy )  90% has a good prognosis

 Radiation history to head & neck is always there esp. for the
malignant ones
Incidence of thyroid carcinoma vs. adenoma

carcinoma

adenoma
Thyroid Neoplasms

biopsy or FNA

cancer follicles thyroiditis

take it out! treat it!

 Thyroid Adenoma

 Common!

 Most patients are euthyroid (some are hyperthyroid)

 Radioactive iodine uptake: most adenomas are “cold”

 It it takes up iodine ( is hyperthyroid – active adenoma )  hot
 If it doesn’t  cold (TSH & T4 levels are normal )
Thyroid adenoma
 Thyroid Adenoma

Normal looking Adenoma

thyroid
Thyroid adenoma

ule
ps Normal thyroid
Ca tissue pushed by
the capsule
Hürthle cell (oxyphil) adenoma
HÜRTHLE CELL ADENOMA, note “atypia”
Thyroid Adenoma

 Take it out!
 Even if it’s benign

 Why, if it’s benign?

 Need to see the whole tumor (including capsule ) to

make sure it’s not carcinoma
 The whole nodule must be taken out, because there might be an
area with capsular invasion that is not taken out when
removing some of the nodule
Thyroid Carcinoma

 Papillary thyroid carcinoma

 Follicular thyroid carcinoma

 Medullary thyroid carcinoma

 Anaplastic thyroid carcinoma

Incidence of different types of thyroid carcinoma
medullary (5%) anaplastic (<5%)

follicular (10%)

papillary
(80%)
 Papillary Carcinoma: The Little Orphan Annie Tumor

 Translocation of RET/PTC gene

 BRAF mutation show adverse prognosis
 Hx of exposure to ionizing radiation
 Often affects younger women
 Good prognosis 10 years survival rate is 95%
 Usually well-behaved; seldom kills people
 Has nuclei that resemble Orphan Annie’s eyes
 Has psammoma bodies (from the greek
psammos, or sand) - Annie’s dog is named
Sandy
Morphology
 Papillae having fibrovascular stalk ( VERY IMP!! Should
be seen )

 Single to multiple layer of cuboidal epithelium

 Ground glass or Orphan Annei eye nuclei

 Intra nuclear grooves

 Intra nuclear inclusion

 Concentrically calcified structures called “Psammoma

bodies”.
 Almost normal looking
thyroid tissue

Papillary thyroid carcinoma

Papillary thyroid carcinoma
Papillary thyroid carcinoma
Papillary thyroid carcinoma
BIOLOGIC BEHAVIOR

 Papillary CA lymph nodes

 Follicular CA  blood vessels, bone

Follicular Carcinoma
 2nd most common

 5% to 15% of primary thyroid cancer

 More common in female 3:1

 Between 40 – 60 years of age

 Frequent in areas of iodine deficiency

 Areas like mountains ( Himalaya / Alps ) or Africa &
China

 Good prognosis
Morphology

 Sharply demarcated lesion on gross examination

 Large lesion may penetrate capsule

 Microscopically show small follicles having colloid.

 Some cells have abundant granular cytoplasm called Hurthle

cell or oncocytes variant.

 Capsular invasion

 Vascular invasion
Which one is follicular carcinoma?
 Medullary Carcinoma

 Rare tumour account for 5%

 Point mutation of RET proto-oncogene

 Remember that in papillary it’s
translocation/inversion of RET/PTC

 Neuroendocrine tumor derived from

parafollicular “C” cells

 Secretes calcitonin
 Diagnosis – do IHC for calcitonin  +ve
 Medullary Carcinoma

 Also secretes serotonin, ACTH, and vasoactive

intestinal peptide (VIP)
 Because it’s a neuroendocrine tumor

 70% arises sporadically and are mostly at the age of

40 – 50 years

 Remaining occurs in setting of MEN syndrome IIA

and IIB (mostly in a younger patients)

 Bad prognosis
Morphology
 Large lesions often contains necrosis and haemorrhage

 May extend through the capsule  capsular invasion is present

 Microscopically composed of polygonal to spindle shaped cells

arranged in nests and trabeculae

 Amyloid deposits ( Most IMP!! ) are present in the adjacent stroma

 Diagnostic feature
 Amyloid deposits stain with Congo red stain show green birefringence
on polorization
 Polarization is done by putting 1 lens above the slide & 1 beneath it  then turn 1
of them, as the light becomes polarized it’ll show green birefringence ( slide 34 )

 IHC show positivity for calcitonin

 For conformation
Medullary thyroid carcinoma
 HYALINIZATION showing APPLE GREEN
birefringence in CONGO RED stain, i.e., AMYLOID
Anaplastic Carcinoma
 Rare, less than 5%

 Bulky, fast-growing, metastatic rate is very high 

metastatisis at diagnosis

 Very bad prognosis

 Mortality rate is almost 100%

 Mean age 65 – 70 ( older pts. )

 These patients has a past history of well differentiated

thyroid carcinoma
 Pt. has a follicular ca. 20 yrs before & the dr. has taken out the
thyroid + chemo & radiotherapy  the pt. was alright but then a
tumor appears again after 20 yrs – the tumor is anaplastic
 Morphology
 Composed of highly anaplastic cells

 Large, pleomorphic giant cell and multinucleated giant cell

 Spindle cell with sarcomatous appearance

 Mixed spindle and giant cells

 IHC show positive for epithelial markers ( e.g. CK-7 )

 However are negative for TTF – 1 and thyroglobulin

 These 2 are markers for thyroid tumours, however for anaplastic tumors as
they have different behaviour they won’t show +ve for these markers
Anaplastic thyroid carcinoma
Thank you