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Endocrine > Thyroid Cancer > Flashcards

Thyroid Cancer Flashcards

1
Q

What are the different histological classifications of thyroid cancer?

A

Papillary (76%), follicular (17%), medullary (3%), anaplastic (2%), other (2%)

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2
Q

What does differentiated thyroid cancer refer to?

A

Papillary and follicular variants = most take up and secrete thyroglobin, TSH driven

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3
Q

What is the link between differentiated features and prognosis?

A

Differentiated features mean good prognosis compared to other solid tumours

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4
Q

What is the epidemiology of differentiated thyroid cancer?

A

Uncommon in children and Afro-Americans, more common in men
Rates increase from age 15-40 in females then plateaus
Rises steadily with age in men

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5
Q

What are some associations of differentiated thyroid cancer?

A 
Strong = radiation
Weak = thyroid adenomata, conditions associated with chronic TSH elevation, increasing parity
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6
Q

What are some factors that are not linked to differentiated thyroid cancer?

A

Diet, family history, other proven malignancies, smoking, other lifestyle factors

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7
Q

How do differentiated thyroid cancers present?

A

Majority present with palpable nodules
Small percentage are change findings
About 5% present with local or disseminated metastases

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8
Q

What are some features of papillary thyroid cancer?

A

Comments next histological type, associated with Hashimoto’s thyroiditis, prognosis generally very good with 10 year mortality <5%

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9
Q

How does papillary thyroid cancer spread?

A

Tends to spread via lymphatics

May spread haematogenously to lungs, bone, liver and brain

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10
Q

What are some features of follicular carcinomas?

A

Second most common histological type, incidence slightly raised in regions of relative iodine deficiency, prognosis similar to that of papillary cancer

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11
Q

How do follicular carcinomas spread?

A

Tend to spread haematogenously

Lymphatic spread and gene lymph node enlargement are rare

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12
Q

How are differentiated thyroid cancers investigated?

A

Usually involves US-guided FNA of lesion, can involve excision biopsy of lymph node

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13
Q

What investigations are useless for differentiated thyroid cancer?

A

Isotope thyroid scan, CT, MRI

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14
Q

What investigation should be done if vocal cord palsy is suspected clinically?

A

Pre-operative laryngoscopy

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15
Q

What are the clinical predictors of malignancy?

A 
New thyroid nodule age <20 or >50
Male
Nodule increasing in size 
Lesion >4cm diameter
History of year and neck irradiation
Vocal cord palsy
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16
Q

What is the treatment of choice for differentiated thyroid cancers?

A

Surgery = thyroid lobectomy with isthmusectomy, sub-total or total thyroidectomy

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17
Q

What is the AMES risk stratification system?

A

Used to stratify patients as high or low risk = age, metastases, extent of primary tumour, size of primary tumour

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18
Q

What patients are classed as AMES low risk?

A 
Younger patients (men<40, women<50) with no evidence of metastases
Older patients with intrathyroidal papillary lesion 
Older patients with minimally invasive follicular lesion and primary tumour <5cm and no distant metastases
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19
Q

What is the 20 year survival of patients in each AMES risk group?

A 
Low = 99%
High = 61%
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20
Q

What patients are classed as AMES high risk?

A

All patients with distant metastases
Extrathyroid disease in patients with papillary cancer
Significant capsular invasion with follicular carcinoma
Primary tumour >5cm in older patients

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21
Q

What patients are treated with a thyroid lobectomy with isthmusectomy?

A

Papillary microcarcinoma (<1cm diameter)
Minimally invasive follicular carcinomas with capsular invasion only
AMES low risk

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22
Q

What patients are treated with sub-total or total thyroidectomy?

A 
DTC with extra-thyroidal spread
DTC with distant metastases 
Bilateral/multifocal DTC
DTC with nodal involvement
AMES high risk
23
Q

How common is lymph node spread at diagnosis in differentiated thyroid cancer?

