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ENT Secrets > Chapter 15 - Thyroid, Parathyroid > Flashcards

Chapter 15 - Thyroid, Parathyroid Flashcards

1
Q

How many thyroid nodules found on PET will be found to be malignant?

A

As many as 2/3

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2
Q

Initial workup of palpable thyroid nodule

A

U/S
Laryngoscopy
Thyroid function assay, calcium

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3
Q

Most common malignancy of thyroid

A

PTC

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4
Q

Most common neoplasm of thyroid

A

follicular adenoma

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5
Q

Percentage of pop with thyroid nodules palpable

Percentage of these that are cancer (and things that increase risk)

A

4-7%
5-10%
<30 >60, male, FHx, rads as child, high TSH/Hashimoto, rapid grow, pain, compression sx, hoarse, cervical LAD

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6
Q

What features on U/S make you FNA a nodule?

A 
>1cm OR:
microcalcification
irregular margin
solid (not cystic)
internal vascularity
multiple nodules
ipsilateral cervical LAD
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7
Q

Diagnostic accuracy of FNA

A

95%
False neg 2.3%
False pos 1.1%

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8
Q

TIRADS Classification (u/s)

A

1- NL
2- Benign (simple cyst, spongiform nodule, isolated macrocalcify, subacute thyroiditis). 3- Probably benign (isoechogenic, hyperechogenic)
4A- low suspicion (moderately hypoechogenic)
4B- 1-2 high risk signs and no adenopathy
5- 3+ signs and/or adenopathy. >80% risk malignant
High risk Signs: Taller than wide, irregular/microlobulated margins, microcalcify, marked hypoechogenicity
6- Biopsy proven malignancy

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9
Q

FNA reporting of thyroid. Classification

A

Benign - 70%
Malignant - 5%
Suspicious- 10%
Indeterminate- 15%

10-20% of suspicious will be follicular CA
May do molecular testing on indeterminate (Mutation panel, gene expression testing)

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10
Q

Mutation panel testing for thyroid cancer, and gene expression testing

A

100% PPV (rule in), but 30% don’t have a mutation
RAS, PPARg, RET/PTC, BRAF

GET: 142 genes, rules out, NPV >95%, $3,000

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11
Q

How to follow benign nodule

A

Serial u/s q6-12 mo
repeat FNA if significant change
If cysts return after multiple FNA, consider removal

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12
Q

Percentage of occurrence of all thyroid CA

A 
PTC 70-85%
Foll CA 15-20%
Huerthle 2-5%
MTC 3-10%
Anaplastic <2%
Insular/poorly differentiated (rare)
Lymphoma, SCC, mets
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13
Q

T Staging thyroid CA

A 
T1a 1cm
1b 1-2cm
T2 2-4cm
T3 >4cm
4a: to ST, larynx, trachea, esophagus, RLN
4b: beyond above regions
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14
Q

N Staging thyroid

A

1a- spread to central (pretracheal, paratracheal, prelaryngeal)
1b- beyond central

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15
Q

Staging of PTC or FTC <45 yo

A

I: Anything less than M1
II: M1

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16
Q

Staging of PTC, FTC >45 yo

A 
I: T1
II: T2-3
III: T4 or N1a
IVa: 4a, or N1b
IVb: 4b
IVc: M1
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17
Q

Low risk prognosis for thyroid cancer (AMES)

A

Age <40/50 (m/f), tumor <4cm, within thyroid

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18
Q

High risk prognosis thyroid: AMES and MACIS

A

Age >41/51 (m/f), extrathyroid, >5cm

Age >40, invasion of gland, incomplete resection, >4cm

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19
Q

Near total vs sub-total thyroidectomy

A

Near: leave SMALL amount thyroid tissue around parathyroids, RLN to reduce morbidity
Sub: large amounts of thyroid left

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20
Q

Treatment of Stage I-II PTC, Foll CA?

