path head and neck - formatted Flashcards
- \ Cancer Thyroid: (false)
a. Follicular overlapping features with papillary
b. Medullary Cancer amyloid deposits
c. Paillary lymph node mets
d. Follicular Hematogenous
e. Female more common than male
a. Follicular overlapping features with papillary - F - follicular has variable architecture: typically microfollicular architecture with uniform cuboidal cells. No nuclear features of papillary carcinoma and no psamomma bodies.
- Cancer Thyroid: (TW)
a. Follicular overlapping features with papillary - F - follicular has variable architecture: typically microfollicular architecture with uniform cuboidal cells. No nuclear features of papillary carcinoma and no psamomma bodies.
b. Medullary Cancer amyloid deposits - T - Medullary - any age (peak 20-30s for MEN, 40-50s sporadic), tumor of parafollicular (C) cell origin, produces calcitonin, MENIIa, MENIIb, Familial MTC, NF, vHL, <50% show broad sheets of amyloid, lymphoid and hematogenous spread. Px 90% 10y survival. More aggressive MENIIb
c. Papillary lymph node mets - T - Papillary - young (esp 20-40yo), female, lymphatic spread, calcification, orphan annie nuclei, irradiation, pasmmoma bodies. Px 10y survival 98%.
d. Follicular Hematogenous - T - Follciular - any age (peak 40s-50s), associated with goitre, not an FNA diagnosis (can look like follicular adenoma), hematogenous spread. Px 92% 10y survival. Worse if larger lesion
e. Female more common than male: *LW Robbins states early and middle age female predominance, while in childhood and late adult life equal sex distribution, thus answer is true.
- Hashimotos – False
a. Lymphocyte infiltrate is sine qua non
b. Hurthle cell
c. Autoimmune thyroiditis
d. Granulosa
e. Hyper functioning early
d. Granulosa - F - ?bad recall - not sure if this meant ‘granuloma’ in which case referring to subacute (granulomatous thyroiditis) AKA DeQuervain thyroiditis.
- Hashimotos – False (TW)
a. Lymphocyte infiltrate is sine qua non - T - extensive infiltration of parenchyma by a mononuclear inflammatory infiltrate containing small lymphocytes, plasma cells, and well-developed germinal centers. The sine quq non is stromal infiltration by lymphocytes and variable numbers of plasma cells.
b. Hurthle cell - T - Thyroid follicles are small and are lined in many areas by epithelial cells with abundant eosinophilic, granular cytoplasm, termed Hürthle cells. Hürthle cells (oncycytes) are observed in both neoplastic and nonneoplastic conditions of the thyroid gland (eg, Hashimoto thyroiditis, nodular and toxic goiter).
c. Autoimmune thyroiditis - T - chronic autoimmune thyroid disorder characterised by a slowly destructive lymphoid infiltrate of the thyroid gland, variable thyroid function, and high circulating titres of antithyroid antibodies,
d. Granulosa - F - ?bad recall - not sure if this meant ‘granuloma’ in which case referring to subacute (granulomatous thyroiditis) AKA DeQuervain thyroiditis.
e. Hyper functioning early - T - transient hyperthyroid with increased T3/T4 and reduced TSH, later have reduced T3/T4 and elevated TSH.
- CA Thyroid
a. 20% MEN with medullary
b. Follicular growth
c. Papillary Hematogenous spread
d. Follicular ill defined mass
e. Medullary calcitonin
- CA Thyroid (JS)
a. 20% MEN with medullary - T - 80% arise sporadically, the remaining 20% occur in the setting of MEN IIA or IIB or as familial tumours without an association with MEN
b. Follicular growth - ???
c. Papillary Hematogenous spread - F - foci of lymphatic invasion are often present but involvement of blood vessels is uncommon. Mets to local LN in half of cases.
d. Follicular ill defined mass - F - present as a slowly enlarging painless nodule
e. Medullary calcitonin - T - neuroendocrine neoplasms derived from parafollicular (C) cells which secrete calcitonin
- Patient with myasthenia gravis for CT chest. What should you look for?
a. Thymic neoplasm
b. Thymic mass + hilar mass
a. Thymic neoplasm - T - Thymus is intimately involved in the pathogenesis of MG.
