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Thyroid & Parathyroid: Click sections headings below (in blue) to expand or collapse the content
Diagnostic Headings (i.e. specimen & procedure)
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Diagnostic |
Headings |
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Thyroid gland, total thyroidectomy: |
Thyroid gland, right lobe and isthmus, hemilobectomy: |
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Thyroid gland, right lobe, thyroidectomy: |
Right neck, level ___ content, neck dissection: |
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Mid esophagus, biopsy: |
Thyroid gland and central neck contents, total thyroidectomy and neck dissection: |
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Thyroid gland, left lobe, completion lobectomy: |
Thyroid gland, right lobe and isthmus, hemithyroidectomy: |
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Dx. Menu -- Wording of Common Abnormalities
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This subsection lists key diagnostic line for the most common diseases in this organ / system. Copy the relevant line(s) by clicking on the button and paste to your report to construct your own report. |
Nearly Normal and :
-- No diagnostic abnormality.
-- No parathyroid gland tissue or lymph node is present.
-- No thyroid or lymphoid tissue identified.
-- No carcinoma or follicular neoplasm identified.
-- Two benign reactive lymph nodes negative for malignancy (0/2).
-- A portion of benign thymic tissue (0.6 cm measured on slides).
Benign Non-neoplastic Nodules and Cysts:
-- Multiple colloid nodules (nodular goiter) and hyperplastic follicular nodules.
-- Hypercellular, microfollicular nodular hyperplasia.
-- A large colloid nodule with focal cystic degeneration and fibrosis.
-- A small thyroglossal duct cyst.
-- Dyshormonogenic goiter.
Neoplastic:
-- Papillary thyroid carcinoma, ___ variant (see Tumor Synopsis).
-- Follicular adenoma (___ cm).
-- Follicular thyroid carcinoma (see Tumor Synopsis).
-- Medullary thyroid carcinoma (see Tumor Synopsis).
-- Undifferentiated (anaplastic) carcinoma (see Tumor Synopsis).
Inflammation and Others:
-- Chronic lymphocytic thyroiditis.
-- Focal previous procedure site changes (old hemorrhage, fibrosis and dystrophic calcification) .
-- Dx Heading above font = 04Heading; Style = 04DxHeadings.
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Clinical scenario: .
Thyroid gland, right lobe and isthmus, hemithyroidectomy:
-- No diagnostic abnormality.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: 42-yo woman with 2 nodules in one lobe, 2.5 cm in greatest dimension.
Thyroid gland, right lobe and isthmus, hemithyroidectomy:
-- Colloid nodules (nodular goiter) with focal adenomatoid follicular hyperplasia.
-- Focal old hemorrhage, fibrosis and dystrophic calcification consistent with previous procedure site changes.
-- Small unremarkable parathyroid gland (0.7 cm measured on slide).
-- No lymph node identified.
-- No malignancy or significant thyroiditis.
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: . test new
Thyroid gland, total thyroidectomy:
-- Multiple colloid nodules (nodular goiter), ___ to ___ cm.
-- Prominent stellate hyalinized fibrosis (scar) and dystrophic calcifications.
-- No inflammation or carcinoma is identified.
-- No parathyroid tissue or lymph node is present.
Slides examined: H&E x __
CPT code: 88304 x __, 88305 x __, 88307 x __
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .test new
Thyroid gland, total thyroidectomy:
-- Bilateral hyperplastic (adenomatous) follicular nodules (___ – ___ cm).
-- Prominent fibrosis and old hemorrhage consistent with previous procedure site changes.
-- Severe lymphocytic thyroiditis.
-- No carcinoma is identified.
-- No parathyroid gland or lymph node is present.
Slides examined: H&E x __
CPT code: 88304 x __, 88305 x __, 88307 x __
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: . test new
Thyroid gland, right lobe and isthmus, hemithyroidectomy:
-- A hyperplastic/adenomatous nodule, ___ cm, completely excised.
-- Recent previous procedure site changes.
-- One small benign reactive lymph node (0/1).
-- No parathyroid gland is identified.
-- No thyroid gland epithelial neoplasm is identified.
Slides examined: H&E x __
CPT code: 88304 x __, 88305 x __, 88307 x __
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: 45-year old female, Hx/ papillary thyroid carcinoma of left lobe, s/p lobectomy.
