ESR Module (021)

Practical of Thyroid Gland

Pathology team
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Objectives

By the end of the lecture and the practical session students should be
able to:
• Recapitulate the normal histology of the thyroid gland
• List causes of a thyroid nodule (non- neoplastic and neoplastic
causes)
• Differentiate between these causes in terms of gross and microscopic
features.
• Know the laboratory and imaging tests needed in the case of thyroid
nodule.
• Understand the role of fine needle aspiration (FNA) cytology in the
diagnosis of a thyroid nodule.

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• The organ shown in this slide is:

1) Pituitary gland
2) Adrenal gland
3) Thyroid gland
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• The organ shown in this slide

1) Pituitary gland
2) Adrenal gland
3) Thyroid gland

Notice the follicles

filled by colloid
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• What is the pink staining material marked A?

1) Calcitonin
2) Thyroglobulin A
3) Follicular cell
A

A
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• What is the pink staining material marked A?

1) Calcitonin
2) Thyroglobulin A
3) Follicular cell
A

A
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Match the labels to 1,2,3 and 4

• Follicular cells
• Capillary
• Parafollicular cells
• Colloid
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Thyroid Gland
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A section of thyroid gland prepared from a patient having
Grave’s disease (hyperactive thyroid gland, thyrotoxicosis)

Describe the microscopic photo (follicle, its lining, its content)

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A section of thyroid gland prepared from a patient having
Grave’s disease (hyperactive thyroid gland, thyrotoxicosis)

 An active
secretory thyroid
follicle lined by
columnar
epithelium with
pale acidophilic
cytoplasm

 Colloid is
scalloped and pale
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Do you think these

thyroid follicles
have active or
inactive secretory
activity and why?
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• These thyroid follicles

have inactive
secretory activity
• They are lined by a
single layer of
flattened follicular
cells
• No peripheral
scalloping
• Densely eosinophilic
colloid
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Case 1
• A 40 female patient complains of recent unexplained
weight gain, increased sensitivity to cold whether and
she feels easily fatigue.
• Physical examination reveals mild diffuse enlargement
of the thyroid gland which is confirmed by
ultrasonography.
• Her thyroid hormone profile shows hypothyroid
function.
• Further auto antibody testing shows anti-TPO (anti-
thyroid peroxidase) and anti-Tg (anti-thyroglobulin)
antibodies.
• Thyroidectomy is done
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Case 1
Describe the gross picture
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Case 1
Diffusely symmetrically enlarged
Tan brown
 Nodular
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Case 1
Describe the microscopic picture
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Case 1
The thyroid parenchyma contains a dense lymphocytic
infiltrate with germinal centers (L). Residual thyroid follicles
lined by Hürthle cells (Askanazy cells).
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Case 1

What is the most likely diagnosis?

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Case 1

What is the most likely diagnosis?

Hashimoto’s thyroditis
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Hürthle cells
(Askanazy cells)
• Large cells with eosinophilic granular cytoplasm and
large nucleus with prominent nucleolus.
• Do you know another thyroid lesion containing
Hürthle cells?
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Differential diagnosis of a
benign thyroid nodule
• Multinodular goitre

• Follicular adenomas

• Hurthle-cell adenomas

• Hashimoto’s thyroiditis

• Cysts (colloid, blood)

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Case 2
• A 35 years old woman complains of neck swelling
causing disfigurement. The condition started one
year ago with slow progression but she seeked
medical advice once she felt difficulty in
swallowing.
• Her labs showed low T3 and T4 serum levels and
high TSH level
• Ultrasound image shows
enlargement of thyroid lobes
and isthmus multiple solid &
cystic thyroid nodules.
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Case 2
Ultrasound guide FNAC was preformed and cytology
smears were prepared with PAP staining.
Describe the cytological findings
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Case 2
• Moderately cellular smears with abundant colloid, flat
sheets of monotonous follicular cells
• Rare microfollicles
• No cytologic features of papillary thyroid carcinoma.
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Thyroidectomy is done.
Describe the gross and microscopic findings.
What is your diagnosis?
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Grossly: the gland is markedly and irregularly enlarged with
variable sized nodules separated by fibrous bands on cut section.
Microscopically: Variable sized dilated follicles with flattened
epithelium.
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MNG
• Clinically: neck swelling with disfigurement and difficulty in
swallowing
• Labs: normal or decreased T3 and T4 levels but elevated TSH
• Ultrasound: multiple solid and cystic nodules with regular
outlines.
• FNAC: flat sheets of monotonous cells with abundant colloid
and absent nuclear features of papillary carcinoma
• Gross: marked and irregular enlargement showing variable
sized nodules separated by fibrous bands. May be associated
hemorrhage, fibrosis, cystification and calcification.
• Microscope: Variable sized dilated follicles with flattened
epithelium. May be associated hemorrhage, fibrosis and
calcification.
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Case 3
A 45 years old female patient presented by right side
neck slowly growing swelling of 9 months duration.
The past week she experienced difficulty in
swallowing. On physical examination the mass was
rubbery in consistency, freely mobile and moves up
and down with deglutition.
Her labs showed normal
thyroid profile.
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Case 3
Ultrasound image shows enlargement of the right
thyroid lobe, solitary solid nodule with uniform
capsule.

