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ER Week 1 > Thyroid Pathology > Flashcards

Thyroid Pathology Flashcards

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1
Q

WHere does the thyroid come fom embryologically?

A

pharyngeal epithelium!

It travels down the thyroglossal duct to get into the neck

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2
Q

What are things that go wrong in this embryology?

A

you can get a lingual thyroid in the tonge

you can get thyroglossal duct cysts

malformations with thymus in the thyroid or parathyroids in the thyroid

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3
Q

What does the hypothalamus release to the pituitary to stimualte the thyroid

A

TRH

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4
Q

What does the pituitary use to stimualte the thyroid?

A

TSH

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5
Q

What are the two things TSH makes the thyroid do?

A
  1. makes it synthesize and release hormone

2. makes it grow

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6
Q

What does T4 do?

A

brain development
bone growth
beta-adrenergic effects
BMR increase

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7
Q

If T4 is high, TSH is ____

A

low (negative feedback)

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8
Q

If TSH is normal, the thyroid is ____

A

fine. period.

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9
Q

Which is a more sensitive test - TSH or T4?

A

TSH.

because a small change in T4 elicits a big change in TSH. if someone is becoming hyper or hypothyorid, the T4 will look like it’s still in the normal range, but TSH will go wacky right away.

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10
Q

If you have high T4 and low TSH, what is it?

A

you know it’s hyperthyroidism (high T4)

TSH SHOULD be low with high T4, so that means it’s primary hyperthyroidism.

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11
Q

If you have higher T4 and high TSH?

A

You know that the pituitary isn’t responding appropriately to the high T4, so you know it’s sdcondary hyperthyroidism (with an issue in the pituitary)

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12
Q

Low T4 and high TSH?

A

low T4 = hypothyroidism

and the TSH shoul dbe high in response, so primary hypothyroidism

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13
Q

Low T4 and low TSH?

A

the TSH should be high in response, bu it’s not = secondary hypothyroidism

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14
Q

If the T4 is normal, but the TSH is low?

A

subclinical hyperthyroidism

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15
Q

If the T4 is normal but TSH is high?

A

subclinical hypothyroidism

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16
Q

If the TSH is normal, but the T4 is high or low?

A

the test probably got messed up - reorder it

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17
Q

What antibody tests can you look for when evaluating the thyroid?

A

anti=peroxidase Ab
anti-thyroglobulin Ab
anti-TSH Ab

note - can either look in the serum or take a biopsy of the thyroid and stain for them

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18
Q

What is radioiodine scanning?

A

you use a radioactive iodine, inject it into the blood

it will go to the thyroid and then you can take an image of it - helps identify nodules that are cancerous - but doesn’t tell you for sure. so just do a biopsy

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19
Q

What’s the difference between a hot nodule and a cold nodule?

which is more likely cancer?

A

hot nodules makes hormone
cold nodule doesn’t

most cancers are cold, but not all cold nodules are cancer

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20
Q

What is hyperthyroidism?

A

a hypermetabolic state caused by increased thyroid hormone

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21
Q

What are some of the findings of hyperthyroidism?

A

jittery
weight loss, heat intolerance
rapid pulse, arrhythmias,
tremor, emotional lability, warm and moist skin, diarrhea, lid lag

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22
Q

What is a thyroid storm?

A

happens in patients who aren’t well controlled

if they get sick or stressed, the thyroid can just release all the T4 that it has - bad news - can kill the patient with heart arrhythmias

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23
Q

What are the thre most common causes of hyperthyroidism?

A

Graves disease
Multinodular goiter
Thyroid adenoma

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24
Q

What are the uncommon causes of hyperthyroidism?

A 
thyroiditis
drugs
thyroid carcinoma
pituitary adenoma
struma ovarii
factitious - taking hormone
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25
Q

WHat is hypothyroidism?

A

a hypometabolic state caused by decreased thyroid hormones

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26
Q

What are the signs and symptoms of hypothyroidism?

A

fatigue, weight gain, col dintolerance, slow pulse, impaired muscle contraction, delayed reflexes, lethargy, rough and dry skin, hair loss, reduced appetite, constpiation, deepend voice, “edema”,

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27
Q

What is myxedema?

A

Myxedema is NOT edema becaus eyou don’t have fluid fuilding up in the tissue

instead, the tissue is full of other substances like ground substance - they accumulate in the tissue and make them look swollen

can happen anywhere - legs, face, throat (hoarse voice)

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28
Q

How about a myxedema coma?

A

opposite of a thyroid storm

suddenly stop secreting anything - heart can stop and mental functioning drops to the point of coma

often in elderly female during cold weather, but can be anyone with hypothyroid

has NOTHING to do with the myxedema. and not everyone who gets the coma has myxedema - in fact, most don’t

myxedema is just an old term that was used for hypotyroidism.

