The significance of nuclear diameter in the biologic behavior of thyroid carcinomas: a retrospective study of 127 cases

Papillary Thyroid Carcinoma and Related Thyroid Neoplastic Lesions: A Light Microscopic Study with Emphasis on Nuclear Changes

A total of 187 thyroid lesions consisting of 2 cases of Grave's disease, 21 cases of multinodular goiter, 40 follicular adenomas and 124 low-grade papillary thyroid carcinomas were studied to identify intermediate neoplastic lesions in the spectrum of nuclear changes between benign reactive thyroid follicles and low-grade thyroid papillary carcinoma. The lesions were examined and classified on the basis of the following nuclear features: fine chromatin seen in the thyroid papillary carcinomas and coarse chromatin seen in follicular carcinomas. Cases with Hürthle cell changes were excluded from the study. Cases with nuclei containing coarse chromatin were classified in the group of follicular adenomas with a coarse chromatin pattern. The neoplastic thyroid lesions containing fine chromatin showed a spectrum of nuclear changes ranging between reactive follicular lesions and papillary thyroid carcinoma with lymph node metastasis. Such lesions were classified as follicular adenomas with a fine chromatin pattern. The nuclei of these lesions were graded into mild to marked "nuclear atypia with a fine chromatin pattern". The degree of atypia depended on the degree and extent of nuclear changes. Encapsulated follicular adenomas with a fine chromatin pattern and with mild atypia (11 cases), moderate atypia (13 cases), marked atypia (27 cases), and encapsulated or nonencapsulated papillary thyroid carcinoma were characterized by uniform nuclei; with mild, moderate and marked nuclear atypia in less than 2/3 of the cell population and marked nuclear atypia in more than 2/3 of the cell population; and measuring 5.4-6.3, 6.0-7.2, 6.3-9 and 7.2-10 microns in diameter, respectively. Follow-up of cases of papillary thyroid carcinoma fulfilling the above criteria showed lymph node metastasis in 33% of cases, whereas follicular adenomas with a fine chromatin pattern, including cases originally diagnosed as papillary carcinoma, showed no evidence of lymph node or distant metastasis in a follow-up period of 30 months to 15 years. In the thyroid tissue surrounding papillary thyroid carcinoma or encapsulated follicular adenoma with a fine chromatin pattern and marked atypia, adenomatous nodules with a fine chromatin pattern and with low-grade nuclear atypia were identified. The adenomatous nodules with a fine chromatin pattern and with mild, moderate and marked atypia showed architectural, cytoplasmic and nuclear features similar to those of follicular adenoma with a fine chromatin pattern of the same grade. Of interest, a large number of cases of follicular adenoma with a fine chromatin pattern had areas with features of follicular adenoma with a coarse chromatin pattern.

Benign Hürthle cell adenoma with papillary architecture: a benign lesion mimicking oncocytic papillary carcinoma

We studied the significance of encapsulated Hürthle cell thyroid nodules with papillary structures lacking the nuclear features of papillary thyroid carcinoma (PTC); 19 cases fulfilling these criteria were encountered The patients' ages ranged from 22 to 40 years (32+/-6), and the F:M ratio was 3:1 The tumors measured from 0.5-5 cm (2+/-1.1). The diameter of the tumor cell nuclei ranged from 5.6 to 7.2 microns. Many nodules had nuclei displaying a fine chromatin pattern somewhat resembling those of PTC, but these were present in <20% of the tumor cells. Immunohistochemically, there was reactivity for MIB-1 in the papillary structures, negativity to focally weak reactivity for HBME and galectin-3, and negativity to moderate diffuse reactivity for CK19. Clinical follow-up from 1 to 19 years revealed no evidence of metastases in any of the cases. It is unlikely that the papillary structures in the study cases represent degenerative changes in view of the proliferative activity we have demonstrated in them. In view of (1) the encapsulation and the uniformity of the constituent cells, (2) the negative or weak immunoreactivity for galectin-3 and HBME and negative to moderate immunoreactivity for CK19, and (3) the absence or paucity of nuclear criteria for the diagnosis of PTC and the absence of lymph node metastasis in all study cases, we believe that these lesions represent the papillary variant of oncocytic follicular adenoma (Hürthle cell adenoma). Recognition of this entity is important to avoid an overdiagnosis of oncocytic PTC.