A

Total thyroidectomy

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21
Q

Treatment Stage III PTC, FTC

A

Total thyroid plus removal of involved LN/other sites of thyroid dz
I-131 ablate if demonstrates uptake, or external beam rads if I-131 uptake is minimal

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22
Q

Treatment Stage IV PTC, FTC

A

total thyroid, neck
Ablate with I-131 or Rads or chemo (VEGF inh)
May remove mets with no I-131 uptake

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23
Q

Which thyroid CA does not spread to LN often?

A

Follicular

Papillary and Medullary do, eval central and II-IV, some authors say do central if PTC >3cm

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24
Q

MEN I, IIa, IIb

A

I- para, pit, panc
IIa- MTC, pheo, para (RET)
IIb- MTC, pheo, mucosal neuromas (RET), most aggressive medullary

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25
Q

How does medullary behave differently?

A

Aggressive
Secrete calcitonin, CEA, prostaglandin, serotonin, histaminase
Incades muscle, trachea, heme spread to lungs/viscera (50% @ pres)
30% are familial/genetic

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26
Q

How to screen for Pheo

A

All patients with medullary get RET testing

If positive, do 24 hr urine catecholamine, abdominal scan

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27
Q

How to screen for parathyroid adenoma

A

serum calcium, PTH

Sestamibi

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28
Q

Imaging workup in patients with medullary

A

MRI, PET, sestamibi, indium-labeled somatostatin scans

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29
Q

Treatment and f/u for medullary

A

total thyroid plus other involved areas

f/u calcitonin, CEA

30
Q

Describe anaplastic thyroid CA

A

80% occur in pre-existing mass
Sudden growth, pain, hoarse, dysphagia, dyspnea
All are stage IV (a to nearby, b beyond nearby, c mets)

31
Q

Treatment and survival of anaplastic

A

Median survival less than 6 mo

Doxorubicin, Rads, debulking surg, trach

32
Q

What to consider when deciding to do RAI

A

Size, lymphovascular invasion, invade thyroid capsule, LN

33
Q

Thyroid cancer recurrence statistics

A

10-30% recur/metastasize
80% recurrences in neck alone (otherwise lungs)
50% cured with second operation
If recur by I-131 and not clinically apparent, good prognosis, Tx with I-131
Multi-tyrosine kinase INH if not resp to I-131

34
Q

How many have 5-7 parathyroid glands? And fewer than 4?

35
Q

Average weight of parathyroid, diameter, blood supply

A

35-50 mcg
1-5mm
ITA (rarely posterior br STA)

36
Q

Causes of primary hyperpara

A

solitary adenoma (85%)
multiple hyperplastic glands (10-15%)
multiple adenomas (3-4%)
carcinoma (<1%)

Overexpression PRAD1 oncogene, low-dose rads exposure may be responsible

37
Q

Secondary and tertiary hyperpara

A

2: CRF, Surg if osteopenia (3 1/2 removal), May use cinacalcet
3: autonomous para

38
Q

Sx of hypercalcemia

A 
GI- nausea, constip, ulcer, pancreatitis
Mm weak 
Stones 
HTN, arrhythmia 
Polydipsia 
Depress, tired, memory
39
Q

DDx hyperCa

A 
Mets from BLTKP
MM
SCLC, ovarian, thymoma
Gloma
Thiazides, lithium, theophylline, hypervit A/D
Immobile
Milk-Alkali
Fam Hypocalciuric hyperCa
Hyperphosphatasia
Pagets
40
Q

Elevated PTH but normal calcium - causes

A

Vitamin D Insuff

Malabsorption

41
Q

Imaging options for primary hyperpara

A

T99 sestamibi - to mitochondria, 2 hours later out of thyroid. 100 Se 90 Sp

T99 MIBI SPECT-3D
T99 thallium subtraction
U/S, FP 15-20%
MRI (T2)
Intraop gamma
Angiography
Venous sample
FNA
42
Q