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29
Q

What are potential causes of congenital hypothyroidism?

A

iodine deficiency

rarely genetic problems

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30
Q

What is the treatment for congenital hypothyroidism?

A

thyroid hormone replacement

but prevention is better! Fortified salt!

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31
Q

WHat are the two common causes of ACQUIRED hypothyroidism?

A

hashimoto thyroiditis

iatrogenic

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32
Q

What are the uncommon causes of acquired hypothyroidism?

A 
goiter
infiltrative stuff
too much iodine
secondary hypothyroidism
tertiary hypothyroidism
other thyroiditis
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33
Q

What is thyroiditis?

A

inflammation of the thyroid gland

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34
Q

Which gender gets thyroiditis more often?

A

females

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35
Q

What will happen with radioactive iodine uptake in thyroiditis?

A

decrease

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36
Q

What are the four types of thyroiditis?

A
  1. Hashimoto
  2. DeQuervain
  3. Silent
  4. Reidel
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37
Q

What is the most common thyroiditis?

A

hashimoto’s

it is SUPER common

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38
Q

True or false: hashimotos is very painful

A

false - painless

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39
Q

Does hashimotos lead to hypothyroidism or hyperthyroidism?

A

hypothyroidism

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40
Q

Which toy story character is Hashimoto thyroiditis?

A

Mrs. Potatohead

female “hash” who’s big - because they get myxedema and when you push your finger into her there won’t be an indent (non-pitting)

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41
Q

What anti-thyroid antibody test will usually be positive in Hashimoto thyroiditis?

A

anti-peroxidase antibody

but the anti-TSH can be positive too

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42
Q

What does Hashimoto thyroiditis look like grossly?

A

It’s big, firm and pale (whereas it’s usually beefy and red)

it’s pale because of all the white cells

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43
Q

What does Hashimoto thyroiditis look like microscopically

A

Tons of lymphocytes (true of all the thyroiditises)

whopping infiltrate - often makes germinal centers (can look like a lymph node)

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44
Q

What are the characteristic cells seen on histology in Hashimoto thyroiditis?

A

Hurthle cells

these are follicular cells that become reactive and respond to the infiltrate and injury by becoming big and pink with granular cytoplasm

this is totally specific for hashimotos

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45
Q

What do T cells do in Hashimoto thyroiditis?

A

they attack the thyroid cells and stimulate B cells to be unwitting accomplices (make anti-TSH receptor antibody, anti-thyroglobulin antibody, and anti-peroxidase antibody)

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46
Q

What is another name for Dequervain Thyroiditis?

A

Granulomatous thyroiditis

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47
Q

Is Dequervain thyroiditis painful?

A

yup - makes a big and sore thyroid

comes on suddenly too, so it can be quite scary

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48
Q

What will be in the recent medical history for DeQuervain Thyroiditis?

A

a recent viral URI

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49
Q

Does DeQuervain make hypothyroidism or hyperthyroidism?

A

hyperthyroidism early on

50
Q

True or false: DeqUervain thyroiditis is usually self-limiting.

A

true

51
Q

What toy story character is Dequervain thyroiditis?

A

Rex - he looks scary, but he’s actually harmless

52
Q

What will DeQuervain thyroiditis look like microscopically?

A

there will be a lymphoid infiltrate

multinucleated giant cells too

53
Q

Why does Dequervain make hyperthyroidism?

A

because it damages follicles which allows colloid to leak out

54
Q

What is the foreign-body giant cell reaction to in DeQuervains?

A

the colloid in the extrafollicular space

55
Q

When does silent thyroiditis usually present?

A

post-partum or during middle age

56
Q

Does silent thyroiditis cause hypo or hyperthyroidism?

A

mild hyperthyroidism early on

57
Q

What toy story character is silent thyroiditis?

A

Bullseye - because he doesn’t talk

also doesn’t cause any real problems

58
Q

What will silent thyroiditis have on histology?

A

lymphoid infiltrate

other than that there are no characteristic findings. So if there is lymphoid infiltrate with no multi-nucleated giant cells and no germinal centers or hurthel cells, it’s probably silent

59
Q

What is the pathogenesis of silent thyroiditis?

A

We don’t really know, but probably immune.

Maybe inherited? HLA? Maybe some autoantibodies?

60
Q

What is the rarest thyroiditis we learned?

A

Reidel Thyroiditis

61
Q

How will reidel thyroiditis present? Hyper or hypo?

A

rock-hard neck mass

hypothyroidism

tracheal compression

62
Q

What is the other name for Reidel thyroiditis?

