Regional teaching thyroid and parathyroid

The UKEPS position statement on NIFTP can be viewed here :http://ukeps.com/NIFTP_Position_Statement.html   

 Endocrine cases

Regional teaching for Severn deanery, June 2016

Prepared by Dr Naomi Carson, Dr Hannah Lowes and Dr Mary Brett

1. Circulation 21 case 7, labelled UKEPS21. Female, late 60s, left thyroid lobectomy, 16mm non-encapsulated hard white tumour.

Medullary carcinoma.

Proffered diagnosis was medullary thyroid carcinoma. Congo red was positive and birefringent. Calcitonin & CEA were positive, and CK19 was negative. Additional tumour foci/ C cell hyperplasia were seen elsewhere in the lobe, but C cell hyperplasia was not confirmed in the completion specimen. An incidental micropapillarythyroid carcinoma was noted. Pre-op FNA had been difficult – suspicious of papillary thyroid carcinoma, sent for external review – follicular-patterned lesion with DD including FVPTC. No mention of MTC by either. The cytology contained “thick colloid” - ?amyloid, and three dimensional groups of cells with crowded nuclei, high nuclear cytoplasmic ratios and follicular formations. 

2. Circulation 30, case 3, labelled 17586/15.   32yr old man Thyroidectomy. “Family history of RET gene”. 

Multiple medullary microcarcinomas favoured over C-cell hyperplasia due to their number and size. 

3. Circulation 24, case 4, labelled EP524 – 70 yr old woman.  Subtotal thyroidectomy for large retrosternal goitre extending behind aortic arch, weighing 136g, with a slightly nodular cut surface and capsular obliteration.

Hurthle cell carcinoma 

Widely invasive Hurthle Cell carcinoma with vascular invasion. In places the tumour had a few insular areas. All members thought this was a Hurthle cell carcinoma.

*See SN13-****** (From Jan 2016 thyroid test set) FNA thyroid – Hurthle cell adenoma*

4. Circulation 25, case 9  - 25 yr old man, with a 5cm, Thy3 nodule in the isthmus of the thyroid.

Hyalinising trabecular tumour.

Most members diagnosed a hyalinising trabecular tumour, with a few diagnoses of medullary and papillary carcinoma. This lesion had nuclear grooving and nuclear pseudoinclusions, with a vescicular chromatin pattern, without necrosis, or pleomorphism. The tumour cells were thyroglobulin, CK7, CD56, MNF116, 34BE12, and CK19+ve, and CK20, HBME1, calcitonin, chromogranin, synaptophysin and S100 –veMIB labelling index <1%. There was a discussion about how these lesions are currently viewed, including LiVolsi’s 3 groups, noting that cytology is often challenging and bizarre, e.g. polyhedral cells, multiple intranuclearinclusions.

*See paper: Hyalinizing trabecular tumor of the thyroid: case report and review of the literature*.

5. Circulation 30, case 7, 3660 – 16yr old woman with a history of medulloblastoma in 1995 treated with excision, chemo and radiotherapy.  Total thyroidectomy.

Cribriform morular variant of papillary thyroid carcinoma.  

*See paper: Cribriform-morular variant of papillary thyroid carcinoma: clue to early detection of familial adenomatous polyposis-associated colon cancer*

6. Circulation 26, case 1, LABELLED CASE131 – Man in his fifties with hyperparathyroidism. Thyroid lobe weighing 9g, measuring 40x28x20mm with a yellow/grey solid nodule, measuring 25mm in diameter.

Intra-thyroid parathyroid adenoma.

(SH11-7516 EXTRA CASE - Primary hyperparathyroidism. Imaging unclear but suggested an enlarged right sided parathyroid gland. Southmead case of intra-thyroid parathyroid with corresponding immunohistochemistry)

7. Circulation 26, case 2 (LABELLED CASE132)  Woman in her late seventies, with primary hyperparathyroidism. Left lower gland weighing 16.5g andmeasuring 60x30x10mm.

Water clear cell adenoma

8. Circulation 24 , case 2, labelled EP 524 – woman in her late thirties.  Thyroidectomy for papillary carcinoma, persisting elevated thyroglobulin levels with 10mm new nodule sternothyroid ? neuroma, ? recurrence.

Benign intramuscular congenital thyroid rest.

The slide circulated showed cytologically normal thyroid tissue with skeletal muscle, with no invasion of muscle or papillary cytological features. This was interpreted by the submitting pathologist as a benign intramuscular congenital thyroid rest. There was a wide range of proffered diagnoses here, and many members were concerned about follicular variant of papillary carcinoma. This lesion was thyroglobulin +ve, HBME1 –ve, and CK19+ve. Benign thyroid lesions are known to infiltrate muscle in some circumstances.

9. Circulation 22, case 4, -  13 year old girl, right thyroid lobectomy.

Minimally invasive follicular carcinoma in a child with PTEN mutation. Somatic PTEN mutation positive.

*See paper: Thyroid pathology findings in Cowden syndrome; a clue for the diagnosis of PTEN Hamartoma syndrome*

10. Circulation 30, case 8, labelled 1A only.  64yr old woman.  Goitre and nodule in right lobe of thyroid. FNA x 2 = Thy3a and Thy1. 

Subacute granulomatous thyroiditis (De Quervain’s) favoured over other causes of granulomatous thyroiditis.

*See paper: Viruses and thyroiditis*

11. Circulation 29 case 5 Male, 59, total thyroidectomy, THY5 FNA

Follicular variant papillary thyroid carcinoma

Agreement that this was an aggressive tumour, some tall cell areas. Also that any element of classical PTC would trump a diagnosis of straightforward FVPTC.

12. Circulation 31 Case 6 (3875/A1) Nodular goitre with compression symptoms, autoimmune thyroiditis, left thyroid nodule Thy3A, left hemithyroidectomy. Single large nodule, 58mm in maximum dimension, partly haemorrhagic, part glistening, with a focally white area measuring 20mm in maximum dimension.

Poorly differentiated thyroid carcinoma with background FVPTC.

Range of responses, but all malignant. Vascular invasion present. Capsule invasion present. Other sections had necrosis and mitoses (not the section provided) but it shows papillary carcinoma nuclei. 

For interest: Nomenclature revision for encapsulated follicular variant of papillary thyroid carcinoma. A paradigm shift to reduce overtreatment of indolent tumours.Nikiforov et al, JAMA Oncology, 2016.

Papers:

Hyalinizing trabecular tumor of the thyroid: case report and review of the literature  - http://www.ncbi.nlm.nih.gov/pubmed/22970009

Cribriform-morular variant of papillary thyroid carcinoma: clue to early detection of familial adenomatous polyposis-associated colon cancer - http://www.ncbi.nlm.nih.gov/pubmed/15593462

Thyroid pathology findings in Cowden syndrome; a clue for the diagnosis of PTEN Hamartoma syndrome -http://ajcp.oxfordjournals.org/content/144/2/322

Viruses and thyroiditis -http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2654877/

Nomenclature revision for encapsulated follicular variant of papillary thyroid carcinoma. A paradigm shift to reduce overtreatment of indolent tumours. Nikiforov et al, JAMA Oncology, 2016 - http://oncology.jamanetwork.com/article.aspx?articleid=2513250

Editorial on the above paper about NIFTP -http://oncology.jamanetwork.com/article.aspx?articleid=2513246

Review of papillary thyroid carcinoma -http://www.nature.com/modpathol/journal/v24/n2s/abs/modpathol2010129a.html

Best wishes,

Hannah