Thyroid scan reveals right lobe solitary hot nodule.

What is meant by a hot nodule?

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Case 3

Thyroid scan reveals right lobe solitary hot nodule.

A nodule that is producing too much hormone

and show up darker in the scan is called "hot "
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Case 3
Ultrasound guide FNAC was preformed and cytology
smears were prepared with PAP staining.
Describe the cytological findings
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Case 4
• High cellularity, 3D arrangement, nuclear crowding
but no papillary carcinoma nuclear features &
minimal colloid.
What do u think about?
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Can you differentiate between follicular

adenoma and follicular carcinoma by FNA?
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You can’t differentiate between follicular

adenoma and follicular carcinoma by FNA
because capsular and/or vascular invasion is
necessary to diagnose follicular carcinoma
which is can be only detected in tissue
biopsy.
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Case 3
Hemithyroidectomy has been done.
Describe the gross and microscopic findings.
What is the most likely diagnosis?
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Case 3
Grossly: Well demarcated encapsulated fleshy solid mass.
Microscopically: Closely packed follicles of normal size
with intact well formed capsule.
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Follicular adenoma
• Clinically: one side neck longstanding swelling with
disfigurement and difficulty in swallowing
• Labs: normal thyroid hormone profile
• Ultrasound: solitary solid nodule with regular outlines.
• Scan: Solitary hot nodule.
• FNAC: hypercellular 3D groups of monotonous cells with few
colloid and absent nuclear features of papillary carcinoma
• Gross: one lobe enlargement showing single capsulated
nodule.
• Microscope: Closely packed follicles of normal size with
intact well formed capsule compressing the surrounding
thyroid tissue.
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What are the other microscopic
types of thyroid adenoma?
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Other microscopic types of
thyroid adenoma
1) Embryonal adenoma: closely packed cells forming
cords or trabeculae
2) Fetal adenoma: small follicles containing no or
little colloid separated by abundant loose
connective tissue
3) Colloid adenoma: large follicles filled with colloid
and lined by flat epithelium
4) Hürthle cell adenoma: shows large granular cells
with abundant eosinophilic cytoplasm (Hürthle
cells) arranged in trabecular pattern

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A hemithyroidectomy specimen of a patient

having a solitary thyroid nodule.

• What is the most likely diagnosis?

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A hemithyroidectomy specimen of a patient

having a solitary thyroid nodule.

• Hurthle cell adenoma

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Case 4
• A 39 year old healthy male discovers left neck mass
while shaving. On physical examination there was a
palpable mass on left lobe of thyroid.
• His labs reveals normal thyroid function.
• Ultrasound showed a
single left thyroid mass.
• Thyroid scan showed left
lobe cold nodule.
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Case 4
Ultrasound guide FNAC was preformed and cytology
smears were prepared with PAP staining.
Describe the cytological findings
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• Microfollicules with nuclear enlargement, overlapping & crowding.

• No or scant colloid.
• Nuclear atypia is not specific for malignancy.
• No papillary carcinoma nuclear features
• Cannot distinguish between follicular adenoma and carcinoma
by FNAC.
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Case 4
Hemithyroidectomy has been done.
Describe the gross findings.
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Case 4
Single encapsulated nodule with tan solid cut surface
and focally thickened irregular capsule.
Irregular capsule Regular capsule
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Case 4
Describe the microscopic findings.
What is the most likely diagnosis?
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Case 4

