Difference between revisions of "Papillary thyroid carcinoma"

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Papillary thyroid carcinoma (view source)

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{{ Infobox diagnosis
{{ Infobox diagnosis
| Name      = {{PAGENAME}}
| Name      = {{PAGENAME}}
| Image      = Papillary_thyroid_microcarcinoma_-_high_mag.jpg
| Image      = Papillary_thyroid_microcarcinoma_-_high_mag.jpg  
| Width      =
| Width      =
| Caption    = Papillary thyroid carcinoma. [[H&E stain]].
| Caption    = Papillary thyroid carcinoma. [[H&E stain]].
| Micro      = nuclear changes: nuclear membrane irregularities (e.g. raisinoid shape), +/-nuclear grooves, +/-[[nuclear pseudoinclusions]], +/-nuclear clearing, nuclear enlargement (usu. mild), nucleoli; architectural changes: overlap of nuclei, papillae (not required), +/-[[psammoma bodies]]
| Micro      = nuclear changes: nuclear membrane irregularities (e.g. raisinoid shape), +/-nuclear grooves, +/-[[nuclear pseudoinclusions]], +/-nuclear clearing, nuclear enlargement (usu. mild), nucleoli; architectural changes: overlap of nuclei, papillae (not required), +/-[[psammoma bodies]]
| Subtypes  = [[Papillary thyroid carcinoma tall cell variant|tall cell variant]], [[Papillary thyroid carcinoma columnar cell variant|columnar cell variant]], [[Papillary thyroid carcinoma follicular variant|follicular variant]], [[Papillary thyroid carcinoma cribriform-morular variant|cribriform-morular variant]], [[Papillary thyroid carcinoma diffuse sclerosing variant|diffuse sclerosing variant]], [[Papillary thyroid carcinoma warthin-like variant|warthin-like variant]], [[Papillary thyroid carcinoma solid variant|solid variant]], [[Papillary thyroid carcinoma oncocytic variant|oncocytic variant]], others
| Subtypes  = [[Papillary thyroid carcinoma tall cell variant|tall cell variant]], [[Papillary thyroid carcinoma columnar cell variant|columnar cell variant]], [[Papillary thyroid carcinoma follicular variant|follicular variant]], [[Papillary thyroid carcinoma cribriform-morular variant|cribriform-morular variant]], [[Papillary thyroid carcinoma diffuse sclerosing variant|diffuse sclerosing variant]], [[Papillary thyroid carcinoma Warthin-like variant|Warthin-like variant]], [[Papillary thyroid carcinoma solid variant|solid variant]], [[Papillary thyroid carcinoma oncocytic variant|oncocytic variant]], others
| LMDDx      = [[lymphocytic thyroiditis]] ([[Graves disease]], [[Hashimoto thyroiditis]]), [[solid cell nest of thyroid]], [[follicular thyroid carcinoma]], [[follicular thyroid adenoma]], [[adenomatoid nodule]]
| LMDDx      = [[lymphocytic thyroiditis]] ([[Graves disease]], [[Hashimoto thyroiditis]]), [[solid cell nest of thyroid]], [[follicular thyroid carcinoma]], [[follicular thyroid adenoma]], [[adenomatoid nodule]], [[noninvasive follicular thyroid neoplasm with papillary-like nuclear features]] (NIFTP)
| Stains    =
| Stains    =
| IHC        =
| IHC        = HBME-1 +ve, [[CK19]] +ve, Galectin-3 +ve, thyroglobulin +ve, TTF-1 +ve
| EM        =
| EM        =
| Molecular  =
| Molecular  =
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| Gross      =
| Gross      =
| Grossing  =
| Grossing  =
| Staging    = [[thyroid cancer staging]]
| Site      = [[thyroid gland]]
| Site      = [[thyroid gland]]
| Assdx      =
| Assdx      =
| Syndromes  =
| Syndromes  = [[familial adenomatous polyposis]] (cribriform-morular variant)
| Clinicalhx =
| Clinicalhx =
| Signs      = thyroid mass
| Signs      = thyroid mass
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==General==
==General==
Medical school memory device P's:
Medical school memory device P's:
*Palpable nodes.
*Palpable [[lymph nodes]].
*Popular (most common malignant neoplasm of the thyroid).
*Popular - most common malignant neoplasm of the thyroid.
*Prognosis is good.
*Prognosis is good.
*Pre-Tx iodine scan.
*Pre-Tx iodine scan.
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*'''A'''ge.
*'''A'''ge.
*'''I'''nvasion of surround tissues.
*'''I'''nvasion of surround tissues.
*'''C'''completeness of excision.
*'''C'''ompleteness of excision.
*'''S'''ize of tumour.  
*'''S'''ize of tumour.


