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Thyroid cytopathology (view source)

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[[Image:Benign thyroid - FNA -- very high mag.jpg|thumb|right|Benign thyroid cells. FNA specimens. (WC)]]
'''[[Thyroid]] cytopathology''' is a large part of cytopathology.
'''[[Thyroid]] cytopathology''' is a large part of cytopathology.


This article deals only with thyroid cytopathology.  An introduction to cytopathology is in the ''[[cytopathology]]'' article.  Head and neck cytopathology is dealt with in the ''[[Head and neck cytopathology]]'' article.
This article deals only with thyroid cytopathology.  An introduction to cytopathology is in the ''[[cytopathology]]'' article.  Head and neck cytopathology is dealt with in the ''[[Head and neck cytopathology]]'' article.


=Normal thyroid cytology=
=Normal thyroid=
Follicular cells:
===Radiology===
Benign features - terms:<ref name=pmid19542415>{{Cite journal  | last1 = Bonavita | first1 = JA. | last2 = Mayo | first2 = J. | last3 = Babb | first3 = J. | last4 = Bennett | first4 = G. | last5 = Oweity | first5 = T. | last6 = Macari | first6 = M. | last7 = Yee | first7 = J. | title = Pattern recognition of benign nodules at ultrasound of the thyroid: which nodules can be left alone? | journal = AJR Am J Roentgenol | volume = 193 | issue = 1 | pages = 207-13 | month = Jul | year = 2009 | doi = 10.2214/AJR.08.1820 | PMID = 19542415 }}</ref>
*Spongiform configuration.
*Colloid clot - cyst.
*Giraffe pattern.
*Diffuse hyperechogenicity.
===Follicular cells===
*Uniform spacing of cells.
*Uniform spacing of cells.
*"Cracks" (spaces) between cell - "crazy paving".<ref name=Ref_APBR672>{{Ref APBR|672}}</ref>
*"Cracks" (spaces) between cell - "crazy paving".<ref name=Ref_APBR672>{{Ref APBR|672}}</ref>


Colloid - acellular crap with:
Note:
*It is interesting that uniform spacing in the context of thyroid is benign... in breast suggests [[DCIS]].
 
====Microfollicles====
Definition:<ref name=pmid16454552>{{Cite journal  | last1 = Renshaw | first1 = AA. | last2 = Wang | first2 = E. | last3 = Wilbur | first3 = D. | last4 = Hughes | first4 = JH. | last5 = Haja | first5 = J. | last6 = Henry | first6 = MR. | title = Interobserver agreement on microfollicles in thyroid fine-needle aspirates. | journal = Arch Pathol Lab Med | volume = 130 | issue = 2 | pages = 148-52 | month = Feb | year = 2006 | doi = 10.1043/1543-2165(2006)130[148:IAOMIT]2.0.CO;2 | PMID = 16454552 }}</ref>
*<15 follicular cells forming at least two thirds of a circle.
*Usually flat, i.e. not three dimensional.
 
Note:
*A small number of microfollicles is considered normal.
 
====Images====
<gallery>
Image: Benign thyroid - FNA -- high mag.jpg | Thyroid - high mag. (WC)
Image: Benign thyroid - FNA -- very high mag.jpg | Thyroid - very high mag. (WC)
</gallery>
<gallery>
Image: Endocrine atypia in thyroid - 1 -- high mag.jpg | Colloid and [[endocrine atypia]] - high mag. (WC)
Image: Endocrine atypia in thyroid - 2 -- very high mag.jpg | Colloid and endocrine atypia - very high mag. (WC)
</gallery>
 
===Colloid===
Essentially - acellular crap with:
*Irregular/sharp borders.
*Irregular/sharp borders.
*Cracks - '''key feature'''.
*Cracks - '''key feature'''.
*Dark (uniform) staining with Romanowsky type stains.
*Dark (uniform) staining with [[Romanowsky stain|Romanowsky type stains]].
**Green edge + red/orange centre with Pap stain.
**Green edge + red/orange centre with [[Pap stain]].
*+/-Entraped red blood cells (RBCs).
*+/-Entraped red blood cells (RBCs).


Note:
====Images====
*It is interesting that uniform spacing in the context of thyroid is benign... in breast suggests DCIS.
<gallery>
Image: Thyroid colloid - FNA -- high mag.jpg | Colloid - high mag. (WC)
Image: Thyroid colloid - FNA -- very high mag.jpg | Colloid - very high mag. (WC)
</gallery>
 
===Hurthle cells===
:May be spelled ''Hürthle cells''.
Features:
*Large epithelioid cells with red granular material on Pap stain.
*Should ''not'' form 3-D balls.
 
