This article will help you read and understand your pathology report for Hurthle cell carcinoma of the thyroid gland.
by Jason Wasserman, MD PhD FRCPC, updated December 24, 2020
The thyroid is a U-shaped gland located in the front of the neck. The normal thyroid gland is divided into right and left lobes that are connected in the middle by the isthmus. Some people also have another small lobe above the isthmus called the pyramidal lobe.
The thyroid gland makes thyroid hormone. Most of the cells in the thyroid gland are called follicular cells. The follicular cells connect together to form small round structures called follicles. Thyroid hormone is stored in a material called colloid which fills the centre of follicles.
Hurthle carcinoma is a type of thyroid cancer. It develops from the follicular cells normally found in the thyroid gland. This type of cancer is more likely to develop in older adults and it is rarely seen in children.
Patients with Hurthle cell carcinoma may notice a growth or lump in the front of their neck. An ultrasound performed may show one or more nodules in the thyroid gland.
Most tumours are separated from the normal surrounding thyroid gland by a thin tissue barrier called a capsule. Overtime, some of the capsule may disappear and large tumours may not have any capsule at all.
The diagnosis of Hurthle cell carcinoma can only be made after the entire tumour is examined by a pathologist. When viewed under the microscope, the cells in a Hurthle cell carcinoma can look very similar to the cells in a non-cancerous type of thyroid tumour called a called Hurthle cell adenoma. The only difference between a Hurthle cell carcinoma and a Hurthle cell adenoma is that the tumour cells in a Hurthle cell carcinoma have broken through the capsule and have entered the surrounding normal thyroid gland. Pathologists describe this as capsular invasion. In contrast, all of the abnormal cells in a Hurthle cell adenoma are separated from the normal thyroid gland by the capsule.
Because the entire capsule needs to be examined, the diagnosis of Hurthle cell carcinoma can only be made after the tumour has been removed and sent to a pathologist for examination under the microscope.
A fine needle aspiration (FNA) is a procedure which removes a small amount of thyroid tissue. This tissue is then examined by a pathologist under the microscope.
The tumour cells in a fine needle aspiration tissue sample are larger and more pink than normal, healthy follicular cells. Words that pathologists use to describe these cells include granular, eosinophilic, or oncocytic. Hurthle cells often have round nuclei with a single large nucleolus.
The tumour cells may be seen in groups, connected together as follicles, or as single cells. Most tumours also contain less colloid than the normal thyroid gland.
The fine needle aspiration pathology report will describe the tumour as a Hurthle cell neoplasm, a category which includes both Hurthle cell carcinoma and Hurthle cell adenoma.
This is the size of the tumour measured in centimetres (cm). The tumour is usually measured in three dimensions but only the largest dimension is described in your report. For example, if the tumour measures 4.0 cm by 2.0 cm by 1.5 cm, your report will describe the tumour as being 4.0 cm. Tumour size plays an important role in determining the pathologic tumour stage for Hurtle cell carcinoma (see Pathologic stage below).
Most Hurtle cell carcinomas are at least partially separated from the normal, healthy thyroid gland by a thin layer of tissue called a capsule. In order to make the diagnosis of Hurthle cell carcinoma, your pathologist must see the tumour cells spreading past the capsular into the surrounding normal thyroid gland. This is called capsular invasion.
Hurthle cell carcinoma can show two patterns of invasion:
Widely invasive tumours are more likely to spread to lymph nodes and other parts of the body. The spread of tumour cells to a lymph node or other body site is called metastasis.
Blood vessels carry blood around the body. Tumour cells that enter a blood vessel are able to spread to distant parts of the body such as the lungs and bones. The movement of tumour cells to another part of the body is called a metastasis.
Tumour cells seen inside of a blood vessel is called vascular invasion (angioinvasion). If vascular invasion is seen, your pathologist will count the number of vessels that contain tumour cells.
Your report will describe vascular invasion as negative if no cancer cells are seen inside of a blood vessel, positive and focal if there are less than 4 blood vessels with cancer cells, and positive an diffuse if there are 4 or more blood vessels with cancer cells.
Lymphatics are small thin vessels that provide a way for fluids and cells to leave a tissue. Lymphatics are found all over the body. Tumour cells that enter a lymphatic vessel are able to spread to other parts of the body, in particular lymph nodes.
Tumour cells seen inside a lymphatic vessel is called lymphatic invasion. Your pathologist will carefully examine your tissue for lymphatic invasion. If lymphatic invasion is seen, it will be called positive. If no lymphatic invasion is seen, it will be called negative.
Extrathyroidal extension is the movement of tumour cells out of the thyroid gland and into the surrounding tissues. Tumour cells that move far enough out of the thyroid gland may come into contact with additional structures such as muscles, the esophagus, or the trachea.
There are two types of extrathyroidal extension:
Macroscopic (gross) extrathyroidal extension increases the tumour stage (see Pathologic stage below) and is associated with worse prognosis. Microscopic extrathyroidal extension does not change the tumour stage.
A margin is the tissue that has to be cut by the surgeon to remove the thyroid gland from your body. A margin is considered positive when there are cancer cells at the very edge of the cut tissue. A negative margin means there were no cancer cells seen at the cut edge of the tissue.
Lymph nodes are small immune organs located throughout the body. Tumour cells can travel from the thyroid to a lymph node through lymphatic channels located in and around the tumour (see Lymphatic invasion above). The movement of tumour cells from the thyroid to a lymph node is called a metastasis.
Lymph nodes from the neck are sometimes removed at the same time as the thyroid in a procedure called a neck dissection. The lymph nodes removed usually come from different areas of the neck and each area is called a level. The levels in the neck are numbered 1 through 7. Your pathology report will often describe how many lymph nodes were seen in each level sent for examination.
Lymph nodes on the same side as the tumour are called ipsilateral while those on the opposite side of the tumour are called contralateral.
Your pathologist will carefully examine each lymph node for tumour cells. Lymph nodes that contain tumour cells are often called positive while those that do not contain any cancer cells are called negative. Most reports include the total number of lymph nodes examined and the number, if any, that contain cancer cells.
A group of cancer cells inside of a lymph node is called a tumour deposit. If a tumour deposit is found, your pathologist will measure the deposit and the largest tumour deposit found will be described in your report.
All lymph nodes are surrounded by a capsule. Extranodal extension (ENE) means that tumour cells have broken through the capsule and spread into the tissue that surrounds the lymph node.
The pathologic stage for Hurthle cell carcinoma is based on the TNM staging system, an internationally recognized system originally created by the American Joint Committee on Cancer.
This system uses information about the primary tumour (T), lymph nodes (N), and distant metastatic disease (M) to determine the complete pathologic stage (pTNM). Your pathologist will examine the tissue submitted and give each part a number. In general, a higher number means more advanced disease and worse prognosis.
Tumour stage (pT) for Hurthle cell carcinoma
Hurthle cell carcinoma is given a tumour stage between 1 and 4 based on the size of the tumour and the presence of tumour cells outside of the thyroid (see Extrathyroidal extension above).
Nodal stage (pN) for Hurthle cell carcinoma
Hurthle cell carcinoma is given a nodal stage of 0 or 1 based on the presence or absence of tumour cells in a lymph node and the location of the involved lymph nodes.
Metastatic stage (pM) for Hurthle cell carcinoma
Follicular carcinoma is given a metastatic stage of 0 or 1 based on the presence of tumour cells at a distant site in the body (for example the lungs). The metastatic stage can only be determined if tissue from a distant site is sent for pathological examination. Because this tissue is rarely sent, the metastatic stage cannot be determined and is listed as MX.