Endocrine Staging

Which surgical specimens are used for thyroid carcinoma staging?

Resection types

• Thyroidectomy

• Lobectomy

• Partial excision

Which thyroid malignancies are included in TNM classification?

Follicular cell-derived thyroid neoplasms

• Papillary, follicular, poorly differentiated

C-cell-derived thyroid carcinomas

• Medullary

Salivary gland-type thyroid carcinomas

Thymic tumors within the thyroid

Embryonal thyroid neoplasm

Thyroid tumors of uncertain cytogenesis

Which thyroid tumors are excluded from this staging protocol?

Thyroid lymphoma

Thyroid sarcoma

Thyroid carcinomas arising in struma ovarii

What is struma ovarii?

An ovarian teratoma composed predominantly of thyroid tissue

What is the most common distant metastatic site for differentiated thyroid carcinomas?

Lung

What is the most common distant metastatic site for medullary thyroid carcinoma?

Liver

Are distant metastases common in thyroid carcinoma?

They are relatively uncommon

How are LN levels categorized for thyroid?

Left I-V

Right I-V

Level VI

Level VII

What is this?

Gross thyroid

What is this showing?

Carcinoma of thyroid

• Hashimotos’s thyroiditis

What is this?

Papillary carcinoma

What is this?

Follicular carcinoma

What is this?

Thyroid carcinoma — Poorly differentiated

What is pT1 for non-medullary thyroid carcinoma?

2 cm or less in greatest dimension

Limited to the thyroid

What is pT1a for non-medullary thyroid carcinoma?

1 cm or less, limited to the thyroid

What is pT1b for non-medullary thyroid carcinoma?

1 cm < x ≤ 2 cm, limited to the thyroid

What defines pT2 non-medullary thyroid carcinoma?

2 cm < x ≤ 4 cm, limited to the thyroid

What defines the pT3 categories for non-medullary thyroid carcinoma?

pT3a — >4 cm, limited to thyroid

pT3b — Invades ONLY strap muscles, ANY size

• Sternohyoid, sternothyroid, thyrohyoid, and omohyoid

What is pT4a for non-medullary thyroid carcinoma?

Gross extrathyroidal extension invading:

• Subcutaneous soft tissues

• Larynx

• Trachea

• Esophagus, or

• Recurrent laryngeal nerve

What is pT4b for non-medullary thyroid carcinoma?

Gross extrathyroidal extension invading:

• Prevertebral fascia

• Encasing the carotid artery

• Mediastinal vessels

How is pT1-pT3 categories defined for medullary thyroid carcinoma?

Similar to non-medullary thyroid carcinoma

What is the most important difference between non-medullary and medullary thyroid T4 staging?

Medullary has the same general progression/involvement as described in non-medullary, with the addition of:

• T4a — Moderately advanced disease

• T4b — Very advanced disease

What T staging distinction is important or non/medullary thyroid carcinoma?

Size matters

Extension matters

Which lymph nodes are considered regional for thyroid carcinoma?

Central compartment nodes (level VI and VII)

Lateral neck nodes (levels I–V)

Retropharyngeal node

What is pN1a for thyroid carcinoma?

Mets to level VI or VII nodes, including:

• Pretracheal

• Paratracheal

• Prelaryngeal/Delphian, OR

• Upper mediastinal

May be unilateral or bilateral

What is pN1b for thyroid carcinoma?

Mets to:

• Unilateral

• Bilateral, or

• Contralateral

lateral neck nodes (levels I–V) or retropharyngeal nodes

What defines pM1 thyroid carcinoma?

Distant mets

Which tumors are included in the adrenal staging protocol?

Adrenal cortical carcinomas

Which tumors are excluded from the adrenal cortical carcinoma staging protocol?

Pheochromocytoma

Sarcoma

Lymphoma

What is pT1 for adrenal cortical carcinoma?

≤ 5 cm, without extra-adrenal invasion

What is pT2 for adrenal cortical carcinoma?

>5 cm, without extra-adrenal invasion

What is pT3 for adrenal cortical carcinoma?

Any size with local invasion

• WITHOUT invasion of adjacent organs

What is pT4 for adrenal cortical carcinoma?

Any size WITH invasion of

• Adjacent organs

  • Kidney, diaphragm, pancreas, spleen, or liver

• Large blood vessels

  • Renal vein or vena cava

What is this?

Adrenal cortical carcinoma

What is pN1 for adrenal cortical carcinoma?

Mets to regional LNs

What is pM1 for adrenal cortical carcinoma?

Distant mets

Why is the distinction between pediatric and adult adrenal cortical tumors important?

Criteria for malignancy differ between pediatric and adult tumors

What is a pheochromocytoma?

A neuroendocrine tumor arising from the adrenal medulla

Usually submitted as a adrenalectomy specimen

Also known as a paraganglioma

What is a paraganglioma?

