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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 | =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==== | ||
* | <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= | |||
{{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> | |||
*Small round-to-oval nucleus. | |||
*Granular chromatin. | |||
*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 overlap. | |||
*+/-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: | |||
*[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= | |||
*>=60 follicular cells. † | |||
*No atypical cells. | |||
Note 1: | |||
*† Typically described as: at least 6 groups (with 10 or more follicular cells) on at least two smears.<ref name=pmid9809173>{{Cite journal | last1 = Carpi | first1 = A. | last2 = Sagripanti | first2 = A. | last3 = Nicolini | first3 = A. | last4 = Santini | first4 = S. | last5 = Ferrari | first5 = E. | last6 = Romani | first6 = R. | last7 = Di Coscio | first7 = G. | title = Large needle aspiration biopsy for reducing the rate of inadequate cytology on fine needle aspiration specimens from palpable thyroid nodules. | journal = Biomed Pharmacother | volume = 52 | issue = 7-8 | pages = 303-7 | month = | year = 1998 | doi = | PMID = 9809173 }}</ref> | |||
Note 2: | |||
*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? | |||
===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== | |||
===General=== | |||
*Diagnosis ''benign thyroid tissue''. | |||
===Cytology=== | |||
Features: | |||
*Colloid - paucicellular material: | |||
**"Thick" colloid = dense appearing blob, well-circumscribed +/- "cracking". | |||
**"Watery" colloid = light, whispy/fluffy material. | |||
*Macrofollicles: | |||
**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== | ||
{{Main|Graves disease}} | {{Main|Graves disease}} | ||
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*+/-Flame cells on [[Romanowsky stain]], e.g. Diff-Quik.<ref name=ouhsc_37>URL: [http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-037-M.htm http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-037-M.htm]. Accessed on: 10 April 2012.</ref> | *+/-Flame cells on [[Romanowsky stain]], e.g. Diff-Quik.<ref name=ouhsc_37>URL: [http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-037-M.htm http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-021-040/CQ-037-M.htm]. Accessed on: 10 April 2012.</ref> | ||
**Red granular discolourization of the cytoplasm - thought to be endoplasmic reticulum. | **Red granular discolourization of the cytoplasm - thought to be endoplasmic reticulum. | ||
Notes: | |||
*Flame cells are indicative of cellular hyperactivity. | |||
**Not pathognomonic for Graves disease, e.g. may be seen in early [[Hashimoto disease]], | |||
Images: | Images: | ||
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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: | ||
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*Lymphoglandular bodies. | *Lymphoglandular bodies. | ||
**Cytoplasmic fragment of a lymphoid cell.<ref>URL: [http://www.definition-of.com/lymphoglandular+body http://www.definition-of.com/lymphoglandular+body]. Accessed on: 27 January 2012.</ref> | **Cytoplasmic fragment of a lymphoid cell.<ref>URL: [http://www.definition-of.com/lymphoglandular+body http://www.definition-of.com/lymphoglandular+body]. Accessed on: 27 January 2012.</ref> | ||
Note: | |||
*Lymphocyte infiltration into fragments of oncocytic cells - strongly suggestive of Hashimoto disease. (???) | |||
=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= | ||
==Papillary carcinoma== | ==Papillary carcinoma== | ||
{{Main|Papillary thyroid carcinoma}} | {{Main|Papillary thyroid carcinoma}} | ||
===General=== | |||
*[[Papillary thyroid carcinoma]] is basically the only entity (in cytopathology) that has near universally accepted criteria. | *[[Papillary thyroid carcinoma]] is basically the only entity (in cytopathology) that has near universally accepted criteria. | ||
**This is why radiation oncologists say... "Basing stuff on pathology is like basing something on shifting sand." | **This is why radiation oncologists say... "Basing stuff on pathology is like basing something on shifting sand." | ||
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*Nuclear grooves may be seen in Hashimoto's disease.<ref>WG. 8 January 2010.</ref> | *Nuclear grooves may be seen in Hashimoto's disease.<ref>WG. 8 January 2010.</ref> | ||
*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". (???) | |||
====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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==Follicular neoplasm== | ==Follicular neoplasm== | ||
* | ===General=== | ||
*Can be thought of as a (neoplasm) garbage category for the thyroid gland - may represent: | |||
**[[Follicular adenoma]]. | |||
**[[Follicular carcinoma]]. | |||
Management: | |||
*Hemithyroidectomy. | |||
===Cytology=== | ===Cytology=== | ||
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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. | ||
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*A few microfollicles are normal. | *A few microfollicles are normal. | ||
*''Atypia'' alone - "suspicious for malignancy" or "malignant". | *''Atypia'' alone - "suspicious for malignancy" or "malignant". | ||
*Nuclei are described as having the shape of an ''orange'' in follicular neoplasms... and ''potatoes'' in papillary thyroid carcinomas. | |||
==Oncocytic neoplasm== | |||
{{Main|Hürthle cell neoplasm}} | |||
*[[AKA]] ''Hurthle cell neoplasm''. | |||
==Oncocytic neoplasm | ===General=== | ||
General | |||
*''Oncocytic'' perferred by WHO over ''Hurthle cell''. | *''Oncocytic'' perferred by WHO over ''Hurthle cell''. | ||
===Cytology=== | |||
Features:<ref name=pmid18478609/> | Features:<ref name=pmid18478609/> | ||
#Single cells or sheets of oncocytic cells. | #Single cells or sheets of oncocytic cells. | ||
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**Multinucleation. | **Multinucleation. | ||
DDx: | |||
* | *[[Granular cell tumour]]. | ||
Image: | ====Images==== | ||
*[http:// | <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-059c.gif ON - Pap stain - high mag. (ouhsc.edu)]. | |||
==Medullary thryoid carcinoma== | ==Medullary thryoid carcinoma== | ||
{{Main|Medullary thyroid carcinoma}} | {{Main|Medullary thyroid carcinoma}} | ||
===General=== | |||
*May be familial - associated with MEN II syndrome. | *May be familial - associated with MEN II syndrome. | ||
*Sometimes described as the ''melanoma of the thyroid'' - as it can look like almost anything. | |||
===Cytology=== | ===Cytology=== | ||
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DDx: | DDx: | ||
*Anaplastic carcinoma. | *[[anaplastic thyroid carcinoma|Anaplastic carcinoma]]. | ||
Images: | Images: | ||
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*Congo-red +ve (if amyloid present) - mnemonic: ''CRAP'' -- congo red amyloid protein. | *Congo-red +ve (if amyloid present) - mnemonic: ''CRAP'' -- congo red amyloid protein. | ||
==Anaplastic carcinoma== | ==Anaplastic thyroid carcinoma== | ||
{{Main|Anaplastic thyroid carcinoma}} | |||
===General=== | |||
*Prognosis: very crappy. | *Prognosis: very crappy. | ||
*Classically rapid growth. | |||
Note: | |||
*Other fast growing lesion: | |||
**Lymphoma (faster than anaplastic carcinoma). | |||
**Blood accumulation. | |||
===Cytology=== | ===Cytology=== | ||
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DDx: | DDx: | ||
*Medullary carcinoma. | *Medullary thyroid carcinoma. | ||
=See also= | =See also= |
edits