==Microscopic==
==Microscopic==
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*Nuclear inclusions are quite rare and not required to make the diagnosis -- but a very convincing feature if seen.
*Nuclear inclusions are quite rare and not required to make the diagnosis -- but a very convincing feature if seen.
*Papillae may be seen in Graves disease.
*Papillae may be seen in Graves disease.
*Thyroid tissue lateral to the jugular vein (often referred to as ''[[lateral aberrant thyroid tissue]]'') is generally considered metastatic thyroid carcinoma (papillary thyroid carcinoma) even if it looks benign.<ref name=pmid14452106>{{Cite journal  | last1 = JOHNSON | first1 = RW. | last2 = SAHA | first2 = NC. | title = The so-called lateral aberrant thyroid. | journal = Br Med J | volume = 1 | issue = 5293 | pages = 1668-9 | month = Jun | year = 1962 | doi =  | PMID = 14452106 | PMC = 1958877 }}</ref>
**This dictum is disputed.<ref name=pmid17319317>{{Cite journal  | last1 = Escofet | first1 = X. | last2 = Khan | first2 = AZ. | last3 = Mazarani | first3 = W. | last4 = Woods | first4 = WG. | title = Lessons to be learned: a case study approach. Lateral aberrant thyroid tissue: is it always malignant? | journal = J R Soc Promot Health | volume = 127 | issue = 1 | pages = 45-6 | month = Jan | year = 2007 | doi =  | PMID = 17319317 }}</ref>
**The level VI and VII [[lymph nodes]] are medial to the jugular.


DDx:
DDx:
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Images:
Images:
*[http://commons.wikimedia.org/wiki/File:Papillary_thyroid_carcinoma_tall_cell_var_intermed_mag.jpg PTC tall cell variant - intermed. mag. (WC)].
<gallery>
*[http://commons.wikimedia.org/wiki/File:Papillary_thyroid_carcinoma_tall_cell_var_high_mag.jpg PTC tall cell variant - high mag. (WC)].
Image:Papillary_thyroid_carcinoma_tall_cell_var_intermed_mag.jpg | PTC tall cell variant - intermed. mag. (WC)
Image:Papillary_thyroid_carcinoma_tall_cell_var_high_mag.jpg | PTC tall cell variant - high mag. (WC)
</gallery>


====Papillary thyroid carcinoma columnar cell variant====
====Papillary thyroid carcinoma columnar cell variant====
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DDx:
DDx:
*[[Noninvasive follicular thyroid neoplasm with papillary-like nuclear features]] (NIFTP).
*[[Follicular thyroid carcinoma]] - has a fibrous capsule and invasion though it.
*[[Follicular thyroid carcinoma]] - has a fibrous capsule and invasion though it.
*[[Follicular thyroid adenoma]] - surrounded by a fibrous capsule.
*[[Follicular thyroid adenoma]] - surrounded by a fibrous capsule.
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Images:
Images:
*[http://www.surgicalpathologyatlas.com/glfusion/mediagallery/media.php?f=0&sort=0&s=2008080217023776 PTC follicular variant (surgicalpathologyatlas.com)].
*[http://www.surgicalpathologyatlas.com/glfusion/mediagallery/media.php?f=0&sort=0&s=2008080216593186 PTC follicular variant (surgicalpathologyatlas.com)].
*[http://www.thyroidcancercanada.org/userfiles/images/Follicular_slide.jpg PTC follicular variant (thyroidcancercanada.org)].<ref>URL: [http://www.thyroidcancercanada.org/types-of-thyroid-cancer.php?lang=en http://www.thyroidcancercanada.org/types-of-thyroid-cancer.php?lang=en]. Accessed on: 9 January 2013.</ref>