A related neuroendocrine tumor arising from paraganglionic tissue OUTSIDE the adrenal gland

True or False: ALL pheochromocytomas hormonally functional

FALSE — May be functioning or nonfunctioning

What are the classic "10% rules" for pheochromocytoma listed in the lecture?

10% of pheochromocytomas are:

• Malignant

• Bilateral

• Extra-adrenal (paraganglioma)

• Pediatric

• Occur without hypertension

What is pT1 for pheochromocytoma?

< 5 cm, without extra-adrenal invasion

What is pT2 for pheochromocytoma?

≥5 cm, OR

A paraganglioma of any size

NO extra-adrenal invasion

What is pT3 for pheochromocytoma?

Any size with invasion into surrounding organs or tissues, such as:

• Liver

• Pancreas

• Spleen, or

• Kidneys

What is pN1 for pheochromocytoma?

Mets to regional LN

What is pM1 for pheochromocytoma?

pM1a — ONLY bone

pM1b — ONLY distant LNs, liver, or lung

pM1c — Bone + multiple other sites

Which pancreatic tumors are included in this staging protocol?

Well-differentiated pancreatic neuroendocrine tumors (NETs)

Which pancreatic tumors are excluded?

Exocrine pancreatic carcinoma

Mixed ductal-neuroendocrine carcinoma

Mixed acinar-neuroendocrine tumors

Poorly differentiated neuroendocrine carcinoma

What determines the pT category for a well-differentiated pancreatic NET?

Size matters

Extension matters

Does extension into peripancreatic adipose tissue alone establish a higher T category?

No — Extension into peripancreatic adipose tissue is NOT a basis for staging

What is pT1 for pancreatic NET?

≤2 cm, limited to pancreas

What is pT2 for pancreatic NET?

2 cm < x ≤ 4 cm, limited to pancreas

What is pT3 for pancreatic NET?

>4 cm, limited to pancreas OR

Invade the duodenum, ampulla of Vater, or common bile duct

What is pT4 for pancreatic NET?

Invade either:

• Adjacent organs, OR

  • Ex. stomach, spleen, colon, adrenal gland

• Wall of large vessels

  • Ex. Celiac axis, superior mesenteric artery or vein, splenic artery or vein, gastroduodenal artery or vein, and portal vein

What is pN1 for pancreatic NET?

Regional LNs involvement

What is the pM1 for pancreatic NET?

pM1a — Confined to liver

pM1b — At least one extrahepatic site

pM1c — BOTH hepatic + extrahepatic site

Which sites are considered reliable sources for definitive metastatic disease in pancreatic NET?

LNs

Bone

What is an appendiceal carcinoid?

A well-differentiated neuroendocrine tumor of the appendix

Helpful surgical specimens — Appendectomy and right hemicolectomy

What is this microscopically showing?

Carcinoid

• Next of blue cells

What are the major considerations when examining an appendix containing a NET?

Tumor location (proximal, distal, or diffusely involved)

Tumor size

Tumor extent

Regional lymph nodes

Distant metastasis

What is the only relevant circumferential margin for appendiceal NET?

Mesenteric resection margin

Why is the mesenteric resection margin important?

It is the relevant circumferential margin for evaluating the extent of resection and possible residual tumor

What is pT1 for appendiceal NET?

≤2cm

What is pT2 for appendiceal NET?

2 cm < x ≤ 4 cm

What is pT3 for appendiceal NET?

>4 cm, OR

Tumor with subserosal invasion, OR

Involvement of the mesoappendix

What is pT4 for appendiceal NET?

Perforates the peritoneum, OR

Directly invades other adjacent organs or structures

• Ex. Abdominal wall or skeletal muscle

Which lymph nodes are regional for appendiceal NET?

Ileocolic lymph nodes

How many lymph nodes should a regional lymphadenectomy include?

12 LNs

What is pN1 for appendiceal NET?

Regional LNs involvement

What is pM1 for appendiceal NET?

pM1a — Confined to liver

pM1b — At least one extrahepatic site

pM1c — BOTH hepatic + extrahepatic site

Which gastrointestinal sites are covered in the lecture's GI NET staging section?

Stomach

Small bowel

Colon

What determines the T category for gastrointestinal NETs?

Tumor size

Depth of invasion into the bowel wall

What is the size cutoff for T1 in the GI NET staging section?

1 cm

What characterizes T2 in GI NETs?

Greater tumor size (>1 cm)

Invasion into the muscularis propria

What characterizes T3 in GI NETs?

Invasion into the subserosa

What characterizes T4 in GI NETs?

Invasion through the visceral peritoneum (serosa)

What is the special T3 consideration for duodenal NETs?

Invasion into peripancreatic adipose tissue OR the pancreas

What determines the N category for all GI NET sites?

Regional LNs involvement

What determines the M category for GI NETs?

Liver involvement or extrahepatic sites

What are these all examples of?

Bowel NET (Carcinoid)

What is this microscopically showing?

Carcinoid

• Of the GI tract