Nuclear markers (star volume, mitotic index, AgNOR and Ki-67) of the primary tumor and its metastasis in non-small cell lung carcinomas

Although tumor growth is controlled by growth rate and cell cycle, it is also likely that the proliferative activity of tumor cells can influence the growth rate of the primary cancer and account for their aggressiveness. Variations in growth rate, cell cycle control and proliferative activity could, in part, explain differences in invasive and metastatic properties among non-small cell lung carcinomas (NSLC). The purpose of this report is to: (1) evaluate growth rate by using growth- and cell cycle-regulating markers (mitotic count, nuclear star volume, AgNOR, and Ki-67) as reflections of growth rate and (2) compare the indices of primary NSLC with the indices of their metastasis in a series of patients with advanced disease. Thirty-three patients with non-small cell lung cancer and hematogenous metastases were retrospectively studied by histochemical, immunohistochemical, and morphometrical investigations. Clinical variables were examined for differences in the frequency of histological subtypes, nuclear star volume, mitotic index, AgNOR area, and Ki-67 immunohistochemistry indices of expression in subgroups of patients stratified by primary tumor and hematogenic metastasis. The impact of these factors on overall follow-up was analyzed. In the samples available in this study, consisting of primary-met paired tumors, which are unique and rarely available for studies of lung cancer, we found that nuclear star volume and mitotic index in metastatic tumors were significantly higher than in the primary tumors. Although there was no significant difference between the Ki-67 index of metastatic and primary tumors, the Ki-67 index in metastatic brain tumors was significantly higher than in the corresponding primary tumors. Examination of Kaplan-Meier survival curves demonstrated that patients with metastatic tumors showing AgNOR area higher than 10.82 microm2 and nuclear star volume lower than 559.50 microm3 had approximately the same odds ratio (log rank of 4.16 and 3.25, p = 0.04 and 0.01, respectively) for survival with a median survival time equal to 17 months for both groups. Analysis of the remaining marker correlation had no impact on survival. We conclude that these results offer future possibilities for more complex studies, including the results of additional immunohistochemical analysis using molecular markers that are known to be important in regulating cell proliferation, e.g., cyclin D1, p27, and cyclin E. These would influence clinical decisions or different therapeutic approaches in advanced stage disease of non-small cell lung cancer.

Follicular adenoma with papillary architecture: a lesion mimicking papillary thyroid carcinoma

AIMS

The purpose of this study was to investigate the significance of 'benign' encapsulated follicular thyroid nodules with papillary structures.

METHODS AND RESULTS

Twenty-one cases of encapsulated neoplastic thyroid nodules with papillary structures and nuclear features not diagnostic of papillary thyroid carcinoma (PTC) were obtained. All cases were reviewed with particular attention to nuclear features (fine chromatin pattern, optical clearing, grooves and inclusions). Representative sections were submitted for measurement of the maximum diameter of 200 round or nearly round nuclei and for immunostaining for MIB1, CK19, HBME and Ret oncogene protein. Nine cases displayed scattered optically clear nuclei or nuclear grooves in less than 30% of total neoplastic cells. They were grouped in the category of thyroid nodules with limited nuclear features of papillary thyroid carcinoma (PTC), but not diagnostic of PTC. The other 12 cases had fine or coarse chromatin, but lacked other features of nuclei in PTC. The diameter of the nuclei ranged from 5.6 to 7.2 microm and were smaller than those of PTC (6.3-10.0 microm). Immunostaining revealed positive reactivity for MIB1 in the papillary structures. Immunostaining for CK19 and HBME varied from negative or focally weak to diffusely moderate reactivity. Ret oncogene protein immunostaining showed focal and weak reactivity in one case and was negative in other cases of the study. Clinical follow-up from 6 months to 15 years revealed no evidence of metastasis.

CONCLUSIONS

The papillary structures in the study cases are unlikely to represent degenerative changes due to their proliferative activity. In view of (i) the encapsulation and the uniformity of the constituent cells, (ii) the varying degrees of immunoreactivity for CK19 and HBME and negative immunoreactivity for Ret oncogene protein, and (iii) the absence or insufficiency of nuclear criteria for the diagnosis of PTC and the absence of lymph node metastasis in all study cases, we believe that these lesions represent the papillary variant of follicular adenoma. Recognition of this pathological entity is important to avoid an over-diagnosis of PTC.