====Papillary thyroid carcinoma cribriform-morular variant====
===Papillary thyroid carcinoma cribriform-morular variant===
=====General=====
=====General=====
*Associated with [[familial adenomatous polyposis]] (FAP).<ref name=pmid18612695>{{cite journal |author=Groen EJ, Roos A, Muntinghe FL, ''et al.'' |title=Extra-intestinal manifestations of familial adenomatous polyposis |journal=Ann. Surg. Oncol. |volume=15 |issue=9 |pages=2439–50 |year=2008 |month=September |pmid=18612695 |pmc=2518080 |doi=10.1245/s10434-008-9981-3 |url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518080/?tool=pubmed}}</ref>
*Associated with [[familial adenomatous polyposis]] (FAP).<ref name=pmid18612695>{{cite journal |author=Groen EJ, Roos A, Muntinghe FL, ''et al.'' |title=Extra-intestinal manifestations of familial adenomatous polyposis |journal=Ann. Surg. Oncol. |volume=15 |issue=9 |pages=2439–50 |year=2008 |month=September |pmid=18612695 |pmc=2518080 |doi=10.1245/s10434-008-9981-3 |url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518080/?tool=pubmed}}</ref>
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=====Microscopic=====
=====Microscopic=====
Features:
Features:
*Cribriform architectural pattern.
*Circumscribed or even encapsulated neoplasm.
*Morules - balls of tissue.
*Morules - interspersed balls of squamoid cells
**No keritinization or intercellular bridges.
**Homogenous, lightly eosinophilic glassy nuclei (biotin accumulation).
*Follicles
**[[Cribriform]], papillary, trabecular and solid patterns.
**Columnar or cuboidal cells.
**Little colloid
**Papillary carcinoma nuclear features.
 
<gallery>
Image:Thyroid PapillaryCarcinoma CribriformMorularVariant MP3 13BR***.jpg|Thyroid - Papillary Carcinoma Cribriform Morular Variant - Medium power (SKB)
Image:Thyroid PapillaryCarcinoma CribriformMorularVariant HP2 13BR***.jpg|Thyroid - Papillary Carcinoma Cribriform Morular Variant - High power (SKB)
Image:Thyroid PapillaryCarcinoma CribriformMorularVariant HP3 13BR***.jpg|Thyroid - Papillary Carcinoma Cribriform Morular Variant - high power]]
Image:Thyroid PapillaryCarcinoma CribriformMorularVariant P16 HP3 13BR***.jpg|Thyroid - Papillary Carcinoma Cribriform Morular Variant - High power (SKB)
Image:Thyroid PapillaryCarcinoma CribriformMorularVariant CDX2 HP 13BR***.jpg|Thyroid - Papillary Carcinoma Cribriform Morular Variant - CDX2 (SKB)
Image:Thyroid PapillaryCarcinoma CribriformMorularVariant P16 HP 13BR***.jpg|Thyroid - Papillary Carcinoma Cribriform Morular Variant - p16 (SKB)
Image:Thyroid PapillaryCarcinoma CribriformMorularVariant ER HP 13BR***.jpg|Thyroid - Papillary Carcinoma Cribriform Morular Variant - ER (SKB)
Image:Thyroid PapillaryCarcinoma CribriformMorularVariant betaCatenin HP 13BR***.jpg|Thyroid - Papillary Carcinoma Cribriform Morular Variant - beta catenin (SKB)
</gallery>
 
 
DDX:
*Papillary thyroid carcinoma
*Papillary thyroid carcinoma, tall cell variant
 
