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| 名称： | |
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- 甲状腺腺瘤
| 以下是引用shihuaiy 在2007-4-14 15:06:00的发言：
按我们科的标准来说，此例要诊断乳头状癌。 可能不同的单位诊断乳头状癌掌握的标准不同，乳头状癌的形态特点有很多，毛玻璃样核是其中之一，诊断需要综合判断。月儿觉得此例无毛玻璃样核吗？（月儿千万不要不高兴啊，绝对是善意讨论）。愿与月儿及大家继续讨论。 |
呵呵，石老师您见笑拉，月儿怎么会不高兴呢，有石老师您的指正，高兴还来不及呢。再看，那些拉长的腺体足够拉，毛玻璃核也是，不知道是我的眼睛骗了我，还是我的电脑骗了我，呵呵。谢谢石老师！
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zhongshihua 离线
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| 以下是引用shihuaiy 在2007-4-14 15:06:00的发言：
可能不同的单位诊断乳头状癌掌握的标准不同，乳头状癌的形态特点有很多，毛玻璃样核是其中之一，诊断需要综合判断。 |
Papillary thyroid carcinoma is the most common thyroid malignancy, and most cases can be readily diagnosed on fine needle aspiration. It is so common that all pathologists have to be very familiar with its cytologic features. Ground glass nuclei (also known as watery clear nuclei or orphan Annie's eye) are one important diagnostic feature of papillary thyroid carcinoma, but they are not the only criterion. In addition to ground glass nuclei, a variety of other features need to be looked for during cytologic examination. Findings in favor of papillary thyroid carcinoma include nuclear enlargement, hypercellularity (on aspiration cytologic smears), abundant papillary structures, epithelial crowding, intranuclear cytoplasmic pseudoinclusions, nuclear grooves and abnormal nuclear chromatin pattern (could be clear or clumpy with or without nucleoli).
In a resected thyroid specimen, gross and microscopic pathology of papillary thyroid carcinoma vary from case to case. It can be microscopic and multifocal, invisible to naked eye gross inspection. On the other hand, it can be large and irregularly shaped with light pink-tan, firm, gritty, focally fibrotic cut surfaces with infiltrative borders. It could also be nodular and encapsulated. In rare cases, papillary thyroid carcinoma can be mostly cystic which makes cytologic diagnosis based on fine needle aspiration very difficult. In general, fibrotic scarring with gritty cut surfaces (this usually correlates with calcification such as formation of psammoma bodies) in any part of the lesion, thick fibrotic capsule around a firm nodule and, rarely, grossly appreciated papillary growths (similar to the appearance of chorionic villi in curetted products of conception) within the lesion are worrisome signs suspicious for papillary thyroid carcinoma.
Microscopically, papillary architecture can be seen either diffusely (as in this case) or just focally. Importantly, some cases of papillary thyroid carcinoma may not show any papillary architectural growth pattern and the correct diagnosis relies mainly on recognition of cytologic details. The classic example for this is the follicular variant of papillary thyroid carcinoma. This commonly underdiagnosed entity often does not display papillary architecture. Instead, they often are comprised of small or microfollicles. Follicular epithelia are more crowded than normal, and have enlarged nuclei, clear or granular nuclear chromatin, and often densely eosinophilic inspissated colloid. Mitotic figures, when found readily, are helpful in making this diagnosis. Needless to say, fine needle aspiration of follicular variant of papillary thyroid carcinoma is difficult to interpret.
Lastly, I wish to emphasize a few exceptions to the accepted rules. Papillary architectural growth pattern is not unique to papillary thyroid carcinoma. It can be seen focally in some cases of nodular hyperplasia (also known as colloid goiter or adenomatoid nodule), and may be present diffusely in hyperthyroidism of Graves disease (thyrotoxicosis). Secondly, psammoma bodies found in the thyroid gland are not unique to papillary thyroid carcinoma. I have seen them in rare cases of benign conditions, such as nodular hyperplasia. Lastly, finding abundant macrophages indicative of focal cystic change does not rule out papillary thyroid carcinoma. This is especially tricky on fine needle aspiration specimens, i.e., do not stop looking for atypical malignant follicular epithelia in a background of abundant macrophages on smears.
聞道有先後,術業有專攻
fibrotic scarring with gritty cut surfaces (this usually correlates with calcification such as formation of psammoma bodies) in any part of the lesion, thick fibrotic capsule around a firm nodule and, rarely, grossly appreciated papillary growths (similar to the appearance of chorionic villi in curetted products of conception) within the lesion are worrisome signs suspicious for papillary thyroid carcinoma。
why the three signs are worrisome?
when we see the sign any of the three, we should conside PTC or exclude PTC?
