Thyroid Cancer

Question 1

What are the differentiated types of thyroid cancer?

Answer 1

Papillary, Follicular, Hurthle cell. Papillary thyroid cancer is the most common type.

Question 2

What is the undifferentiated type of thyroid cancer that can be pretty aggressive?

Answer 2

Anaplastic Thyroid Cancer

Question 3

Medullary thyroid cancer involves what cells of the thyroid?

Answer 3

Parafollicular C cells

Question 4

In hereditary medullary thyroid cancer, what is the activating mutation found here? Also what about in sporadic cases

Answer 4

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.

Question 5

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?

Answer 5

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.

Question 6

For locally advanced/metastatic papillary/follicular thyroid cancer what is the agent that can be given as a second line option?

Answer 6

Cabozantinib if progression after Lenvatinib and/or Sorafenib

Question 7

What is the tx for N-TRK mutated papillary/follicular thyroid cancer in the locally advanced/metastatic setting?

Answer 7

Larotrectinib, Entrectinib, Repotrectinib

Question 8

What are the options for RET mutated papillary/follicular thyroid cancer in the locally advanced/metastatic setting?

Answer 8

Selpercatinib, Pralasetinib

Question 9

When is Pembro alone indicated for locally advanced/metastatic thyroid cancer?

Answer 9

If TMB is 10 or higher, dMMR or MSI-H

Question 10

According to NCCN guidelines for locally advanced/metastatic Papillary thyroid cancer for those that have a BRAF mutation, what meds are indicated and when?

Answer 10

Dabrafenib/Trametinib only after they have progressed from prior therapy and there are no other acceptable options.

Question 11

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?

Answer 11

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.

Question 12

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?

Answer 12

Suppress TSH with levothyroxine. And then continue surveillance with unstimulated thyroglobulin levels and imaging.

Question 13

What is the preferred tx for CNS mets in papillary/follicular thyroid cancer?

Answer 13

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.

Question 14

For anaplastic thyroid cancer remember there are three different type of stages, what are they?

Answer 14

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

Question 15

For those with Stage IVA/B anaplastic thyroid cancer, what is the tx?

Answer 15

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.

Question 16

What chemo do you give w/EBRT for Anaplastic Thyroid cancer?

Answer 16

Paclitaxel/Carbo, Docetaxel/Carbo, or Docetaxel or Paclitaxel alone

Question 17

What is the tx for Stage IVC anaplastic thyroid cancer?

Answer 17

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.

Question 18

In a patient with a poor PS and/or wide spread disease w/anaplastic thyroid cancer, what are your options here?

Answer 18

Palliative tx-locoregional surgery or RT

Question 19

What is the tx for BRAF V600E mutation in Papillary/Follicular, Anaplastic thyroid cancer?

Answer 19

Dabrafenib/Trametinib

Question 20

Medullary thyroid cancer is what type of hormonal tumor? What substance does it secrete and what are the symptoms?

Answer 20

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.

Question 21

Medullary thyroid cancer is associated with what genetic syndrome? What is the underlying genetic mutation assoc with each?

Answer 21

MEN2A and MEN 2B.
MEN2A-RETC634R
MEN2B-RETM918T Just remember that it is a RET mutation (this is the more aggressive MEN disease, 2B)

Question 22

MEN2A and MEN2B are associated with what other tumors besides medullary thyroid cancer?

Answer 22

MEN2A-pheochromocytoma and parathyroid hyperplasia (hyperparathyroidism)
MEN2B-pheochromocytoma, mucosal neuromas, toxic megacolon.

Question 23

What are the treatment options for locally advanced/metastatic medullary thyroid cancer? What if there is a RET mutation?

Answer 23

Vandetanib (Cat 1)
Cabozantinib (Cat 1)
RET-Selpercatinib (Cat 1)
RET-Pralsetinib (Cat 2B)

Question 24

When can you use Pembro in advanced/metastatic medullary thyroid cancer?

Answer 24

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

Question 25

Vendatinib has a black box label for what? What are some other toxicities?

Answer 25

Black box label for QT prolongation and sudden death. Can also cause diarrhea, dermatitis acneiform/acne, nausea, HTN, skin rash

Question 26

What are the factors that say a patient needs a total vs partial thyroidectomy after FNA results?

Answer 26

Bilateral nodularity, tumor greater than 4cm, poorly differentiated or high grade well differentiated, lateral cervical node mets or gross central lymph node mets

Question 27

For well differentiated thyroid cancer what are soft indications for RAI therapy?

Answer 27

Primary tumor greater than 2cm, high risk subtypes, lymphatic invasion, microscopic positive margins, macroscopic focality (one lesion >1cm).

Question 28

What are strict criteria for RAI therapy for well differentiated tumors?

Answer 28

Significant N1b dx, gross extrathryoidal extension, postoperative Tg>10, bulky or more than 5 nodes, vascular invasion, differentiated high grade lesions

Question 29

Which thyroid cancer has a RET fusion vs a RET mutation?

Answer 29

RET fusion-papillary thyroid RET mutation-medullary thyroid cancer

Question 30

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)

Answer 30

Carbo or Cisplatin with Etoposide +/- doxorubicin +/- Mitotane. Resectable dx-you can give Mitotane (this is Cat 3 rec).

Question 31

Pheochromocytoma can be assoc with which genetic syndromes?

Answer 31

VHL, MEN-2, NF1

Question 32

What is the tx for pheochromocytoma both unresectable and locally advanced/metastatic?

Answer 32

131I-MIBG, Sunitinib, CVD or TMZ, Lu 177 if SSRT +, Octreotide or Lanreotide