DEPT PATOLOGI ANATOMI FK UMI

THYROID GLAND

KELAINAN PADA THYROID GLAND

Congenital Infection Neoplasma Others (Graves Disease

Thyroid gland
The thyroid gland (N):

on the anterior trachea of the neck. Has a right lobe & a left lobe connected by a narrow isthmus. Weight: 10-30 gr.

Normal thyroid (microscopic)

Consists of follicles lined by a an epithelium and filled with

colloid. The interstitium, which may contain "C" cells

THYROIDITIS Hashimoto Thyroiditis (Chonic Lymphocytic Thyroiditis) Subacute Granulomatous Thyroiditis (De Quervain Thyrooiditis) Subacute Lymphocytic Thyroiditis Riedel Thyroiditis

Hashimoto's Thyroiditis Thyroid failure because of autoimmune destruction Microscopis : extensive infiltration of the parenchym by a mononuclear inflammtory infiltrat (germinal centers) Atrophic follicles thyroid Hurtle cell (+) metaplastic respon of the normally low cuboidal follicular epithelium to ongoing injury

Thyroid gland (atrophy)

This patient was hypothyroid. The end result of Hashimoto's thyroiditis. Hashimoto's thyroiditis results from abnormal T cell activation & subsequent B cell stimulation to secrete a variety of autoantibodies.

Hashimoto's thyroiditis
(low power microscopic)

Hashimoto's thyroiditis
(High power microscopic)

Demonstrates the pink Hrthle cells at the center and right. Initially leads to painless enlargement of the thyroid, followed by atrophy years later

Sub-acute granulomatous thyroiditis (DeQuervain's disease)

Caused by viral infection or postviral inflammatory process Granulomatous Multinucleated giant cell Early stage : microabscess follicles

Sub-acute granulomatous thyroiditis (DeQuervain's disease)

Note: the foreign body giant cells with destruction of thyroid follicles.

RIEDEL THYROIDITIS
Unknown etiology Characterized by extensive fibrosis involving the thyroid and contiguous neck structur May be associated with idiopathic fibrosis in other sites in the body

This thyroid gland is about normal in size, but there is a larger colloid cyst at the left lower pole and a smaller colloid cyst at the right lower pole.

smaller colloid cyst

larger colloid cyst

Diffuse and Multinodular Goiters

Enlargement of the thyroid or goiter Reflect impaired synthesis of the thyroid hormon,

most often caused by dietary iodine deficiency

This diffusely enlarged thyroid gland is somewhat nodular.

This represents the most common cause for an enlarged thyroid gland and the most common disease of the thyroid--a nodular goiter.

Multinodular goiter
(Low power microscopic)

Grave's Disease An autoimmune disorder Diffusely hyperplastic thyroid The follicles are lined by tall columnar epithelium The crowded, enlarged epithelial cells project into the lumens of the follicles The active cells resorb the colloid in the centers of the follicles scalloped appearance of the edges of the colloid

Grave's disease
(low power-autoimmune disease the action of TSI's)

Grave's disease
(high power, the tall columnar thyroid epithelium)

Follicular adenoma
The mass is well circumscribed. Gross : felt firm. By scintigraphic scan "cold."

Follicular Adenoma

This adenoma is a well- differentiated neoplasm because it closely resemble normal tissue.

Classification & Incidence of Thyroid Cancer

Follicular cell origin

Differentiated
Papillary Follicular Hurthle cell

80% 10% 3-5% 1-2% 5%

Undifferentiated
Anaplastic

Parafollicular cell origin

Medullary

Papillary Carcinoma
Accounts for 90% radiation induced cancer
Classified as microcarcinoma, intrathyroidal, and extrathyroidal
Histologic variants: tall-cell, clear-cell, columnar, diffuse

sclerosing

Multicentric in 30-50% of tumors Spreads via lymphatics with propensity for midand lower-anterior cervical chain (Level VI) 20-50% patients have involvement of cervical LN

Follicular Carcinoma
Only 10% of thyroid cancers in developed countries, although more prevalent in regions with iodine deficiency Diagnosis depends on demonstration of vascular or capsular invasion Classified as minimally or widely invasive
Vascular invasion tends to have a more aggressive course

than capsular invasion

Uncommon to have multicentric disease Hematogenous spread

Contd

Where does follicular carcinoma tend to metastasize? Bone lung

FOLLICULAR CA THYROID

Anaplastic Carcinoma
Increasingly rare Arise within differentiated cancers Pts > 60 years old with rapidly expanding neck mass Local invasion very common at time of dx (FNA) Surgery plays limited role given advanced stage at dx Radiation and chemotherapy have not

demonstrated any significant improvement in survival Median survival ~ 4 - 6 months

Medullary Thyroid Carcinoma

Originates from the parafollicular C cells Elevation in calcitonin and CEA (50%) 80% have sporadic MTC (unifocal), remainder have

genetic component 75% patients have LN metastasis at time of dx, 20% distant mets

Sectioning through a lobe of excised thyroid gland reveals papillary carcinoma

Multifocal Because of the propensity

to invade lymphatics within thyroid, and lymph node metastases are common. The larger mass is cystic and contains papillary excresences. Most often arise in middle-aged females

Papillary Carcinoma (Microscopic)

The fronds of tissue have thin fibrovascular cores. The fronds have an overal papillary pattern.

Papillary Carcinoma (Microscopic)

Note the small psammoma body in the center. The cells of the neoplasm have clear nuclei.