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本帖最后由 于 2007-04-15 18:22:00 编辑
翻译不当之处，请mjma老师以及各同仁批评指正！
甲状腺乳头状癌是最常见的甲状腺恶性肿瘤，大部分病例可以容易的在细针穿刺下得到诊断。因为常见，每一个病理医生都必须熟练掌握其细胞学特征。毛玻璃核Ground glass nuclei (有人也称之为空化核或孤儿Annie 的眼睛)是甲状腺乳头状癌的一项具有诊断意义的重要的特征，但是并非是唯一标准。在细胞学诊断时，除了毛玻璃核，还需要寻找一系列其它特征。支持该诊断的其它发现包括核增大、细胞增多（在针吸细胞涂片上）、大量乳头结构、上皮拥挤、核内假包涵体、核沟以及异常核染色质（空化或块状染色质，具有或不具有核仁）等。
在切除甲状腺标本中，大体和镜下病理特点可以各不相同。它可以非常微小和多灶性，致肉眼检查难以发现。另一方面，也可以巨大、形状不规则，切面示浅粉到褐色、质硬、有沙砾感、局部纤维化和浸润性边界。它也可以是多结节状且包膜完整。少数情况下，甲状腺乳头状癌呈现大部分囊性结构，导致细针穿刺细胞学诊断的困难。通常情况下，病变的任何部分出现纤维瘢痕和切面沙砾感（这常与钙化如沙砾体形成有关）、质硬结节周围出现厚的纤维包膜以及在一些少见病例中肉眼即可观察到的病变内明显的乳头状生长方式（类似于妊娠的刮出物中的绒毛）都是都是怀疑甲状腺乳头状癌的有力线索。
显微镜下，乳头状结构可以广泛存在（如本例）或仅在局部出现。关键是一些甲状腺乳头状癌根本看不到乳头状结构，此时，乳头状癌的诊断就主要依赖于细胞学特征了。典型的例子就是甲状腺乳头状癌的滤泡变异型，其常不显示乳头状结构，而是由小或微滤泡构成。滤泡上皮比正常更加拥挤，增大的核、空化或颗粒样染色质，常伴有嗜酸的浓染胶质。核分裂像活跃则更支持该诊断。毫无疑问，细针穿刺对甲状腺乳头状癌滤泡变异型的诊断是非常困难的。
最后，我想强调几项公认的规律。首先，乳头状结构生长方式不是甲状腺乳头状癌所独有。其可以在甲状腺结节性增生（或甲状腺肿以及腺瘤样结节）的局部出现，也可以在Graves病的甲状腺功能亢进（毒性甲状腺肿）中弥漫出现。（译者注：也可出现在Hashimoto甲状腺炎、柱状细胞癌和髓样癌中）。其次，沙砾体也不是甲状腺乳头状癌所独有。我在个别良性病例如结节性甲状腺肿内就曾看到过沙砾体。最后，具有局部囊性改变的病变中发现大量巨噬细胞不一定就意味着甲状腺乳头状癌。这在细针穿刺时要尤其注意不要被蒙蔽， 此时要继续在抹片的大量巨噬细胞中仔细寻找是否有非典型性的恶性滤泡上皮。
译者注：甲状腺乳头状癌滤泡变异型的诊断有以下标准：
1， 主要标准：卵圆形核；核拥挤重叠；空化核或核沟；沙砾体。
2， 次要标准：流产型乳头；明显伸长或不规则滤泡；深染胶质；核内假包涵体；滤泡腔内多核组织细胞。
大于等于3主要标准或2主要标准加上大于等于4次要标准即可诊断。- 境随心转
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liguoxia71 离线
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| 以下是引用liguoxia71 在2007-4-16 19:34:00的发言：
对不起,我是不懂就问的小学生,想问: "Lastly, finding abundant macrophages indicative of focal cystic change does not rule out papillary thyroid carcinoma."是否该译为"在局灶囊性变中发现大量巨噬细胞并不能排除甲状腺乳头状癌"?? |
滤泡内出现巨噬细胞（或组织细胞）是支持滤泡型甲状腺乳头状癌的一个次要标准。而囊性变中出现巨噬细胞也是常见现象。所以个人认为翻译成“在局灶囊性变中发现大量巨噬细胞并不意味着甲状腺乳头状癌”更贴切。
谢谢你的精益求精的精神，值得我们学习！
- 境随心转
