Thyroid Cancer Flashcards
What are the differentiated types of thyroid cancer?
Papillary, Follicular, Hurthle cell. Papillary thyroid cancer is the most common type.
What is the undifferentiated type of thyroid cancer that can be pretty aggressive?
Anaplastic Thyroid Cancer
Medullary thyroid cancer involves what cells of the thyroid?
Parafollicular C cells
In hereditary medullary thyroid cancer, what is the activating mutation found here? Also what about in sporadic cases
There is a mutation in the RET kinase pathway. In about 40-50% of cases you can also see this mutation present in sporadic cases.
What is the preferred first line tx options for papillary/follicular thyroid cancer in the locally advanced/metastatic setting if indicated? When could you observe in these cases?
So the preferred options are Sorafenib and Lenvatinib. Keep in mind that Sorafenib has a higher ORR. For those patients with low burden and indolent disease you can just observe these patients.
For locally advanced/metastatic papillary/follicular thyroid cancer what is the agent that can be given as a second line option?
Cabozantinib if progression after Lenvatinib and/or Sorafenib
What is the tx for N-TRK mutated papillary/follicular thyroid cancer in the locally advanced/metastatic setting?
Larotrectinib, Entrectinib, Repotrectinib
What are the options for RET mutated papillary/follicular thyroid cancer in the locally advanced/metastatic setting?
Selpercatinib, Pralasetinib
When is Pembro alone indicated for locally advanced/metastatic thyroid cancer?
If TMB is 10 or higher, dMMR or MSI-H
According to NCCN guidelines for locally advanced/metastatic Papillary thyroid cancer for those that have a BRAF mutation, what meds are indicated and when?
Dabrafenib/Trametinib only after they have progressed from prior therapy and there are no other acceptable options.
For patients who have papillary/follicular thyroid cancer and develop recurrent or metastatic disease, what is the first option should be considered? If a lesion is resectable, what should be done here?
They will need RAI imaging to see if they have positive lesions, if so this is the best next therapy to use. If a lesion is resectable it is preferred to resect it over giving RAI treatment.
What is one treatment approach for papillary/follicular thyroid cancer that is recurrent with neg RAI imaging and no dx detected but rising thyroglobulin level and are not resectable?
Suppress TSH with levothyroxine. And then continue surveillance with unstimulated thyroglobulin levels and imaging.
What is the preferred tx for CNS mets in papillary/follicular thyroid cancer?
Surgical resection or sterotactic radiosurgery. If for some reason you can’t use these you have your other options that you use for metastatic dx.
For anaplastic thyroid cancer remember there are three different type of stages, what are they?
All anaplastic thyroid cancer is stage IV due to the aggressive nature and poor prognosis. You have Stages: IVA-intrathyroidal, IVB-extrathryoidal, IVC-distant disease
For those with Stage IVA/B anaplastic thyroid cancer, what is the tx?
So for disease that is resectable you resect w/node dissection and then give EBRT w/chemo. For disease that is not resectable run molecular testing, tx with targeted therapy to shrink tumor and resect. Or if no targeted options, provide def EBRT/Chemo and then resect.
What chemo do you give w/EBRT for Anaplastic Thyroid cancer?
Paclitaxel/Carbo, Docetaxel/Doxorubicin, or Docetaxel or Paclitaxel alone
What is the tx for Stage IVC anaplastic thyroid cancer?
Resect if possible w/node dissection. Locoregional RT. Systemic therapy +/- RT (using EBRT chemo, refer to flash card) Note when using single agent systemic therapy options are: Targeted therapy or Paclitaxel or Doxorubicin. Paclitaxel/Carboplatin and Docetaxel/Doxorubicin are Cat2B.
In a patient with a poor PS and/or wide spread disease w/anaplastic thyroid cancer, what are your options here?
Palliative tx-locoregional surgery or RT
What is the tx for BRAF V600E mutation in Papillary/Follicular, Anaplastic thyroid cancer?
Dabrafenib/Trametinib
Medullary thyroid cancer is what type of hormonal tumor? What substance does it secrete and what are the symptoms?
Its a neuroendocrine tumor. It secretes calcitonin. This can cause facial flushing and diarrhea. Some of these tumors can also secrete ACTH causing cushing syndrome.
Medullary thyroid cancer is associated with what genetic syndrome? What is the underlying genetic mutation assoc with each?
MEN2A and MEN 2B.
MEN2A-RETC634R
MEN2B-RETM918T Just remember that it is a RET mutation (this is the more aggressive MEN disease, 2B)
MEN2A and MEN2B are associated with what other tumors besides medullary thyroid cancer?
MEN2A-pheochromocytoma and parathyroid hyperplasia (hyperparathyroidism)
MEN2B-pheochromocytoma, mucosal neuromas, toxic megacolon.
What are the treatment options for locally advanced/metastatic medullary thyroid cancer? What if there is a RET mutation?
Vandetanib (Cat 1)
Cabozantinib (Cat 1)
RET-Selpercatinib (Cat 1)
RET-Pralsetinib (Cat 2B)
When can you use Pembro in advanced/metastatic medullary thyroid cancer?
In those with TMB-H (10 or higher), MSI-H/d-MMR after they have progressed on one agent and no other options are available
Vendatinib has a black box label for what? What are some other toxicities?
Black box label for QT prolongation and sudden death. Can also cause diarrhea, dermatitis acneiform/acne, nausea, HTN, skin rash
What are the factors that say a patient needs a total vs partial thyroidectomy after FNA results?
Bilateral nodularity, tumor greater than 4cm, poorly differentiated or high grade well differentiated, lateral cervical node mets or gross central lymph node mets
For well differentiated thyroid cancer what are soft indications for RAI therapy?
Primary tumor greater than 2cm, high risk subtypes, lymphatic invasion, microscopic positive margins, macroscopic focality (one lesion >1cm).
What are strict criteria for RAI therapy for well differentiated tumors?
Significant N1b dx, gross extrathryoidal extension, postoperative Tg>10, bulky or more than 5 nodes, vascular invasion, differentiated high grade lesions. N1b-unilateral, bilateral, contralateral lateral neck nodes (I,II, III, IV, V nodes)
Which thyroid cancer has a RET fusion vs a RET mutation?
RET fusion-papillary thyroid RET mutation-medullary thyroid cancer
What is the tx for locally advanced or metastatic adrenalcortical carcinoma? For those tumors that are resectable what can you consider giving to reduce hormonal symptoms (Cushing, Aldosterone, Androgens)
Carbo or Cisplatin with Etoposide +/- doxorubicin +/- Mitotane. Resectable dx-you can give Mitotane (this is Cat 3 rec).
Pheochromocytoma can be assoc with which genetic syndromes?
VHL, MEN-2, NF1
What is the tx for pheochromocytoma both unresectable and locally advanced/metastatic?
131I-MIBG, Sunitinib, CVD or TMZ, Lu 177 if SSRT +, Octreotide or Lanreotide
