Discussion on Papillary carcinoma thyroid - category, types with definitions, other DD for pap ca thyroid along with a whole lot of beautiful cytology pictures - a feast to the eyes

1. INTERESTING CASE
PRESENTATION - CYTOLOGY
DR TAMIL NILA
POST GRADUATE

2. CASE HISTORY
A 65 YEAR OLD MALE CAME WITH A COMPLAINT OF SWELLING IN THE
ANTERIOR ASPECT OF NECK FOR PAST 6 MONTHS
NOT ASSOCIATED WITH PAIN
INCREASING IN SIZE RAPIDLY

3. EXAMINATION
SINGLE SWELLING
3 X 3 CM
EXTERNAL SURFACE – ENGORGED VEINS
CONSISTENCY – SOFT
RESTRICTED MOBILITY

4. PAST HISTORY
TOTAL THYROIDECTOMY WITH MODIFIED RADICAL NECK DISSECTION
DONE 7 YEARS BACK
PATIENT WAS ON TAB ELTROXIN 100 MCG 1 – 0 – 0 OD
DISCONTINUED SUPPRESSIVE DOSE DUE TO COVID PANDEMIC

5. FNAC
• BLOODY ASPIRATE
• 2 SLIDES
• SEVERE BLEEDING WAS PRESENT

6. FNAC – SCANNER VIEW
CELLULAR SMEAR
ARRANGEMENT
CLUSTERS
MONOLAYERED SHEETS
PAPILLARY PATTERN
SCATTERED

7. FNAC – LOW POWER VIEW
ANATOMICAL EDGING PRESENT
NUCLEAR CROWDING

8. FNAC – HIGH POWER VIEW
NUCLEI FEATURES
ENLARGED
OVAL
CROWDING
OVERLAPPING
THICK NUCLEAR MEMBRANE
PALE CHROMATIN
NUCLEAR GROOVING

9. DIAGNOSIS
PAPILLARY CARCINOMA OF
THYROID

10. COLLOID • GROSS: SHINY, VISCOUS AND
LIGHT YELLOW OR GOLD
• CRACKS & BUBBLES
• BROKEN GLASS APPEARANCE –
AIR DRIED
• TISSUE PAPER LIKE FOLDING
• SURROUNDS FOLLICULAR
EPITHELIAL CELLS
• MORE COLLOID – MORE LIKELY
BENIGN
• ALTERS THE ADEQUACY

11. NORMAL FOLLICULAR EPITHELIUM
• LARGE FLAT SHEETS OF COHESIVE FOLLICULAR
CELLS – MACROFOLLICLES
• HONEY COMB APP
• NUCLEUS – ROUND, COARSE CHROMATIN
• CYTOPLASM
SCANT – MOD
DELICATE

12. INTACT MACRO & MICRO FOLLICLES

13. DEFINITION - PTC
CONVENTIONAL (CLASSIC) PTC IS A MALIGNANT EPITHELIAL TUMOR
DERIVED FROM THE THYROID FOLLICULAR EPITHELIUM
DISPLAYS PAPILLARY ARCHITECTURE
CHARACTERISTIC NUCLEAR ALTERATIONS.

14. CRITERIA
• PAPILLAE AND/OR MONOLAYERS
• CELLULAR SWIRLS
• ENLARGED NUCLEI
• CROWDED NUCLEI, OFTEN
MOLDED
• OVAL OR IRREGULARLY SHAPED
NUCLEI
• LONGITUDINAL NUCLEAR
GROOVES
• INCIS
• PALE NUCLEI WITH POWDERY
CHROMATIN
• THICK NUCLEAR MEMBRANES
• MARGINALLY PLACED
MICRONUCLEOLI (1 OR >1)
• PSAMMOMA BODIES
• MULTINUCLEATED GIANT CELLS
• BUBBLEGUM COLLOID
• “HOBNAIL” CELLS
• ONCOCYTIC (HÜRTHLE CELL)
METAPLASIA
• SQUAMOID METAPLASIA
• “HISTIOCYTOID” CELLS

