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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5794_Библиотеки_им_академика_М_И_Перельмана.pdf
4.6 Follicular Thyroid Carcinoma
Fig. 4.308 Surgical
histopathology revealed
hurthle cell carcinoma
Fig. 4.309 Surgical
histopathology revealed
hurthle cell carcinoma
(Fig.4.306, Fig.4.307,
Fig.4.308) showing
mushroom like capsular
invasion of the tumor
(arrow)
143
Fig. 4.310 Masson
Trichrome stain showed
brotic area appeared
mainly around the
margin of the nodule
and nearly none in the
tumor explaining low
elasticity on the
stiffeness map, the shear
wave elastogram
(Fig.4.304)
144
4 Dierential Diagnosis ofThyroid Nodules
showed a 1.54cm round nodule in the left lobe
(Figs.4.293, 4.294, and 4.295) and SWE showed
low elasticity in the nodule (E
32.2 kPa,
Max
Fig.4.296) except the medial margin of the nodule (E
132.2kPa, Fig.4.297), suggesting the
Max
probability of follicular neoplasm. After the
explanation of the results, she preferred surgery,
and total thyroidectomy was performed. Surgical
histopathology was microinvasive follicular carcinoma, showing mushroom-like capsular invasion (Figs. 4.298, 4.299, and 4.300) showing a
thick brous capsule in the medial margin of the
nodule (Fig.4.299), compatible with the nding
of the high elasticity on the medial margin on
SWE (Fig.4.297).
4.6.2 Case 2
A 36-year-old woman was found to have a left
3.0cm thyroid nodule and FNA showed microfollicles, suggesting follicular neoplasm. On
USG follow-up three years later, the nodule
increased to 3.84 cm and showed an isoechoic
solid nodule, with increased internal vascularity
on color Doppler (Figs.4.301, 4.302, and 4.303).
Shear wave elastogram showed low elasticity in
the whole nodule, which is color coded with deep
blue (E
30.0 kPa, Fig. 4.304). CNB showed
Max
abortive oxyphilic microfollicles, suggesting
oxyphilic follicular neoplasm (Fig. 4.305). She
underwent total thyroidectomy. Surgical histopathology revealed Hürthle cell carcinoma
(Figs. 4.306, 4.307, and 4.308), showing
mushroom- like capsular invasion of the tumor
(arrow, Fig.4.309). The Masson Trichrome stain
showed that the brotic area appeared mainly
around the margin of the nodule and nearly none
in the tumor (Fig.4.310), explaining low elasticity on the stiffness map, the shear wave elastogram (Fig.4.304).
4.7 Medullary Thyroid
Carcinoma
Medullary thyroid carcinoma (MTC) is derived
from the calcitonin-producing C-cells or parafollicular cells, and accounts for 5% of thyroid
malignant neoplasm. About 30% of MTCs are
heritable forms; multiple endocrine neoplasia
(MEN) type 2A (Sipple’s syndrome) including
pheochromocytomas and hyperparathyroidism,
and MEN type 2B (mucosal neuroma syndrome)
Fig. 4.311 On
ultrasonogram, a 1.679
cm isoechoic round
nodule mixed with
hypoechoic foci was
found in the right upper
lobe
4.7 Medullary Thyroid Carcinoma
Fig. 4.312 On
ultrasonogram, a 1.679
cm isoechoic round
nodule mixed with
hypoechoic foci was
found in the right upper
lobe
Fig. 4.313 Color
Doppler showed
increased internal
vascularity
145
and familial MTC (FMTC). The hereditary forms
are associated with germ-line mutations in the
RET proto-oncogene on chromosome 10 and
autosomal dominant mode of inheritance.
Sporadic MTC and FMTC are usually found in
older age with a peak incidence of 40–50 years.
Up to 50–70% of patients with palpable nodules
have cervical lymph node metastasis. Serum levels of calcitonin correlate with tumor burden and
are helpful for the diagnosis of MTC.
