Thyroid

Background

Thyroid lesions may be investigated by fine needle aspiration followed by total thyroidectomies to remove benign tumours such as follicular adenomas or malignant neoplasms such as papillary, follicular, medullary and anaplastic carcinomas. 1-3 Expertise in endocrine pathology is required to distinguish pseudomalignant conditions that mimic thyroid cancers. 4,5

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Hyperplastic conditions (goitre) such nodular hyperplasia and Grave’s disease may also be treated by surgery. 6 Thyroidectomy may be required to compression symptoms that have not been resolved by medical treatment of thyrotoxicosis. Multinodular goitre and Hashimoto’s thyroiditis may also be treated by surgery for cosmetic reasons. 5,7

Parathyroid glands and lymph nodes may be included in resection specimens. Thyroids may be resected prophylactically where there is a high risk of familial medullary carcinoma on genetic testing. 8

Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

Fresh tissue received
  • No
    • Non-routine fixation (not formalin), describe.
  • Yes
    • Special studies required, describe.
    • Ensure samples are taken prior to fixation.
Intraoperative consultation
  • Not performed
  • Performed, describe type and result
    • Frozen section
    • Imprints/cytology
    • Other, describe

See general information for more detail on specimen handling procedures.

Inspect the specimen and dictate a macroscopic description.

External InspectionBack to top


Orientate and identify the anatomical features of the specimen.

Orientate the thyroid by identifying the isthmus which is located inferiorly to lateral lobes which have posterior concave surfaces. 1

Orientation markers

Record additional orientation or designation provided by operating clinician:

  • Absent
  • Present
    • Method of designation (e.g. suture, incision)
    • Featured denoted

Photograph the intact specimen if required.

Describe the following features of the specimen:

Procedure

Describe as stated by the clinician.

Orientate and identify the anatomical features of the specimen.

Options
  • Partial lobectomy
  • Lobectomy
  • Lobectomy with isthmusectomy (hemithyroidectomy)
  • Neat total thyroidectomy
  • Subtotal thyroidectomy
  • Total thyroidectomy
  • Completion thyroidectomy
  • Neck dissection See specific protocol
  • Other, describe

Anatomical components included (more than one may apply) and specimen dimensions (mm)

Describe and measure the components present.

Thyroid

  • Right lobe, in three dimensions
  • Left lobe, in three dimensions
  • Isthmus, in three dimensions

Parathyroid glands

  • Absent (or not identified)
  • Present, number. See specific parathyroid protocol for more detail.
  • Other, describe

Specimen weight (g)

Record the weight of the entire specimen.

Specimen laterality (if applicable)

  • Left
  • Right
  • Unoriented

Specimen integrity

  • Intact
  • Disrupted, describe

Thyroid capsule

  • Intact
  • Not intact

Describe the capsular surface and measure the maximum dimension (mm) of each area of abnormality.

  • Adhesions
  • Fibrotic
  • Purulent
  • Nodular
  • Tumour present

DissectionBack to top


Paint the relevant surgical margins with ink and record the colours applied.

Serially section the specimen transversely along the short axis at 3-4mm intervals. One suggested method is to retain orientation is to leave slices attached at lower edge rather than completely cutting through the specimen.1

After opening the specimen may require longer fixation in larger quantity of formalin.

Photograph the dissected specimen if required. An annotated photograph may be useful to facilitate block labelling.

Internal InspectionBack to top


Describe the cut surface appearance including the following items:

Focal lesions

  • Absent
  • Present

Multiple lesions

  • No
  • Yes
    • Number; if more than one tumour, designate and describe each tumour separately

Tumour location 1

  • Right lobe
    • Superior
    • Central
    • Inferior
  • Left lobe
    • Superior
    • Central
    • Inferior
  • Isthmus

Lesion size (mm)

  • Maximum dimension

Tumour description

  • Solid
  • Cystic 8

Borders 1

  • Encapsulated
    • Thin
    • Thick
  • Infiltrating

Distance of tumour to margins (mm)

  • Distance of tumour to nearest excision margin 1

Non-lesional tissue appearance

  • Colour
  • Consistency
  • Contour
  • Calcifications
Lymph nodes
Retrieved from resection specimen
  • Describe site(s)
  • Number retrieved

Separately submitted

  • For each container, record specimen number and designation
  • Collective size of tissue in three dimensions (mm)
  • Number of grossly identified lymph nodes submitted
  • Maximum diameter of each (mm)

ProcessingBack to top


Dissect the specimen further and submit sections for processing according to the illustrations provided.