====Images====
<gallery>
Image: Hurthle cells - thyroid FNA -- high mag.jpg | HC - high mag. (WC)
Image: Hurthle cells - thyroid FNA -- very high mag.jpg | HC - very high mag. (WC)
</gallery>


=Normal parathyroid cytology=
=Normal parathyroid cytology=
*May be confused with thyroid - single definitively separates them.<ref name=pmid11891946/>
{{Main|Parathyroid gland}}
===General===
*May be confused with thyroid.
**No single feature can be use to reliably separate them, though several features may allow this.<ref name=pmid11891946/>
*FNAs are not useful for parathyroid lesions;<ref name=pmid19283690/> however, a parathyroid may be sampled inadvertently.


===Cytology===
Chief cells:<ref name=pmid11891946>{{Cite journal  | last1 = Absher | first1 = KJ. | last2 = Truong | first2 = LD. | last3 = Khurana | first3 = KK. | last4 = Ramzy | first4 = I. | title = Parathyroid cytology: avoiding diagnostic pitfalls. | journal = Head Neck | volume = 24 | issue = 2 | pages = 157-64 | month = Feb | year = 2002 | doi =  | PMID = 11891946 }}</ref>
Chief cells:<ref name=pmid11891946>{{Cite journal  | last1 = Absher | first1 = KJ. | last2 = Truong | first2 = LD. | last3 = Khurana | first3 = KK. | last4 = Ramzy | first4 = I. | title = Parathyroid cytology: avoiding diagnostic pitfalls. | journal = Head Neck | volume = 24 | issue = 2 | pages = 157-64 | month = Feb | year = 2002 | doi =  | PMID = 11891946 }}</ref>
*Small round-to-oval nucleus.
*Small round-to-oval nucleus.
*Granular chromatin.
*Granular chromatin.
*Cytoplasm - often not distinct.
*Cytoplasm - often not distinct.
*Scattered naked nuclei.<ref name=pmid24255635>{{Cite journal  | last1 = Heo | first1 = I. | last2 = Park | first2 = S. | last3 = Jung | first3 = CW. | last4 = Koh | first4 = JS. | last5 = Lee | first5 = SS. | last6 = Seol | first6 = H. | last7 = Choi | first7 = HS. | last8 = Cho | first8 = SY. | title = Fine needle aspiration cytology of parathyroid lesions. | journal = Korean J Pathol | volume = 47 | issue = 5 | pages = 466-71 | month = Oct | year = 2013 | doi = 10.4132/KoreanJPathol.2013.47.5.466 | PMID = 24255635 }}</ref>
*+/-Nuclear moulding.
*+/-Nuclear moulding.
*+/-Nuclear overlap.
*+/-Nuclear overlap.
*+/-Papillary fragment - uncommon.<ref name=pmid19283690>{{Cite journal  | last1 = Agarwal | first1 = AM. | last2 = Bentz | first2 = JS. | last3 = Hungerford | first3 = R. | last4 = Abraham | first4 = D. | title = Parathyroid fine-needle aspiration cytology in the evaluation of parathyroid adenoma: cytologic findings from 53 patients. | journal = Diagn Cytopathol | volume = 37 | issue = 6 | pages = 407-10 | month = Jun | year = 2009 | doi = 10.1002/dc.21020 | PMID = 19283690 }}</ref>
*+/-Papillary fragments - uncommon.<ref name=pmid19283690>{{Cite journal  | last1 = Agarwal | first1 = AM. | last2 = Bentz | first2 = JS. | last3 = Hungerford | first3 = R. | last4 = Abraham | first4 = D. | title = Parathyroid fine-needle aspiration cytology in the evaluation of parathyroid adenoma: cytologic findings from 53 patients. | journal = Diagn Cytopathol | volume = 37 | issue = 6 | pages = 407-10 | month = Jun | year = 2009 | doi = 10.1002/dc.21020 | PMID = 19283690 }}</ref>


