1. Endocrine Pathology Lab
April 3, 2014

2. Case 1: Q1: Please describe the following gross and microscopic thyroid

3. Case 2 CHIEF COMPLAINT: “I have a lump in my neck”
HISTORY: The patient is a 42-year-old female who noticed a painless lump in her neck about a month ago. It has not seemed to increase or decrease in size.
She has no chronic medical problems and has had no surgeries.
She takes no medications.
Her father and mother are alive and well. She is an only child.
She has no diarrhea or constipation, no heat or cold intolerance, stable weight, no change in skin or hair texture.

4. PHYSICAL EXAMINATION:
A painless 3cm mass is palpated in the left neck. The mass moves when the patient swallows and seems contiguous with the thyroid gland. The remainder of the thyroid gland is normal. There is no cervical or supraclavicular lymphadenopathy. The remainder of the physical exam is unremarkable.

5. Q1: What is the main clinical problem and differential diagnosis?

6. Q2: Based on the given data, is the patient clinically euthyroid, hyperthyroid, or hypothyroid?

7. Lab Data
TSH ( uu/mL)

8. Iodine uptake scan Cold nodule left upper thyroid gland
Most benign and virtually all malignant thyroid
nodules concentrate iodine radioisotopes less
avidly than adjacent normal thyroid tissue
These nodules appear “cold” and generally
require further evaluation by FNA
Cold nodule left upper thyroid gland
Remainder of thyroid uptake is normal.

9. Fine Needle Aspiration
“Follicular Neoplasm”

10. Q4: Discuss the term Follicular Neoplasm, differential, and distinguishing features

11. Q5: Describe gross findings

12. Q6: Describe the histopathology

13. Q7: Compare and contrast the histopathology seen here
Normal Thyroid
Follicular Adenoma of the thyroid

14. Q8: What is your diagnosis?

15. Q9: Correlate the clinical findings with the pathology

16. Q10: Discuss the term“Toxic” Follicular adenomas

17. Case 3 CHIEF COMPLAINT: Routine physical.
HISTORY: 55-year-old woman presents for an annual physical exam. She feels well and has no concerns except that perhaps her cholesterol might be high due to dietary indiscretion.
She has no chronic medical problems and has had no surgeries.
She takes no medications.
She is adopted and does not know of her family history.

18. PHYSICAL EXAMINATION:
A painless 2.5 cm nodule is palpated in the left thyroid gland. There is an enlarged, nontender 2cm left cervical lymph node. Exam is otherwise unremarkable.

19. Q1: What is the main clinical problem and differential diagnosis?

20. Diagnostic work-up Normal TSH
“Cold” thyroid nodule on iodine uptake scan
FNA
Results of above lead to Thyroidectomy

21. Q2: Identify organ and describe gross findings

22. Q3: Describe the histopathology findings

23. What is your diagnosis? Papillary carcinoma
The most common thyroid carcinoma
About half of cases will have metastasis to cervical lymph nodes at the time of a diagnosis

24. Q4: What is gene is involved in the pathogenesis of this condition?

26. Other genes
BRAF
Encodes a signaling intermediary in MAP kinase pathway
33-50% papillary thyroid cancers have activating mutation in BRAF gene

27. Q5: What are the clinical implications of gene mutations in carcinoma?

28. Case 4
CHIEF COMPLAINT: “I’ve been feeling tired and cold all the time”
HISTORY: 60-year-old previously healthy woman presents with fatigue and cold intolerance. She has had about 10 pound weight gain over the past 6 months which she attributes to inactivity. She is being treated for hypertriglyceridema with gemfibrozil. She started taking laxatives about 3 months ago for constipation. She does not smoke or drink alcohol.

29. PHYSICAL EXAMINATION:
Alert and oriented female
Pulse 61, BP 150/90
Thyroid gland is diffusely enlarged. No nodules are palpated. No cervical LAD is present.
Lung, heart, and abdominal exams are unremarkable.

30. Q1: What are the main clinical problems and differential diagnosis?

31. Diagnostic evaluation
TSH ( uu/mL)
Free T ( ng/dL)

32. Q2: Etiologies of Primary Hypothyroidism?

33. Q3: Identify organ, which one is normal?

34. Q4: Please describe the histopathology

35. Q5: What is your diagnosis?

36. Q6: What is the primary immunologic defect in this entity?

37. Q7: Clinical Course?

38. Case 5
HISTORY year-old female presents for physical exam. She has not seen a physician in many years. She feels well except for some mild dyspnea on exertion. She has no chest pain, no leg edema, no weight loss or weight gain, no heat or cold intolerance, no palpitations, no difficulty swallowing. She has no known chronic medical problems. She had an appendectomy at age 15. She takes no medications.

39. PHYSICAL EXAMINATION:
Well-developed, pulse 72, BP 112/64. Both lobes of the thyroid gland are enlarged. Several small, bilateral nontender thyroid nodules are palpated. Exam is otherwise unremarkable.

41. Q1: What is the main clinical problem and differential diagnosis?

42. Q2: Based on history and physical, what do you expect serum TSH to be?

43. Thyroid Ultrasound

44. Q3: Identify the organ and describe pathologic changes

45. Q4: Describe the histopathology

46. Q5: What is your diagnosis?

47. Q6: Clinical Manifestations of this condition?

48. Goiter Causing
Tracheal
compression