PSC Thyroid Guidelines Bill Faquin, M.D., Ph.D.

Diagnostic Terminology and criteria Non Follicular !esions"

Chronic lym#hocytic thyroiditis Primary lym#homa Pa#illary thyroid carcinoma $ndi%%erentiated carcinoma Medullary carcinoma Secondary tumors

Chronic !ym#hocytic Thyroiditis"

First descri&ed in '(') Most common %orm o% thyroiditis Most common cause o% hy#othyroidism in the $.S. *(+, #atients ha-e autoanti&odies

Cytologic Features o% Chronic !ym#hocytic Thyroiditis"

Mi.ed #o#ulation o% lym#hocytes and #lasma cells !ym#hohistiocytic aggregates Cohesi-e grou#s o% %ollicular cells /ith oncocytic %eatures 0aria&le nuclear aty#ia

Di%%erential Diagnosis o% Chronic !ym#hocytic Thyroiditis"

Pa#illary thyroid carcinoma 1urthle cell neo#lasm 2eacti-e lym#h node Primary lym#homa

Primary Thyroid !ym#homa"

N1! accounts %or 34, o% #rimary thyroid neo#lasms5 ).4, o% e.tranodal lym#homas 6+ '++, arise in the setting o% 1ashimoto7s thyroiditis 8229:+ ;+.< )+ =+ years a%ter onset o% thyroiditis >##ro.. 4+, #resent /ith a single dominant thyroid nodule

Derringer et al. 8>F?P< 8>@SP, )+++, ):"A)= A=(< '+; cases );, M>!T ==, D!BC! B M>!T =;, D!BC! only ', Follicle center lym#homa 1odgCin lym#homa, #lasmactyoma, and T cell lym#homas are -ery rare

Marker studies such as flow cytometry are essential in the evaluation of aspirates where there is a suspicion of lymphoma. Pa#illary Thyroid Carcinoma" $# to ;+, o% thyroid carcinomas ?ndolent 8although certain -ariants are aggressi-e< 3A.4, mortality May sho/ local in-asion and !N mets Doung to middle aged /omen Prior radiation e.#osure

FN> is highly accurate %or the diagnosis o% #a#illary carcinoma"

*(+, are diagnosed as #ositi-e or sus#icious &y FN> ?n some studies, FN> is more accurate than %roEen section False negati-e rate is lo/" o Cystic #a#illary carcinomas o Follicular -ariant o% #a#illary carcinoma o >dmi.ture o% &enign thyroid tissue

Diagnostic Cytologic Features o% Pa#illary Carcinoma" Fnlarged, o-al nucleus /ith eccentric nucleolus Fine, #ale chromatin !ongitudinal nuclear groo-es ?ntranuclear #seudoinclusions >dditional Cytologic Features" Pa#illary cytoarchitecture Syncytial monolayers Dense squamoid cyto#lasm GBu&&le gumH colloid Psammoma &odies Multinucleated giant cells Ihat are the most diagnostic %eatures o% #a#illary carcinomaJ
Kini et al. 8'(;+<"
Syncytial ty#e %ragments Pale, enlarged nuclei Multi#le nucleoli ?ntranuclear #seudoinclusions Nuclear groo-es

Miller et al. 8'(;A< ste#/ise regression analysis"

Pa#illary structures /ithout -essels ?ntranuclear #seudoinclusions Meta#lastic cyto#lasm

Basu et al. 8'(()<"

F.tensi-e nuclear groo-es Dense squamoid cyto#lasm Pa#illary architecture

No single cytologic %eature is diagnostic o% #a#illary thyroid carcinomaL 0ariants o% Pa#illary Carcinoma"
Follicular Di%%use sclerosing Iarthin liCe Solid Tra&ecular Cri&ri%orm morular Mncocytic Tall cell Columnar cell >K>" >na#lastic carcinoma 3 4, o% all thyroid malignancies 2a#idly %atal #rognosis local in%iltration 8mean sur-i-al 9 A months< Flderly #atients 8-ery rare &e%ore age :+< Clinical history"

