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Update to the College of American Pathologists reporting on thyroid carcinomas.

Ghossein R - Head Neck Pathol (2009)

Bottom Line: While there are defined criteria for invasion, there is not universal agreement in what constitutes capsular invasion, angioinvasion and extrathyroidal invasion.These findings assist clinicians in their assessment of the recurrence risk and potential for metastatic disease.Large meticulous clinico-pathologic and molecular studies with long term follow up are still needed in order to increase the impact of microscopic examination on the prognosis and management of TC.

View Article: PubMed Central - PubMed

Affiliation: Department of Pathology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, 10065, New York, NY, USA. ghosseir@mskcc.org

ABSTRACT

Background: The reporting of thyroid carcinomas follows the recommendations of the College of American Pathologists (CAP) protocols and includes papillary carcinoma, follicular carcinoma, anaplastic carcinoma and medullary carcinoma. Despite past and recent efforts, there are a number of controversial issues in the classification and diagnosis of thyroid carcinomas (TC) that, potentially impact on therapy and prognosis of patients with TC.

Discussion: The most updated version of the CAP thyroid cancer protocol incorporates recent changes in histologic classification as well as changes in the staging of thyroid cancers as per the updated American Joint Commission on Cancer staging manual. Among the more contentious issues in the pathology of thyroid carcinoma include the defining criteria for tumor invasiveness. While there are defined criteria for invasion, there is not universal agreement in what constitutes capsular invasion, angioinvasion and extrathyroidal invasion. Irrespective of the discrepant views on invasion, pathologists should report on the presence and extent (focal, widely) of capsular invasion, angioinvasion and extrathyroidal extension. These findings assist clinicians in their assessment of the recurrence risk and potential for metastatic disease. It is beyond the scope of this paper to detail the entire CAP protocol for thyroid carcinomas; rather, this paper addresses some of the more problematic issues confronting pathologists in their assessment and reporting of thyroid carcinomas.

Conclusion: The new CAP protocol for reporting of thyroid carcinomas is a step toward improving the clinical value of the histopathologic reporting of TC. Large meticulous clinico-pathologic and molecular studies with long term follow up are still needed in order to increase the impact of microscopic examination on the prognosis and management of TC.

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Vascular invasion (VI): Schematic drawing for the interpretation of the presence or absence of VI. The diagram depicts a follicular neoplasm (green) surrounded by a fibrous capsule (blue). a Bulging of tumor into vessels within the tumor proper does not constitute VI. b Tumor thrombus covered by endothelial cells in intracapsular vessel qualifies as VI. c Tumor thrombus in intracapsular vessel considered as VI since it is attached to the vessel wall. d Although not endothelialized, this tumor thrombus qualifies for VI because it is accompanied by a fibrin thrombus. e Endothelialized tumor thrombus in vessel outside the tumor capsule represents VI. f Artefactual dislodgement of tumor manifesting as irregular tumor fragments into vascular lumen unaccompanied by endothelial covering or fibrin thrombus. Modified from: Chan JKC Reprinted with permission [3]
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Fig2: Vascular invasion (VI): Schematic drawing for the interpretation of the presence or absence of VI. The diagram depicts a follicular neoplasm (green) surrounded by a fibrous capsule (blue). a Bulging of tumor into vessels within the tumor proper does not constitute VI. b Tumor thrombus covered by endothelial cells in intracapsular vessel qualifies as VI. c Tumor thrombus in intracapsular vessel considered as VI since it is attached to the vessel wall. d Although not endothelialized, this tumor thrombus qualifies for VI because it is accompanied by a fibrin thrombus. e Endothelialized tumor thrombus in vessel outside the tumor capsule represents VI. f Artefactual dislodgement of tumor manifesting as irregular tumor fragments into vascular lumen unaccompanied by endothelial covering or fibrin thrombus. Modified from: Chan JKC Reprinted with permission [3]

Mentions: While the criteria for capsular invasion are quite controversial, there is currently relatively good consensus on what constitutes lymph-vascular invasion. The majority of authors agree that lymph-vascular invasion should involve capsular or extra-capsular vessels (Fig. 2). These images (Fig. 2) depict intracapsular LVI with endothelialized thrombus, tumor thrombus with fibrin, and tumor thrombus attached to vessel wall. The tumor thrombus should protrude into the lumen and needs to be covered by endothelial cells (Fig. 2b). However, endothelialization is not a requirement if the tumor is attached to the vessel wall (Fig. 2c) or admixed with a fibrin thrombus (Fig. 2d). The point of attachment of the tumor to the vessel wall has to be identified for some authorities [7] to assure that free floating tumor artifactually displaced by the surgeon or the pathologist are not misinterpreted as LVI. Tumor in intra-tumoral or subcapsular vessels does not qualify for LVI and should not be interpreted as such (Fig. 2a).Fig. 2


Update to the College of American Pathologists reporting on thyroid carcinomas.

