Thyroid cancer Flashcards
Thyroid cancer workup
Thyroid US
CT neck WITHOUT contrast
CT chest
Initial workup of medullary thyroid cancer
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
How age affects staging in differentiated thyroid cancer
- Patients younger than age 55 can only be staged as Stage I or II
Staging of anaplastic thyroid cancer
Everyone is considered Stage IV due to aggressive disease biology
Gender demographics in thyroid cancer
Women have 2x higher prevalence than men
RF’s for thyroid cancer
- ## XRT
Familial syndromes associated with thyroid cancer
MEN2A, MEN2B, Cowden, FAP
Differentiated thyroid cancers
Follicular
Papillary
Huerthle cell
Management of differentiated thyroid cancers
- Upfront surgery
- IF high risk, adjuvant RAI
- *TSH suppression w/ synthroid
Indications for adjuvant RAI in differentiated thyroid cancer
- Gross extrathyroid extension
- N1b
- bulky or greater than 5 lymph nodes involved
- greater than 4 cm
*postoperative unstimulated thyroglobulin greater than 10 - vascular invasion
Toxicities of RAI
- 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.
Risks associated with TSH suppression with synthroid in thyroid cancer
*risks of hypothyroidism
- - AFib
- osteoporosis
- CAD exacerbation
Surveillance for well differentiated thyroid cancer patients
- Serial thyroglobulin levels
- serial neck US
- RAI scan or PET if concern for progression
RAI refractoriness definition
- *RAI scans don’t pick up tumor but is visualized on CT OR nodules are present on RAI scans but growing in size
1) Systemic therapies for RAI refractory thyroid cancer 2) preferred
- sorafenib
- lenvatinib (preferred)
- cabo
second line TKI in thyroid cancer
cabo
Anaplastic thyroid cancer management
- 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)
Targetable mutation in anaplastic thyroid cancer
- BRAF
Actionable mutation in medullary thyroid cancer
RET
1) medullary thyroid cancer management 2) size threshold for surgery
IF >1cm, total thyroidectomy with bilateral neck dissection
IF <1cm, total thyroidectomy with consideration of bilateral neck dissection
Systemic therapies for medullary thyroid cancer
VEGF or EGFR targeted therapy
vandetanib
cabozantinib
RET targeted therapy if mutant
vandetanib SE’s
- QT prolongation
Biomarker for surveillance
Thyroglobulin
Adjuvant management of follicular with RO resection and low risk features
TSH suppression
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
RAI
Management of metastatic differentiated RAI refractory thyroid cancer
Sorafenib or lenvatinib
Metastatic medullary thyroid cancer management that is RET wildtype
vandetanin or cabozantinib
First line for unresectable anaplastic thyroid cancer that is BRAF mutant
Dabrafenib/trametinib