A morphometric analysis of cytological features of tall cell variant and classical papillary carcinoma of the thyroid

In order to assess whether morphometric parameters could be of value in distinguishing between tall cell variant and classical pattern of thyroid papillary carcinoma, the fine needle aspiration cytology (FNAC) samples of 14 cases were analysed using Arcimage 5 software on an Acorn computer. Histological examination of the specimens allowe classification of nine of them as classical pattern and the remaining five as tall cell variants. The nuclear diameter (NDD) and standard deviation distribution (NDSDD), th nuclear area (NAD) and standard deviation distribution (NASDD), and the nuclear/cytoplasmic ratio (NCR) were assessed on May-Grunwald-Giemsa stained smears. Statistical analysis was performed by use of one-way analysis of variance (ANOVA) of the two groups as identified by histology. Whilst NDD (P = 0.007), NAD (P = 0.015) and NADSD (P = 0.026) all appeared statistically significant, NDSD (P = 0.06) and NCR (P = 0.71) were not. The cytological diagnosis of papillary carcinoma is established and reproducible, but morphometric data on the thyroid have so far focused on the differential diagnosis between benign and malignant nodules. The choice of simple morphometric parameters appears to be helpful in the preoperative distinction between the classical pattern and tall cell variant of papillary carcinoma.

Neoplastic non-papillary thyroid carcinoma lesions with a fine chromatin pattern

In papillary thyroid carcinoma (PTC) in cytological and surgical specimens, fine chromatin, nuclear grooves and nuclear pseudoinclusions are the hallmarks of diagnosis. We investigated the significance of these nuclear changes in neoplastic non-PTC lesions. Fine needle aspiration biopsies (FNAB) of thyroid lesions were reviewed with histologic correlation. Twenty-five low-grade PTC and 35 neoplastic non-PTC lesions with a fine chromatin pattern in cytology specimens were identified. These lesions were studied along with five multinodular goiters and five follicular adenomas with a coarse chromatin pattern. The neoplastic non-PTC lesions were selected from cases with a histopathologic diagnosis of follicular neoplasm (accompanied by cytopathologic examination) but lacking a coarse chromatin pattern. The nuclear changes were separated into three grades of nuclear atypia with a fine chromatin pattern, depending on the degree of nuclear enlargement and nuclear membrane thickening, or the presence of nuclear grooves or pseudoinclusions. Thyroid lesions with a higher grade of nuclear atypia with a fine chromatin pattern were associated with larger nuclei and more readily visible nucleoli. These lesions correlated histologically with PTC and follicular adenomas with a fine chromatin pattern. The latter could be divided into three grades: grade 1 lesions having a fine chromatin pattern similar to that of nuclei with open chromatin seen in areas of nodular goiter; grade 3 lesions having nuclear features closest to those of PTC; and grade 2 lesions showing intermediate changes. In conclusion, there is a spectrum of nuclear changes in neoplastic non-PTC lesions with a fine chromatin pattern. These lesions are often diagnosed as follicular adenomas in surgical pathology and pose cytopathologic diagnostic problems between nodular goiter, follicular adenoma and PTC. The significance of follicular adenomas with a fine chromatin pattern will be discussed.

Assessment of nuclear size, nuclear DNA content and proliferation index in stereotaxic biopsies from brain tumours

In this paper we study the feasibility of measuring the diverse biological parameters in stereotaxic biopsies from human brain lesions. These biological parameters are the nuclear area (NA), the proliferation index (PI) and the ploidy level, the latter of which was evaluated by means of the DNA index (DI) and histogram type (DHT). These parameters were assessed by means of the digital cell image analysis of Feulgen-stained nuclei. This analysis was performed on 124 samples from 22 computed tomography (CT)-guided stereotaxic biopsies. The data show that the methodology used here enables the above parameters to be assessed on small samples without limiting the classical anatomopathological diagnosis. The data also reveal that the DHT corresponded more accurately to the ploidy level in the sample analysed than the DI. Lastly, it appears that supratentorial astrocytic tumours of the adult, which constituted the majority of the cases analysed here, are strongly heterogeneous at a biological level.

Well differentiated follicular neoplasms of the thyroid: reproducibility and validity of a 'decision tree' classification based on nucleolar and karyometric features