Ectopic para locations

A

Sup Med, thymic capsule, retro-esoph, carotid sheath, medial to sup thyroid pole

Sup para usually near lateral lobe. Inferior more variable

43
Q

When to perform surgery in asymptomatic primary hyperpara

A 
Serum Ca 1 above NL
GFR <60
T score <2.5 or prior fx/fragile
<50
Patient wants surgery, cannot be reliably followed
44
Q

Intraop PTH monitoring

A

1/2 life 3-5 min

Want see decrease by 50% 10 min after removal of adenoma/hyperplasia

45
Q

Autotransplant para

A

Immediate or up to 18 mo frozen
SCM, brachioradialis
Fxn within 3 m, success rate 50%
Arm: can remove under local if hyperplasia

46
Q

When could it be appropriate to do lobectomy for thyroid CA

A

<1cm low risk papillary CA

5-10% recur c/l

47
Q

When to not do RAI, risks of RAI

A

No benefit if complete resection, no nodes, T1-2, >45

Second CA, Sialadenitis, Lacrimal, Salivary Dysfxn

Give with rhTSH to decrease risk

48
Q

Parathyroid re-exploration

A 
SCM to retroesoph
Thymus
PVS
Thyroid lobe palpate 
Open sheath hyoid to mediastinum 
Explore Sup Mediastinum
49
Q

Which cancers go to 1a?

A

Oral tongue, FOM, lower gum/lip

50
Q

Which cancers go to 1b?

A

OC (buccal, tongue, lateral FOM)
Anterior nasal cavity
Max sinus
SM gl

51
Q

Which cancers go to 2?

A

OC, nose, NP, OP, HP, larynx, parotid

52
Q

Which cancers go to 3?

A

OC, OP, NP, HP, larynx

53
Q

Which cancers go to 4?

A

HP, thyroid, larynx, esophagus

54
Q

Which cancers go to 5?

A

Skin post scalp/neck, NP, OP

55
Q

Which cancers go to 6?

A

Thyroid, larynx (glott, subglott), esophagus, piriform sinus apex

56
Q

Nasopharyngeal nodal staging

A

1: unilat, <6cm, above supraclav
2: bilat
3: >6 or to supraclavicular fossa (b)

57
Q

Deficit from injured XI

A

Can’t raise shoulder above 90 degrees, shoulder pain

58
Q

If need to remove both IJ, how long do you wait?

A

2 weeks to remove second one

10% die when simultaneous

59
Q

Which neck dissection to do for: OC

60
Q

Which neck dissection to do for: OP, HP, Lar

61
Q

Which neck dissection to do for: post scalp

A

2-5, retroauric, Suboccip (PL neck diss)

62
Q

Which neck dissection to do for: Ant/lat face

A

1-3, parotid, facial

63
Q

Which neck dissection to do for:

Thyroid, esoph, advanced laryngeal

64
Q

Chyle Leak

A

Occurs 1-2%
Duct enters IJ sup to jxn with subclavian
Surgery if >500cc/day (May do TPN instead)
Less- pressure dressing, low fat diet, drainage

65
Q

Cause of SIADH after IJ ligation

A

Cerebral edema

66
Q

Which patients are at risk for facial/cerebral edema after ND?

A

Prior Rads, IJ ligation

67
Q

Things that INC risk of carotid blowout

A 
Salivary fistula 
Flap breakdown (prior Rads)
Malnutrition, Infxn, diabetes
68
Q

When to do neck dissection along with chemo Rads

A

N2b/3

N1-2 and persistent nodal Disease 3mo after Tx

69
Q

When to do open biopsy rather than FNA for suspected cancer in node

A

Only if suspected lymphoma

70
Q

Sacrifice carotid?

A

If you assess COW collaterals (balloon occlusion, xenon inhalation CT) then CNS compl 12%, 1 year disease free survival 45%, 2 year 22%.

71
Q

When to consider postop radiation

A

ECS, multiple positive nodes

72
Q

When to do MRND for salvage rather than SND

A

Fixate, infiltrate surrounding tissue from nodal Mets

ENT Secrets (79 decks)

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