- Patient with myasthenia gravis for CT chest. What should you look for? (JS + TW)
a. Thymic neoplasm - T - Thymus is intimately involved in the pathogenesis of MG.
b. Thymic mass + hilar mass - F
It is postulated that all patients with MG have B cells that produce AChR-Ab in the thymus. In addition, 75% of patients with MG have thymic abnormalities - thymic hyperplasia is most common (85%), but various tumors (primarily thymoma) are present in up to 15%. The thymic tumors are usually noninvasive cortical thymomas, but invasive carcinoma can occur.
Important to image mediastinum of any patient with MG.
MG can be considered a paraneoplastic effect of thymoma, but not of extrathymic tumors. Nonetheless, MG has been assoc with extrathymic tumors, such as small cell lung cancer (?hilar mass) and Hodgkin lymphoma. It is uncertain from these studies whether this co-occurrence represents a true association. The data DO NOT warrant an extensive search for malignancy, other than thymoma, in myasthenics, even in older patients.
- In regards to thyroid cancer
a. 20% of medullary thyroid cancer associated with MEN
a. 20% of medullary thyroid cancer associated with MEN - T - Medullary - any age (peak 20-30s for MEN, 40-50s sporadic). Sporadic 80%, familial 20%. Tumor of parafollicular (C) cell origin, produces calcitonin, MENIIa, MENIIb, Familial MTC, NF, vHL, <50% show broad sheets of amyloid, lymphoid and hematogenous spread. Px 90% 10y survival. More aggressive MENIIb. Penetrance of medullary thyroid cancer in MEN2A is nearly 100%. MTC occurs in almost all MEN2b patients.
- Turners with Hurthle cells
i. Hashimoto’s ( commonest cause of hypoT in turners) Hürthle cells are observed in both neoplastic and nonneoplastic conditions of the thyroid gland (eg, Hashimoto thyroiditis, nodular and toxic goiter).
i. Hashimoto’s - T - HT = chronic autmoimmune thyroid disorder characterised by slowly destructive lymphoid infiltrate of thyroid gland (and high circulating titres of antithyroid Abs). Occurs with increased frequency in patients with Down’s syndrome and Turner’s syndrome. Hürthle cells (oncycytes) are observed in both neoplastic and nonneoplastic conditions of the thyroid gland (eg, Hashimoto thyroiditis, nodular and toxic goiter).
- Anaplastic thyroid cancer prognosis
- Good
- Not so good
- Bad
- Really bad
- Shithouse
- Shithouse -
Malignant thyroid tumors: Papillary 75-85%, Follicular 10-20%, Medullary 5%, Anaplastic <5%.
Papillary - young (esp 20-40yo), female, lymphatic spread, calcification, orphan annie nuclei, irradiation, pasmmoma bodies. Px 10y survival 98%.
Follciular - any age (peak 40s-50s), associated with goitre, not an FNA diagnosis (can look like follicular adenoma), hematogenous spread. Px 92% 10y survival. Worse if larger lesion.
Medullary - any age (peak 20-30s for MEN, 40-50s sporadic), tumor of parafollicular (C) cell origin, produces calcitonin, MENIIa, MENIIb, Familial MTC, NF, vHL, <50% show broad sheets of amyloid, lymphoid and hematogenous spread. Px 90% 10y survival. Mor aggressive MENIIb.
Anaplastic - >60yo, locally invasive, 50% have goitre, 20% has Hx or previously more differentiated tumor (?develops from this ?due to p53 tumor suppressor gene loss). Px approx 100% mortality.
- 55yo man - Oncocytes in biopsy specimen from solitary parotid cyst
- Benign pleomorphic adenoma
- Warthins
- HIV
- Type 1 branchial cleft cyst
- Mucoepidermoid
- Warthins - T - Warthins: 5th – 7th decades; M>F; 8 x risk in smoking, oncocytes p 772 old Robbins. Oncocytes are epithelial cells stuffed with mitoondria that impart the granular appearance to the cytoplasm.