=====IHC=====
*CDX2 - Highlights the morules (CDX2 is positive in the biotin rich nuclei associated with morule formation in a variety of situations)<ref>{{Cite journal  | last1 = Wani | first1 = Y. | last2 = Notohara | first2 = K. | last3 = Nakatani | first3 = Y. | last4 = Matsuzaki | first4 = A. | title = Aberrant nuclear Cdx2 expression in morule-forming tumours in different organs, accompanied by cytoplasmic reactivity. | journal = Histopathology | volume = 55 | issue = 4 | pages = 465-8 | month = Oct | year = 2009 | doi = 10.1111/j.1365-2559.2009.03382.x | PMID = 19817898 }}</ref>
*CD10 - Highlights the morules <ref>{{Cite journal  | last1 = Cameselle-Teijeiro | first1 = J. | last2 = Alberte-Lista | first2 = L. | last3 = Chiarelli | first3 = S. | last4 = Buriticá | first4 = C. | last5 = Gonçalves | first5 = L. | last6 = González-Cámpora | first6 = R. | last7 = Nogales | first7 = FF. | title = CD10 is a characteristic marker of tumours forming morules with biotin-rich, optically clear nuclei that occur in different organs. | journal = Histopathology | volume = 52 | issue = 3 | pages = 389-92 | month = Feb | year = 2008 | doi = 10.1111/j.1365-2559.2007.02911.x | PMID = 18081818 }}</ref>
*Beta-catenin - nuclear and cytoplasmic - all tumour cells.
*Estrogen receptor - positive
*TTF-1 - positive
 
=====Molecular=====
*Up-regulating disturbances in the Wnt signaling pathway promote formation of morules with optically clear biotin rich nuclei <ref>{{Cite journal  | last1 = Gamachi | first1 = A. | last2 = Kashima | first2 = K. | last3 = Daa | first3 = T. | last4 = Nakatani | first4 = Y. | last5 = Tsujimoto | first5 = M. | last6 = Yokoyama | first6 = S. | title = Aberrant intranuclear localization of biotin, biotin-binding enzymes, and beta-catenin in pregnancy-related endometrium and morule-associated neoplastic lesions. | journal = Mod Pathol | volume = 16 | issue = 11 | pages = 1124-31 | month = Nov | year = 2003 | doi = 10.1097/01.MP.0000092953.20717.48 | PMID = 14614052 }}</ref>
**Mutation of the beta-catenin gene
**Mutation in APC
*Examples
***Well-differentiated fetal adenocarcinoma
***Papillary thyroid carcinoma, cribriform morular variant (mutation in APC in familial variants)
***Pancreatoblastoma


====Papillary thyroid carcinoma diffuse sclerosing variant====
====Papillary thyroid carcinoma diffuse sclerosing variant====
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*Lymphocytic thyroiditis (esp. Hashimoto's thyroiditis).
*Lymphocytic thyroiditis (esp. Hashimoto's thyroiditis).


====Papillary thyroid carcinoma warthin-like variant====
====Papillary thyroid carcinoma Warthin-like variant====
*Resemble [[Warthin tumour]].
*Resembles [[Warthin tumour]].
=====Microscopic=====
=====Microscopic=====
Features:<ref name=Ref_Sternberg5_506>{{Ref Sternberg5|506}}</ref>
Features:<ref name=Ref_Sternberg5_506>{{Ref Sternberg5|506}}</ref>
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Note:
Note:
*CK19 +ve -- though ''not'' specific or sensitive.
*CK19 +ve -- though ''not'' specific or sensitive.
<gallery>
Image: Papillary thyroid carcinoma oncocytic variant -- low mag.jpg | PTC oncocytic - low mag. (WC)
Image: Papillary thyroid carcinoma oncocytic variant -- intermed mag.jpg | PTC oncocytic - intermed mag. (WC)
Image: Papillary thyroid carcinoma oncocytic variant -- high mag.jpg | PTC oncocytic - high mag. (WC)
Image: Papillary thyroid carcinoma oncocytic variant -- very high mag.jpg | PTC oncocytic - very high mag. (WC)
</gallery>


===IHC===
===IHC===
Thyroid versus something else:
Thyroid versus something else:
*Thyroglobulin +ve.
*Thyroglobulin +ve.<ref name=pmid23637102>{{Cite journal  | last1 = Sathiyamoorthy | first1 = S. | last2 = Maleki | first2 = Z. | title = Cytomorphologic overlap of differentiated thyroid carcinoma and lung adenocarcinoma and diagnostic value of TTF-1 and TGB on cytologic material. | journal = Diagn Cytopathol | volume = 42 | issue = 1 | pages = 5-10 | month = Jan | year = 2014 | doi = 10.1002/dc.22997 | PMID = 23637102 }}</ref>
*TTF-1 (thyroid transcription factor-1) +ve.
*TTF-1 ([[thyroid transcription factor-1]]) +ve.
*CD15 +ve.{{fact}}
*CD15 +ve.{{fact}}