Ghossein R - Head Neck Pathol (2009)

Vascular invasion (VI): Schematic drawing for the interpretation of the presence or absence of VI. The diagram depicts a follicular neoplasm (green) surrounded by a fibrous capsule (blue). a Bulging of tumor into vessels within the tumor proper does not constitute VI. b Tumor thrombus covered by endothelial cells in intracapsular vessel qualifies as VI. c Tumor thrombus in intracapsular vessel considered as VI since it is attached to the vessel wall. d Although not endothelialized, this tumor thrombus qualifies for VI because it is accompanied by a fibrin thrombus. e Endothelialized tumor thrombus in vessel outside the tumor capsule represents VI. f Artefactual dislodgement of tumor manifesting as irregular tumor fragments into vascular lumen unaccompanied by endothelial covering or fibrin thrombus. Modified from: Chan JKC Reprinted with permission [3]
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2807537&req=5

Fig2: Vascular invasion (VI): Schematic drawing for the interpretation of the presence or absence of VI. The diagram depicts a follicular neoplasm (green) surrounded by a fibrous capsule (blue). a Bulging of tumor into vessels within the tumor proper does not constitute VI. b Tumor thrombus covered by endothelial cells in intracapsular vessel qualifies as VI. c Tumor thrombus in intracapsular vessel considered as VI since it is attached to the vessel wall. d Although not endothelialized, this tumor thrombus qualifies for VI because it is accompanied by a fibrin thrombus. e Endothelialized tumor thrombus in vessel outside the tumor capsule represents VI. f Artefactual dislodgement of tumor manifesting as irregular tumor fragments into vascular lumen unaccompanied by endothelial covering or fibrin thrombus. Modified from: Chan JKC Reprinted with permission [3]
Mentions: While the criteria for capsular invasion are quite controversial, there is currently relatively good consensus on what constitutes lymph-vascular invasion. The majority of authors agree that lymph-vascular invasion should involve capsular or extra-capsular vessels (Fig. 2). These images (Fig. 2) depict intracapsular LVI with endothelialized thrombus, tumor thrombus with fibrin, and tumor thrombus attached to vessel wall. The tumor thrombus should protrude into the lumen and needs to be covered by endothelial cells (Fig. 2b). However, endothelialization is not a requirement if the tumor is attached to the vessel wall (Fig. 2c) or admixed with a fibrin thrombus (Fig. 2d). The point of attachment of the tumor to the vessel wall has to be identified for some authorities [7] to assure that free floating tumor artifactually displaced by the surgeon or the pathologist are not misinterpreted as LVI. Tumor in intra-tumoral or subcapsular vessels does not qualify for LVI and should not be interpreted as such (Fig. 2a).Fig. 2

Bottom Line: While there are defined criteria for invasion, there is not universal agreement in what constitutes capsular invasion, angioinvasion and extrathyroidal invasion.These findings assist clinicians in their assessment of the recurrence risk and potential for metastatic disease.Large meticulous clinico-pathologic and molecular studies with long term follow up are still needed in order to increase the impact of microscopic examination on the prognosis and management of TC.

View Article: PubMed Central - PubMed

Affiliation: Department of Pathology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, 10065, New York, NY, USA. ghosseir@mskcc.org

ABSTRACT

Background: The reporting of thyroid carcinomas follows the recommendations of the College of American Pathologists (CAP) protocols and includes papillary carcinoma, follicular carcinoma, anaplastic carcinoma and medullary carcinoma. Despite past and recent efforts, there are a number of controversial issues in the classification and diagnosis of thyroid carcinomas (TC) that, potentially impact on therapy and prognosis of patients with TC.

Discussion: The most updated version of the CAP thyroid cancer protocol incorporates recent changes in histologic classification as well as changes in the staging of thyroid cancers as per the updated American Joint Commission on Cancer staging manual. Among the more contentious issues in the pathology of thyroid carcinoma include the defining criteria for tumor invasiveness. While there are defined criteria for invasion, there is not universal agreement in what constitutes capsular invasion, angioinvasion and extrathyroidal invasion. Irrespective of the discrepant views on invasion, pathologists should report on the presence and extent (focal, widely) of capsular invasion, angioinvasion and extrathyroidal extension. These findings assist clinicians in their assessment of the recurrence risk and potential for metastatic disease. It is beyond the scope of this paper to detail the entire CAP protocol for thyroid carcinomas; rather, this paper addresses some of the more problematic issues confronting pathologists in their assessment and reporting of thyroid carcinomas.

Conclusion: The new CAP protocol for reporting of thyroid carcinomas is a step toward improving the clinical value of the histopathologic reporting of TC. Large meticulous clinico-pathologic and molecular studies with long term follow up are still needed in order to increase the impact of microscopic examination on the prognosis and management of TC.

Show MeSH
Related in: MedlinePlus