Thyroid Pathology Case 10 Semester 1 - Graves Disease - Papillary cancer

Normal function and microanatomy

Normal: epithelium filled with colloid, cuboidal follicular epithelium, rich vascular supply C cells(parafollicular cells) which secrete calcitonin

Causes of Thyroid enlargement Investigations Blood: TSH, FBE

Thyroid U/S ECG Thyroid antibodies o Anti-thyroid peroxidase antibodies o Anti-thyroblobulin assay Post Thyroidectomy- PTH, calcium, albumin Cancer- LN FNA, radioiodine scan for functioning metastases calcium PTH calcium PTH Thyroid Hormone Function - Total energy expenditure - Growth and maturation of tissue - Turnover of hormones and vitamins - Cell regeneration Thyroid Function Tests: Serum TSH best screening test for thyroid dysfunction TSH = primary hypothyroidism TSH = Thyrotoxicosis (Graves disease) or hypopituitarism/hypothalamic dysfunction (Secondary/tertiary hypothyroidism) T4= bound to TBG and free T4

GRAVES DISEASE Break down of self-tolerance to thyroid autoantigens. Thyroid-stimulating immunoglobulin is a IgG antibody that binds to TSH receptor mimicking its action. Gross: enlarged gland (usually symmetrical), diffuse hyperplasia. Gland is smooth and soft, capsule intact. Microscopically: Scalloping due to overactivity, tall columnar epithelium, folding of epithelium

Exopthalmus, eye lid retr

action, fine hair Gross: fleshy e.g. Hyperplasia decrease in colloid production HASHIMOTOS THYROIDITIS Atrophy of thyroid Initially enlarged and hyperthyroidism followed by euthyroid with eventual atrophy years later. Abnormal T cell activation then B cell stimulation to produce autoantibodies Antithyroglobulin and antimicrosoal (thyroid peroxidase) antibodies

Pink Hurthle cells (right), lymphoid follicle (left) SUBACUTE GRANULOMATOUS THYROIDITIS (DEQUERVAINS DISEASE) Follows viral infection Large painful thyroid Self-limited weeks months then euthyroid

Foreign giant cells with destruction of thyroid follicle I123 radioactive uptake Diffuse increase = Graves Decrease = thyroiditis (acute, chronic, Hashimotos) Nodules: Cold = cyst, adenoma, cancer Hot toxic nodular goiter BENIGN TUMOUR Follicular adenoma most common Surrounded by complete capsule Presents as cold nodule 10% -> follicular cancer MALIGNANT Papillary carcinoma most common thyroid and endocrine tumour F3:M1, 20s and 30s Radiation exposure Gross: multifocal Microscopic: Psammoma bodies Empty appearing nuclei- Orphan Annie nuclei Met to cervical nodes, lung Dx: FNA

Cells crowded, nuclei enlarged, nuclei show nuclear grooves (curved arrows), orphan annie nuclei (arrow).

Follicular Carcinoma: Presents solitary cold nodule Gross: Encapsulated or invasive, follicles invade blood vessels, LN mets uncommon Met to lung and bone (haematogenous spread) Medullary Carcinoma: Can be familial- MEN Ectopic hormones ACTH -> Cushing syndrome From parafollicular C cells, produce calcitonin (tumour marker, may produce hypocalcaemia, converted into amyloid) Dx: FNA and serum calcitonin

Medullary carcinoma on the right, pink hyaline material (amyloid- stain congo red) Primary B-cell malignant lymphoma - from Hashimotos thyroiditis most likely Anaplastic thyroid cancer Older women RF: multinodular goiter, history of follicular cancer Aggressive and fatal- palliative surgery, chemo, radio Quiz: High calcitonin Medullary Carcinoma