Surgical Pathology For Dentistry Students - Surgical Pathology of Thyroid and Adrenal Glands

SURGICAL PATHOLOGY OF
THYROID AND ADRENAL GLANDS

MEDICAL & SURGICAL PATHOLOGY 1
THYROID
THYROID NODULE
THYROID CANCER
Anatomy
Critical structures in thyroid surgery
Vessels : arteries and thyroid veins – risk of compressive acute hematoma
with tracheal compression and asphyxiation
• Nerves :
• Upper laryngeal (external branch) – inability to produce high-pitched tones in the event
of injury
o Lower laryngeals – dysphonia in unilateral injuries; paralysis of both vocal cords
with acute gothic obstruction and risk of suffocation in bilateral injuries
• Parathyroid glands : transient or permanent hypocalcaemia (vital risk)
Thyroid nodule
Thyroid nodule (NT) - well-defined and identifiable thyroid lesion by

imaging tests
Palpable TN are detected in 1% of men and 5% of women, while the
incidence of not palpable nodules but visible with imaging techniques is
much higher
Most are solitary, non-functioning and benign: they do not require any
treatment
• Only 5% of NTs are malignant
TN evaluation
• Local symptoms
• Hormone secretion
• Benign/malignant character
TN assessment
Clinical
o Medical history and physical exam
o Symptoms: dyspnoea, dysphagia, globus sensation (pharyngeal globus), pain
o Risk factors for malignancy :
o childhood
o age < 30 or > 60 years
o male sex
o exposure to ionizing radiation
- specific syndromes (multiple endocrine neoplasia, familiar medullary thyroid carcinoma)
o Clinical characteristics: dimensions, consistency, number, tenderness, infiltration
of adjacent structures
TN assessment
Laboratory
• Hormonal secretion :
 TSH :
 High – hypothyroidism (usually in relation to autoimmune thyroiditis)
o Low – hyperthyroidism (hyperfunctioning nodules)
 Thyroglobulin: for the follow-up of surgically treated thyroid cancer
 Calcitonin: in cases of suspected medullary thyroid carcinoma (derived from

thyroidal parafollicular cells)
TN assessment
Ultrasound
allows quantification of the risk of malignancy of TN according to their

characteristics (dimensions, calcifications, regularity, etc.)
used to guide the fine-needle biopsy
• cervical lymph nodes assessment
TN evaluation
Gammagraphy
Use of radioisotopes : 99Tc, 123I, 131I

Evaluation of the uptake pattern and identification of hyperfunctioning nodules
• Evaluation of thyroid cancer and metastases
Hyperfunctioning Kidney metastasis of

nodule thyroid cancer
TN evaluation
Fine needle aspiration biopsy
Depending on nodule’s characteristics (clinical and

ultrasound)
Ultrasound-guided aspiration
• Evaluation of cellularity according to the
Bethesda classification system that stratifies the
risk of malignancy, allowing to guide subsequent
management (follow-up or resection)
TN managment (Bethesda classification)
Thyroidectomy types
THYROID CANCER
• 90-95% are differentiated thyroid cancers (DTCs), derived from

follicular cells:
• Papillary carcinoma
• Follicular carcinoma
1. Hürthle cell carcinoma (variant of folicullar carcinoma)
2. 5-6% are medullary thyroid carcinomas (MCTs) derived from
parafollicular cells
• < 1% are anaplastic cancers
Papillary thyroid carcinoma
Represents 70-80% of all thyroid cancers

Most important risk factor: exposure to ionizing radiation during
childhood
Incidence peak between 30-50 years
• Women/Men - 2.5 :1
Papillary thyroid
carcinoma
• Clinical presentation :
• palpable nodule
• incidental finding on image test
o laterocervical mass (lymph node
metastases)
• Preoperative diagnosis: fine needle biopsy –

correlation with final postoperative
diagnosis in nearly 100% of cases
Papillary thyroid carcinoma
• Dissemination:
• Lymphatic : cervical lymph nodes
o Hematogenic : bone, lung
• Prognosis :
• In most cases: 95% survival at 10 years after diagnosis
• Most important prognostic factor : age (< 40 years – excellent prognosis)
• Lymph node metastases – prognostic impact correlated with age (not important in patients < 45 years)
o Remote metastases – depending on location (brain – survival < 1 year; pulmonary – survival up to
50% at 10 years)
Follicular thyroid carcinoma
• Diagnosis is based on the identification of follicular cells in abnormal
location – capsular or vascular invasion
• Therefore, the diagnosis is histological (in resection specimen) and

cannot be done preoperatively on a cytological sample (fine needle
biopsy) – the FTC cells are similar to normal cells
• Mainly hematogenic spread unlike CPT

Follicular thyroid carcinoma
• Remote metastases (bone and lung) – 15% of cases
• Main prognostic factor: age at diagnosis (< 40 years old - 95%

survival 10 years after diagnosis
• Hürthle cell carcinoma – variant of FTC with oxyphilic cells, usually

affects older patients and is more aggressive
Treatment of differentiated thyroid
carcinoma
• Thyroidectomy - treatment of choice
• Radioiodine
• Thyroid hormone suppression therapy

DTC treatment
Thyroidectomy
• Lobectomy or total thyroidectomy +/- cervical lymphadenectomy
• Lobectomy – feasible in 1-4 cm tumours, patients < 45 years old, without

extracapsular extension or lymph node involvement
• Total thyroidectomy – in all other cases and always when radiation therapy is
proposed (to maximize the effect of radioiodine by removing all macroscopic
thyroid tissue)
Total thyroidectomy + lymphadenectomy (central cervical and bilateral laterocervical)
DTC treatment
Radioiodine
• Objectives:
• Ablation of residual thyroid tissue in the
cervical region (usually microscopic)
• Eradication of hidden metastatic disease
1. Primary treatment of known
persistent disease
DTC treatment
Hormone suppressive therapy
Treatment based on the expression of TSH receptors by DTC cells

