CIS/DSA Thyroid nodules/surgery (Tieman) Flashcards
nodules are more common in what sex
women x4
BUT they are more often malignant in men
what age is risky for nodules
malignant nodules more common in ages 60
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
what labs do you order in work up of thyroid nodules
TSH
T4
T3
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
what if FNA is benign in thyroid nodule work up
requires 6-12 month follow up
5% false negative rate
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
FNA showing orphan annie cells
psammoma bodies
intra-nuclear grooving
papillary projectings
papillary carcinoma of thyroid
what are the low risk factors with papillary carcinoma
<2 cm
well differentiated
what is the long-term survival of papillary carcinoma of thyroid
ranges from 50-99%
◦ Survival rates depend on prognostic factors
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
stippled cytoplasm
sheets of cells
follicular lesion of thyroid
extensive amyloid deposits in the cellular matrix
hurthle cells
what two things define the indeterminate FNA
hurthle cells
follicular lesion
when you have an FNA that is indeterminate, what is done first after this finding>
gene expression classifier method to determine likelihood of malignancy
large bi lobed nuclei with intense staining
parafollicular c cells
medullary carcinoma
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
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
very aggressive, rapidly enlarging painful mass with obstructive symptoms
can be diagnosed with FNA
anaplastic thyroid carcinoma - 1% of thyroid cancers
what is the treatment of anaplastic thyroid carcinoma
Palliative care only, doesn’t respond well to
surgery, radiation therapy, or
chemotherapy