A

fibrosing thyroiditis

63
Q

Which toy story character is Reidel thyroiditis?

A

woody because pathologist will call it a woody mass due to all the fibrosis

64
Q

What will Reidel look like grossly?

A

just a really hard fir glob of scar tissue - it won’t look anything like a thyroid

65
Q

What will Reidel look like microscopically

A

you may see a few follicles, but it’s mostly lymphocytes and then tons of fibrosis

eventually the fibrosis will just take over the whole thing

66
Q

Describe the pathogenesis of Reidel THyroiditis.

A

we don’t really know

probably autoimmune

67
Q

What is the triad of Graves Disease?

A

hyperthyroidism
ophthalmopathy
dermopathy

68
Q

Describe the dermopathy you see in Graves.

A

It’s rough, scaly, thickened skin usually on the anterior lower legs

69
Q

What will happen with the radioactive iodine scan in the context of Graves Disease?

A

diffuse increased uptake

because it’s using all the iodine to make it’s excess hormone

70
Q

What will you see microscopically in Graves Disease?

A

it looks really busy

there are so many follicles working that they’ll sort of bulge into the colloid to make what looks like papillae

makes the colloid look scalloped

there will be so many cells that you’ll hardly be able to tell it’s thyroid

71
Q

What is the most common antibody found in Grabes disease?

A

anti-TSH receptor antibodies

72
Q

If there are antibodies against the TSH receptor, then why does Graves cause a hyperthyroidism?

A

because the antibodies are stimulating antibodies

73
Q

Do you get the opthalmopathy with other forms of hyperthyroidism, or just Graves?

A

it’s specific to graves because there are TSH receptors in the tissue behind the eye for some reason

so these activating antibodies bind there and cause all sorts of problems like inflammation and deposition of things like glycosaminoglycs ans and hyaluronic acid. this is what makes the eye bulge out

note - this is the same mechanism of the pre-tibial dermopathy (the pre-tibial fibrlblasts have TSH receptors0

74
Q

What are the treatments to decrease the symptoms of Graves>

What are the treatments fo decrease thyroid hormone synthesis?

A

Beta blockers or surgery if necessary

drugs to decreased thyroid hormone synthesis or ablation with 131-I or surgery

75
Q

What is a goiter?

A

just a term for a big thyroid gland

76
Q

In general, what are the two different causes of goiter?

A
  1. inflammatory (thyroiditis)

2. non-inflammatory (defective T4 synthesis)

77
Q

Why does decreased T4 productoin cause a goiter?

A

because the low T4 will make the pituitary keep releasing TSH. So TSH becomes elevated and essentially tries to whip the thyroid into action, making it grow and grow and grow

so if you have no iodine, you get a goiter

78
Q

At first the goiter is just a simple goiter, meaning it’s anormal shape, but big. What happens after a while though?

A

THe goiter will continually undergo the process of getting bigger. the follicle will try to make more hormone, so you get proliferation in some areas but no tin others so you have areas of hyperplasia and areas of involution

the follicles can rupture and the body will respond by laying down scar tissue

as this keeps happening, over time you’ll build nodules in the thyroid, which is called a multinodular goiter

79
Q

When you’re at the simple goiter stage, what will you T4 levels be?

A

euthyroid - the thyroid is able to compensate appropriately under the rule of the pituitary TSH increase

80
Q

WHen you’re at the multinodular goiter stage, what will your T4 levels be?

A

can be euthryoid, can be hyperfuncitoning nodules (hyperthyroid) or hypothyroid

81
Q

What will goiter look like on microsocpy?

A

you get hyperplasia of the follicles and involution where they don’t have their usually round shape anymore

82
Q

How do we typically treat a goiter?

A
  1. try levothyroxine

2. thyroidectomy

83
Q

Why should you beware of giving iodine to someone with a goiter?

A

they have a big thyroid, right? So if you suddenly give them iodine, they can use it to make TONs of T4. That’s bad because it can kill them with heart arrhythmias

84
Q

Nodules are super common. Most are _____

A

benign

85
Q

True or false: a nodule is more likelyto be cancer if the patient is female.

A

false - male

86
Q

True or false: a nodule is more likely to be cancer if it is solitary?

A

true

87
Q

True or false: a nodule is more likely to be cancer if it is cold.

A

true

hot nodules are never cancer (but most cold nodules are not cancer either)

88
Q

What medical history would make a thyroid nodule more likely to be cancer?

A

head or neck radiation

89
Q

What do we do if we feel a nodule?

A

we do a thyroid fine needle aspiration with cytopathology

90
Q

What are the three options for what a aspiration could show? Which ones would make you take the nodule out?

