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thyroid cancer Flashcards

1
Q

risk factors for hyperthyroidism

A

female
family history
smoking - dose-dependent risk factor for Graves disease and Graves Orbitopathy
low iodine take

autoimmune disease - Graves’ orbitopathy, hyperthyroidism and postpartum thyroiditis

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2
Q

causes of hyperthyroidism

A

Graves’ disease - TSH receptor antibodies

toxic multinodular goitre

toxic thyroid nodule (adenoma)

  • TSH-secreting pituitary adenoma
  • Pituitary thyroid hormone resistance syndrome
  • iodine

thyroiditis

  • postpartum thyroiditis
  • subacute (de Quervain’s) thyroiditis
  • drug induced - amiodarone,antiretrovirals and cancer immunotherapy
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3
Q

complications of hyperthyroidism

A

Graves Orbitopathy -
thyrotoxic crisis - thyroid storm

compression - dysphagia or breathlessness - oesophageal or tracheal compression

Thyrotoxic periodic paralysis

heart failure

Reduced bone mineral density and osteoporosis

psychosis

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4
Q

eye complications of hyperthyroidism

A

dysthyroid optic neuropathy

severe corneal exposure and. ulceration

corneal breakdown leading to frank perforation

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5
Q

clinical features of thyroid storm

A

fever, tachycardia, agitation, hyperthermia, hypertension, atrial fibrillation, heart failure, jaundice, delirium, and coma

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6
Q

what is Thyrotoxic periodic paralysis

A

complication characterized by muscle paralysis and hypokalaemia, which is more prevalent in Asian people with hyperthyroidism

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7
Q

pregnancy complications of hyperthyroidism

A

increased risk of miscarriage, pregnancy-induced hypertension, maternal heart failure, preterm delivery, intrauterine growth restriction, low birthweight, and fetal death, if maternal hyperthyroidism is inadequately controlled during pregnancy

Fetal complications of maternal hyperthyroidism include intrauterine growth restriction, fetal goitre, fetal hydrops and heart failure, fetal or neonatal thyrotoxicosis

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8
Q

symptoms of hyperthyroidism

A

Rapid-onset malaise, fever, and thyroid pain (may suggest subacute thyroiditis).

Compression symptoms of breathlessness, hoarse voice, dysphagia, neck pressure (may be caused by a toxic multinodular goitre).

Agitation, emotional lability, insomnia, irritability, anxiety, palpitations.

Exercise intolerance, fatigue, muscle weakness.

Heat intolerance, increased sweating.
Increased appetite with unintentional weight loss, diarrhoea.

Subfertility, oligomenorrhoea, amenorrhoea.

Polyuria, thirst, generalized itch.
Reduced libido, gynaecomastia in men.

Deterioration in blood glucose control and hyperglycaemia in people with diabetes mellitus.

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9
Q

signs of hyperthyroidism

A

Agitation, fine tremor, warm moist skin, palmar erythema.

Sinus tachycardia, atrial fibrillation, heart failure, peripheral oedema.

Pruritus, urticaria, vitiligo, diffuse alopecia.

Muscle wasting, proximal myopathy, hyper-reflexia.

Splenomegaly, lymphadenopathy.

Gynaecomastia in men.

Extrathyroid manifestations of Graves' disease (rare):
Thyroid acropachy (clubbing and swelling of the distal fingers and toes).

Thyroid dermopathy (slightly pigmented thickened skin and swelling of both legs, usually in the pretibial area).

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10
Q

how would a toxic multinodular goitre lump feel

A

non-tender thyroid nodules.

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11
Q

how would a graves’ deisease lump feel

A

diffusely symmetrically enlarged without nodules, and there may be a bruit.

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12
Q

how would a toxic adenoma nodule feel

A

unilateral, non-tender thyroid mass.

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13
Q

how would a subacute thyroiditis lump feel

A

tender, firm, irregular, diffusely enlarged thyroid gland which may be asymmetrical.

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14
Q

when to suspect Graves’ orbitopathy

A

Eye irritation, photophobia, or excessive watering of the eyes.

Redness of the eyes or eyelids and/or lid swelling.

Change in the appearance of the eye or eyelids:
Eyelid retraction (sclera is visible above the superior corneal limbus).

Lid lag (delay in moving the eyelid as the eye moves downward).

Proptosis (exophthalmos, eyeball protrusion, an inability to fully close the eyes as the upper and lower lids do not fully appose).

Persistent double vision in any direction of gaze (typically when looking upwards and outwards).

Unexplained deterioration in visual acuity; change in the intensity or quality of colour vision in one or both eyes; orbital aching or restricted eye

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15
Q

what is subclinical hyperthyroidism

A

TSH is suppressed below the normal reference range, but FT4 and FT3 concentrations are within the normal reference range.

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16
Q

medications for hyperthyroidism

A

carbimazole

propylthiouracil - prepregnancy or first trimester

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17
Q

management for hyperthyroidism

A

drugs

radioiodine treatment

surgery

18
Q

when is radioactive iodine treatment first line

A

Graves’ disease
toxic multinodular goitre

contradicted in Graves’ disease with active or severe orbitopathy
pregnancy or planning to get pregnagnt in 4-6 months

19
Q

when is surgery considered in hyperthyroid patients

A

To prevent the recurrence of hyperthyroidism.
With compression symptoms from a large toxic multinodular goitre.
With a co-existing potentially malignant thyroid nodule.
Who have not tolerated antithyroid drug treatment or it is ineffective, especially in pregnancy or active Graves’ orbitopathy, or if radioactive iodine treatment is unsuitable.

