goitre case discussion for post graduate students .pptx

goitre case discussion for post graduate students

1. Case 1 A 42 yr old female patient came to Anil Neerukonda Hospital with c/o swelling in front of neck since 2 months and c/o pain since 2 days. Patient was apparently normal 2 months back later which she noticed swelling in front of the neck which was initially 1×2cm in size, gradually progressive and attained the size of 3×2 cm extending in front of neck.

2. Clinical examination A Well defined swelling measuring 3x2 cm is present in front of the neck predominantly towards right side . Skin over the swelling is normal. No local rise of temperature. No tenderness Soft to firm in consistency Surface is nodular. Moves with deglutition . Does not move with protrusion of tongue .

3. Investigations Ent opinion taken. Indirect laryngoscopy adviced : Normal vls findings. Thyroid profile – Euthyroid state All other routine investigations are within normal range .

4. USG neck- features are suggestive of nodular goiter Suggested FNAC correlation to rule out neoplastic etiology

5. FNAC: Impression: NODULAR GOITER

6. Provisional Diagnosis: solitary thyroid nodule. Plan of care : Right hemithyroidectomy . Right lobectomty + isthumectomy ( Hemithyroidectomy ) done. Procedure was uneventful. Specimen sent for histopathological examination

7. An open thyroid biopsy – a rarely used operation where a nodule is excised directly. A hemi- thyroidectomy or thyroid lobectomy – where one lobe (one half) of the thyroid is removed. An isthmusectomy – removal of just the bridge of thyroid tissue between the two lobes; used specifically for small tumors that are located in the isthmus. A total or near-total thyroidectomy is removal of all or most of the thyroid tissue.

8. 1486/24 Gross Specimen NRIIMS 1486/24 NRIIMS 1486/24

9. 1486/24 Right hemithyroidectomy sent for HPE. Clinical Diagnosis: Solitary thyroid nodule Macroscopic Features: Received right hemithyroidectomy specimen measuring 5 x 3 x 2cm and isthmus measuring 2 x 0.5cm. External surface :Nodular. Cut section: Circumscribed, homogenous, solid, grey white area measuring 3 x 2 x 2cm.

10. Microscopic Pictures SCANNER 4X H&E 10X H&E

11. SCANNER 4X H&E 10X H&E

12. 40X H&E 100X H&E

13. 10X H&E 40X H&E

14. 1486 /24 Microscopic Features : Sections studied from grey white nodular area in the thyroid show thyroid follicular cells arranged in microfollicular pattern with dense colloid. The cells show ground glass nucleus with focal areas show nuclear overlapping. There are foci of nuclear grooves. Adjacent thyroid shows multiple nodules separated by fibrovascular stroma and focal lymphoid aggregates, some with germinal centers. Adjacent parathyroid gland seen. No lymphatic / vascular emboli seen. Impression: Features are suggestive of “Follicular variant of Papillary Thyroid Carcinoma” Advise IHC markers CK19/ HBME1/ Galectin - 3 for confirmation.

15. Case 2 A 24 yr old female patient came to Anil Neerukonda Hospital with c/o swelling in front of neck since 3 yrs. She noticed swelling in front of the neck which was initially 4×3cm in size, gradually progressive and attained the size of 9x7x2 cm extending in front of neck predominantly on the right side.

16. Clinical examination A well defined swelling measuring 9x7x2 cm is present in front of the neck predominantly towards right side . Skin over the swelling is normal. No local rise of temperature. No tenderness. Soft to firm in consistency Surface is smooth and congested. Moves with deglutition . Does not move with protrusion of tongue.

17. Investigations Ent opinion taken. Indirect laryngoscopyadv : Normal vls findings. Thyroid profile – Euthyroid state USG neck- features are suggestive of Solitary Thyroid Nodule FNAC Thyroid reported as features suggestive of Nodular goiter. All other routine investigations are within normal range .