- DeQuervain macroscopic appearance
- Diffuse smooth symmetrical goiter
- Multiple nodules
- Bilateral or unilateral enlarged lobes
- Only microscopic changes
- Bilateral or unilateral enlarged lobes
- DeQuervain macroscopic appearance (TW)
- Diffuse smooth symmetrical goiter - F - Hashimotos / Graves
- Multiple nodules - F - MNG
- Bilateral or unilateral enlarged lobes
- Only microscopic changes - F - subacute lymphocytic (painless) thyroidits. AKA lymphocytic thyroiditis.
DeQuervains (AKA subacute (granulomatous) thyroiditis): Self-limited granulomatous thyroiditis with distinct histology characterised by GC formation / granulomata. Probably viral links with previous viral infection (mumps, measles, flu adenovirus, coxsackievirus, echovirus).
30-50yo. Women 5x > men.
- Inverting papilloma
- Goes into the eye
- Benign
- Exophytic characteristically
- Malignant
- Arises in frontal sinus and inverts into infundibulum
- Benign - T
- Inverting papilloma (TW)
- Goes into the eye - F
- Benign - T
- Exophytic characteristically - F - endophytic papillomas AKA inverted papillomas.
- Malignant - F - benign (malign trans in 5-15%)
- Arises in frontal sinus and inverts into infundibulum - F - characteristically, they arise from the lateral nasal wall near the middle turbinate and extend into the sinuses. This secondary extension involves the maxillary and ethmoidal sinuses, but extension into the sphenoid and frontal sinuses has been documented. Rarely do they arise from the nasal septal wall, and fewer than 4% occur bilaterally.
Inverting nasal papillomas are rare, benign but aggressive neoplasms of the nasal cavity and paranasal sinuses. Inverted nasal papillomas comprise 0.5 -7% of all nasal cavity tumors. Approximately 5-15% are associated with malignancy - usually squamous cell carcinoma, and less commonly adenocarcinoma - which may be synchronous or metachronous.
Although the underlying etiology is not well-understood, nasal epithelial neoplastic transformation secondary to viral infection and smoking has been postulated. There is a 4:1 male to female predominance and peak incidence occurs between the 4th and 7th decades of life, although children and adolescents can also be affected.
55yo man - Oncocytes in biopsy specimen from solitary parotid cyst
- Benign pleomorphic adenoma
- Warthins
- HIV
- Type 1 branchial cleft cyst
- Mucoepidermoid
- Warthins - T - Warthins: 5th – 7th decades; M>F; 8 x risk in smoking, oncocytes p 772 old Robbins. Oncocytes are epithelial cells stuffed with mitoondria that impart the granular appearance to the cytoplasm.
- 55yo man - Oncocytes in biopsy specimen from solitary parotid cyst (TW)
- Benign pleomorphic adenoma - F - great histologic heterogeneity. Epithelial elements resembling ductal cells or myoepithelial cells.
- Warthins - T - Warthins: 5th – 7th decades; M>F; 8 x risk in smoking, oncocytes p 772 old Robbins. Oncocytes are epithelial cells stuffed with mitoondria that impart the granular appearance to the cytoplasm.
- HIV - F
- Type 1 branchial cleft cyst - F - fibrous walls, usually lined by stratified squamous or pseudostratified columnar epithelium underlaid by an intesne lymphocytic infiltrate.
- Mucoepidermoid - F - cords, sheets, or cystic configurations of squamous, mucous, or intermediate cells.
- Solitary lytic mass parotid, FNA polygonal cells, lymphocytes
- HIV lymphoepithelial cyst
- Warthin’s tumour
- Pleomorphic adenoma
- Mucoepidermoid carcinoma
- Warthin’s tumour - (AKA papillary cystadenoma lymphomatosum) round to oval encapsulated masses. Pale gray surface punctuated by narrow cystic or cleft-like spaces filled with a mucinous or serous secretion. Microscopic: spaces are lined by a double layer of epithelial cells resting on a dense lymphoid stroma. Lining cells with surface palisade of columnar cells having an abundant, finely granular, eosinophilic cytoplasm giving an oncocytic appearance, resting on a layer of cuboidal to polygonal cells.
