1. Thyroid Stuff Cytopathology & Pathology Ryan Orosco Sept 2013

2. Objective Understand benefits of FNA Learn an algorithmic approach to FNA cytopathology Be able to name and identify key cytologic features of papillary thyroid cancer

3. Benign Causes of Thyroid Nodules Adenomatous nodule Colloid nodule Follicular adenoma Simple thyroid cyst Graves disease Chronic lymphocytic thyroiditis (Hashimoto’s) Focal subacute thyroiditis Developmental conditions

4. Thyroid Cytopathology, Faquin and Clark, Springer 2010

5. Benefits of Using FNA to Evaluate Thyroid Nodules Reduces number of patients requiring surgery by 50% Increases the yield of thyroid malignancies at thyroidectomy by 2-3x Decreases the cost of managing thyroid nodules by 25%

6. Thyroid Cytopathology, Faquin and Clark, Springer 2010

8. Diagnostic Categories Nondiagnostic – occurs in 10-30% of cases Benign – about 70% of the time – Low false negative rate (1-3%) gives you confidence to follow non- surgically Malignant – about 10-20% of the time – Low false negative rate (1-3%) gives you confidence to follow non- surgically Suspicious for Malignancy – about 60-75% risk for malignancy – Usually managed with total thyroidectomy given high risk Suspicious for Follicular Neoplasm – 10-30% risk for malignancy – Usually managed with lobectomy Atypia of Undetermined Significance – should be less than 10% of FNAs. Risk of malignancy 5-15%. – Usually managed with repeat FNA in 3 months Thyroid Cytopathology, Faquin and Clark, Springer 2010

9. Sensitivity/specificity depends on how indeterminate specimens and suspicious groups of lesions are handled, skill of the person doing the u/s and FNA, cytopathologist expertise False neg and false pos are usually less than 1% in most series About 18% of pts who get a FNA are treated surgically Sensitivity/specificity depends on how indeterminate specimens and suspicious groups of lesions are handled, skill of the person doing the u/s and FNA, cytopathologist expertise False neg and false pos are usually less than 1% in most series About 18% of pts who get a FNA are treated surgically

10. The Spectrum of Thyroid Cancer The good: well-differentiated The bad: poorly differentiated The ugly: undifferentiated (anaplastic) Thyroid Cytopathology, Faquin and Clark, Springer 2010

12. Cystic

13. Inflammatory & Lymphoma Thyroid Cytopathology, Faquin and Clark, Springer 2010

14. Colloid Predominant

15. Epithelium-Predominant

16. Thyroid Cytopathology, Faquin and Clark, Springer 2010

17. Epithelium-Predominant – Hurthle cell Thyroid Cytopathology, Faquin and Clark, Springer 2010

18. Epithelium-Predominant – PTC Thyroid Cytopathology, Faquin and Clark, Springer 2010

19. Epithelium-Predominant – PTC Thyroid Cytopathology, Faquin and Clark, Springer 2010