Thyroid cancer

Question 1

what could ddx be for solitary thyroid nodule

Answer 1

cyst 
colloid nodule 
bengin follicular adenoma 
hyperplastic nodule 
papillary/follicular/medullary/anaplastic cancer 
lymphoma

Question 2

how is a minimally invasive and vasular invasive follicular thyroid carcinoma managed

Answer 2

minimally invasive - lobectomy

invasion of vasculature or significant invasion then total thyroidectomy

Question 3

what is the tumour cell marker in meduallary cell cancer

Answer 3

calcitonin

Question 4

causes of medullary cell cancer?

Answer 4

sporadic, familial non MEN, or familial MEN

Question 5

features of MEN2a?

Answer 5

MTC, hyperparathyroidism, phaeochromocytoma

Question 6

how would you possibly manage MEN2a

Answer 6

prophylactic thyroidectomy as a child

Question 7

biggest risk factor for thyroid lymphoma and how may it present

Answer 7

AA hypothyroidism

rapid onset mass in thyroid in female 70-80s

Question 8

how would a lymphoma of the thyroid be managed

Answer 8

FNA or biopsy for histology then chemo, DXT, steroids, radiotherapy

Question 9

what is the bethesda classification on FNA

Answer 9

thy1 inadequate 
thy2 benign 
thy3 atypical 
thy4 probs malignant 
thy5 malignant

Question 10

how would you recognise a low risk papillary cell carcinoma and what is the management

Answer 10

<50 and tumour <4cm
lobectomy
lower TSH and baseline Tg to monitor

Question 11

how would you recognise a high risk papillary cell carcinoma and what is the management

Answer 11

anything not in low risk category
total thyroidectomy with consiered radioactive iodine
TSH<1mU/L
annual Tg monitor as tumour cell marker

Question 12

follow up for thyroid cancer

Answer 12

low risk may be discharged post 5y

get TSH/Tg for 6m for the first 5y and if not discharged then annually

Question 13

what features may be seen on multinodular goitre on CT

Answer 13

retrosternal extension

tracheal deviation

Question 14

when would you offer surgery for multinodular goitre causing issues

Answer 14

lifestyle interfering symptoms
stridor
tracheal compression and symptomatic
possibility of cancer

Question 15

what does differentiated thyroid cancer refer to?

Answer 15

papillary and follicular cancers

Question 16

risk factors for DTC

Answer 16

females
no association with diet, FHx, malignancy, smoking
ionising radiation exposure is the exception

Question 17

investigation of DTC

Answer 17

USS FNA
excision biopsy of lymph node
pre op laryngoscopy if vocal cord palsy

Question 18

why would a subtotal thyroidectomy be done over total

Answer 18

risk to damage of recurrent larygeal nerves

Question 19

when would a total body iodine scan be done

Answer 19

3-6m post op subtotal or total thyroidectomy

Question 20

describe the use of rhTSH and total body iodine scan

Answer 20

engineered to raise TSH<20
monday/tuesday IM injection
on wed give I-131
image on fri

Question 21

what would you see on a total body iodine scan

Answer 21

physiological uptake into salivary glands, pituitary and concentration in stomach and bladder
may see thyroid remnant in sub-total thyroidectomy

Question 22

side effects of thyroid remnant ablation

Answer 22

sialadenitis

sore throat

Question 23

how is thyroid remnant conducted

Answer 23

pre treatment with rhTSH and higher dose I-131
patient admitted to lead lined room, use of disposable cutlery, sheets and clothing are stored until deemed safe with little contact with visitors/nurses

Question 24

what are the TSH/FT4 aims post radioactive remnant ablation

Answer 24

TSH<0.1mU/l
FT4<25
use throxine to suppress TSH but not too much to increase FT4

Question 25

describe possibly issues in using Tg as a tumour marker post radioactive remnant ablation

Answer 25

need suppressed TSH
anti-Tg Ab may affect result if +ve
presure pre op as not all subjects secrete Tg

Question 26

long term effects of I-131 ablation

Answer 26

small, but significant risk in AML in those with repeated high doses within 12m

Question 27

how may recurring differentiated thyroid cancer present

Answer 27

lymphadenopathy - papillary
haematogenous mets - follicular
rising Tg or spotted on imaging - usually I-131 but also PET

Question 28

what is the recurrence rate of differentiated thyroid cancer

Answer 28

30%

Question 29

management of DTC refractory to I-131 management

Answer 29

sorafenib, lenvatinib
tyrosine kinase inhibitors thought to be of benefit
small patient evidence base