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Surgery Mock Oral Board Prep > Thyroid > Flashcards

Thyroid Flashcards

1
Q

Initial workup of a thyroid nodule

A
  • H&P
  • TSH
  • US
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2
Q

Thyroid Nodule (not neck mass) Differential

A
  • Benign
    • Colloid containing cyst
    • Thyroid adenoma
    • Hyperplastic nodule
    • Thyroiditis
  • Malignant
    • Papillary
    • Follicular
    • Medullary
    • Anaplastic
    • Hürthle
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3
Q

Suspicious sonographic findings of the thyroid

A
  • Hypoechoic
  • Microcalcifications
  • Extrathyroidal extensions/Infiltrative margins
  • Irregular margins
  • Taller than wide
  • Lymph node involvement
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4
Q

Bethesda Criteria

A
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5
Q

Two big risk factors for thyroid malignancy

A
  • Hx of neck radiation
  • Fm hx of thyroid cancer or endocrine tumors
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6
Q

Familial Syndromes of Thyroid Disease

A
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7
Q

Preoperative workup in clinic for thyroid carcinoma

A

History:

  • Focus on risk factors (h/o radiation; family hx, previous neck surgery)

Physical Exam:

  • Focused neck exam (size, tracheal deviation, substernal extension, LN)
  • Voice quality and volume
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8
Q

Preoperative labs and imaging in thyroid carcinoma

A

Labs

  • TFT for all
  • DTC - TSH, thyroglobulin, antithyroglobulin antibodies
  • MTC - CEA, calcitonin

Imaging

  • US thyroid & neck for LN
  • +/- CT/MRI (for locally advanced disease or vocal cord paresis)

Other test

  • +/- Laryngoscopy (vocal complaints/abnormalities, prior neck surgery/radiotherapy)
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9
Q

What special test can be performed with thyroid carcinoma?

A

Molecular Marker Testing

  • Aid in risk-stratification
  • Multiple tests available
  • Afirma looks at 167 genes (BRAF, RAS, RET, etc.)
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10
Q

In thyroid carcinoma, what is the T staging?

A

T1

  • 0-2 cm

T2

  • >2-4 cm

T3

  • >4 cm
  • In MTC, includes extrathyroidal extensions

T4

  • Gross extrathyroidal extension beyond strap muscles
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11
Q

In thyroid carcinoma, what is the N staging?

A

N0

  • No nodal involvement

N1

  • Nodal involvement
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12
Q

What is unique about Staging in DTC of the thyroid?

A
  • Age < 55 can only have stage I or II
    • 10 year survival >85%
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13
Q

What is unique about Staging in anaplastic carcinoma of the thyroid?

A

All anaplastic carcinoma is Stage IV by definition

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14
Q

PTC Surgical Treatment

A

SAFE ANSWER: IF >1 CM, TOTAL THYROIDECTOMY +/- therapeutic LN dissection for known disease only

  • Can consider lobectomy if ALL:
    • No prior radiation
    • No distant mets
    • No LN disease
    • No extrathyroidal extension
    • Tumor size 1-4 cm
  • Active surveillance vs lobectomy
    • <1 cm and LN negative
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15
Q

What are the pros and cons of total thyroidectomy vs lobectomy in PTC?

A

Pros of total thyroidectomy

  • Maximizes therapeutic impact of RAI
  • Easier mechanism of surveillance (no cells making thyroid hormone)

Cons of total thyroidectomy

  • Increased risk of nerve injury
  • Increased risk of damage to parathyroid glands

NO DIFFERENCE IN OVERALL OR DISEASE-SPECIFIC SURVIVAL

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16
Q

What are indications to go back for completion thyroidectomy after lobectomy for PTC?

A

Any of the following are indications for completion thyroidectomy:

  • Tumor >4 cm
  • Positive margins
  • Extrathyroidal extension
  • Macroscopic, multifocal disease (>1 cm)
  • Contralateral disease
  • Nodal metastasis
  • Vascular invasion
  • Poorly differentiated
17
Q

FTC Surgical Treatment

A

Total thyroidectomy +/- therapeutic neck dissection for involved compartments for:

  • Invasive cancer
  • Metastatic disease
  • Patient preference

OR

Lobectomy/isthmusectomy.

  • If final path shows invasive cancer, proceed with completion thyroidectomy.

