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Zorluk: OrtaPathology and Biopsy Interpretation

A 38-year-old woman is evaluated in the clinic for a newly discovered, painless swelling in her anterior neck. She has no history of radiation exposure to the head or neck and no family history of endocrine malignancies. Physical examination reveals a 2.5-cm, firm, non-tender, mobile nodule in the right lobe of the thyroid gland. Her thyroid-stimulating hormone (TSH) level is within normal limits. A neck ultrasound shows a solid, hypoechoic nodule with irregular margins and microcalcifications. Fine-needle aspiration (FNA) of the nodule is performed. The cytopathology report describes highly cellular smears with flat sheets and syncytial clusters of epithelial cells. The cells demonstrate enlarged, overlapping nuclei with finely dispersed, optically clear chromatin, longitudinal nuclear grooves, and distinct intranuclear pseudoinclusions. Scattered concentrically laminated calcifications are also noted.

Based on the cytopathology findings, which of the following is the most likely diagnosis?

  1. Papillary thyroid carcinomaCevap
  2. B
    Follicular thyroid carcinoma
  3. C
    Medullary thyroid carcinoma
  4. D
    Hashimoto thyroiditis
  5. E
    Anaplastic thyroid carcinoma

Cevap

Papillary thyroid carcinoma
The correct diagnosis is papillary thyroid carcinoma. The cytopathology report details the pathognomonic microscopic features required to establish this diagnosis. These classic features include enlarged, overlapping nuclei with cleared, pale chromatin (often referred to as 'Orphan Annie eye' nuclei), prominent longitudinal nuclear grooves, and intranuclear pseudoinclusions (which are actually cytoplasmic invaginations into the nucleus). Furthermore, the 'concentrically laminated calcifications' represent psammoma bodies. Psammoma bodies are highly characteristic of papillary thyroid carcinoma and perfectly correlate with the microcalcifications observed on the patient's neck ultrasound.

Adım Adım Çözüm

1
Analyze the patient's clinical presentation and ultrasound findings.
The patient has an asymptomatic, firm thyroid nodule with normal TSH. Ultrasound shows concerning features (solid, hypoechoic, microcalcifications), which correctly prompted a diagnostic fine-needle aspiration.
Establishing the clinical context and indication for the biopsy is the first step in evaluating a suspected thyroid malignancy.
2
Interpret the cytopathological features detailed in the fine-needle aspiration report.
The report highlights overlapping nuclei with optically clear chromatin ('Orphan Annie eyes'), longitudinal nuclear grooves, intranuclear pseudoinclusions, and concentrically laminated calcifications (psammoma bodies).
Accurate identification of specific microscopic cellular features is required to establish the correct pathologic diagnosis.
3
Correlate the cytopathology findings with the correct diagnosis.
The constellation of clear nuclei, nuclear grooves, pseudoinclusions, and psammoma bodies is highly specific and pathognomonic for papillary thyroid carcinoma.
Synthesizing the microscopic findings leads to the definitive diagnosis, distinguishing it from other malignant or benign thyroid conditions.

Anahtar Kavram

The cytopathological diagnosis of papillary thyroid carcinoma relies on distinct nuclear features, including optically clear chromatin ('Orphan Annie eyes'), nuclear grooves, intranuclear pseudoinclusions, and the presence of psammoma bodies.
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Pathology and Biopsy Interpretation

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