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Painless enlargement of thyroid

Non-neoplastic

Neoplastic

Hashimoto’s thyroiditis

 Papillary carcinoma

Iodine deficiency goiter

Follicular carcinoma

Drugs

Medullary carcinoma

Dyshormogenic goiter

Anaplastic carcinoma

Reidel’s thyroiditis

Poorly differentiated carcinoma

Diffuse toxic nodular goiter

Follicular adenoma

Painless thyroiditis

 

 

Painful enlargements of thyroid:

1.Acute infectious thyroiditis

2.Granulomatous thyroiditis

Thyroid lesions in children

Developmental:

    1. Lingual thyroid
    2. Thyroglossal duct
    3. Pyramidal lobe of thyroid

Neonatal thyrotoxicosis associated with maternal gestational diabetes

Neoplastic:

    1. Benign:
      1. Teratoma
    2. Malignant:
      1. Solid variant of papillary carcinoma thyroid
      2. Diffuse sclerosing variant of papillary carcinoma thyroid

Spindle epithelial tumor with thymus like differentiation (SETTLE) : CK,EMA, CD99,SMA,CD117,Bcl2 positive

Differential diagnosis of lymphocytes in thyroid

Non-neoplastic

neoplastic

Primary:

Primary:

Graves disease

Tall cell variant of papillary carcinoma thyroid

Reidel’s thyroiditis

Warthin like variant cell of papillary carcinoma thyroid

Subacute granulomatous thyroiditis

Diffuse sclerosing variant of papillary carcinoma thyroid

Drug induced thyroiditis

Lymphoma of marginal zone B cell lymphocytes

Painless thyroiditis

Diffuse large B cell lymphoma

Focal chronic non-specific thyroiditis

Metastatic:

Hashimoto thyroiditis

Multiple myeloma

Secondary:

Mycosis fungoides

Histicytosis

Chloroma

Rosai dorfman disease

Lymphoma

 

Leukemia

 

Mimickers of carcinoma on gross examination

Reidel’s thyroiditis

Sub-acute granulomatous thyroiditis

Squamous cells in thyroid

Developmental:

    1. Thymic remnants
    2. Thyroglossal duct remnants
    3. Ultimobranchial body rests

Non-neoplastic:

    1. Squamous cells metaplasia

Neoplastic:

    1. Papillary thyroid carcinoma
    2. Muco-epidermoid carcinoma
    3. Squamous cell carcinoma; primary and metastatic
    4. CASTLE
    5. SETTLE

Thyroid tumors with poor prognosis

Anaplastic carcinoma

Poorly differentiaited (insular) carcinoma

Widely invasive follicular carcinoma

Papillary carcinoma

    • Hobnail variant
    • Tall cell variant
    • Diffuse sclerosing variant
    • Solid trabecular variant

Sclerosing mucoepidermoid carcinoma with eosinophilia

Mucinous carcinoma

Medullary thyroid carcinoma

Angio-invasive follicular carcinoma especially when more than four vessels are involved

Thyroid tumors with good prognosis

Papillary thyroid carcinoma,

    • classic variant
    • follicular variant
    • warthin like variant

Papillary microcarcinoma

Minimally invasive follicular carcinoma

Localized lymphoma

SETTLE

CASTLE

Comparison of follicular and hurthle cell lesions

Features

Follicular lesion

Hurthle cell lesion

Entities included

Follicular adenoma

Follicular carcinoma

Hurthle cell adenoma

Hurthle cell carcinoma

Criteria of malignancy

Capsular and or vascular invasion

Capsular and or vascular invasion

Age

Younger than hurthle cell lesions

Older age

Gender

No gender predominence

Male predominence

Size

Not that large

Larger

Survival rate

More than hurthle cell lesion patient

Lesser

Radio-iodine treatment

Sensitive

Relatively resistant

Cytology

Resembles normal follicular cells

Granular cytoplasm, large centrally placed nuclei with prominent nucleoli

Cytoplasm

Not oncocytic

oncocytic

Genetics

PI3K-PTEN-AKT pathway

PAX8-PPARG re-arrangements

TERT promoter mutations

RAS mutations

Mitochondrial DNA mutations

WNT/beta-catenin pathway

PI3K-AKT-mTOR pathway

Aneuploidy

 

Thyroid lesion with follicular architecture

Neoplastic lesions:

    1. Benign:
      1. Follicular adenoma
      2. Hyalinising trabecular tumor

Hurthle cell adenoma

Malignant:

    1. Follicular carcinoma
    2. Follicular variant of papillary carcinoma thyroid

Hurthle cell carcinoma

Non-neoplastic lesions:

    1. Increased TSH:
      1. Inborn errors of metabolism
      2. Pituitary adenoma

Goitrogenic drugs

Inadequate iodine

Trophoblastic disease

Decreased TSH:

    1. Graves disease

Tumors in borderline category of follicular tumors

Follicular tumors of uncertain malignant potentiall

Well-differentiated tumor of undetermined malignant potential

Non-invasive follicular thyroid neoplasm with papillary like nuclear features

New WHO classification (2017) changes in papillary thyroid carcinoma:

New pathological variants:

    1. Hobnail variant: Aggressive histological features, necrosis, mitosis, lymphovascular invasion and extrathyroidal extension

Re-classification of previously recognized vzriants:

    1. Encapsulated variant: conventional Papillary carcinoma surrounded by fibrous capsule that may be intact or focally infiltrated.
    2. Follicular variant: exclusively or almost exclusively follicular pattern. Could be infiltrative or encapsulated with invasion

Variants with updated information:

    1. Diffuse sclerosing variant: confirmed to have aggressive biological behaviour. RET/PTC frequent. BRAF mutations low incidence
    2. Tall cell variant: 2-3 times taller than wide. At least 30% cells must fulfil the criteria. BRAF and TERT promoter mutations
    3. Cribriform-morular variant: seen exclusively in females

 

                 Dr Saadia Hafeez

               

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