Thyroid hormone administration inhibits TSH secretion and therefore
minimizes/nullifies its effect on cancer cells
• The degree of suppression depends on the aggressiveness of the
cancer: balance between the potential for relapse/tumour progression
and hyperthyroidism
ADRENAL GLANDS
INCIDENTALOMA
PHEOCHROMOCYTOMA
ANATOMY
ADRENAL INCIDENTALOMA
Adrenal nodule/mass diagnosed with an imaging technique performed

for reasons unrelated to adrenal glands
Appears in up to 4% of abdominal CT and MRI
In the presence of a history of other malignancies, the most likely cause
of an incidentaloma is metastatic disease
• In the absence of a history of malignancy, most of AIs are non-
functioning adenomas
CAUSES OF INCIDENTALOMA
AI MANAGEMENT
• Hormonal profile:
• Evaluation of adrenal medulla (detection of urinary metanephrines - catecholamines
metabolites)
o Evaluation of the adrenal cortex :
o Dexamethasone suppression test (evaluates autonomous glucocorticoid secretion)
o Aldosterone/Renine (mineralocorticoids)
o DHEA (sexoesteroids)
• Size : risk of malignant pathology - 25% in tumours > 6 cm

AI
MANAGEMENT
ADRENALECTOMY
• Laparoscopic intervention - procedure of choice
• Disconnection of adrenal vessels :

• arteries - direct branches of the aorta
 veins – lower vena cava (right side) / renal vein (left side)
• Dissection of the adrenal gland from the upper pole of the kidney and the
diaphragm
PHEOCHROMOCYTOMA
Catecholamine-secreting tumour
Classically, the clinical presentation of pheochromocytoma is described
by the triad : headache – palpitations – diaphoresis
High blood pressure occurs in 90% of cases
• Risk of sudden cardiovascular death secondary to hypertensive crisis
and myocardial infarctions, caused by massive discharge of
catecholamines
PHEOCHROMOCYTOMA
Can be bilateral
May be extraadrenal (paragangliomas)
Most are sporadic while some are related to other endocrine pathologies
(sd. of multiple endocrine neoplasia – e.g. MEN 2 : pheochromocytoma
+ medullary thyroid carcinoma + parathyroid adenomas)
• Can be malignant: malignancy is not demonstrable with histological
criteria but only in case of metastases in other organs
PHEOCHROMOCYTOMA
DIAGNOSIS
• Biochemical :
• - 24-hour total urinary metanephrines measurement (catecholamine
catabolic products)
• Imaging techniques:
• TC abdominal
• RM abdominal
o MIBG scan
PHEOCHROMOCYTOMA
DIAGNOSIS
ABDOMINAL MRI GAMMAGRAPHY

PHEOCHROMOCYTOMA
TREATMENT
• Surgical : uni or bilateral adrenalectomy
• Need for preoperative hemodynamic optimization to prevent :

• uncontrolled heart rate increase and high blood pressure while handling pheochromocytoma with secondary discharge of large
amounts of catecholamines into circulation
1. shock generated by diffuse vasodilation after removing the tumour with subsequent reduction of the vasopressor stimulus
• Preoperative medication :
• alpha-adrenergic blockage with phenoxybenzamine to normalize heart rate and blood pressure
• alpha blockage reduces the expression of alpha-adrenergic receptors and restores their sensitivity to vasopressive medication
- beta-adrenergic blockage after alpha block, for patients who are still tachycardic
PHEOCHROMOCYTOMA
RESECTION
(curative in 90%)

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SURGICAL PATHOLOGY OF

THYROID AND ADRENAL GLANDS

Thyroid nodule (NT) - well-defined and identifiable thyroid lesion by

 Thyroglobulin: for the follow-up of surgically treated thyroid cancer

 Calcitonin: in cases of suspected medullary thyroid carcinoma (derived from

allows quantification of the risk of malignancy of TN according to their

Use of radioisotopes : 99Tc, 123I, 131I

Hyperfunctioning Kidney metastasis of

Depending on nodule’s characteristics (clinical and

• 90-95% are differentiated thyroid cancers (DTCs), derived from

Represents 70-80% of all thyroid cancers

• Preoperative diagnosis: fine needle biopsy –

• Therefore, the diagnosis is histological (in resection specimen) and

• Mainly hematogenic spread unlike CPT

• Remote metastases (bone and lung) – 15% of cases

• Main prognostic factor: age at diagnosis (< 40 years old - 95%

• Hürthle cell carcinoma – variant of FTC with oxyphilic cells, usually

• Thyroidectomy - treatment of choice

• Thyroid hormone suppression therapy

• Lobectomy or total thyroidectomy +/- cervical lymphadenectomy

• Lobectomy – feasible in 1-4 cm tumours, patients < 45 years old, without

Treatment based on the expression of TSH receptors by DTC cells

Adrenal nodule/mass diagnosed with an imaging technique performed

• Size : risk of malignant pathology - 25% in tumours > 6 cm

• Disconnection of adrenal vessels :

ABDOMINAL MRI GAMMAGRAPHY

• Surgical : uni or bilateral adrenalectomy

• Need for preoperative hemodynamic optimization to prevent :

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