CIS/DSA Thyroid nodules/surgery (Tieman) Flashcards by Andrea Parsons

nodules are more common in what sex

women x4

BUT they are more often malignant in men

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what age is risky for nodules

malignant nodules more common in ages 60

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what in the history is significant in terms of work up for thyroid nodules

gender
-more common to find nodules in women but more common to have malignant nodules in men

age

history of radiation exposure to head and neck

family history of thyroid cancer, FAP, MEN, multiple hamartoma syndrome

Voice symptoms

Visual symptoms

fatigue, anxiety

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what labs do you order in work up of thyroid nodules

TSH
T4
T3

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when is FNA indicated (Fine needle aspiration) in work up of thyroid nodules

> 1cm and/or suspicious on US (hypoechoic, irregular, intranodular, vascularity, calcifications, nodal mets)

May need to aspirate multiple nodules, if more
than one meets criteria (up to 4 nodules

90% sensitivity and specificity

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what if FNA is benign in thyroid nodule work up

requires 6-12 month follow up

5% false negative rate

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what happens if you find an indterminant result on FNA of thyroid nodule

Usually contains follicular cells or Hurthle cells

” Formerly required surgery to examine entire nodule

◦ Malignancy in follicular lesions determined by invasion of capsule
or follicular cells in surrounding blood vessels or lymphatics

” Now can be further evaluated by gene-expression
classifier profile with 90-95% sensitivity and specificity

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FNA showing orphan annie cells

psammoma bodies

intra-nuclear grooving
papillary projectings

papillary carcinoma of thyroid

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what are the low risk factors with papillary carcinoma

<2 cm

well differentiated

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what is the long-term survival of papillary carcinoma of thyroid

ranges from 50-99%

◦ Survival rates depend on prognostic factors

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what are the high risk factors associated with papillary carcinoma of thyroid

> 40 years old
male
capsular invasion, extrathyroidal extension

distant mets

> 4 cm

poorly differentiated

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stippled cytoplasm

sheets of cells

follicular lesion of thyroid

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extensive amyloid deposits in the cellular matrix

hurthle cells

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what two things define the indeterminate FNA

hurthle cells

follicular lesion

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when you have an FNA that is indeterminate, what is done first after this finding>

gene expression classifier method to determine likelihood of malignancy

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large bi lobed nuclei with intense staining

parafollicular c cells

medullary carcinoma

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what are medullary carcinomas of the thyroid derived from….

what do they secrete?

what percentage are sporadic and what percentage are familial ?

what is the gene involved ?

◦ Parafollicular “C” cells which secrete calcitonin

◦ 5-10% of thyroid cancers, PTC and FTC ~90%

◦ Sporadic (75%) Usually more indolent

◦ Familial (25%)—MEN 2A (60%),2B (5%) or Familial
(35%)

” Screen for parathyroid and adrenal disease if 2B
suspected

” Pre-operative calcitonin levels
“ RET proto-oncogene in patient and relatives

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what is the treatment of medullary carcinoma and what is the follow up

◦ Total thyroidectomy +/- lymph node dissection

Radioactive iodine and serum thyroglobulin of no use in follow-up

Medullary cancers followed with serum calcitonin levels
and family evaluation

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very aggressive, rapidly enlarging painful mass with obstructive symptoms

can be diagnosed with FNA

anaplastic thyroid carcinoma - 1% of thyroid cancers

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what is the treatment of anaplastic thyroid carcinoma

Palliative care only, doesn’t respond well to
surgery, radiation therapy, or
chemotherapy

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what is the follow up for well -differentiated epithelial thyroid cancer (post-op)

Most well-differentiated epithelial thyroid
cancer treated with post-op radioactive
iodine to ablate subclinical disease or
mets

! Thyroid replacement

! Monitor physical exam and thyroglobulin
levels to look for recurrent disease

! Use of PET scan promising but not yet standard of care

in what cases is surgery appropriate in hyperthyroidism

Hot nodule

toxic nodular goiter

grave’s disease - especially pregnant pt

multinodular goiter

what is the concern with a rapidly growing goiter

carcinoma

what are the complications that might occur with thyroidectomy

recurrent laryngeal n injury
superior laryngeal n. injury
hypoparathyroidism
hypothyroidism
extensive blood loss
rare infection

are multiple nodules or firm solitary nodules more risky?