15. PAPILLARY CARCINOMA THYROID - GROSS
• FIBROSIS, ENCAPSULATION &
CYSTIC CHANGE
• C/S – WHITISH TAN, FLESHY &
FIRM, PAPILLARY AREAS
• MULTIFOCAL

16. BASIC ARCHITECTURE

17. SWIRLING OF TUMOUR CELLS
• MINOR ARCHICTECTURAL
DIAGNOSTIC CRITERION
• FLATTENING OF CELLS AT EDGE
OF CELL CLUSTERS

18. MOLDED NUCLEI

19. INTRA NUCLEAR CYTOPLASMIC INCLUSIONS
• TRUE INCLUSION
• SAME COLOR & TEXTURE OF
CYTOPLASM
• SHARP DISCRETE BORDER
• BEST SEEN IN PAP STAIN
• F/O TALL CELL VARIANT
• SOAP BUBBLE NUCLEUS
• FALSE INCLUSIONS
DEGENERATIVE VACUOLES
ARTIFACT
SUPERIMPOSED RBC *

20. PIN POINT SMALL NUCLEOLUS
• SUBMEMBRANAL NUCLEOLUS
• CYTOPLASM
• DENSE
• SQUAMOID

21. PICKET FENCE ARCHITECTURE & TRUE
ANATOMIC EDGE

22. PSAMMOMA BODIES
• AT TIP OF PAPILLAE
• AVASCULAR NECROSIS
• CONCENTRIC LAMELLATIONS
• CALCIUM PHOSPHATE
• 1 OR >1
• EXTRA / INTRA FOLLICULAR
• 5 – 20% CASES OF FNA
• PPV – 50%

23. MULTINUCLEATED GIANT CELLS

24. CHEWING GUM COLLOID

25. HISTIOCYTOID CELLS • SPECIFIC FOR PAP CA
• FOLLICULAR ORIGIN
• NUCLEUS – ENLARGED
• COARSE CHROMATIN
• PROMINENT NUCLEOLI
• INTRANUCLEAR CYTOPLASMIC
PSEUDOINCLUSIONS
• ABUNDANT VACUOLATED
CYTOPLASM

26. VARIANTS

27. FOLLICULAR VARIANT
COMPLETELY OR ALMOST COMPLETELY
COMPOSED OF SMALL- TO MEDIUM-
SIZED FOLLICLES LINED BY CELLS WITH
VARIABLE NUCLEAR FEATURES OF PTC.

28. TRABECULAR PATTERN THICK & STICKY COLLOID

29. MACROFOLLICULAR VARIANT
>50% OF THE FOLLICLES ARE
ARRANGED AS MACROFOLLICLES
MORE THAN 200 ΜM IN DIAMETER
SUBTLE PTC FEATURES
NO PAPILLAE
NO PSAMOMMA BODIES
ABUNDANT COLLOID

30. CYSTIC VARIANT
• PREDOMINANTLY CYSTIC
• COMPRISED OF THIN,
WATERY FLUID
• ABUNDANT HISTIOCYTES
• HYPERVACUOLATED
TUMOR CELLS

31. ONCOCYTIC VARIANT
• NUCLEAR CHANGES
CHARACTERISTIC OF PTC
• COMPOSED
PREDOMINANTLY OF
ONCOCYTIC CELLS WITH
VARIABLE ARCHITECTURE
• WARTHIN – LIKE VARIANT
• ONCOCYTES
• LYMPHOCYTES

32. TALL CELL VARIANT
• AGGRESSIVE FORM OF PTC
• ELONGATED (“TALL”) TUMOR CELLS
• HEIGHT IS AT LEAST THREE TIMES
THEIR WIDTH
• ABUNDANT DENSE GRANULAR
CYTOPLASM
• TYPICAL NUCLEAR CHANGES OF PTC

