Endocrine - Thyroid Masses Flashcards
Presentations and treatment of Nontoxic Multinodular Goitre?
More common in females
Usually asymptomatic and euthyroid
- can get compressive symptoms
- can get sudden pain due to haemorrhage
Treatment:
- usually manage conservatively
- AVOID contrast or iodine substance (can enhance thyroid production = Jod Basedown Effect)
- Radioactive iodine
- Steroids if acute compression
- surgery is highly effective
Presentations and treatment of Toxic Multinodular Goitre?
Often in elderly patients
Can present with goitre and subclinical hyperthyroidism
Can be precipitated by contrast
Scan: heterogenous uptake
Treatment:
- antithyroid drugs if elderly
- radioiodine
- surgery for definitive treatment
What is a Toxic Thyroid Adenoma (Hyperfunctioning solitary nodule) usually due to? How is it treated?
Usually due to somatic activating mutation of TSH-R
Treat with radioiodine ablation
What are the ultrasound characteristics of a malignant thyroid nodule?
- hypoechoic nodule, SOLID
- Irregular margin and intranodular vascularity
- “taller than wide” shape
- egg shell calcification around nodule periphery
When do do FNA for thyroid nodule?
TSH: if suppressed then may be ‘HOT’ and should do Tc99m scan
Based on lesion size:
<1cm: repeat evaluation in 6-12 months
1-2cm: FNA if high risk features
>2cm: FNA
if volume increases by 30% of diameter by 10mm –> FNA!!
What mutations are associated with toxic adenoma?
TSH-R antibody
Gs protein
What mutations are associated with PAPILLARY THYROID CANCER
- BRAF V600E (MEK kinase gene)
- RET/PTC
- TRK
- RAS gives papillary follicular variant
What mutations are associated with FOLLICULAR THYROID CANCER?
RAS
MET
What mutations are associated with MEDULLARY THYROID CANCER?
RET in MEN2
What mutations are associated with ANAPLASTIC THYROID CANCER?
p53
p21/WAF
beta-catenin
What is the RAS pathway?
RET/PTC–>RAS–>BRAF–>MEK1/2–>ERK1/2
Poor prognostic features of thyroid cancer?
Age >40yrs
Tumour size >4cm
Local extension or distal metastases
Features suggestive of FOLLICULAR thyroid cancer:
- previous neck irradiation
- FHx of thyroid cancer
- Rapid growth
- Very firm or hard nodule
- fixation ot adjacent structures
- vocal cord paralysis
- Distal metastases
- regional lymphadenoapthy
- PET incidentaloma
Histo of PAPILLARY thyroid cancer
Psammoma bodies
Cleaved nucleus with “Orphan Annie” appearance due to large nucleoli
Papillary structures
Tend to be slow growing
Histo of FOLLICULAR thyroid cancer
spreads haematogenously
Histo: microfollicular architecture
Histo for thyroid mass has psammoma bodies…what is the diagnosis?
Papillary thyroid cancer
Histo for thyroid mass has microfollicular architecture…what is the diagnosis?
Follicular thyroid cancer
Histo for thyroid mass has “Orphan Annie” large nucleoli with cleaved nucleus….what is the diagnosis?
Papillary thyroid cancer
Treatment for thyroid cancer?
Total thyroidectomy
Remnant ablation with Iodine 131
If non-iodine avid recurrence and progressive:
- VEGF inhibitors
- BRAF inhibitors
Management of thyroid cancer post thyroidectomy?
If >1cm OR follicular:
- post op TSH stimulated remnant ablation with iodine 131
- lifelong TSH suppression
- regular surveillance scan and Tg levels
If <1cm without invasion/mets:
- NO remnant ablation needed
- NO TSH suppression needed
What are the Systemic Therapies for FOLLICULAR thyroid cancer?
Rosiglitazone / Pioglitazone ONLY if PPARy expression
Multitargeted Kinase Inhibitors:
- selemetinib
- sorafenib
- vandetanib
- lenvatinib
- vemurafenib
–> kinase inhibitors improve PFS, best results seen in lung metastases patients
BUT stabilises disease rather than halting progression
What does Vemurafenib do?
Targets BRAF Val600glu
How is Tg used as a biochemical marker post surgery for thyroid cancer?
Tg is dependent on thyroid volume
It is SENSITIVE and SPECIFIC for differentiated thyroid cancer
Used:
- at 6 months post op to check completeness of surgery and as a prognostic marker
- at >6 months to monitor efficacy
- also need to check Anti-Tg antibodies to check validity