Medullary Carcinoma

These neoplasms are derived from the thyroid "C" cells and, therefore, have neuroendocrine features such as secretion of calcitonin

PARATHYROID GLAND

Parathyroid hyperplasia

Parathyroid hyperplasia

There is little or no adipose tissue, but any or all cell types normally found in parathyroid are present. Note the pink oxyphil cells here.

Parathyroid adenoma

A rim of normal parathyroid tissue (with a pink oxyphil cell nodule) at the upper right, and a small benign parathyroid cyst (an incidental finding) is at the upper left.

Parathyroid adenoma

rim of normal parathyroid

A rim of normal parathyroid tissue admixed with adipose tissue cells is seen compressed to the right and lower edge of the adenoma.

Gross appearance of a parathyroid carcinoma

Note the large size and irregular cut surface. These carcinomas have a tendency to invade surrounding tissues in the neck, complicating their removal.

Parathyroid carcinoma

The nests of neoplastic cells that are not very pleomorphic. Note the bands of fibrous tissue between the nests. Parathyroid carcinomas infiltrate surrounding structures in the neck.

A normal parathyroid gland for comparison.

Adipose tissue cells are mixed with the parathyroid tissue. The amount of fat varies somewhat.

NORMAL PARATHYROID GLAND

PITUITARY GLAND

The normal gross appearance of the pituitary gland removed from the sella turcica

The normal microscopic appearance of the pituitary gland

The adenohypophysis is at the right and the neurohypophysis is at the left.

The normal microscopic appearance of the adenohypophysis

The adenohypophysis contains three major cell types: acidophils, basophils, and chromophobes.

Neurohypophysis

The neurohypophysis shown here resembles neural tissue, with glial cells, nerve fibers, nerve endings, and intra-axonal neurosecretory granules

Microadenoma of the anterior pituitary

Adenohypophyseal adenoma
Endocrine neoplasms are composed of small round cells with small round nuclei and pink to blue cytoplasm. The cells may be arranged in nests or cords and endocrine tumors also have prominent vascularity.

The circumscribed mass lesion present here in the sella turcica is a pituitary adenoma

The microscopic appearance of the pituitary adenoma

Craniopharyngioma

ADRENAL GLANDS

Sectioning across the adrenals reveals a golden yellow outer cortex and an inner red to grey medulla (Normal adrenal glands )

Each adult adrenal gland weighs from 4 to 6 grams.

These adrenals are black-red from extensive hemorrhage in a patient with meningococcemia.

This produces the Waterhouse-Friderichsen syndrome.

This is the microscopic appearance of the adrenals with meningococcemia.

There is marked hemorrhagic necrosis with acute adrenal insufficiency.

An enlarged adrenal gland

Demonstrate tan-white metastatic carcinoma infiltrating in and around the residual golden yellow cortex . The most common primary site for adrenal metastases is lung.

This is a caseating granuloma of tuberculosis in the adrenal gland.

Tuberculosis used to be the most common cause of chronic adrenal insufficiency. Now, idiopathic (presumably autoimmune) Addison's disease is much more often the cause for chronic adrenal insufficiency.

This adrenal gland removed surgically in a patient with Cushing's syndrome

Some remaining atrophic adrenal is seen at the right. The adenoma is composed of yellow firm tissue just like adrenal cortex.

Adrenal adenoma

Here is a 1.3 cm left adrenal adenoma found in a patient with

hypertension. Such adenomas are typically less than 2 cm in size and yellow on cut surface.

Microscopically, the adrenal cortical adenoma at the right resembles normal adrenal fasciculata.

The capsule is at the left. There may be some cellular pleomorphism.

Adrenal cortical carcinoma

Such neoplasms are usually functional (secreting corticosteroids or sex steroids). They have a poor prognosis.

Adrenal cortical carcinoma (microscopically at high power)

The larger the neoplasm, the more likely it is malignant, but the best indicators are invasion and metastasis.

This high power microscopic appearance of an adrenal cortical carcinoma

It is difficult to determine malignancy in endocrine neoplasms based upon cytology alone.

This large adrenal neoplasm has been sectioned in half.

Note the grey-tan color of the tumor compared to the yellow cortex stretched around it and a small remnant of remaining adrenal at the lower right.

This pheochromocytoma demonstrates the chromaffin reaction.

This neoplasm of the adrenal medulla contains catecholamines (epinephrine and norepinephrine).

There is some residual adrenal cortical tissue at the lower center right, with the darker cells of pheochromocytoma seen above and to the left.

Pheochromocytoma (Microscopic)
Composed of large cells that are pink to mauve and arranged in nests with capillaries in between. Remember 10% when you think of a pheochromocytoma: 10% are bilateral 10% are in children 10% are malignant.

Here is a normal pancreatic islet of Langerhans surrounded by normal exocrine pancreatic acinar tissue.

The islets contain alpha cells secreting glucagon, beta cells secreting insulin, and delta cells secreting somatostatin.

Immunoperoxidase staining can help identify the nature of the cells present in the islets of Langerhans.

On the right, antibody to insulin has been employed to identify the beta cells. On the left, antibody to glucagon identifies the alpha cells.

A insulitis of an islet of Langerhans in a patient who will eventually develop type I diabetes mellitus.
The presence of the lymphocytic infiltrates in this edematous islet suggests an autoimmune mechanism for this process. The destruction of the islets leads to an absolute lack of insulin that characterizes type I diabetes mellitus.

This islet of Langerhans demonstrates pink hyalinization (with deposition of amyloid) in many of the islet cells.

This change is common in the islets of patients with type II diabetes mellitus.

An islet cell adenoma

Separated from the pancreas by a thin collagenous capsule. A few normal islets are seen in the pancreas at the right for comparison.