Thyroid gland, right lobe, completion thyroidectomy/lobectomy:
-- Small colloid nodules, 3 mm in greatest dimension.
-- One small intrathyroid parathyroid gland, 3 x 1 mm measured on slides.
-- No (residual) carcinoma is identified.
-- No lymph node identified.
Slides examined: H&E x __
CPT code: 88304 x __, 88305 x __, 88307 x __
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: 42-yo woman with a 3.5-cm nodule.
Thyroid gland, right lobe, lobectomy:
-- A large colloid nodule with focal cystic degeneration and fibrosis.
-- No parathyroid or lymphoid tissue identified.
-- No carcinoma.
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Thyroid gland, total thyroidectomy:
-- Benign microfollicular nodular hyperplasia.
-- Mild intrathyroidal lymphocytic infiltrate with occasional germinal center formation.
-- No parathyroid gland or lymph node.
-- No carcinoma identified.
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Thyroid gland, left lobe, lobectomy:
-- Hypercellular, microfollicular nodular hyperplasia.
-- Two small benign perithyroid lymph nodes (0/2).
-- No parathyroid tissue identified.
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
Such colloid nodules may resemble follicular adenoma on cytological material obtained via fine needle aspiration.
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Clinical scenario:
Thyroid gland, total thyroidectomy:
-- Papillary thyroid carcinoma, ___ variant, both right and left lobes (see Tumor Synopsis).
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
To prepare "Synoptic Report" with an on-line tool, go to Home page and click on Tumor Reporting. It usually takes less than 30% of the time required by routine dictation method.
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Clinical scenario:
Thyroid gland, total thyroidectomy:
-- Bilateral papillary thyroid carcinoma (0.1 cm in the right and 1.7 cm in the left lobe), follicular variant, involving inked posterior resection margin in left lobe (see Tumor Synopsis).
-- Metastatic papillary thyroid carcinoma in one of three lymph nodes (1/3).
-- Severe lymphocytic thyroiditis.
-- Previous biopsy site change.
-- No parathyroid gland identified.
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
Follicular cells in or adjacent to lymphocytic infiltrates tend to show cytologic changes (nuclear enlargement and "clearing") resembling those of papillary thyroid carcinoma. Stay away from the area with lymphocytic infiltrates when assessing cytologic features for papillary thyroid carcinoma.
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Clinical scenario:
Thyroid gland, total thyroidectomy:
-- Papillary thyroid carcinoma with prominent Hürthle cell changes (see Tumor Synopsis).
-- Previous biopsy site change.
-- No parathyroid gland or lymph node identified.
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
Reportedly, Hürthle cell carcinoma and tumor with significant Hürthle cell changes have poor capability to enrich iodide. They are poor responder to radio-iodide therapy.
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Clinical scenario:
Thyroid gland, total thyroidectomy:
-- Papillary thyroid carcinoma, follicular variant with marked capsular fibrosis (see Tumor Synopsis).
-- Previous biopsy site change.
-- No parathyroid gland or lymph node identified.
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
Recent literature seem to indicate that follicular variant of papillary thyroid carcinoma with thick fibrous capsule rarely metastasis.
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Clinical scenario:
Thyroid gland, right lobe and isthmus, hemilobectomy:
-- Hyalized scar with several well-formed psammoma bodies (see Note).
-- Multiple colloid nodules and mild lymphocytic thyroiditis.
-- One small parathyroid gland (0.5 cm measured on histologic slides).
-- No carcinoma identified on all examined tissue sections.
Note: No carcinoma is found in this thyroid specimen that is submitted entirely for histologic examination. Multiple additional levels of the tissue block with the psammoma bodies is examined. It has been reported that greater than 80% of surgically resected thyroid gland and perithyroid lymph nodes with well-formed psammoma bodies harbor papillary thyroid carcinoma (see ref.).
Reference:
Jennifer L. Hunt and E. Leon Barnes: Non–Tumor-Associated Psammoma Bodies in the Thyroid. Am J Clin Pathol. 119:90-94, 2003.
Editor's comment:
This is a good example why "No evidence of carcinoma." should NOT be used in report. According to the study cited, psammoma body is a clue to existence of papillary thyroid carcinoma and should prompt further work -up.