There is no single universal method for sampling thyroid neoplasms. It is recommended that tissue is widely sampled between the nodule and adjacent capsule and thyroid tissue. Areas of thickened capsule, fleshy cut surface, pale or very solid areas are considered suspicious.1

No focal lesion

Submit representative sections of:

  • Each lobe, at least three sections
  • Isthmus, at least one section
  • Multinodular thyroid gland
  • Each nodule, at least one section including rim and adjacent normal gland
  • Submit sections from all foci of white-cream tissue (as they may represent cancer) 1
Solitary encapsulated follicular nodule
  • < 30mm in maximum dimension, submit the entire lesion 1
  • >30mm in maximum dimension, alternate serial sections 2 or one section per 10mm of lesion 1, including sections demonstrating relationship with margins
  • Submit entire capsule demonstrating relationship with adjacent tissue
  • Non-lesional tissue, two further blocks from in each lobe and one from the isthmus
Suspected invasive cancer

For suspected invasive cancer i.e. papillary, medullary or undifferentiated carcinoma 1

  • <20mm, submit all tumour tissue
  • >20mm, at least one section per 10mm of tumour
  • Non-lesional tissue -three further sections from each lobe and one from the isthmus

It may be considered necessary to submit all tissue from suspected medullary carcinomas. 1 Other rare inflammatory conditions are occasionally encountered that may require more extensive sampling of the thyroid.

Completion thyroidectomy

Submit all foci of white-cream tissue 1 (if present). Alternatively submit all tissue for processing. 2

Submit all lymph nodes and parathyroid glands, if present. 1

Record details of each cassette.

An illustrated block key similar to those provided may be useful.

Block allocation keys 

No focal lesion
Cassette id
Site
No. of pieces
A-C
Right lobe
 
D-F
Left lobe
 
G
Isthmus
 
H-J
Nodules, if applicable, including rim and normal gland
 
K-L
White-cream foci, if applicable
 
M+
Lymph nodes, if applicable
 
 
Parathyroids, if applicable
 
Solitary encapsulated follicular nodule
Cassette id
Site
No. of pieces
A-C
Lesional tissue, all sections or representative sections (see above)
 
D-E
Lesion demonstrating relationship with margins
 
F-G
Capsule demonstrating relationship with adjacent tissue
 
H-I
Non-lesional tissue, representative sections
 
J+
Lymph nodes, if applicable
 
 
Parathyroids, if applicable
 
Suspected invasive cancer
Cassette id
Site
No. of pieces
A-C
Lesional tissue, all sections or representative sections (see above)
 
D-E
Lesion demonstrating relationship with margins
 
F-H
Non-lesional tissue, representative sections one from each lobe and the isthmus
 
I+
Lymph nodes, if applicable
 
 
Parathyroids, if applicable
 
Completion thyroidectomy
Cassette id
Site
No. of pieces
A-H
White-cream foci or all sections, as applicable
 
I+
Lymph nodes, if applicable
 
 
Parathyroids, if applicable
 

Acknowledgements

Prof Alfred Lam for his contribution in reviewing and editing this protocol.

ReferencesBack to top


  1. Lam A, Chan JKC, Chong G, Dahlstrom J, McNicol AM and Wight G. Thyroid cancer structured reporting protocol, The Royal College of Pathologists of Australasia, Surry Hills, NSW, 2011.
  2. Stephenson TJ and Johnson SJ. Dataset for thyroid cancer histopathology reports, The Royal College of Pathologists, London, 2014.
  3. Rosai J, Carcangiu ML and DeLellis RA. Tumors of the Thyroid Gland. Atlas of tumor pathology. Armed Forces Institute of Pathology, Washington DC, Third series, Fascicle 5, 1992.
  4. Al-Sam S, Lakhani SR and Davies JD (eds). A Practical Atlas of Pseudomalignancy: Benign Lesions Mimicking Malignancy, Hodder Arnold, London, 1998.
  5. Lloyd RV, Douglas BR and Young WF (eds). Endocrine Diseases: AFIP Atlas of Nontumor Pathology, American Registry of Pathology and Armed Forces Institute of Pathology, Washington, 2002.
  6. Wheeler MH. Primary hyperparathyroidism: a surgical perspective. Ann R Coll Surg Engl 1998;80(5):305-312.
  7. Milne D, Johnson SJ, Stephenson T and Poller D. Tissue pathways for endocrine pathology, The Royal College of Pathologists, London, 2012.
  8. British Thyroid Association Royal College of Physicians. Guidelines for the management of thyroid cancer, Report of the Thyroid Cancer Guidelines Update Group, (Perros P, ed) Royal College of Physicians, London, 2007.