Vascular invasion of capsular vessels Capsular mushroom like invasion

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Follicular carcinoma
• Clinically: one side neck accidentally discovered swelling .
• Labs: normal thyroid hormone profile
• Ultrasound: solitary solid nodule with regular outlines and
focal hypoechoic halo.
• Scan: Solitary cold nodule.
• FNAC: hypercellular 3D groups of crowded monotonous cells
(may be atypical) with few colloid and absent nuclear
features of papillary carcinoma
• Gross: one lobe enlargement showing single capsulated
nodule with focally irregular capsule.
• Microscope: Capsular mushroom like invasion and vascular
invasion of the capsular vessels.
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Case 5
• A 41 years old male presented to the surgery
outpatient clinic by enlarged firm neck lymph
nodes. On physical examination his surgeon felt a
small thyroid nodule.
• Urgent neck ultrasound showed two nodules with
unclear boundaries and
microcalcification and the
lymph nodes showed
deposits
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Case 5
Ultrasound guide FNAC was preformed and cytology smears
were prepared with PAP staining.
Describe the cytological findings
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Papillary structure with fibro-vascular core
Psammoma body
Nuclear grooving
Nuclear inclusions
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Case 5
Thyroidectomy is done.
Describe the gross and microscopic pictures.
Do you need higher magnification???
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Case 5
Grossly: larger solid & cystic mass with regular outlines & granular
cut section, smaller solid mass with irregular outlines.
Microscopically: Branching papillae with fibro-vascular cores
surrounded by atypical epithelial cells.
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What are the nuclear features

of papillary thyroid carcinoma?
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Papillary thyroid carcinoma

 Nuclear enlargement Central vascular core

 Nuclear overlapping
 Nuclear clearing
 Thick nuclear
membrane
(peripheral
condensation of
nuclear chromatin)
 Nuclear grooves
 Nuclear pseudo-
inclusions
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Papillary thyroid carcinoma

• Clinically: presents with one or more thyroid
nodules and may present by enlarged lymph nodes.
• Ultrasound: Two solid nodules with solid and cystic
nature, regular and irregular outlines and malignant
lymph nodes.
• FNAC: branching papillae, nuclear grooving, nuclear
pseudo-inclusions and psammoma body.
• Gross: Two solid nodules with solid and cystic
nature, regular and irregular outlines and granular
cut section.
• Microscope: branching papillae, psammoma bodies
and nuclear features.
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Differential diagnosis of
malignant thyroid nodule

• Papillary carcinoma
• Follicular carcinoma
• Medullary carcinoma
• Anaplastic carcinoma
• Primary lymphoma
• Metastatic (breast, renal)
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Medullary thyroid carcinoma
• What is the cell of
origin of this tumor?

• What is the pink

material present in
this slide?

• Name the special stain

that can be used to
confirm the nature of
this material
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Medullary thyroid carcinoma
 A cancer of the C-cells
(neuroendocrine
tumor)

 The pink material is

amyloid deposits

 Congo red stain

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This is a FNAC from the
same mass
What is this??
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This is a FNAC from the
same mass
Medullary thyroid carcinoma. Congo red, a special
stain, strongly highlightling the stromal amyloid
deposits.
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How can you confirm your

diagnosis by IHC
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How can you confirm your

diagnosis by IHC

Calcitonin
 Thyroidectomy
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Who am I?

FNAC Histology
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Who am I?

Marked Pleomorphism
pleomorphism Mitosis
Huge mass
Hemorrhage
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Anaplastic carcinoma

Marked Pleomorphism
pleomorphism Mitosis
Huge mass
Hemorrhage
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Enumerate benign and malignant

thyroid lesions
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Thyroid nodules

Benign (90%) Malignant (10%)

Multinodular goitre Papillary carcinoma
Follicular adenoma Follicular carcinoma
Hurthle-cell adenoma Medullary carcinoma
Hashimoto’s thyroiditis Anaplastic carcinoma
Cysts (colloid, blood) Primary lymphoma
Metastatic (breast, renal)
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Thyroid enlargement (Goitre)

Malignant tumors
Benign conditions
(Localized)

Diffuse Localized
Non-tumorous Benign tumors (Adenoma)

Symmetric Asymmetric
Papillar carcinoma
Embryonal adenoma Follicular carcinoma
Grave's disease Fetal adenoma
# Multinodular goitre # Medullary carcinoma
Hashimoto's #
Cyst Follicular adenoma Anaplastic carcinoma
thyroiditis
# Colloid adenoma Lymphoma
Hurthle cell adenoma Metastatic
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Objectives

By the end of the lecture and the practical session students should be
able to:
• Recapitulate the normal histology of the thyroid gland
• List causes of a thyroid nodule (non- neoplastic and neoplastic
causes)
• Differentiate between these causes in terms of gross and microscopic
features.
• Know the laboratory and imaging tests needed in the case of thyroid
nodule.
• Understand the role of fine needle aspiration (FNA) cytology in the
diagnosis of a thyroid nodule.

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