Follicular Adenomas and Hürthle Cell Nodules
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Clinical scenario: .
Thyroid gland, total thyroidectomy:
-- Large adenomatous nodule (___ cm) with calcifications, fibrosis and central degenerative changes (___ lobe).
-- Colloid nodules (___ lobe).
-- No carcinoma is identified.
-- No parathyroid or lymphoid node is present.
Slides Examined: H&E x __
CPT code: 88304 x __, 88305 x __, 88307 x __
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Thyroid, left lobe and isthmus, left thyroid lobectomy:
-- Follicular adenoma (2.2 cm) with central degenerative changes, completely excised.
-- Multiple colloid nodules.
-- Two benign reactive lymph nodes.
-- No malignancy is identified.
-- No parathyroid tissue is present.
Slides Examined: H&E x __
CPT code: 88304 x __, 88305 x __, 88307 x __
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario:
Thyroid gland, left lobe, hemithyroidectomy:
-- Follicular adenoma (dominant nodule)
-- Colloid nodules (nodular goiter) with focal lymphocytic infiltrates, favor nonspecific thyroiditis.
-- One small benign perithyroid lymph node.
-- No carcinoma is identified.
-- No perithyroid gland tissue is present.
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario:
Thyroid gland, left lobe, hemithyroidectomy:
-- Follicular adenoma with biopsy/procedure site changes (superior portion).
-- Nodular goiter with focal microfollicular hyperplasia.
-- One small parathyroid gland (0.3 cm).
-- No carcinoma identified.
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario:
Thyroid gland, total thyroidectomy:
-- One adenomatoid nodule / follicular adenoma (2 cm).
-- Multiple colloid nodules (nodular goiter) with focal microfollicular nodular hyperplasia.
-- One small parathyroid gland (5 mm), unremarkable.
-- Two small benign lympho nodes (0/2).
-- No carcinoma identified.
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: 59-yo woman with mass lesion; hx/ right breast cancer, s/p lumpectomy 2 years ago; s/p chemoradiation therapy.
Right superior parathyroid, parathyroidectomy:
-- Hypercellular parathyroid gland, favor adenoma (see Note).
Note: Although not characteristic histologically, the changes most likely represent an adenoma if no other parathyroid gland is involved and there is no known causes (esp., renal diseases) for the hyperparathyroidism. Clinical correlation is recommended.
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Thyroid gland, total thyroidectomy:
-- Adenomatoid follicular nodule with extensive Hürthle cell changes.
-- Multiple colloid nodules (nodular goiter).
-- No carcinoma.
-- One small extra thyroid lymph node negative for metastasis (0/1).
-- No parathyroid gland.
Slides examined: H&E x X
CPT code: 8830X x X
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Thyroid gland, right lobe, hemithyroidectomy:
-- Follicular adenoma (2.8 cm), Hürthle cell type.
-- No carcinoma or inflammation is identified.
-- No parathyroid or lymph node tissue is identified.
Slides examined: H&E x 8
CPT code: 88307 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Thyroid gland, left lobe, lobectomy: (outside slide SP-07-1234)
-- Thyroid follicular adenoma (3.1 cm) with extensive oncocytic (Hürthle cell) changes.
-- No diagnostic features of malignancy are identified.
-- No parathyroid tissue or lymph node is present.
Slides Examined: H&E x 15
CPT code: 883?? x 1
Editor's comment:
The CPT code for outside consult case is different.
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Clinical scenario: .
Thyroid gland, right lobe and isthmus, hemithyroidectomy:
-- Hürthle cell/oncocytic adenoma (__ cm).
-- Focal prominent lymphocytic thyroiditis and reactive follicular epithelial atypia.
-- No tumor is present at the inked capsular and isthmic margins.
-- No parathyroid gland or lymph node is present.
Slides Examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Thyroid gland, total thyroidectomy:
-- One hyperplastic Hürthle cell (oncocytic) nodule (0.9 cm) associated with old hemorrhage, fibrosis and histiocytic reaction consistent with previous biopsy site changes, right lobe.
-- Small colloid nodules.
-- One small intrathyroidal parathyroid gland, 2 mm measured on slide, right inferior lobe.
-- No carcinoma is identified.