A 
Papillary = 35-60%
Follicular = 20%
24
Q

What patients should undergo nodal clearance?

A

Patients with macroscopic lymph node disease

25
Q

How is lymph node involvement treated?

A 
Papillary = central compartment clearance and lateral lymph node sampling 
Follicular = central lymph node clearance
26
Q

When should calcium he checked post-op?

A

Within 24hrs = replacement initiated if corrected calcium falls below 2mmol/L

27
Q

When should IV calcium be given?

A

When levels fall below 1.8mmol/L

28
Q

What medication are patients discharged on after surgery?

A

T3 or T4

29
Q

When is whole body iodine scanning used?

A

In patients who have undergone sub-total or

total thyroidectomies = usually 3-6 months post-op

30
Q

What must be stopped before a whole body iodine scan?

A 
T4 = stopped 4 weeks before scan
T3 = stopped 2 weeks before scan
31
Q

Why is rhTSH a better measure for whole body iodine scans?

A

No need to stop T3 or T4

32
Q

What should TSH levels be to give the best results in a whole body iodine scan?

A

Greater than 20 = sensitivity determined by ensuring TSH is elevated

33
Q

How are whole body iodine scans carried out?

A

rhTSH injections have n Monday/Tuesday
75-150 MBq I-131 administered as capsule on Wednesday
Patient returns for imaging on Friday

34
Q

What are the results of whole body iodine scans used for?

A

Informing treatment decision

35
Q

How is thyroid remnant ablation carried out?

A

Patient admitted to lead lined room with mains sewerage, pre-treated with rhTSH before procedure, 2-3 GBq capsule of I-131 administered

36
Q

What are some side effects of thyroid remnant ablation?

A

Sialadenitis, sore throat

37
Q

What precautions are in place during thyroid remnant ablation?

A

Patient uses disposable cutlery, sheets and clothes stored until safe
Little or no contact with nurses and visitors

38
Q

When are patients discharged after a thyroid remnant ablation?

A

When count rate <500cps at 1m

39
Q

How much radiation is excreted in the first 24hrs after thyroid remnant ablation?

A

80% = significant radiation protection regulations

40
Q

What do patients normally undergo before they are discharged after thyroid remnant ablation?

A

Post-therapy scan = maintained on T4 after therapy and scan

41
Q

What is the aim of thyroid remnant ablation?

A

Suppress TSH < 0.1mU/l and have FT4 below 25

42
Q

What is the rationale behind thyroid remnant ablation?

A

Ablate residual thyroid tissue in order to destroy occult microfoci
Remove residual thyroid tissue which may be a source of Tg and therefore confound the levels during follow up

43
Q

What does thyroid remnant ablation allow?

A

Predictively useful scanning in whole body scans and subsequent high dose therapy if required

44
Q

What are the long term effects of thyroid remnant ablation?

A

Small but significant increase in incidence of AML = mainly in patients with cumulative I-131 doses >800mCi and repeated therapy doses within 12 months

45
Q

That can thyroglobin (Tg) be used as?

A

Tumour marker = raised TSH is associated with elevated Tg so results can be affected by thyroid status

46
Q

What may occur is anti-thyroid antibodies are measured at the same time as a titre?

A

May affect interpretation of results

47
Q

When should thyroglobin be measured?

A

Pre-op = not all patients secrete Tg

48
Q

What is the 10 year survival of differentiated thyroid cancer?

A 
Papillary = 95%
Follicular = 88%
49
Q

How is recurrent disease detected?

A

Rising Tg and imaging

50
Q

What commonly causes recurrence in cervical lymph nodes?

A

Papillary cancer

51
Q

What commonly causes haematogenous spread?

A

Follicular cancer = lungs, bone and brain

52
Q

What is the recurrent rate of differentiated thyroid cancer?

A

30%

53
Q

What is the difficult patient group in recurrent disease?

A

Rising Tg but negative whole body I-131 scan = PET scans used to identify disease sites and allow targeted treatment

Endocrine (42 decks)

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