$ndi%%erentiated Thyroid Carcinoma"

2a#id increase in siEe o% a long standing cold thyroid nodule in an elderly #atient $# to ;+, ha-e a history o% /ell or #oorly di%%erentiated thyroid carcinoma

Diagnostic Cytologic Features o% undi%%erentiated carcinoma" 1ighly malignant and &iEarre cells
1igh grade nuclear %eatures" MarCed #leomor#hism DarC clum#ed chromatin Macronucleoli >ty#ical mitoses Tumor diathesis

Com&ination o% three cellular #atterns"

S#indle cell Giant cell Squamoid

1o/ to distinguish undi%%erentiated carcinoma %rom other lesionsJ"

?mmunocytochemistry" !MI Ceratin B Thyroglo&ulin B TTF 'B Calcitonin N CF> FM"

Demonstrates e#ithelial %eatures Clinical" 2adiologic e-idence o% thyroid origin Clinical history o% #rior &etter di%%erentiated thyroid carcinoma

Medullary Thyroid Carcinoma" Cytologic Features o% Medullary Carcinoma"

$ni%orm, dis#ersed single cells" o Plasmacytoid o S#indled o Polygonal Granular Gsalt and #e##erH chromatin BacCground amyloid 8a##ro.. ;+, o% cases< Fccentric nuclei are common Multinucleation ?ntranuclear #seudoinclusions Predominantly indistinct nucleoli 2ed cyto#lasmic granules in 2omano/sCy stains

>dditional Cytologic Features o% Medullary Carcinoma"

GCytologically and histologically, MTC is a great mimicCerLH Medullary Carcinoma 0ariants"

Mncocytic S#indle cell Pa#illary Melanin #roducing Clear cell Small cell Giant cell

?mmunocytochemistry %or calcitonin is recommended &e%ore maCing a de%initi-e diagnosis &y FN>. Secondary Tumors o% the Thyroid Gland" $ncommon 8+.', o% thyroid FN>s< Most %requent include"
2enal 8among the most di%%icult to recogniEe< !ung Breast Malignant melanoma Colorectal Malignant lym#homa 1ead and necC squamous cell carcinoma

2e%erences"

1. Farwell AP, Braverman LP. Inflammatory thyroid disorders. Otolaryngol lin ! Am 1""#$%"&'(1. 2. Poropatich C, Marcus D, Oertel YC. Hashimoto's thyroiditis: fine-needle aspirations of ! asymptomatic cases. )iagn yto*athol "##$%"":"$"-"$ . +. )erringer ,A, -hom*son L), Frommelt .A, Bi/waard 01, 2effess 3, A44ondan5o 3L. 6alignant lym*homa of the thyroid gland& a 7lini7o*athologi7 st8dy of 19: 7ases. Am ; 38rg Pathol %999$%(&#%+.<#%". $. &aur ', (ayaram ). *hyroid tumors: cytomorpholo+y of papillary carcinoma. )iagn yto*athol "##"%,:$-2-$-.. . '/htar M, 'li M', Hu0 M, 1a/ry M. 2ine-needle aspiration 3iopsy of papillary thyroid carcinoma: cytolo+ic, histolo+ic, and ultrastructural correlations. )iagn yto*athol "##"%,:4,4-4,#. -. 5en/atesh Y6, Ordone7 8), 6chult7 P8, Hic/ey 9C, )oepfert H, 6amaan 8'. 'naplastic carcinoma of the thyroid: ' clinicopatholo+ic study of "2" cases. an7er "##!%--:42"-4!. ,. 9andolph ):, De la Cru7 ', 2a0uin :C. Medullary carcinoma of the thyroid. ;n: Pellitteri P&, McCaffrey *5 <eds= >ndocrine sur+ery of the head and nec/. Clifton Par/, 8Y: *hompson Delmar ?earnin+, 2!!4:"-,-".2. .. 6chmid &:, Hittmair ', Ofner C, *otsch M, ?adurner D. Metastatic tumors in fine needle aspiration 3iopsy of the thyroid. A7ta ytol "##"%4 :,22-$.