thyroiditis in the differential diagnosis of lymphoma · thyroiditis (lymphocytic thyroiditis,...
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Thyroiditis in the differential diagnosis of lymphoma
2nd Pannonia Congress of Pathology
Siofok, Hungary, May 17-19, 2012
Božo Krušlin, M.D., Ph.D., Dpt of Pathology, School of Medicine, University of Zagreb, Croatia
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Acute, subacute or chronic
Different settings
- subacute lymphocytic (postpartum)
- subacute granulomatous (de Qervain)
- Riedel thyroiditis
- palpation thyroiditis
- chronic lymphocytic (Hashimoto disease)
Inflammation of the thyroid gland –thyroiditis
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Subacute lymphocytic thyroiditis (postpartum)
• Silent or painless thyroiditis• In a subset of patients the onset of the disease
follows pregnancy• Most likely autoimmune• Middle-aged woman• Increased risk after subsequent pregnancies• Microscopically – lymphocytic infiltration with
secundary follicles• Unlike Hashimoto – follicle atrophy and oxyphilic
changes may be rarely seen
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De Quervain’ disease
• Subacute granulomatous thyroiditis - probably follows a viral infection and leads to a painful enlarged thyroid
• Usually self-limited over weeks to months and the patients return to a euthyroid state
• foreign body giant cells with destruction of thyroid follicles
Utah web site
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Riedel thyroiditis
• Thyroid gland in Riedel thyroiditis –asymetrically enlarged and hard due to extensive fibrosis that is usually spreading to adjacent soft tissues
• The cause of Riedel's thyroiditis is not known, probably autoimmune
• in a number of studies, the majority of patients with the condition tested positive for antithyroid antibodies
• DD – fibrosing variant of Hashimo thyroiditis and anaplastic carcinoma
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Palpation thyroiditis
• Caused by vigorous clinical palpation resulting in multifocal disruption of the follicles
• Focal collection of multinuclear giant type cells
• No abnormalities of thyroid function• Incidental finding• Clinical history
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Hashimoto disease
• Chronic lymphocytic thyroiditis - autoimmune disorder of the thyroid
• The most common cause of hypothyroidism in the USA• Primary defect in T cells• Autoimmune disease - antithyroglobulin and
antimicrosomal antibodies often can be detected. • Other autoimmune diseases such as Addison's disease
or pernicious anemia may also be present. • Both thyroid growth immunoglobulins (TGI) and thyroid
stimulating immunoglobulins (TSI) are present, though blocking antibodies to TSI mitigate their effect
• Initially, the thyroid is enlarged and painless and there may be transient hyperthyroidism, followed by a euthyroid state and then hypothyroidism with eventual atrophy years later
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Atrophic thyroid gland in a hypothyroid patient with Hashimoto's thyroiditis. Utah web site
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Thyroid with Hashimoto's thyroiditis Utah web site
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Courtesy of Teacher and friend, Dpt of Pathology, The University of Kansas School of Medicine, Kansas City, Kansas, USA
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Courtesy of Teacher and friend, Department of Pathology, The University of Kansas School of Medicine, Kansas City, Kansas, USA
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Hashimoto's thyroiditis with the pink Hurthle cells
Utah web site
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Primary thyroid gland lymphoma
• 1-5% of all thyroid malignant tumors• 2% of all extranodal malignant lymphomas• The most common types
– Large B-cell lymphoma, Marginal Zone B-Cell Lymphoma of MALT Type (MZBL), Mixed DLBCL and MZBL (Marginal Zone B-Cell
– Lymphoma of MALT-Type With Large Cell Transformation)
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Primary thyroid gland lymphoma
• PTLs typically occur in middle - to older-aged women
• Symptoms: dysphagia, dyspnea, stridor or hoarseness, pain, choking, coughing
• Usually arise in the setting of autoimmune thyroiditis (lymphocytic thyroiditis, Hashimoto’s disease).
• The relative risk of a patient with lymphocytic thyroiditis developing lymphoma has been estimated to be 40 to 80 times greater than in the general population
• It takes on average, 20 to 30 years to develop after the onset of lymphocytic thyroiditis
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Primary thyroid gland lymphoma
• Up to 20 cm in largest diameter
• Cut surface – smooth, pale tan, white-gray or red, fleshy appearance, foci of haemorrhage and/or necrosis
• Majority of patients in stage IE or IIE
• Those with LBCL – stage IIIE or IVE WHO 2004
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Primary thyroid gland lymphoma
• Extranodal MZBCL– Heterogenous B-cell population, atypical
small lymphocytes, centrocyte like cells, monocytoid B-cells, scattered immunoblasts and plasma cells
- Reactive germinal centers colonized by neoplastic cells
- Lymphoepithelial lesions – rounded masses distending the lumen of the thyroid follicle (MALT balls)
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Lymphocytic thyroiditis
Marginal zone lymphoma – monocytoid, centrocyte like cells and immunoblasts
WHO 2004
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Diffuse large B-cell lymphoma
• Single or multifocal areas adjacent to low grade component
• Areas of LBCL without low grade foci• Centroblasts, immunoblasts, monocytoid
B-cells, plasmocytoid cells• Numerous mitoses• Occasionally Burkitt like pattern
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Courtesy of Teacher and friend, Dpt of Pathology, The University of Kansas School of Medicine, Kansas City, Kansas, USA
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Courtesy of Teacher and friend, Dpt of Pathology, The University of Kansas School of Medicine, Kansas City, Kansas, USA
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Courtesy of Teacher and friend, Dpt of Pathology, The University of Kansas School of Medicine, Kansas City, Kansas, USA
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Differential diagnosis• Thyroiditis versus EMZBCL may be occasionally
difficult– Histology – gold standard, however sometimes
additional immunohistochemical, flow cytometrical and molecular genetic analyses may be needed
• EMZBCL versus follicular lymphoma– Reactive, colonized germinal centres in EMZBCL
should be distinguished from neoplastic germinal centres in FL
– FL will show positivity for bcl-2 and germinal cell markers CD10 and bcl6
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Differential diagnosis
• Large B-cell lymphoma versus carcinoma (primary undifferentiated carcinoma of the thyroid), metastatic carcinoma, melanoma or myeloid sarcoma– LCA, CD20, cytokeratin, S-100, HMB45 and
myelomonocytic markers
Large B cell lymphoma
WHO 2004
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References
• Derringer GA et al. Am J Surg Pathol 2000;24:623-9
• WHO 2004• Takano t et al. J Clin Endocrinol Metabol
2000;85:671-5• Onal C et al. Ann Oncol 2011;22:156-64• Lee SC et al. J Korean Surg Soc.
2011;81:374-9.
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Welcome to Croatia!!!