SAFE ANSWER: TOTAL THYROIDECTOMY +/- therapeutic LN dissection for known disease

18
Q

Hurthle cell surgical treatment

A

Total thyroidectomy +/- therapeutic neck dissection for involved compartments for:

  • Invasive cancer
  • Metastatic disease
  • Patient preference

OR

Lobectomy/isthmusectomy.

  • If final path shows invasive cancer, proceed with completion thyroidectomy.

SAFE ANSWER: TOTAL THYROIDECTOMY +/- therapeutic LN dissection for known disease

19
Q

Which thyroid carcinomas should RAI be considered in?

A

Cancers that are derived from follicular cells (since they uptake iodine)

  • DTC (papillary, follicular, Hurthle cell)
20
Q

In DTC, what are indications to consider RAI?

A

Consider RAI for:

  • Tumors >2 cm
  • Lymphovascular invasion
  • LN metastasis
  • Positive marins
  • Gross extrathyroidal extension
  • Postop unstimulated Tg >5-10
  • Known or sustpected mets at presentation
21
Q

RAI treatment plan

A
  1. 6-12 weeks post thyroidectomy
  2. With draw all thyroid hormone tx
  3. Pre-RAI imaging (whole body imaging with TSH stimulation)
  4. Treatment with oral Sodium Iodide I-131
  5. Post-RAI imaging
22
Q

What additional postop treatment for papillary, follicular, or Hürthle carcinoma can be used (in addition to RAI)?

A

Levothyroxine to induce TSH suppresion.

23
Q

DTC Follow-up (PTC, FTC, Hurthle)

A

q6month x2, then q1year

  • H&P
  • TSH
  • Tg
  • Anti-Tg antibodies
24
Q

MTC Specific Workup

A
  • CEA, Calcitonin, Ca
  • Pheo screening (plasma free or 24-hour urine metanephrines)
  • RET proto-oncogene genetic testing
    • If positive, obtain PTH & metanephrines
  • Consider CT/MRI w/ contrast chest and liver
25
Q

MTC Treatment

A
  • < 1.0 cm and unilateral
    • Total thyroidectomy
    • Consider central LN dissection (VI)
  • >/= 1.0 cm or bilateral
    • Total thyroidectomy w/ central neck dissection
    • Therapeutic neck dissection for identifiable disease

SAFE ANSWER EVERYTIME: TOTAL THYROIDECTOMY AND CENTAL NECK DISSECTION +/- additional neck dissection for known disease

*No role for RAI post-op as MTC is from parafollicular cells that do not take up I.

26
Q

MTC Follow-up

A

2-3 months postop obtain CEA and calcitonin. If undetectable, enter active surveillance.

  • Annual CEA, calcitonin
  • For MEN2A or MEN2B, annual biochemical screening for HPT (PTH) or Pheo (metanephrines)
27
Q

Timing of thyroidectomy in MEN2(A or B)

A

MEN2A/FMTC - Thyroidectomy by age 5 or when mutation identified if older.

MEN2B - Thyroidectomy during first year of life or at diagnosis.

28
Q

Anaplastic Specific Workup

A
  • CT Head/Neck/C/A/P w/ contrast
  • Laryngoscopy
  • PET scan (skull to thigh)
  • +/- bronchoscopy
29
Q

Anaplastic Surgical Treatment

A

If resectable:

  • Total thyroidectomy with therapeutic lymph node dissection
30
Q

In anaplastic carcinoma, what are treatment options for unresectable disease or incomplete resection?

A
  • External Beam RT (EBRT)/Intensity-modulated RT (IMRT)
  • Chemo
  • Palliative care (median survival –> 6 months)
31
Q

Key steps of Total Thyroidectomy

A
32
Q

Neck Lymph Node Levels

A
33
Q

Steps of LN Dissection

A
34
Q

During thyroid/parathyroid surgery, what are two nerves that can be injured and their respective deficits?

A
  • RLN (Recurrent laryngeal nerve)
    • unilateral paralysis of ipsilateral cord
      • affects speaking and swallowing
    • bilateral injury can result in airway emergency given medialization of cords
  • EBSLN (External branch of the superior laryngeal nerve)
    • innervated cricopharyngeous muscle
    • inability to control high pressure phonation (high-pitched singing or yelling)
35
Q

What do you do if you are concerned that all parathyroid glands have been compromised?

A

Mince and reimplant in SCM

Surgery Mock Oral Board Prep (15 decks)

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