Thyroid cancer

Question 1

Thyroid cancer workup

Answer 1

Thyroid US
CT neck WITHOUT contrast
CT chest

Question 2

Initial workup of medullary thyroid cancer

Answer 2

1) Preoperative baseline serum calcitonin + CEA
2) Rule out pheochromocytoma with plasma + urine metanephrines (*need to rule out MEN2 prior to surgery to avoid intraoperative hypertensive crises)
3) RET gene testing

Question 3

How age affects staging in differentiated thyroid cancer

Answer 3

• Patients younger than age 55 can only be staged as Stage I or II

Question 4

Staging of anaplastic thyroid cancer

Answer 4

Everyone is considered Stage IV due to aggressive disease biology

Question 5

Gender demographics in thyroid cancer

Answer 5

Women have 2x higher prevalence than men

Question 6

RF’s for thyroid cancer

Answer 6

• ## XRT

Question 7

Familial syndromes associated with thyroid cancer

Answer 7

MEN2A, MEN2B, Cowden, FAP

Question 8

Differentiated thyroid cancers

Answer 8

Follicular
Papillary
Huerthle cell

Question 9

Management of differentiated thyroid cancers

Answer 9

• Upfront surgery
• IF high risk, adjuvant RAI
• *TSH suppression w/ synthroid

Question 10

Indications for adjuvant RAI in differentiated thyroid cancer

Answer 10

• Gross extrathyroid extension
• N1b
• bulky or greater than 5 lymph nodes involved
• greater than 4 cm
  *postoperative unstimulated thyroglobulin greater than 10
• vascular invasion

Question 11

Toxicities of RAI

Answer 11

• nasolacrimal duct stenosis
• cytopenias
• secondary MDS or solid tumor
• infertility, amenorrhea (as well as in men). Can’t have sex for 6-12 months after a dose.

Question 12

Risks associated with TSH suppression with synthroid in thyroid cancer

Answer 12

*risks of hypothyroidism
- - AFib
- osteoporosis
- CAD exacerbation

Question 13

Surveillance for well differentiated thyroid cancer patients

Answer 13

• Serial thyroglobulin levels
• serial neck US
• RAI scan or PET if concern for progression

Question 14

RAI refractoriness definition

Answer 14

• *RAI scans don’t pick up tumor but is visualized on CT OR nodules are present on RAI scans but growing in size

Question 15

1) Systemic therapies for RAI refractory thyroid cancer 2) preferred

Answer 15

• sorafenib
• lenvatinib (preferred)
• cabo

Question 16

second line TKI in thyroid cancer

Answer 16

cabo

Question 17

Anaplastic thyroid cancer management

Answer 17

• Upfront surgery if resectable (total thyroidectomy with nodal dissection)
• XRT with or without sensitizing chemo (w/ carbo/taxol)
  *TSH suppression
• IF braf mutant, dab/trem
• clinical trial (preferred)

Question 18

Targetable mutation in anaplastic thyroid cancer

Answer 18

• BRAF

Question 19

Actionable mutation in medullary thyroid cancer

Answer 19

RET

Question 20

1) medullary thyroid cancer management 2) size threshold for surgery

Answer 20

IF >1cm, total thyroidectomy with bilateral neck dissection
IF <1cm, total thyroidectomy with consideration of bilateral neck dissection

Question 21

Systemic therapies for medullary thyroid cancer

Answer 21

VEGF or EGFR targeted therapy
vandetanib
cabozantinib
RET targeted therapy if mutant

Question 22

vandetanib SE’s

Answer 22

• QT prolongation

Question 23

Biomarker for surveillance

Answer 23

Thyroglobulin

Question 24

Adjuvant management of follicular with RO resection and low risk features

Answer 24

TSH suppression

Question 25

Adjuvant management of follicular with RO resection and high risk features (gross extrathyroidal extension, primary tumor >4cm, extensive vascular invasion, postop unstimulated elevated Tg, bulky or greater than 5 positive nodes

Answer 25

RAI

Question 26

Management of metastatic differentiated RAI refractory thyroid cancer

Answer 26

Sorafenib or lenvatinib

Question 27

Metastatic medullary thyroid cancer management that is RET wildtype

Answer 27

vandetanin or cabozantinib

Question 28

First line for unresectable anaplastic thyroid cancer that is BRAF mutant

Answer 28

Dabrafenib/trametinib