33. COLUMNAR CELL VARIANT
• COLUMNAR CELLS
• HYPERCHROMATIC, OVAL, AND
PSEUDOSTRATIFIED NUCLEI
• SUPRANUCLEAR OR SUBNUCLEAR
CYTOPLASMIC VACUOLES
• REMINISCENT OF A COLONIC
ADENOMA OR SECRETORY-TYPE
ENDOMETRIUM

34. SOLID VARIANT
• PRESENCE OF SOLID AREAS THAT LACK PAPILLAE, FOLLICLES, AND COLLOID
STORAGE
• OCCUPY AT LEAST 50% OF THE LESION
• THE NEOPLASTIC CELLS HAVE TYPICAL NUCLEAR FEATURES OF PTC.

35. DIFFUSE SCLEROSING VARIANT
• DIFFUSE INVOLVEMENT OF ONE OR BOTH THYROID
LOBES
• EXTENSIVE LYMPHOVASCULAR INVASION
• NUMEROUS PSAMMOMA BODIES
• SQUAMOUS METAPLASIA
• MARKED LYMPHOCYTIC INFILTRATION
• PROMINENT FIBROSIS

36. CRIBRIFORM MORULAR VARIANT
• CRIBRIFORM AND SOLID ARCHITECTURE
LACKING COLLOID
• TALL AND COLUMNAR OR SPINDLE SHAPED
CELLS & SQUAMOID MORULES
• NUCLEI - HYPERCHROMATIC &
PSEUDOSTRATIFIED
• TYPICAL NUCLEAR FEATURES OF PTC
• NUCLEAR CLEARING CAUSED BY BIOTIN
ACCUMULATION (MORULES)

37. HOBNAIL VARIANT
• LOSS OF CELLULAR POLARITY/COHESIVENESS
• APICALLY PLACED NUCLEI AND BULGING OF THE APICAL CELL
SURFACE
• >30% OF NEOPLASTIC CELLS.

38. DIFFERENTIAL DIAGNOSIS

39. HYALINIZING TRABECULAR ADENOMA
• RARE TUMOUR
• FOLLICULAR CELL ORIGIN
• TRABECULAR GROWTH
• MARKED INTRATRABECULAR
HYALINIZATION
• NUCLEAR CHANGES OF PAP CA

40. HURTHLE CELL ATYPIA IN LYMPHOCYTIC
THYROIDITIS
• REACTIVE ATYPIA
• MARKED NUCLEAR
PLEOMORPHISM
• CROWDING & OVERLAPPING
• PALE CHROMATIN
• SMALL NUCLEOLI
• ?ONCYTIC VARIANT OF PAP CA

41. BENIGN PAPILLARY HYPERPLASIA

42. PAPILLARY HYPERPLASIA IN ADENOMATOID
NODULE

43. CYSTIC DEGENERATION IN BENIGN NODULE

44. ATYPIA WITH TREATED GRAVE’S DISEASE
• RADIOIODINE – NUCLEAR
CHANGES
• PALE CHROMATIN
• RARE NUCLEAR GROOVES

45. ATYPIA OF UNDETERMINED SIGNIFICANCE

46. SUSPICIOUS OF MALIGNANCY
• POSITIVE PREDICTIVE VALUE – 60 – 75%
• CELLULAR
• NUCLEI – ENLARGED, ROUND
• POWDER CHROMATIN
• NUCLEAR GROOVES
• SMALL DISTINCT NUCLEOLI
• FOLLICULAR VARIANTS PAP CA PRESENT
AS SOM

47. REFERENCES
• ORELL & STERRETTS FINE NEEDLE ASPIRATION CYTOLOGY 5TH
EDITION
• DIAGNOSTIC CYTOLOGY, PRANAB DEY
• BIBBO M., WILBUR D. COMPREHENSIVE CYTOPATHOLOGY
• THE BETHESDA SYSTEM FOR REPORTING THYROID PATHOLOGY
• ATLAS OF THYROID CYTOPATHOLOGY, SYED Z ALI
• COMMON DIAGNOSTIC PITFALLS IN THYROID CYTOPATHOLOGY