This study was conducted on fine-needle aspirates of well differentiated follicular neoplasms of the thyroid. A 'decision tree' classification based on the percentage of nucleolated nuclei, percentage of nuclei with two or more nucleoli and mean major nuclear diameter was adopted. We observed that the reproducibility and the validity of the follicular adenoma vs follicular carcinoma discrimination are greater than in the subjective evaluation. Moreover, similar classification results were obtained when measurements were performed either with a fully automated image analysis system or with semiautomatic or manual instrumentation. As for reproducibility of the inter-instrument comparisons, the k statistic values ranged from 0.85 to 1.00 (mean value 0.90, that is, an 'almost perfect' degree of agreement); in the subjective evaluations, the inter-observer comparisons showed values ranging from 0.20 to 0.56 (mean value 0.37, that is, 'fair'). In the decision tree classification, feature value thresholds were selected in order to have specificity of 100% and the predictive value of a positive result (carcinoma) of 100%; accuracy was 87% (range 86-89%), sensitivity 74% (71-79%), the predictive value of a negative result (adenoma) 79% (78-82%). In the subjective evaluation the values were as follows: accuracy 67% (64-71%), sensitivity 57% (50-64%), specificity 77% (71-79%), predictive value of a negative result (adenoma) 64% (61-69%), predictive value of a positive result (carcinoma) 71% (67-75%). The conclusion is that, by using a routine microscope equipped with a micrometer, the preoperative diagnosis of follicular carcinoma from smears can be formulated with a high degree of certainty.

Cytologic diagnosis of non-oxyphil follicular neoplasias of the thyroid. Multivariate classification procedure based on quantitative nucleolar features

The study was done on cytologic material of 58 non-oxyphil follicular neoplasias of the thyroid, 32 of which were adenomas and 26 carcinomas. Three groups of nucleolar features were quantified using a routine microscope with an ocular micrometer: frequency-, size-, and margination-related features. Since value overlap was present between two categories for all the variables, stepwise discriminant analysis was applied. The following three features were selected by the computer for calculation of one canonical discriminant function: percentage of marginated nucleoli, percentage of nuclei with one nucleolus, mean major nucleolar diameter. The percentage of agreement between morphologic and computer classifications was 95%. Two follicular adenomas were allocated to the carcinoma category, whereas one follicular carcinoma was allocated to the adenoma category. Out of 58, 52 were diagnosed by the computer into one of the two diagnostic categories with a very high probability, i.e. P greater than 0.75, the remaining 6 being considered intermediate.

Value of quantitative nucleolar features in the preoperative cytological diagnosis of follicular neoplasias of the thyroid

Nucleolar prevalence, size, and outline were investigated on cytological material from cold thyroid nodules obtained by fine needle aspiration. The percentage of nucleolated nuclei in follicular adenoma (32 cases) was less than in follicular carcinoma (26 cases). In adenoma most nuclei contained one nucleolus, and nuclei with two or more nucleoli were less common than in carcinoma where most cases showed the highest nucleolar diameter values. There was some overlap between adenomas and carcinomas, however, when the mean of the 10 largest values of the major nucleolar diameter was considered. In follicular carcinoma the percentage of marginated nucleoli--that is, those touching the nuclear membrane--was, in general, greater than 20%; in adenoma the values were equal to or lower than 16%. The overlap index showed that the percentages of marginated nucleoli and nucleolated nuclei are the two best discriminatory features between adenoma and carcinoma.

Quantitative nuclear cell image analyses of thyroid tumors from archival material

Sixty-three sections of Feulgen-stained thyroid cell nuclei from paraffin-embedded material, including five multinodular goiters, 10 adenomas, 36 papillary carcinomas, seven follicular carcinomas, and five medullary carcinomas were analyzed by means of the SAMBA 200 (TITN, Grenoble, France) cell image processor. This was done in order to obtain nuclear characteristics of papillary versus follicular carcinomas. The nuclear features were assessed by morphometric, densitometric, and textural parameters. Our preliminary results indicate that the cell nuclei from typical histopathologic specimens of follicular thyroid cancers belong to a larger thyroid cell nuclei population corresponding to the histopathologic family of papillary thyroid cancers. This follicular neoplastic cell nuclei population appears to be quite distinct from the typical medullary neoplastic cell nuclei population which also belongs to the papillary neoplastic cell nuclei population. It appears that there is a specific papillary cell nuclei subpopulation containing typical hypochromatic cell nuclei. We also observed a dramatic increase in nuclear size and hyperchromatism between normal (multinodular goiters) and neoplastic (carcinomas) thyroid tissues, with the benign tissues (adenomas) showing intermediate nuclear characteristics.