Images:
Images:
*[http://www.ncbi.nlm.nih.gov.qe2a-proxy.mun.ca/pmc/articles/PMC1770637/figure/f1/ Parathyroid gland (nih.gov)].<ref name=pmid15790694>{{Cite journal  | last1 = Johnson | first1 = SJ. | last2 = Sheffield | first2 = EA. | last3 = McNicol | first3 = AM. | title = Best practice no 183. Examination of parathyroid gland specimens. | journal = J Clin Pathol | volume = 58 | issue = 4 | pages = 338-42 | month = Apr | year = 2005 | doi = 10.1136/jcp.2002.002550 | PMID = 15790694 | PMC = 1770637 }}</ref>
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1770637/figure/f1/ Parathyroid gland (nih.gov)].<ref name=pmid15790694>{{Cite journal  | last1 = Johnson | first1 = SJ. | last2 = Sheffield | first2 = EA. | last3 = McNicol | first3 = AM. | title = Best practice no 183. Examination of parathyroid gland specimens. | journal = J Clin Pathol | volume = 58 | issue = 4 | pages = 338-42 | month = Apr | year = 2005 | doi = 10.1136/jcp.2002.002550 | PMID = 15790694 | PMC = 1770637 }}</ref>
 
DDx of naked nuclei:
*[[Granular cell tumour]].
*Parathyroid.<ref name=pmid19283690/>


=Adequacy criteria=
=Adequacy criteria=
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*The inadequate & suspicious rate with these criteria is 10-30%. In excision specimens, 75-80% are benign.<ref name=pmid11940037>{{Cite journal  | last1 = Haugen | first1 = BR. | last2 = Woodmansee | first2 = WW. | last3 = McDermott | first3 = MT. | title = Towards improving the utility of fine-needle aspiration biopsy for the diagnosis of thyroid tumours. | journal = Clin Endocrinol (Oxf) | volume = 56 | issue = 3 | pages = 281-90 | month = Mar | year = 2002 | doi =  | PMID = 11940037 }}</ref>
*The inadequate & suspicious rate with these criteria is 10-30%. In excision specimens, 75-80% are benign.<ref name=pmid11940037>{{Cite journal  | last1 = Haugen | first1 = BR. | last2 = Woodmansee | first2 = WW. | last3 = McDermott | first3 = MT. | title = Towards improving the utility of fine-needle aspiration biopsy for the diagnosis of thyroid tumours. | journal = Clin Endocrinol (Oxf) | volume = 56 | issue = 3 | pages = 281-90 | month = Mar | year = 2002 | doi =  | PMID = 11940037 }}</ref>
**The above begs the question - should the criteria be changed?
**The above begs the question - should the criteria be changed?
===Sign out===
<pre>
Thyroid Gland, Right Lobe, Fine Needle Aspiration:
- Unsatisfactory; specimen processed and examined, but unsatisfactory due to insufficient
  material. Scant follicular cells, Hurthle cells and colloid present in a background of
  mixed inflammatory cells and abundant macrophages. 
Note: A repeat aspiration should be considered if clinically warranted.
</pre>
====Alternate====
<pre>
Thyroid Gland, Right Lobe, Fine Needle Aspiration:
- Non-diagnostic. (Category I)
Specimen processed and examined, but unsatisfactory due to scant cellularity. 
Some cellular degeneration noted, rare colloid and inflammatory cells present.
Note: A repeat aspiration should be considered if clinically warranted.
</pre>


=Standard sign-out language=
=Standard sign-out language=
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=Benign disease=
=Benign disease=
==Adenomatoid nodule==
{{Main|Adenomatoid nodule of the thyroid gland}}
===General===
*Diagnosis ''benign thyroid tissue''.
===Cytology===
Features:
*Benign follicular cells (abundant) with relatively little colloid.
DDx:
*[[Colloid nodule]] - has more colloid.
===Sign out===
<pre>
Thyroid Gland, Left, Fine Needle Aspiration:
- Benign.
- Cellular aspirate.
- Benign-appearing follicular cells with colloid, consistent with an adenomatous nodule.
</pre>
==Colloid nodule==
==Colloid nodule==
===General===
===General===
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*Macrofollicles:
*Macrofollicles:
**Ball of cells ~ 20 cells across.
**Ball of cells ~ 20 cells across.
====Images====
<gallery>
Image: Thyroid colloid - FNA -- high mag.jpg | Colloid - high mag. (WC)
Image: Thyroid colloid - FNA -- very high mag.jpg | Colloid - very high mag. (WC)
</gallery>


==Graves disease==
==Graves disease==
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*Non-specific finding.
*Non-specific finding.
**May represent [[Hashimoto thyroiditis]].
**May represent [[Hashimoto thyroiditis]].
 
