Goitre, thyroid nodules and cancer

Question 1

What is a goitre

Answer 1

an enlarged thyroid gland and may be diffuse or nodular

Question 2

A patient presents with a goitre. Give a differential

Answer 2

Graves' disease 
Multinodular goitre
solitary adenoma 
thyroiditis 
Hashimoto's thyroiditis 
Simple goitre 
Malignancy (thyroid carcinoma, lymphoma 
Riedel's thyroiditis

Question 3

What sex are more prone to goitres

Answer 3

Females

Question 4

Prevalence of goitres increases with what 3 things

Answer 4

age
iodine deficiency
previous exposure to ionising radiation

Question 5

Where are the most important goitrous areas in th world

Answer 5

Himalayas and the Andes

Question 6

What features in the history raise the suspicion of malignancy

Answer 6

Age 60
recent rapid enlargement of a thyroid nodule
dysphagia, dyspnoea, hoarseness, stridor
Family history of thyroid cancer or MEN (multiple endocrine neoplasia)
History of exposure to radiant
lymphadenopathy
Hashimoto’s thyroiditis

Question 7

What tests should be requested to exclude thyrotoxicosis

Answer 7

TSH and free T4

Question 8

Serum thyroglobulin levels are increased in what type of nodules

Answer 8

Benign and malignant nodules

Question 9

What should be measured when medullary cell carcinoma is suspected

Answer 9

Calcitonin

Question 10

What test should all patients with a thyroid nodule have

Answer 10

A fine needle aspiration for cytological examination

Question 11

What test is required if there is a high suspicion of malignancy

Answer 11

Ultrasound-guided fine needle aspiration

MEN2, suspicious ultrasound features, presence of cervical lymph nodes

Question 12

What scan should be carried out for all patients with suppressed TSH

Answer 12

Radioisotope uptake scan

Question 13

Why is Technetium pertechnetate more commonly used than iodine

Answer 13

Cheaper and more readily available

Question 14

What should patients with suspicious or malignant cytology be offered

Answer 14

Surgery

Question 15

What is the most common form of thyroid carcinoma

Answer 15

Papillary

Question 16

What is the second most common form of thyroid carcinoma

Answer 16

Follicular

Question 17

What genes are papillary carcinomas associated with

Answer 17

rearrangement of RET and NTRK1 and the formation of chimeric genes

Question 18

In what populaiton is papillary thyroid cancer most prevalent

Answer 18

young women (30-50 years)

Question 19

How do papillary carcinomas metastasise

Answer 19

Lymphatics to regional lymph nodes and distantly to the lungs and bones

Question 20

What are papillary carcinomas characterised by?

Answer 20

One or two layers of tumour cells surrounding a fibrovascular core Cells and nuclei are large and their cytoplasm has a GROUND GLASS appearance

Question 21

What does follicular carcinoma show

Answer 21

follicular differentiation and capsular or vascular invasion - it is epithelium derived

Question 22

When is the peak incidence of follicular carcinomas

Answer 22

between the ages of 40 and 60

Question 23

How can the distinction between follicular adenoma and carcinoma be made

Answer 23

through histological identification of capsule and or vascular invasion

Question 24

How do follicular carcinomas spread

Answer 24

Haematogenous - (lung and bones) rather than to regional lymph nodes

Question 25

In what population does anaplastic carcinoma more frequently occur

Answer 25

In older patients (60-80 years

Question 26

How do patients with anaplastic carcinoma present

Answer 26

Rapidly enlarging neck mass

Question 27

How is anaplastic carcinoma spread

Answer 27

Haemoatgenous spread

Question 28

The risk of thyroid lymphoma is increased in patients with what

Answer 28

autoimmune thyroiditis

Question 29

What is the treatment for papillary and follicular carcinoma

Answer 29

Initial thyroidectomy postoperative TSH suppression with thyroxine and in high risk patients, postoperative radio-iodine ablation

Question 30

Why should all patients receive thyroxine post operatively

Answer 30

to prevent hypoparathyroidism and minimise potential TSH stimulation of tumour growth

Question 31

How does radio-iodine treatment work

Answer 31

It causes cell death by the emission of beta rays when the thyroid follicular cells take up the radio-iodine

Question 32

Prior to a radio-iodine scan, thyroxine is stopped and replaced with what

Answer 32

Shorter acting triiodothyronine

Question 33

What are some complications of radio=iodine

Answer 33

radiation thyroiditis painless neck oedema sialoadenitis tumour haemorrhage or oedema nausea

Question 34

What is the treatment for anapaestic thyroid carcinoma

Answer 34

Total thyroidectomy with lymph node clearance chemotherapy and external beam irradiation

Question 35

What are some poor prognostic factors in differentiated thyroid carcinomas

Answer 35

Age 45+, male, family history, tumour size, local extension, lymph node and distant metastases

Question 36

What type of thyroid cancer has the poorest survival rate

Answer 36

Anaplastic carcinoma, then follicular then papillary

Question 37

When do most recurrences of differentiated thyroid carcinoma happen

Answer 37

Within the first 5 years after initial treatment

Question 38

Describe the serum thyroglobulin concentration if initial surgery and thyroid remnant ablation are successful

Answer 38

It should be very low

Question 39

Patients with autoimmune thyroiditis have an increased risk for what type of cancer

Answer 39

Thyroid lymphoma