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    Thyroid lesions may be investigated by fine needle aspiration followed by partial or 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

    Enlarged thyroid gland (goitre) due to hyperplastic conditions such as such nodular hyperplasia and Grave’s disease may also be treated by surgery.6 Thyroidectomy may be required to treat compression symptoms that have not been resolved by medical treatment.  Multinodular goitre and Hashimoto’s thyroiditis may also be treated by surgery for cosmetic reasons or to investigate a suspicious nodule within the thyroid gland.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  specimen description as designated on the container.

    Record the clinical notes including all relevant previous history and treatment. Note the receipt of fresh tissue, requests for special studies and any intraoperative consultant performed.

    Inspect the specimen and dictate a macroscopic description.

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

    External Inspection

    Orientate and identify the anatomical features of the specimen.

    Orientate the thyroid by identifying the isthmus which is located inferiorly to the two lateral lobes which have concave surfaces posteriorly. The lobes tend to taper superiorly.1,9

    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:


    Describe as stated by the clinician.

    Orientate and identify the anatomical features of the specimen.

    • Partial lobectomy
    • Lobectomy
    • Lobectomy with isthmusectomy (hemithyroidectomy)
    • 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.


    • 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


    Paint the entire throid gland surgical margins with ink and record the colours applied.

    Serially section the specimen transversely from superior to inferior 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 Inspection

    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 location1

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

    Lesion size (mm)

    • Maximum dimension

    Tumour description

    • Solid or cystic
    • Colour
    • Consistency8


    • Encapsulated
      • Thin
      • Thick
    • Infiltrating

    Distance of tumour to margins (mm)

    • Distance of tumour to nearest excision margin1

    Non-lesional tissue appearance

    • Colour
    • Consistency
    • Contour
    • Calcifications

    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)


    • Describe any adjacent tissue such as fat, skeletal muscle, and parathyroid glands, and note any extension of tumor into these tissues.9


    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

    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
      • Additional sections to be submitted from nodules with thick capsules or heterogeneous appearance.9
      • Submit sections from all foci of white-cream tissue (as they may represent cancer)1

    These thyroids are often small and any tumours present may be difficult to detect macroscopically. It is therefore common practice to submit all thyroid tissue including the isthmus for processing.2 Immunohistochemistry for Calcitonin will assist in identifying medullary carcinoma and the presence of C cell hyperplasia.2

    • < 30mm in maximum dimension, submit the entire lesion1
    • >30mm in maximum dimension, alternate serial sections2 or one section per 10mm of lesion1
    • Regardless of the size of the lesion, submit the entire capsule demonstrating relationship with adjacent tissue
    • Non-lesional tissue, two further blocks from in each lobe and one from the isthmus

    For suspected invasive cancer i.e. papillary, medullary or undifferentiated carcinoma1

    • <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.

    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

    Cassette id
    No. of pieces
    Right lobe
    Left lobe
    Nodules, if applicable, including rim and normal gland
    White-cream foci, if applicable
    Lymph nodes, if applicable
    Parathyroids, if applicable
    Cassette id
    No. of pieces
    Lesional tissue, all sections or representative sections (see above)
    Lesion demonstrating relationship with margins
    Entire capsule demonstrating relationship with adjacent tissue
    Non-lesional tissue, representative sections
    Lymph nodes, if applicable
    Parathyroids, if applicable
    Cassette id
    No. of pieces
    Lesional tissue, all sections or representative sections (see above)
    Lesion demonstrating relationship with margins
    Non-lesional tissue, representative sections one from each lobe and the isthmus
    Lymph nodes, if applicable
    Parathyroids, if applicable
    Cassette id
    No. of pieces
    White-cream foci or all sections, as applicable
    Lymph nodes, if applicable
    Parathyroids, if applicable



    Prof Alfred Lam, Prof Jane Dahlstrom and A/Prof Kais Kasem for their contribution in reviewing and editing this protocol.


    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.
    9. Lester, S. C. Manual of Surgical Pathology E-Book, Elsevier Health Sciences, 2010.

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      Thyroid right lobe dissected

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      RCPA | 24 March 2016

      Thyroid description and dissection

      Thyroid description and dissection

      RCPA | 24 March 2016

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