. Solitary lytic mass parotid, FNA polygonal cells, lymphocytes (TW)
- HIV lymphoepithelial cyst - F - Cyst lined by glandular or squamous epithelium and surrounded by prominent lymphoid follicles. Lymphocytes may have clear cytoplasm and penetrate epithelium. Cyst epithelium derives from striated ducts.
- Warthin’s tumour - (AKA papillary cystadenoma lymphomatosum) round to oval encapsulated masses. Pale gray surface punctuated by narrow cystic or cleft-like spaces filled with a mucinous or serous secretion. Microscopic: spaces are lined by a double layer of epithelial cells resting on a dense lymphoid stroma. Lining cells with surface palisade of columnar cells having an abundant, finely granular, eosinophilic cytoplasm giving an oncocytic appearance, resting on a layer of cuboidal to polygonal cells.
- Pleomorphic adenoma - F - rounded, well-demarcated masses. Great histologic heterogeneity. Epithelial elements resemble ductal cells or myoepithelial cells which are disposed in duct formations, acini, irregular tubules, strands, or sheets of cells. Background loose myxoid tissue.
- Mucoepidermoid carcinoma - F - composed of variable mixtures of squamous cells, mucus-secreting cells, and intermediate hybrids. Histo: cords, sheets, or cystic configurations of squamous, mucus, or intermediate cells.
- 76 year old male for radiotherapy of thyroid lesion. Most likely?
- Anaplastic
- Follicular
- Medullary
- Papillary
- Lymphoma
- Anaplastic - T - surgery often not indicated as usually advanced disease. Locally advanced inoperable disease - combined XRT and chemotTX. If localized, complete resection should be attempted with postoperative combined modality therapy with radiation and chemotherapy for tumors that are resected completely (no extrathyroid spread). Hyperfractionated XRT (high
- 76 year old male for radiotherapy of thyroid lesion. Most likely? (TW) - presuming they mean ‘external beam’
- Anaplastic - T - surgery often not indicated as usually advanced disease. Locally advanced inoperable disease - combined XRT and chemotTX. If localized, complete resection should be attempted with postoperative combined modality therapy with radiation and chemotherapy for tumors that are resected completely (no extrathyroid spread). Hyperfractionated XRT (high ‘radical’ doses >Gy) appears to be associated with improved local control of disease.
- Follicular - F - Surgery + I131
- Medullary - F - Best treatment for MC is thyroidectomy and lymphadenectomy. Note that early studies found no survival benefit from ext beam XRT (ie path notes), however retrospective analysis showed XRT may prolong the interval until disease progression or recurrence in some patients. XRT useful for primary therapy if resection incomplete, and for adjuvant therapy. ChemoTx, transarterial chemoembolisation also can be used for advanced / residual disease.
- Papillary - F - surgery + I131
- Lymphoma - ?F (but also potentially true as well) - Pts with thyroid lymphoma should be staged like any other patient with lymphoma. Stage I or limited stage II - choid is between radiotherapy alone for indolent lymphoma, or combined XRT and chemoTx for aggressive histologies. Rate of local contral with 35-40Gy given in 4 weeks is excellent. Radiation therapy alone is adequate Tx for localized indolent lymphomas, such as MALT lymphoma or follicular lymphoma. Combined Tx for all patients with aggressive histiology thyroid lymphoma.
- Persistent elevated PTH post surgery for hyperparathyroidism. Most likely cause
- Neoplasm producing PTH
- Parathyroid adenoma in chest
- Pituitary adenoma
- Multiple parathyroid adenomas
- Parathyroid hyperplasia
- Multiple parathyroid adenomas - T- single account for 89% of primary HPTH, and double adenomas found in an additional 5%. When removing single adenoma, some surgeons biopsy the other three glands.
- Persistent elevated PTH post surgery for hyperparathyroidism. Most likely cause (TW)
- Neoplasm producing PTH - F - rare. A few patients with hypercalcemia and non-parathyroid tumors that secreted PTH have been reported, but in vast majority the hypercalcemia is ude toumor production of PTHrP.