Sporadic MTC presents as a single nodule, but
heritable MTCs are usually bilateral and multifocal. MTCs are composed of round, polygonal-tospindle-shaped cells containing calcitonin
secretory granules and form nests, follicles or
trabeculae. MTCs exhibit a wide variety of histologic and cytologic appearance including papillary, giant cells, spindle cell, small cells,
oncocytic and clear-cell variants. Amyloid depos-
146
Fig. 4.314 Shear wave
elastogram showed focal
increased elasticity and
E
was 63.2 kPa
Max
4 Dierential Diagnosis ofThyroid Nodules
Fig. 4.315 FNA
showed ovoid,
plasmacytoid cells with
abundant cytoplasm and
salt and pepper
appearance chromatin
4.7 Medullary Thyroid Carcinoma
Fig. 4.316 CNB
showed sheets of
polygonal cells with
brous capsule-like
structure
Fig. 4.317 CNB
showed sheets of
polygonal cells with
brous capsule-like
structure and positivity
for calcitonin
147
Fig. 4.318 Surgical
histopathology was
medullary thyroid
carcinoma which
showed nested growth of
plasmacytoid or
polygonal cells with
hyperchromatic nuclei
and low mitotic gures
148
Fig. 4.319 Surgical
histopathology was
medullary thyroid
carcinoma which
showed nested growth of
plasmacytoid or
polygonal cells with
hyperchromatic nuclei
and low mitotic gures
Fig. 4.320 Surgical
histopathology was
medullary thyroid
carcinoma which
showed positivity for
calcitonin
4 Dierential Diagnosis ofThyroid Nodules
Fig. 4.321 On USG,
2.50 cm suspicious
hypoechogenic nodule
with echogenic foci was
observed in the left
middle lobe
4.7 Medullary Thyroid Carcinoma
Fig. 4.322 On USG,
2.50 cm suspicious
hypoechogenic nodule
with echogenic foci was
observed in the left lobe
Fig. 4.323 Moderately
increased internal
vascularity was observed
on color Doppler
149
its derived from calcitonin polypeptides are present in the stroma in 90% of cases [9].
On B-mode ultrasound, MTC showed a solid
hypoechoic nodule with echogenic foci in
80–90% due to amyloid deposition or calcication [16]. SWE results have not been reported
yet.
4.7.1 Case 1
An 84-year-old woman was found to have a thyroid nodule on routine check and referred for
evaluation. On ultrasonogram, a 1.679 cm
isoechoic round nodule mixed with hypoechoic
foci was found in the right upper lobe (Figs.4.311
and 4.312) and color Doppler showed increased
internal vascularity (Fig. 4.313). Shear wave
elastogram showed focal increased elasticity
63.2kPa, E
(E
Max
26.3kPa, Fig.4.314). The
mean
preoperative level of serum calcitonin was
248.88pg/mL.FNA showed ovoid, plasmacytoid
cells with abundant cytoplasm, and chromatin
with salt and pepper appearance (Fig. 4.315).
CNB showed sheets of polygonal cells with
brous capsule-like structures (Fig. 4.316) and
positivity for calcitonin (Fig.4.317), suggesting
medullary thyroid carcinoma. Total thyroidec-
150
Fig. 4.324 SWE
showed low elasticity
(E
33.8 kPa) except in
Max
the upper margin of the
nodule (E
141.0 kPa)
Max
4 Dierential Diagnosis ofThyroid Nodules
Fig. 4.325 FNA
showed clusters of ovoid
cells with small to
moderate amount of
cytoplasm and
hyperchromatic nuclei
4.7 Medullary Thyroid Carcinoma
Fig. 4.326 CNB
showed proliferation of
polygonal cells with
amphophilic cytoplasm
on the background of
hyalinized stroma with
amyloid deposition
(arrow)
Fig. 4.327 CNB
showed tumor cells were
positive for calcitonin
(arrow).
151
Fig. 4.328 Surgical
histopathology was
medullary thyroid
carcinoma which was
consisted of polygonal
cells with abundant
amphophilic cytoplasm
on the markedly
hyalinized stroma
152
Fig. 4.329 Surgical
histopathology was
medullary thyroid
carcinoma (Fig.4.328)
which was consisted of
polygonal cells with
abundant amphophilic
cytoplasm on the
markedly hyalinized
stroma with amyloid
deposition (arrow).
Fig. 4.330 Surgical
histopathology was
medullary thyroid
carcinoma and tumor
cells showed positivity
for calcitonin
immunostaining (arrow)
4 Dierential Diagnosis ofThyroid Nodules
Fig. 4.331 On USG,
2.37 cm isoechogenic
nodule was observed in
the right middle lobe