Sunteți pe pagina 1din 4

CLINICAL DIAGNOSIS:

Papillary thyroid carcinoma stage 1 (T2 N1 M0) s/p FNA

DIFFERENTIAL DIAGNOSIS:
Dx History/Physical Histologic Findings
Examination
Hashimoto Presents as painless extensive infiltration of
thyroiditis enlargement of the the parenchyma by a
thyroid, usually with mononuclear
some degree of inflammatory infiltrate
hypothyroidism, in a containing small
middle-aged woman. lymphocytes,
Enlargement of the plasma cells, and well-
gland is usually developed germinal
symmetric and centers. Thyroid
diffuse, and follicles are atrophic
hypothyroidism and are lined in many
develops gradually. areas by epithelial cells
distinguished by the
presence of abundant
eosinophilic, granular
cytoplasm, termed
Hürthle cells.
Follicular mass is painless. constituent cells often
adenoma Some patients have a form uniform-appearing
tight or full feeling in follicles that contain
the neck, hoarseness, colloid. Follicular
or signs of tracheal or growth pattern is
esophageal usually distinct from
compression. adjacent
Palpable thyroid non-neoplastic thyroid.
nodules are usually Neoplastic cells show
solitary, with a hard little variation in cell
consistency, an size, cell shape, or
average size of less nuclear morphology,
than 5 cm, and ill- and mitotic figures are
defined borders. rare. Occasionally the
neoplastic cells acquire
brightly eosinophilic
granular cytoplasm
(oxyphil or Hürthle cell
change). Hallmark is
the presence of an
intact, well-formed
capsule encircling the
tumor
Follicular present as slowly follicular carcinomas
carcinoma enlarging painless are composed of
nodules. Most fairly uniform cells
frequently they are forming small follicles
cold nodules on containing colloid, quite
scintigrams, although reminiscent of normal
rare, better- thyroid (Fig. 24-20B).
differentiated lesions In other cases follicular
may be differentiation may be
hyperfunctional, take less apparent, and there
up radioactive iodine may be
and appear warm on nests or sheets of cells
scintiscan without colloid.
Occasional tumors are
dominated by cells with
abundant granular,
eosinophilic cytoplasm
(Hürthle cell or
oncocytic variant of
follicular carcinoma).
Whatever the pattern,
the nuclei lack the
features
typical of papillary
carcinoma, and
psammoma bodies are
not present.

DIAGNOSIS:
Papillary carcinoma, follicular variant, infiltrative

DISCUSSION:
a. Epidemiology
Papillary carcinoma is the most common type of thyroid malignancy, accounting for
approximately 80% of all thyroid carcinomas. Females are more affected than males. It can
present in any age group, the mean age at the time of diagnosis being approximately 40
years.
b. Etiology
In 5-10% of cases, there is a history of irradiation to the neck. Iron deficiency has also
shown to increase he incidence of thyroid carcinoma.
c. Pathogenesis
Several chromosomal rearrangements have been identified in papillary thyroid carcinoma
such as chromosomal rearrangements involving the rearranged during transfection (RET)
proto-oncogene, which arises from a paracentric inversion of chromosome 10. RET fusion
proteins (the RET/PTC family) appear to play an oncogenic role in approximately 20% of
papillary thyroid carcinomas, with RET/PTC1, RET/PTC2, and RET/PTC3 accounting for
most cases.
Evidence also suggests that some molecules that physiologically regulate the growth of the
thyrocytes, such as interleukin-1 and interleukin-8, or other cytokines (eg, insulinlike
growth factor-1, transforming growth factor-beta, epidermal growth factor) could play a
role in the pathogenesis of this cancer.
Mutation in the BRAF gene resulting in the BRAF V60E protein is prominent in papillary
thyroid carcinoma. The BRAF V600E mutation is associated with aggressive
clinicopathological characteristics of papillary thyroid carcinoma, including lymph node
metastasis, extrathyroidal invasion, and loss of radioiodine avidity, which may lead to
failure of radioiodine treatment and disease recurrence.
d. Histopathologic final diagnosis

Typical papillary carcinoma contains numerous true papillae- usually complex, branching
and randomly oriented, with a central fibrovascular core and a single or stratified lining of
cuboidal cells, some of which may have hobnail features. Papillary carcinoma have
characteristic nuclear features which can be made as basis for the diagnosis of papillary
carcinoma.
Papillary carcinoma cells have ground glass (optically clear) nuclei due to finely dispersed
chromatin- also known as Orphan Annie nuclei. Nuclear pseudoinclusions, which represent
invaginations of the cytoplasm, can also be seen as sharply outlined (nuclear membrane-
bound) round acidophilic vacuoles. Nuclear grooves and nuclear microfilaments are also
apparent.
Psammoma bodies can be seen in approximately 50% of the cases in the papillary stalk,
fibrous stroma or between tumor cells in solid foci.
Follicular variant is a common variant of papillary thyroid carcinoma with an increasing
frequency, comprising about 20-30%. It is composed exclusively or almost exclusively of
follicles lined by cells showing nuclear features of papillary carcinoma; well-formed
papillae should not be observed in follicular variant of papillary carcinoma. It commonly
presents as a well circumscribed or encapsulated tumor. This variant is one of the most
challenging for the pathologist evaluating a solitary encapsulated thyroid nodule with a
follicular architecture and some form of atypia. The problem is when to diagnose the lesion
as a follicular adenoma versus the follicular variant of papillary thyroid carcinoma. A
useful set of guidelines for distinguishing the follicular variant of papillary carcinoma from
follicular adenomas that includes the presence of at least 3 of 4 major histologic features
(ovoid nuclei, nuclear crowding, pale chromatin or extensive nuclear grooves, psammoma
bodies) and at least 4 minor features (abortive papillae, elongated irregular follicles, dark-
staining colloid, nuclear pseudoinclusions, and multinucleated histiocytes within follicle
lumens) when less than 4 major features are present
e. Immunochemical staining
The cells of papillary carcinoma are reactive for pan-keratin stains. It is positive for CK
19, high molecular weight keratin, CK7, RET, TTF 1, PAXS, S-100, vimectin, EMA, CEA
(occasionally), CA-125 (~50% of cases), HBME-1, inyolucrin, galectin 3, CD15, CD57,
α-antichymotrypsin, estrogen receptors, and the p75 neurotrophin receptor. It is negative
for CK20.
However, among all the listed stains, HBME-1 (alone or in conjunction with CK19) is the
one with the greatest discriminatory power for benign mimics.
f. Prognosis
Papillary thyroid cancers have an excellent prognosis, with a 10-year survival rate in excess
of 95%. Between 5% and 20% of patients have local or regional recurrences, and 10% to
15% have distant metastases. The prognosis of someone with papillary thyroid cancers is
dependent on several factors including age (in general, being less favorable among patients
older than 40 years), the presence of extrathyroidal extension, and presence of distant
metastases (stage).
g. Treatment
Thyroid lobectomy alone is considered sufficient treatment for small (<1 cm), incidentally
discovered, low-risk, unifocal, intrathyroidal papillary carcinomas in the absence of prior
head and neck irradiation or radiologically or clinically involved cervical nodal metastases.
For patients with high risk tumors or bilateral tumors should undergo total or near-total
thyroidectomy. Enlarged or obviously involved central neck nodes should be removed
(therapeutic central compartment, level VI), along with nodes with known lateral neck
metastases. Biopsy-proven lymph node metastases detected clinically or by imaging in the
lateral neck in patients with papillary carcinoma are managed with modified radical or
functional neck dissection.

S-ar putea să vă placă și