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Figure 1-29. Hashimoto's thyroiditis is a chronic autoimmune thyroid disorder that may cause compressive symptoms. A, A 50-year-old patient underwent an isthmectomy to remove a benign nodule that had caused pressure symptoms over the trachea immediately below the larynx, which is also seen covered by the cricothyroid muscles. Note the typical pale appearance of the gland as a result of replacing the thyroid follicles with lymphoid tissue. B, Photomicrograph of Hashimoto's thyroiditis shows extensive infiltration with mature lymphocytes and oxyphilic changes in the follicular epithelium (hematoxylin and eosin; x100 original magnification).

Figure 1-29. Hashimoto's thyroiditis is a chronic autoimmune thyroid disorder that may cause compressive symptoms. A, A 50-year-old patient underwent an isthmectomy to remove a benign nodule that had caused pressure symptoms over the trachea immediately below the larynx, which is also seen covered by the cricothyroid muscles. Note the typical pale appearance of the gland as a result of replacing the thyroid follicles with lymphoid tissue. B, Photomicrograph of Hashimoto's thyroiditis shows extensive infiltration with mature lymphocytes and oxyphilic changes in the follicular epithelium (hematoxylin and eosin; x100 original magnification).

Figure 1-30. Hashimoto's thyroiditis is the most common cause of hypothyroidism in nonendemic areas. It is occasionally associated with hyperthyroidism. A, Patient underwent total thyroidectomy for a rapid increase in the growth of a Hashimoto's gland. Instead of the usual pale appearance, this gland has a dark appearance owing to increased vascularity of active thyroid tissue. B, Another case of atypical Hashimoto's thyroiditis with rapid growth evident by an enlarged dark thyroid gland. Both patients in A and B were diagnosed to have combined Hashimoto's and Graves' disease, a condition referred to as hashitoxicosis. C, The gland in B was bivalved. Note the multinodular appearance of the gland. No evidence of malignancy was seen.

is indicated when there are persistent local symptoms and when malignancy cannot be excluded.

Riedel's Thyroiditis

Patients who have Riedel's thyroiditis, a very rare condition, have an infiltrative dense fibrotic reaction secondary to idiopathic chronic inflammation. It results in a rock-hard and fixed thyroid gland highly suspicious of malignancy. The fibrotic process extends into the perithyroidal soft tissues and skeletal muscle with complete obliteration of the thyroid capsule (Figure 1-31). This process may involve other organs, resulting in synchronous sclerosing mediastinitis, pseudotumor of the orbit, or retroperi-toneal fibrosis. It is more prevalent among women. Patients may complain of hoarseness, dyspnea, or dysphagia, but it rarely causes pain. FNA is needed to exclude malignancy.27 When the aspirate is acel-lular, as is usually the case, then a core or opened biopsy becomes necessary to exclude malignancy.

The disease has a very favorable prognosis. Once the diagnosis is confirmed, surgical treatment is limited to debulking to diminish the goiter size in symp-

Figure 1-31. Riedel's thyroiditis is characterized by chronic inflammation and extensive fibrosis that replaces the entire thyroid gland with loss of all anatomic planes. Note that the invasion extends into the skeletal muscles, which usually raises suspicion of malignancy. However, the lack of atypical cells, mitosis, or vascular invasion on opened biopsy rules out thyroid cancer and confirms the diagnosis of Riedel's thyroiditis, which has a favorable prognosis (hematoxylin and eosin; x40 original magnification).

Figure 1-31. Riedel's thyroiditis is characterized by chronic inflammation and extensive fibrosis that replaces the entire thyroid gland with loss of all anatomic planes. Note that the invasion extends into the skeletal muscles, which usually raises suspicion of malignancy. However, the lack of atypical cells, mitosis, or vascular invasion on opened biopsy rules out thyroid cancer and confirms the diagnosis of Riedel's thyroiditis, which has a favorable prognosis (hematoxylin and eosin; x40 original magnification).

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