A
  1. cancer - take it out
  2. just follicles - take it out
  3. thyroiditis - treat it, leave the nodule in
91
Q

Why must you take a nodule out if the biopsy shows just follicles? Arent they supposed to be there?

A

ther eis a cancer of the thyorid called follicular caricnoma which would only show follicular cells on biopsy

92
Q

Which is by far more common for the thyroid: carcinoma or adenoma?

A

adenoma - like 10x more

93
Q

Will most patients with a thyroid adenoma be euthyroid, hypothyroid or hyperthyroid?

A

most are euthyroid
some are hyperthyroid

so TSH and T4 are usually normal and most adenomas are cold

94
Q

Are thyroid adenomas usually solitayr or multiple?

Do they have a capsule?

Can they invade?

A

usually solitary

encapsulated

no invasion

95
Q

Thyroid adenomas are never malignant, but can have mutations in what family?

A

G-protein gain of function mutation

96
Q

How can you tell the different between an adenoma and a follicular carcinoma?

A

adenoma wn’ tinvade the capsule

follicular carcinoma will

97
Q

What are the four differnt types of thyroid cracinoma in order of incidence?

A

papillary - 80%
follicular - 10%
medullary 5%
anaplastic - 5%

98
Q

What patient group gets papillary thyroid carcinoma?

A

females more than males

in their 30s-50s

99
Q

Where is metastasis common for papillary thyroid carcinoma?

A

local lymph nodes only - visceral metastasis is super rare

100
Q

What is the prognosis for papillary thyroid carinoma?

A

excellent

over 95% 10 year survival rate

101
Q

What will papillary thyroid carcinoma look like grossly?

A

you cut it open and you’ll see just a bunch of cystic structures

102
Q

What will a papillary thyroid carcinoma look like microscopically?

A

there will be chords of fibrovascular tissue which clearly appear papillary

103
Q

What type of cells are classsic for papillary carcinoma?

A

orphan annie nuclei

the nuclei will be optically clear, which is weird and look like orphan annie eyes

104
Q

What other deposit will you see microscopically in papillary carcinoma?

A

psammoma bodies

collections of calcium that form a concentric lamellated structure

105
Q

Describe the pseudoinclusion you see in papillary carcinoma.

A

the cytoplasm invaginates into the nucleus so it looks like there’s a bubble inside of it

106
Q

What else can you see invlving the nucleus besides pseudoinclusions in papillary carcinoma?

A

nuclear grooves - make the nucleus look like a coffee bean

107
Q

Why can papillary carcinoma be thought of as the litle orphan annie tumor?

A
  1. affects younger women
  2. tends to stay around for years iwthout getting any bigger
  3. usually well behaved and seldom kills people
  4. has nuclei that resemble her eyes
  5. has psammoma bodies (psammos = sand, her dog’s name is sandy)
108
Q

What patient group gets follicular thyroid carcinoma?

A

females more than males

in their 40s-50s

109
Q

If metastases are present in follicular htyroid carcinoma, where do they tend to be?

A

lung or bone

110
Q

What is the 10 year survival rate in a young patient with a small, minimally invasive tumor?

A

95%, so pretty good

but prognosis worsens with increasing age, tumor size and invasiveness

111
Q

What will follicular thyroid carcinoma look like?

A

you get a lot of follicular cells trying to make follicles, but failing

oftentimes it looks exactly like normal tissue or a thyroid adenoma, so that’s why you need to look for invsion into the capsule or a blood vessel within the capsule

112
Q

Medullary thyroid carcinoma is uncommon, but what is it a malignancy of?

A

C cells

113
Q

What patient population gets medullary thyroid carcinoma?

A

females more than males

in their 50s-60s

114
Q

True or false; most medullary thyroid carcinomas ar efamilial?

A

false

115
Q

What is the 10 year survival for medullary carcinoma htat is confined to the thyroid? How about if mets are present?

A

90% if confined to the thyroid

20% if distant mets are present

116
Q

What will you see microscopically in medullary thyroid carcinoma?

A

you’ll see a bunch of pink wtuff which is AMYLOID! Not colloid! So apple green birefringence on polarized light

also, the follicular cells will have salt and pepper appearing nuclei

117
Q

Anaplastic thyroid carcinoma is super rare. What patient group gets it?

A

females more than males

50-60s

118
Q

Describe how a anaplastic thyroid carcinoma presents?

A

it’s a bulky, fast-growing invasive neck mass

119
Q

Why does anaplatsic thyroid carcinoma have such a bag prognosis?

A

it’s uusally metastatic at diagnosis

less than 10% survival rate at 5 years

120
Q

What will an anaplastic thyroid carcinoma look like microscopically?

A

hardly anything - the cells won’t even try to form follicles

cells will just look ugly - lot of size differences

ER Week 1 (11 decks)

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