- Parathyroid adenoma in chest - F 5-10% of patients undergoing surgery for HPTH have persistent disease. In several studies, the abnormal parathyroid glands were found at the second operation in the following sites: 30-54% in the neck, 16-34% in mediastinum, 14-39% retroesophageal, 5% in aortic arch area, 8% upper cervical area, a few in the carotid sheath.If you think about it, this is multiple parathyroid adenomas, therefore I think 4 is most correct
- Pituitary adenoma - F - rare (pituitary)
- Multiple parathyroid adenomas - T- single account for 89% of primary HPTH, and double adenomas found in an additional 5%. When removing single adenoma, some surgeons biopsy the other three glands.
- Parathyroid hyperplasia - F - this was a previous ‘correct’ answer. Primary HPTH caused by glandular hyperplasia - all 5 glands are enlarged (lower glands bit larger than upper). Generally 3 and 1/2 glands are removed, or all 4 removed with autoTx in the forearm.
I think that the answer may relate to what the initial surgery was for initially - ie did prior Ix demonstrate single adenoma, hyperplasia, multiple adenomas?
Post surgery persistent HPTH - Sestamibi and US - if positive in neck then operate / if positive in chest then operate or CT if requird. If negative US and sestamibi then obtain CT, MRI, and/or invasives (UTD).
(Answer still debatable Gary )
• Article by American Physicial state if intra operative PTH levels remain elevated after removal should extend search to look for ectopic glds.
o Approximately 85% of cases of primary hyperparathyroidism are caused by a single adenoma. Therefore, most patients who undergo full neck exploration to evaluate all parathyroids endure some unnecessary dissection. Rather than explore all parathyroid glands, a newer technique, directed parathyroidectomy, has evolved. This technique relies on preoperative imaging studies to localize the abnormal gland. The surgeon then removes only that gland, without visualizing the other glands.
o With either sestamibi scanning or ultrasonography, an abnormal parathyroid may be detected preoperatively in 70-80% of cases. However, neither technique is reliable for detecting multiple abnormal glands. Therefore, an additional method is required to confirm that no other abnormal glands are present after excision of the imaged lesion.
o For this purpose, many centers have begun to use the intraoperative PTH assay. Because the plasma half-life of PTH is only approximately 4 minutes, the level falls quickly after resection of the source. If the level fails to fall after resection of the identified abnormal gland, the procedure is extended to allow for further exploration. However, the intraoperative PTH assay is expensive and is usually available only in centers that perform a high volume of parathyroidectomies.
*Agree that answer is debatable.
Big Robbins (8th ed pg 1102) states:
- adenoma 85-95% cause for primary hyperparathyroidism
- hyperplasia 5-10% cause for primary hyperparathyroidism
- adenomas are ‘almost always solitary’.
No mention of persistent hyperparathyroidism.
- Wegeners, which is against the diagnosis
a. Involvement of nasal mucosa
b. Renal involvement
c. c ANCA
d. Female
e. Necrotizing Vasculitis
f. Necrotizing glomerular nephritis
g. Neg ANCA
h. Granulomatosis of upper and lower resp tracts
- Neg ANCA - F - see ans 3. However in limited forms of the disease (eg subsets in which upper respiratory tract disease predominates and renal involvement is absent, up to 40% may be ANCA negative.
- Wegeners, which is against the diagnosis (TW)
- Involvement of nasal mucosa - T - nasal or oral inflammation. Chronic inflammation, often with granulomatous features.
- Renal involvement - T - renal involvement is anotehr common component of Wegener’s granulomatosis and microscopic polyangiitis. Microscopic hematuria +/- red cell cases and varying degrees of renal insufficiency, including RPGN.
- c ANCA - T - 95% of patients are positive
- Female - T - (males more common than females but not strongly)
- Necrotizing Vasculitis - T - ANCAs likely induce necrotizing vasculitis and endothelial injury via activation of primed neurtophils, binding of neutrophils to the vascular endothelium, degranulation, and release of chemoattractants and other mediators.
- Necrotizing glomerular nephritis - T - focal necrotizing, pauci-immune GN.
- Neg ANCA - F - see ans 3. However in limited forms of the disease (eg subsets in which upper respiratory tract disease predominates and renal involvement is absent, up to 40% may be ANCA negative.
- Granulomatosis of upper and lower resp tracts - T - see ans 1.