PTC versus benign:<ref>{{Cite journal  | last1 = Mataraci | first1 = EA. | last2 = Ozgüven | first2 = BY. | last3 = Kabukçuoglu | first3 = F. | title = Expression of cytokeratin 19, HBME-1 and galectin-3 in neoplastic and nonneoplastic thyroid lesions. | journal = Pol J Pathol | volume = 63 | issue = 1 | pages = 58-64 | month = Mar | year = 2012 | doi =  | PMID = 22535608 }}</ref>
PTC versus benign:<ref>{{Cite journal  | last1 = Mataraci | first1 = EA. | last2 = Ozgüven | first2 = BY. | last3 = Kabukçuoglu | first3 = F. | title = Expression of cytokeratin 19, HBME-1 and galectin-3 in neoplastic and nonneoplastic thyroid lesions. | journal = Pol J Pathol | volume = 63 | issue = 1 | pages = 58-64 | month = Mar | year = 2012 | doi =  | PMID = 22535608 }}</ref>
*HBME-1 +ve (strong, diffuse).
*HBME-1 +ve (strong, diffuse).
*CK19 +ve (strong, diffuse).
*[[CK19]] +ve (strong, diffuse).
*Galectin-3 +ve (strong, diffuse).
*Galectin-3 +ve (strong, diffuse).


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- PAPILLARY THYROID MICROCARCINOMA.
- PAPILLARY THYROID MICROCARCINOMA.
-- MARGINS NEGATIVE FOR MALIGNANCY.
-- MARGINS NEGATIVE FOR MALIGNANCY.
-- TUMOUR SIZE ~ 1 MM.
-- TUMOUR SIZE ~ 1 MILLIMETRE.
-- NEGATIVE FOR LYMPHOVASCULAR INVASION.
-- NEGATIVE FOR LYMPHOVASCULAR INVASION.
-- NEGATIVE FOR PERINEURAL INVASION.
-- NEGATIVE FOR PERINEURAL INVASION.
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- TWO LYMPH NODES, NEGATIVE FOR MALIGNANCY ( 0 POSITIVE / 2 ).
- TWO LYMPH NODES, NEGATIVE FOR MALIGNANCY ( 0 POSITIVE / 2 ).
</pre>
</pre>
<pre>
THYROID GLAND, TOTAL THYROIDECTOMY:
- INCIDENTAL PAPILLARY THYROID MICROCARCINOMA.
-- MARGINS NEGATIVE FOR MALIGNANCY.
-- TUMOUR SIZE ~ 1 MILLIMETRE.
-- NEGATIVE FOR LYMPHOVASCULAR INVASION.
-- NEGATIVE FOR PERINEURAL INVASION.
- NODULAR HYPERPLASIA.
- ONE PARATHYROID GLAND.
</pre>
===Lymph node dissection===
<pre>
A. NECK, RIGHT LEVEL 2 AND 3, LYMPH NODE DISSECTION:
- ONE LYMPH NODE POSITIVE FOR PAPILLARY THYROID CARCINOMA ( 1 POSITIVE / 4 ).
B. NECK, RIGHT LEVEL 4, LYMPH NODE DISSECTION:
- TWO LYMPH NODES, NEGATIVE FOR MALIGNANCY ( 0 POSITIVE / 2 ).
C. NECK, RIGHT LEVEL 6 AND 7, LYMPH NODE DISSECTION:
- ONE LYMPH NODE POSITIVE FOR PAPILLARY THYROID CARCINOMA ( 1 POSITIVE / 3 ).
</pre>
====Micro====
The sections show lymph nodes with tumour that has a papillary architecture.  The
tumour cell nuclei are enlarged and overlap. They also have nuclear grooves, nucleoli
and abundant pseudoinclusions. The chromatin of the tumour cells has a powdery
appearance.


==See also==
==See also==
Brigitte
30

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