20
Q

side effects of carbimazole or propylthiouracil,

A

agranulocytosis or neutropenia such as fever, sore throat, mouth ulcers, febrile or non-specific illness, bruising, or malaise, and to stop the medication immediately.

21
Q

side effects specifically of carbimazole

A

acute pancreatitis

22
Q

side effects specifically of propylthioiracil

A

liver disease, such as anorexia, nausea, vomiting, fatigue, abominal pain, jaundice, light-coloured stool, dark urine, or itch.

23
Q

what bloods should be done before starting the drugs

A

Full blood count (FBC) including white cell count and differential, and liver function tests (LFTs) should be checked.

24
Q

what to monitor after starting drugs and stopping

A

start - chech TSH T3 T4 every 6 weeks until in range then every 3 months

STOP - TSH 8 weeks then every 3 months

25
Q

what to monitor after radioactive iodine treatment

A

TSH T3 T4 every 6 weeks for the the first 6 months

26
Q

types of thyroid cancer

A

papillary, follicular, medullary, anaplastic, and lymphoma

27
Q

what is papillary carcinoma

A

multiple lesions within the gland and they are rarely encapsulated. Histologically, cells are a mixture of papillary and colloid-filled follicles, with papillary projections and pale empty nuclei. They commonly spread via the lymphatics.

most common type 40-50

28
Q

what is follicular carcinoma

A

focal encapsulated lesions (multifocal disease is rare), with microscopic capsular invasion*. Where metastasis occurs, it is usually via haematogenous spread to bones and lungs.

29
Q

what is medullary carcinoma

A

arise in the parafollicular cells (calcitonin C-cells, derived from the neural crest cells).

raised calcitonin levels

MEN 2 syndrome (both 2a and 2b).

Medullary carcinoma can spread by both lymphatic and medullary routes; unfortunately nodal disease is associated with a very poor prognosis.

30
Q

what is anaplastic carcinoma

A

elderly and are very aggressive.

They tend to grow rapidly with early local invasion and often have spread

no curative treatment

31
Q

risk factors of thyroid cancer

A

Female gender
Family history
Also includes relevant cancer syndromes (e.g. medullary subtype associated with Multiple Endocrine Neoplasia (MEN) Syndrome type IIa and IIb)
Radiation exposure in childhood
Full body radiotherapy for bone marrow transplant
Hashimoto’s disease
Predisposes to lymphoma subtype

32
Q

clinical features of thyroid cancer

A

incidental lump

red flags
Rapid growth
Pain
Cough, hoarse voice, or stridor
Multiple enlarged cervical lymph nodes
Tethering of the lump to surrounding structures
33
Q

Ix for thyroid cancer

A

TFTs

US

FNAC

34
Q

what increases suspicion of thyroid cancer on US scan

A

Microcalcifications

Hypoechongenicity

Irregular margin

35
Q

The TNM staging system for thyroid cancer

A

Thy1 is inconclusive and requires a further sample

Thy2 is non-malignant

Thy3 is follicular lesion and requires diagnostic hemithyroidectomy for histology to determine between follicular adenoma (benign) or carcinoma

Thy4 is suspicious and requires diagnostic hemithyroidectomy

Thy5 is malignant and requires work up for appropriate treatment

36
Q

management for thyroid cancer

A

Adenomas – require no further treatment after diagnostic hemithyroidectomy

surgery - total thyroidectomy for papillary, follicular and medullary

radio-iodine treatment - papillary and follicullar carcinoma

37
Q

complications of thyroid surgery

A

haematoma - large go back to surgery
infection
hypoparathyroidism
hypocalcaemia - parasethesia -> tingling around mouth and fingertips.
tetany: muscle twitching, cramping and spasm
Chvostek’s sign
tapping over parotid causes facial muscles to twitch
Trousseau
carpal spasm if the brachial artery occluded by inflating the blood pressure cuff and maintaining pressure above systolic
wrist flexion and fingers are drawn together
prolonged QT interval

recurrent laryngeal nerve palsy 
-> vocal cord paralysis
-> unilateral - hoarse
-> bilateral - stridor and tracheostomy
hypothyroidism
38
Q

more likely to develop Graves’

A 
RA
pernicious anaemia
lupus
addison's disease
coeliac disease
vitiligo
type 1 diabetes
39
Q

what are the types of thyroiditis

A

Viral or sub-acute thyroiditis
Postpartum thyroiditis
Drug-induced thyroiditis
Autoimmune thyroiditis

40
Q

recurrent laryngeal nerve pathway

A

nerves branch off the vagus nerves in the neck.
The left side loops under the aortic arch
Right side loops under the right subclavian artery

Both pass upwards to supply the laryngeal muscles passing deep to thyroid and entering the larynx posterior to the cricothyroid joint

ENT (15 decks)

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