multiple nodules or diffuse nodularity --> benign firm solitary nodule ---> particularly in older men is more suggestive of malignancy

what does low serum TSH in a thyroid nodule mean?

lower liklihood of malignancy

ultrasound findings in a nodule that are considered suspicious for malignancy include what?

microcalcifications hypervascularity infiltrative margins being hypoechoic compared with surrounding parenchyma having a shape that is taller than its width on transverse view

is malignancy more common in cold or hot nodules

more common in cold nodules

what do the presence of colloid and macrophages in aspirate (FNA) suggest

benign lesion

what factors confirm the diagnosis of follicular carcinoma

permanent section pathology

what factors confirm the diagnosis of medullary carcinoma

surgery FNA calcitonin level RET oncogene

what factors are associated with a worse prognosis in medullary carcinoma

MEN2B and sporadic

what is the next step in a pt with a thyroid nodule and normal thyroid function tests

ultrasound cystic are more likely benign

what is the most common genetic alteration in Papillary thyroid cancer

PTC-RET proto-oncogene

most common thyroid neoplasm

papillary carcinoma young female pt's childhood radiation exposure peak age is b/w ages 30-50 -calcified clumps of cells (psammoma bodies)

what is the most important prognostic factor in well-differentiated thyroid cancer

age at diagnosis

what is the primary treatment of differentiated thyroid cancer

surgical ablation

``` peak incidence b/w 40-60 more common in women more common in iodine deficient areas can spread hematogenously can spread to liver, bone, lung (mets) ```

follicular carcinoma painless thyroid mass 80% 10 year survival in 40-60 yr olds diagnosis requires demonstrations of cellular invasion of capsule or vascular or lymphatic channels - can't be determined with FNA

what is the very first step in working up the thyroid nodule

serum TSH

after you have done the TSH as the first step in workup of thyroid nodule, what do you do .... normal TSH? low TSH?

Normal- thyroid Ultrasound Low TSH- radioisotope scan

lets say you have low TSH (high T3 and T4) and you have a hot nodule after you perform a radioisotope scan....

surgery or radioablate with iodine

what is the next step in workup of a nodule AFTER you have done TSH and it is normal....

do an ultrasound if the pt is euthyroid you don't scan them and you now the nodule is going to be cold

what does an ultrasound of a nodule tell us

cystic or solid

what if you found a solid nodule on Ultrasound (after you found normal thyroid studies) what is the next step

FNA if the FNA is benign then the next step in management is to follow the patient b.c there is a 5% chance of having false negative if they come back in 6 months for follow up, what might prompt you to get another FNA? - symptomatic - gets bigger- hard and fixed

if a pt has MEN IIA syndrome , what do you need to do before surgery

urinary VMA's and metenephrines to screen for pheochromocytoma

what is the treatment for medullary carcinoma

total thyroidectomy PLUS all the lymph nodes must do lymph dissection b/c chemo doesn't work/ radiation doesn't work the only shot at survival is surgery

pt has pre-clinical MEN 2A b/c he tested positive for RET proto-oncogene . what should be done next ?

prophylactic thyroidectomy

are papillary carcinomas more likely multifocal or unifocal and how does this play into treatment ?

multifocal there are usually a lot of nodules that you can't see or feel for treatment of papillary carcinoma you will want to do a total thyroidectomy AND take out the lymph nodes b/c it spreads through the lymph nodes

what do you do after you have performed a total thyroidectomy for papillary carcinoma and you have also taken the lymph nodes out...

radioactive iodine to prevent mets- small subclinical mets also check thyroglobulin ! if it starts increasing in the serum then you know you probably have mets

lets say you did thyroid function tests and they were normal then you did ultrasound and you found solid nodule then you did FNA and found follicular lesion how do you know if it is benign or malignant ? and what if the lesion is malignant ?

the FNA can't tell you benign or malignant you must see invasion of the capsule or malignant cells in the surrounding blood vessels in the old days you had to go to surgery but now you can just do gene-expression classifier profile - genetic test that tells you if this is a worrisome nodule or not if it is malignant --> it is typically unifocal and you want to do a total thyroidectomy b/c you are going to treat them post-operatively wtih radioactive iodine so just take the whole lobe anyways to increase effectiveness of the iodine also don't have to take lymph nodes b/c it spreads hematogenously