-- No lymph node is present in this specimen.
Slides Examined: H&E x 16
CPT code: 88307 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario:
Thyroid gland, total thyroidectomy:
-- Follicular thyroid carcinoma (see Tumor Synopsis).
-- Multiple colloid nodules (nodular goiter) and hyperplastic follicular nodules.
-- Previous procedure site changes associated with both benign and tumor components.
-- No metastatic carcinoma in three small peri-thyroid lymph nodes (0/3).
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
To prepare "Synoptic Report" with an on-line tool, go to Home page and click on Tumor Reporting. It usually takes less than 30% of the time required by routine dictation method.
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Clinical scenario:
Thyroid gland, left lobe, hemithyroidectomy:
-- Minimally invasive follicular thyroid carcinoma with focal capsular invasion (see Note).
-- No vascular invasion.
Note: In the experiences of Chernobyl Pathologists Group, this is best considered as follicular neoplasm of uncertain malignant potential. Some experts believe that vascular invasion is more reliable than (minimal) capsular invasion in predicting bad outcome.
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario:
Thyroid gland, total thyroidectomy:
-- Medullary thyroid carcinoma, left lobe (see Tumor Synopsis).
-- No parathyroid gland or lymph node identified.
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
The main differential diagnosis should include poorly differentiated thyroid carcinoma. Immunohistochemical stain for calcitonin is very helpful and is generally considered the defining marker for thyroid medullary carcinoma.
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Clinical scenario: 46-year old woman. s/p right thyroidectomy for papillary carcinoma .
Thyroid gland, left lobe, completion lobectomy:
-- A single minute medullary thyroid carcinoma (1.5 mm), confined in the thyroid lobe, incidental finding.
-- Focal patchy mild lymphocytic thyroiditis.
-- One benign reactive lymph nodes negative for metastasis (0/1).
-- All margins are free of the tumor.
-- No (residual) papillary thyroid carcinoma identified.
-- No parathyroid gland is present.
Slides examined: H&E x X
CPT code: 8830X x X
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Clinical scenario: 45-yo woman with hypothyroidism.
Thyroid gland, total thyroidectomy:
-- Chronic lymphocytic thyroiditis (Hashimoto thyroiditis).
-- A colloid nodule with previous procedure site changes.
-- No prominent fibrosis or granuloma.
-- No carcinoma or follicular neoplasm identified.
-- Two benign reactive lymph nodes negative for malignancy (0/2).
-- One small parathyroid gland with no significant abnormality (4 mm measured on slides).
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
Main differential diagnosis includes lymphoma and papillary thyroid carcinoma. Follicular cells in or adjacent to lymphocytic infiltrates tend to show cytologic changes (nuclear enlargement and "clearing") resembling those of papillary thyroid carcinoma.
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Clinical scenario: .
Inferior pole right thyroid lobe, partial thyroidectomy:
-- Prominent lymphocytic thyroiditis.
-- Focal cholesterol clefts, foreign body giant-cell reaction and fibrosis, consistent with previous procedure site changes.
-- No malignancy is identified.
-- No parathyroid gland or lymph node is present.
Slides examined: H&E x __
CPT code: 88304 x __, 88305 x __, 88307 x __
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Left thyroid lobe and isthmus, left thyroid lobectomy:
-- Lymphocytic thyroiditis with prominent colloid nodules (nodular goiters).
-- One small parathyroid gland (1 mm).
-- One benign extrathyroidal lymph node.
-- No malignancy is identified.
Slides examined: H&E x __
CPT code: 88304 x __, 88305 x __, 88307 x __
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Thyroid gland, total thyroidectomy:
-- Chronic thyroiditis with multiple intrathyroidal lymphoid germinal centers.
-- Small nodular goiters.
-- No granulomas, adenomatous change or neoplasia.
-- No parathyroid tissue is identified.
-- One small extrathyroidal reactive lymph node.
Slides examined: H&E x __
CPT code: 88304 x __, 88305 x __, 88307 x __
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: 47-yo woman with a hard thyroid nodule.
Thyroid gland, total thyroidectomy:
-- Fibrous thyroiditis (Riedel struma).
-- Focal occlusive lymphoplasmacytic phlebitis.