18. Provisional Diagnosis: solitary thyroid nodule. Plan of care : Right hemithyroidectomy . Right lobectomty + isthumectomy ( Hemithyroidectomy ) done. Procedure was uneventful. Specimen sent for histopathological examination

19. 1596/24 Gross Specimen NRIIMS 1596/24 NRIIMS 1596/24

20. 1569 / 24 Right thyroid lobe sent for HPE. Clinical Diagnosis: Right Multinodular Goitre Macroscopic Features : Received right hemithyroidectomy specimen measuring 9 x 7 x 5cm and isthmus measuring 2 x 1 cm External surface : Smooth, congested. Cut section: Grey white to grey tan and dark brown hemorrhagic area seen. Grey white area measuring 5.5 x 4 x 3.5cm.

21. Microscopic pictures SCANNER 4X H&E 10X H&E

22. 40X H&E SCANNER 4X H&E

23. 1569 / 24 Right thyroid lobe sent for HPE. Clinical Diagnosis: Right Multinodular goitre Microscopic Features : Sections studied show multiple nodules of thyroid follicles interspersed with diffusely placed well defined follicular cells arranged in nodules showing nuclear features of papillary carcinoma of thyroid i.e nuclear grooves and clearing. Impression: Features are suggestive of “Diffuse Follicular Variant of Papillary Carcinoma” Advise IHC markers CK19/ Galectin - 3 for confirmation.

24. Papillary Carcinoma of thyroid Papillary carcinoma is defined by the presence of a distinctive set of alterations of nuclear morphology, the PTC-type nuclei with or without the presence of either papillae or invasion of the surrounding thyroid parenchyma. It is the most common type of thyroid carcinoma and the most common endocrine malignancy. Females are more affected than males. It can present in any age group, the mean age at the time of initial diagnosis being approximately 40–50 years

25. Papillary thyroid carcinoma (PTC) nuclear scoring system is composed of three categories: (1) nuclear size and shape (enlarged, elongated, overlapped and crowded), (2) nuclear membrane irregularities (irregular nuclear membranous contours, nuclear grooves, or pseudoinclusions ), (3) chromatin characteristics (clearing, margination , or glassy nuclei. The nuclear score is calculated as the sum of these categories, with one point scored if each category is identified.

26. VARIANTS OF PAPILLARY CARCINOMA OF THYROID

27. Follicular Variant. This is a papillary carcinoma composed entirely or almost entirely of follicles It is also referred to as Lindsay tumor. The diagnosis is based on the presence of PTC-type nuclei. The behavior of these tumors, when infiltrative and not encapsulated, is analogous to that of conventional papillary carcinoma, particularly in regard to the high incidence of nodal metastases. Interestingly, these metastases sometimes exhibit well-developed papillary formations

28. Based on the outline of the tumor when it grows into the surrounding non- neoplastic tissue, two major groups of follicular variant papillary carcinoma with different histologic , clinical, and molecular features are recognized Infiltrative Follicular Variant Papillary Carcinoma. Encapsulated Follicular Variant and Noninvasive Follicular Thyroid Neoplasm With Papillary-Like Nuclear Features

29. Infiltrative Follicular Variant Papillary Carcinoma The tumor is characterized by infiltrative growth margins with neoplastic cells pervading the thyroid parenchyma with irregular strands and nests composed of neoplastic follicles It is typically devoid of a fibrous capsule. Only partial remnants of a capsule can sometimes be identified. The tumor is very similar to follicular predominant classic papillary carcinoma, where well-developed papillae are found in the minority of the neoplastic mass that largely consists of follicular structures A rare diffuse (or multinodular ) variant has been described, where most of a thyroid lobe—or sometimes both lobes—are diffusely infiltrated by the tumor, which is difficult to recognize because of its very diffuseness. The infiltrative follicular-variant papillary carcinoma is characterized by a BRAF p.V600E–like molecular signature

