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SURGICO PATHOLOGY

This presentation by Dr. Shwetha Jose focuses on the pathology and characteristics of papillary carcinoma of the thyroid, along with the presence of multi nodular goitre. It covers the nature of the specimen, microscopic features, etiology, cytogenetic and molecular features, morphological characteristics, variants, immunohistochemistry, and prognostic factors.

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SURGICO PATHOLOGY

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  1. SURGICO PATHOLOGY Presented by Dr. Shwetha Jose Moderator : Dr. Prema Saldanha Professor of Pathology

  2. NATURE OF SPECIMEN Thyroid with isthmus

  3. GROSS • Specimen of thryoid 4X3X2cms & isthmus 1.2X1X0.2cms. • Outer surface smooth, capsule intact • Cut surface hemorrhagic areas.

  4. MICROSCOPY Tumor cells arranged as papillary structures with fibrovascular core. Nuclei show ground glass appearance. Nuclei are deeply grooved along with small nucleoli.

  5. Section from isthmus shows features of multi nodular goitre.

  6. IMPRESSION PAPILLARY CARCINOMA – THYROID ALONG WITH MULTI NODULAR GOITRE

  7. Thyroid tumors - Overview • Common • 0.5-10 cases/100,000/year • Papillary carcinoma – most common • More frequent in women • Females: Slightly better prognosis • Better differentiated in younger age group

  8. Frequency of the primary malignant tumors

  9. WHO Classification (2004) • Thyroid Carcinomas: • Papillary carcinoma • Follicular carcinoma • Poorly differentiated • Undifferentiated • Squamous cell carcinoma • Mucoepidermoid Ca • Mucinous • Medullary • Mixed medullary and follicular cell • Thyroid adenomas and related tumors • Follicular adenoma • Hyalinising trabecular tumor

  10. PAPILLARY CARCINOMA OF THYROID • “Malignant epithelial tumor showing evidence of follicular cell differentiation, and characterised by distinctive nuclear features” • Demonstration of invasive growth – not required • Cell of origin is the follicular cell.

  11. Etiology & Predisposing factors • Previous irradiation to head & neck • Radiation exposure from nuclear accident or atomic bomb • Hashimoto’s thyroiditis • Familial Adenomatous Polyposis • Cowden disease • No known precursor lesion

  12. Cytogenetic and molecular features • RET & TRK rearrangements • RET/PTC • Intrachromosomal inversion or chromosomal translocation • BRAF mutation • ras mutation

  13. Environmental Genetic Hormonal

  14. Natural history

  15. Indolent course • Excellent long term prognosis • Cancer related mortality – 6.5% • Propensity to invade locally (thyroid parenchyma, perithyroid soft tissues, trachea) • Metastasize to regional LNs (cervico central and I/L cervico lateral nodes) • Local recurrence – not uncommon • Distant mets – uncommon ; late

  16. Stratification by risk group (Papillary & Follicular)

  17. Morphology GROSS • Infiltrative • Irregular ill-defined borders • Hard consistency • White-tan • Granular texture (papillae) • Cut surface – gritty (psammoma bodies ; calcifications) • Multifocal – 65% • ? Intraglandularmets ; independent neoplasms • Rare - Circumscribed / Encapsulated • Calcifications ; Bone formation • Cystic change • Follicular variant – Fleshy cut surface

  18. Morphology MICROSCOPY • Cytologic features : • Nuclei : large, crowded, ovoid, ground glass, grooved, small distinct nucleoli • Ground glass change : • ?artifact of formalin fixation • Nuclear grooves : • Deep folding of nuclear membrane • Nuclear pseudoinclusions : intra nuclear herniation of pockets of cytoplasm • Nuclear crowding

  19. Empty looking nuclei ; “Orphan Annie eye nuclei.”Up & Down placement-Nuclear crowding.

  20. Deeply grooved nuclei

  21. Morphology • Architectural features • Usually infiltrative • Maybe circumscribed or encapsulated (rare) • Arborizing papillae with delicate fibrovascular cores • Broad papillae • Follicles : • Frequent • Vary in size and contour • Contain dark staining colloid • Intrafollicular hemorrhage

  22. Morphology • Stroma • Abundant sclerotic stroma • Dense hyaline fibrosis • Cellular desmoplasticstroma • Multinucleated histiocytes (diagnostic) • Psammoma bodies (pathognomonic when in thyroid)

  23. Variants • Follicular variant • Solid variant • Encapsulated variant • Diffuse sclerosing variant • Diffuse follicular variant • Tall cell variant • Columnar cell variant • Oxyphilic variant • Warthin tumor like variant • Clear cell variant • Macrofollicular variant • Trabecular variant • Cribriform-morular variant • With lipomatousstroma • Exuberant nodular fasciitis like stroma • With spindle cell metaplasia • Dedifferentiated papillary carcinoma

  24. Immunohistochemistry • Pan-cytokeratin • Thyroglobulin • Thyroid origin of metastatic carcinoma • TTF-1

  25. Prognostic factors • Age • Sex • Extra thyroidal extension • Microscopic variants • History of previous irradiation • Tumor size • Capsule & margins • Multicentricity • Distant metastases • Poorly diffrentiated,squamous or anaplastic foci • Grading • EMA & Leu M1 positivity • DNA ploidy • Rb protein • Circulating tumor cells

  26. No correlation with prognosis • Relative proportion of papillae & follicles • Presence or amount of fibrosis • Presence or amount of psammoma bodies • Microvessel density • Cervical node mets • ?Effect of type of therapy

  27. References : • WHO classification of tumors, Pathology and Genetics of the Endocrine organs,2006 • Diagnostic Histopathology of tumors, Fletcher 3rd edition,2010 • Rosai and Ackerman's Surgical Pathology, 9th edition, 2004

  28. THANK YOU

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