**Can be seen in [[Graves' disease]].<ref name=pmid6129766>{{Cite journal  | last1 = Leövey | first1 = A. | last2 = Bakó | first2 = G. | last3 = Sztojka | first3 = I. | last4 = Bordán | first4 = L. | last5 = Szabó | first5 = T. | last6 = Kálmán | first6 = K. | last7 = Balázs | first7 = C. | title = The pathogenetic connection between Graves' disease and chronic lymphocytic thyroiditis. (The role and incidence of thyroid stimulating antibodies). | journal = Acta Med Acad Sci Hung | volume = 39 | issue = 1-2 | pages = 1-6 | month =  | year = 1982 | doi =  | PMID = 6129766 }}</ref>
===Cytology===
===Cytology===
Features:
Features:
Line 218: Line 319:
=Waffle category=
=Waffle category=
==Follicular lesion of undetermined significance==
==Follicular lesion of undetermined significance==
Abbreviated ''FLUS''.
*Abbreviated ''FLUS''.
*Also known as ''atypia of undetermined significance'' (abbreviated ''AUS'').


===General===
===General===
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**Mild size variation or nuclear enlargement.
**Mild size variation or nuclear enlargement.
**Mild accentuation of nuclear staining.
**Mild accentuation of nuclear staining.
===Sign out===
<pre>
Atypia of undetermined significance (AUS).
</pre>


=Neoplastic and malignant=
=Neoplastic and malignant=
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*Papillary architecture may be seen in [[Graves disease]].<ref>Biopsy Interpretation of the Thyroid. PP.97-98.</ref>
*Papillary architecture may be seen in [[Graves disease]].<ref>Biopsy Interpretation of the Thyroid. PP.97-98.</ref>
*Thick (dense) colloid common - described as "bubble gum". (???)
*Thick (dense) colloid common - described as "bubble gum". (???)
====Images====
<gallery>
Image: Papillary thyroid carcinoma -- intermed mag.jpg | PTC - intermed. mag. (WC)
Image: Papillary thyroid carcinoma -- high mag.jpg | PTC - high mag. (WC)
Image: Papillary thyroid carcinoma -- very high mag.jpg | PTC - very high mag. (WC)
Image: Papillary thyroid carcinoma - pi -- high mag.jpg | PTC - high mag. (WC)
Image: Papillary thyroid carcinoma - pi -- very high mag.jpg | PTC - very high mag. (WC)
</gallery>
<gallery>
Image:Papillary_Carcinoma_of_the_Thyroid.jpg | PTC. (WC)
</gallery>


===Variants of PTC===
===Variants of PTC===
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#Nuclear overlap/crowding.
#Nuclear overlap/crowding.
#+/-Microfollicles, numerous.
#+/-Microfollicles, numerous.
#*Microfollicles are defined as: <15 cells forming at least two thirds of a circle.
#*[[Microfollicles]] are defined as: <15 cells forming at least two thirds of a circle.
#+/-Atypia marked.
#+/-Atypia marked.


Line 325: Line 445:
**Multinucleation.
**Multinucleation.


Diagnosis by MB:
DDx:
*If single cells -- need abundant.
*[[Granular cell tumour]].


Images:
====Images====
*[http://commons.wikimedia.org/wiki/File:Hurthle_cell_neoplasm.jpg Hurthle cell neoplasm (WC)].
<gallery>
Image:Hurthle_cell_neoplasm.jpg | Hurthle cell neoplasm. (WC)
</gallery>
www:
*[http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CI-Image-0803/FQ-059b.gif ON - Diff-Quik - intermed. mag. (ouhsc.edu)].<ref>URL: [http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-039-M.htm http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-039-M.htm]. Accessed on: 10 April 2012.</ref>
*[http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CI-Image-0803/FQ-059b.gif ON - Diff-Quik - intermed. mag. (ouhsc.edu)].<ref>URL: [http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-039-M.htm http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-039-M.htm]. Accessed on: 10 April 2012.</ref>
*[http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CI-Image-0803/FQ-059c.gif ON - Pap stain - high mag. (ouhsc.edu)].
*[http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CI-Image-0803/FQ-059c.gif ON - Pap stain - high mag. (ouhsc.edu)].
Line 359: Line 482:


DDx:
DDx:
*Anaplastic carcinoma.
*[[anaplastic thyroid carcinoma|Anaplastic carcinoma]].


Images:
Images:
Michael
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