30. Encapsulated Follicular Variant and Noninvasive Follicular Thyroid Neoplasm With Papillary-Like Nuclear Features The tumor is entirely surrounded by a capsule (or well circumscribed, with a smooth contour facing the adjacent parenchyma), has follicular growth pattern (with no papillae), but the nuclear alterations of papillary carcinoma. As in the case of follicular neoplasms , there may or may not be evidence of capsular and/or blood vessel invasion Minute follicles with the typical nuclear alteration are scattered in a background of normal-appearing follicles (the “sprinkling” sign of the follicular variant of papillary carcinoma).

31. Noninvasive Follicular Thyroid Neoplasm With Papillary-Like Nuclear Features The diagnostic criteria of NIFTP are : 1. Encapsulation or clear demarcation from the adjacent thyroid tissue 2. Follicular growth pattern with <1% papillae No psammoma bodies <30% solid/ trabecular /insular growth pattern 3. Nuclear alterations of papillary carcinoma (with a score of 2–3) 4. No vascular or capsular invasion (after thorough examination of the tumor interface with the surrounding tissues) 5. No tumor necrosis 6. No high mitotic activity (i.e., <3 mitoses per 10 high-power fields[×400])

32. FA follicular adenoma; FT-UMP follicular tumor of uncertain malignant potential; WDT-UMP well-differentiated tumor of uncertain malignant potential; NIFTP non-invasive follicular thyroid neoplasm with papillary-like nuclear features ; IEFVPTC invasive encapsulated follicular variant papillary carcinoma

33. The diagnostic term “ well-differentiated tumor of uncertain malignant potential (WDT-UMP)” was proposed in the year 2000 for noninvasive nodules with questionable/incomplete nuclear changes that fall short of a diagnosis of papillary carcinoma, and That of “ well-differentiated carcinoma, not otherwise specified (WDC-NOS)” for similar cases with invasive features, but neither has been widely utilized.

34. The balanced result of two opposing biologic properties of the tumor cell: differentiation in the form of secretory activity (thereby making colloid-filled follicles), and proliferation . When one of these forces predominates over the other, two additional variants emerge: Solid Variant Macrofollicular Variant

35. Solid Variant The Proliferation predominates over secretion. It is characterized by solid nests of generally round shape that can be viewed as filled-up follicles . It is distinguished from insular carcinoma and other forms of poorly differentiated carcinoma because the nuclear features remain those of papillary carcinoma Macrofollicular Variant The secretory activity predominates over proliferation, resulting in large dilated follicles, so that the tumor resembles not so much a follicular neoplasm as a hyperplastic nodule

36. immunohistochemistry Markers of thyroid follicular cells, including  cytokeratin AE1 / AE3 ,  CK7 ,  TTF1 ,  thyroglobulin  and  PAX8 A proportion is positive for mutation specific protein by, e.g.,  BRAF V600E  (VE1 antibody) and  NRAS  Q61R Utility of  CK19 ,  galectin3  and  HBME1  to differentiate from benign mimics remains controversial

37. REFERENCES Zubair W. Baloch ·Sylvia L. Asa ·Justine A.Barletta Ronald A.Ghossein · C.Christofer Juhlin ·Chan Kwon Jung · VirginiaA . LiVolsi1 ·Mauro G. Papotti ·Manuel Sobrinho‑Simoes ·Giovanni Tallini·Ozgur Mete Overview of the 2022 WHO Classification of Thyroid Neoplasms , springer2022 (Endocrine Pathology (2022) 33:27–63) Goldblum JR, Lamps LW, McKenney J, Myers JL. Rosai and Ackerman’s Surgical Pathology 11 th Edition. Elsevier Health Sciences; 2018 Kumar V, Abbas AK, Aster JC. Robbins & Cotran Pathologic Basis of Disease. 10th Edition. Elsevier; 2020. https://www.thyroid.org/thyroid-surgery