-- No dense lymphoid aggregate with germinal center or granuloma.
-- No carcinoma or follicular neoplasm identified.
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
Riedel struma is considered a (thyroid) form of so called "IgG4-associated autoimmune disease" characterized by fibrosing inflammation rich in IgG4-positive plasma cells and lymphoplasmacytic phlebitis. Demonstrating IgG4-positive plasma cells not only support this diagnosis but also help exclude lymphoma and late-stage Hashiboto thyroiditis.
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Clinical scenario: .
Thyroid, total thyroidectomy:
-- Diffuse hyperplastic goiter consistent with Graves disease (diffuse toxic goiter).
-- No malignancy is identified.
-- No parathyroid tissue or lymph node is present.
Slides examined: H&E x __
CPT code: 88304 x __, 88305 x __, 88307 x __
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: .
Thyroid, total thyroidectomy:
-- Diffuse lymphocytic thyroiditis consistent with treated Graves disease.
-- Small colloid nodules.
-- No carcinoma is identified.
-- No lymph node or parathyroid tissue is present.
Slides examined: H&E x __
CPT code: 88304 x __, 88305 x __, 88307 x __
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario:
Thyroid gland, total thyroidectomy:
-- Patchy prominent papillary hyperplasia with colloid depletion, suggestive of treated hyperthyroidism.
-- No prominent inflammatory infiltrate, fibrosis or granuloma.
-- No carcinoma or follicular neoplasm identified.
-- Two benign reactive lymph nodes negative for malignancy (0/2).
-- One small parathyroid gland with no significant abnormality (4 mm measured on slides).
-- A portion of benign thymic tissue (0.6 cm measured on slides).
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
Thyroglossal Duct Cyst and Branchial Cleft Cyst
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Clinical scenario: 21-year old woman with a thyroid nodule noted for 2 months. r/o cancer.
Specimen designated as "Thyroid nodule", resection:
-- Thyroglossal duct cyst.
-- No diagnostic abnormality in adjacent thyroid follicles.
-- No inflammation, granuloma or carcinoma.
Slides examined: H&E x 2
CPT code: 88305 x X
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
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Clinical scenario: 12-year old boy. Neck cyst.
Neck cyst, resection:
-- Benign cyst with acute and chronic inflammation and fragments of espiratory and squamous epithelium consistent with thyroglossal duct cyst.
-- No lymphoid aggregates or granuloma.
-- No diagnostic abnormality in overlying skin.
Slides examined: H&E x 2
CPT code: 88305 x X
Editor's comment:
Occasionally, it can be difficult to distinguish thyroglossal duct cyst from branchial cleft cyst histologically. However, thyroglossal duct cyst is almost always in central neck and lacks lymphoid aggregates.
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Clinical scenario: 16-year old girl with a right neck mass.
Specimen designated as " right neck mass", excision:
-- Branchial cleft cyst.
-- No inflammation, granuloma or lymph node (architecture).
Slides examined: H&E x 2
CPT code: 88305 x X
Editor's comment:
Be careful with lesion from a middle-aged or elder patient, esp. cyst with lining exclusively composed of squamous cells. Metastatic squamous cell carcinoma to a neck lymph node is more common than branchial cleft cyst in adults.
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Clinical scenario: .
Thyroid gland, total thyroidectomy:
-- ‘Black thyroid’ (diffuse prominent pigment deposition secondary to tetracycline or minocycline therapy).
-- No psammoma body or carcinoma.
Note: 02958203.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
The"black thyroid" occurs almost exclusively in patients who ingest minocycline. The melanin-like pigments lack autoimmune fluorescence, iron deposits, or lipofuscin after bleaching with potassium permanganate. However, attention should not be distracted by this rare extraordinary finding since at least two studies suggest that papillary thyroid carcinoma occurs in much higher frequency in "black thyroid" than in general population (30% v.s. 0.003%). Carefully search for malignancy esp. in areas devoid of the pigment!
Reference:
C. Birkedal et al.: Minocycline-induced black thyroid gland: Medical curiosity or a marker for papillary cancer? J. Surg Edu. 58(5):470–471, 2001.
D.A. Hecht et al.: Black thyroid: A collaborative series. Otolaryngology - Head and Neck Surgery 121(3): 293-296, 1999.