Thyroid carcinoma infiltrating the trachea: clinical, histologic, and morphometric analyses

Forty-five patients with papillary or follicular thyroid carcinomas with tracheal infiltration were examined by clinical, histologic, and morphometric analyses. Twenty-four patients with completely encapsulated carcinomas (encapsulated cases) and 26 patients with carcinomas confining within the thyroid capsule (nonencapsulated cases) were examined as controls. Patients with tracheal infiltration were significantly more often male and older than the patients without (P less than 0.01 and P less than 0.05, respectively). The histologic grade of differentiation did not correlate with tracheal infiltration. The nuclear area of tumor cells was significantly larger in the cases with tracheal infiltration than in the cases without (P less than 0.01). In 12 recurrent cases with tracheal infiltration, the nuclear area of recurrent tumors was significantly larger than those of their own primary tumors (P less than 0.01). These results confirm that thyroid carcinomas with tracheal infiltration were more frequent in male and older patients and had more significant nuclear atypia than the tumors without tracheal infiltration.

The number of nucleoli in benign and malignant thyroid lesions: a useful diagnostic sign in cytological preparations

The slides of fine needle aspiration cytology specimens from 99 cases of cold thyroid nodules with known histology were reviewed and the number of nucleoli per nucleus counted and correlated with the different histopathological groups. Significant differences were observed between benign and malignant thyroid lesions in the number of nucleoli in the cytological material. Lower values were present in nodular goitres and follicular adenomas compared to carcinomas. In benign lesions the majority of nuclei contained one nucleolus and nuclei with two, three or more nucleoli were less frequent than in follicular, papillary, medullary and anaplastic carcinomas. Only one case of follicular adenoma had cells containing three or more nucleoli compared to more than half the cases of follicular carcinoma.

Ultrastructural morphometric analysis of papillary neoplasms: biological and diagnostic relevance

Ten papillary adenocarcinomas of thyroid origin (P-Thy), ten papillary adenocarcinomas of ovarian origin (P-Ov), and eight papillary neoplasms of non-thyroid/non-ovarian origin (P-Other) were morphometrically compared using 19 distinct quantitative nuclear and nucleolar parameters as a database for diagnosis. The selected cases consisted of 16 primary and 12 metastatic neoplasms. It was determined that the P-Thy group had a significantly smaller nucleolar area (NuA) and nucleolar perimeter (NuP), and smaller SDs of nuclear area (NA), NuA, and NuP compared with the P-Ov and P-Other groups (P less than .05). The P-Ov group had a significantly smaller SD of NA compared with the P-Other group (P less than .05). The P-Ov group exhibited the greatest variability among the papillary neoplasms. Linear regression analysis indicated that in the P-Thy group alone there was a significant correlation between mean nuclear form factor (4 pi A/P2) and mean NuA (r = -.82; P less than .01), and mean NP and mean NuA (r = +.77; P less than .01). Linear regression analysis also indicated that in the P-Ov group alone, there was a significant correlation between mean NA and mean NuA (r = +.75; P less than .02). Morphometric domains were established using statistically significant sets of variables that distinguished between the groups. The application of three-dimensional computerized cluster analysis techniques indicated that the P-Thy group consistently had the smallest morphometric domains. It was concluded that ultrastructural morphometric analysis of papillary neoplasms has diagnostic potential and reveals interesting biological relationships among distinct nuclear features in the different groups of neoplasms.

Morphometric and morphologic evaluations in stage III non-small cell lung cancers. Prognostic significance of quantitative assessment of infiltrating lymphoid cells

This study evaluated data from 30 non-small cell lung cancer (NSCLC) patients to determine whether demographic, clinical, and morphologic and morphometric data that were obtained prior to treatment, could be used to predict survival. All patients had Stage III disease, and all subsequently were treated identically with concurrent radiotherapy, cisplatin, and 5-fluorouracil. The series consisted of 18 squamous carcinomas, eight adenocarcinomas, and four large cell carcinomas. Morphometric measurements of randomized selected cancer cells per case included diameter of cytoplasm, nuclei, and nucleoli. Morphologic parameters evaluated were mitotic index, histologic differentiation, and pattern of nuclear chromatin of cancer cells, and the degree of necrosis and fibrosis of tumor tissue. The lymphoid and neutrophil index defined as the ratio of lymphoid cells and neutrophils to cancer cells from randomized microscopic fields (median = 25) at 400 x magnification were also determined. Our study indicated that the peritumor lymphoid index was the only factor significantly associated with the length of survival. The correlation coefficient (Pearson r) of these two factors was 0.5 (P less than 0.005). The median survival time of patients with peritumor lymphoid index less than 3 and greater than or equal to 3 was 95 days and 376 days, respectively (Kaplan-Meier estimation). The peritumor lymphoid index was an independent prognosticator of clinical outcome of Stage III NSCLC patients, and did not correlate with any of the other parameters analyzed.