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Medicine > Thyroid Malignancy > Flashcards

Thyroid Malignancy Flashcards

1
Q

Biosynthetic defect and dec iodine

A

Dec efficiency of thyroid hormone synthesis

Inc TSH

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2
Q

Inc thyroid stimulating Ig
Upregulation of TSH receptor
Hyperthyroidism

A

Grave’s

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3
Q

Lymphocytic infiltration
Release of immune system growth factor
Hypothyroidism

A

Hashimoto’s thyroiditis

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4
Q

Grayscale sonographic features of thyroid cancer

A

Hypoechoic compared with surrounding thyroid 81% M sensitivity
Hypoechogenicity (94% high specificity)
Microcalcification
Irregular microlobulated margin
Solid consistency (highest median sensitivity 78-91)
Taller than wide shape on transverse view

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5
Q

Most common malignancy of endocrine system
2x common in women than men
Male worse prognosis

A

Thyroid cancer

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6
Q

Rf for thyroid ca

A 
Head and neck irrad before 18
Ionizing radiation from fallout in childhood
<20 >65 years
Rapid enlarging mass
Male gender
Family hx of papillary
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7
Q

Thyroid CA pathogenesis

A

Radiation
High TSH
Oncogenes

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8
Q

Papillary thyroid ca alteration

Most common

Rearrangement

A

BRAF V600E

RET rearrangement/PTC/RAS/MAPK

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9
Q

Follicular CA genetic alteration

A

PAX8-PPARy1 rearrangement

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10
Q

Anaplastic Thyroid Ca genetic alteration

A

TERT
BRAF
CTNNB1

And

P53

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11
Q

Loss of iodine uptake by tumor cell

A

BRAF mutation

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12
Q

BRAF + thyroid ca signals

A

inc recurrence rate

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13
Q

Medullary thyroid Ca is related to point mutation in

With hyperplasia of C cell

A

RET gene MEN 2

C cell produces calcitonin

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14
Q

PTH increases

A

serum calcium

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15
Q

Calcitonin dec

A

serum calcium

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16
Q

80-85% of well differentiated thyroid malignancies are

Pathognomonic histologic finding

A

Papillary

Orphan annie eye Clear cell nuclei

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17
Q

Multifocal
Invade locally within thyroid gland ane capsule and neck

Spreads via

A

Papillary thyroid ca
Lymlhatic but mets hematogenously bone and lung

Excellent prognosis

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18
Q

Follicular TC histology

A

Hurthle cell

Marked vascular invasion

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19
Q

Well differentiated thyroid ca tx

Small micropap thyroid T1a

A

Active surveillance

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20
Q

Tumor >1cm T1b or larger tx

A

Surgical excision

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21
Q

Tumor >4cm in presence of metastases

A

Neart total thyroidectomy

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22
Q

Mainstay tx of well diff thyroid cancer

A

Levothyroxine supression of TSH

TARGET
low risk: 0.5-2.0
Intermediate 0.1-0.5

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23
Q

After near total thyroidectomy, g of thyroid tissue remains in thyroid bed

Follow up with

A

<1 g

Postsurgical RAI eliminate residual gland

Contraindicated in pregnancy

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24
Q

Thyroid ablation and tx

A 
Iodine dep for 2 weeks
Inc serum TSH >25?
Pretx scan 
Ablation
Whole body scan post ablation
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25
Q

Indications of RAI

A 
Large tumors
More aggressive variants of papillary
Extrathyroidal invasion
Tumor vascular invasion
Presence of large volume LN mets
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26
Q

Surveillance thyroid test

Sensitive marker of residual recurrent thyroid cancer after ablation

Neck UTZ

External beam RT

A

Serum thyroglobulin tg

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27
Q 
RAS
BRAF 
RET
EGFR 
VEGR
Angiogenesis
A

Kinase inhibitors

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28
Q

Doubling of PFS To 10.8 months among progressive metastatic thyroid cancer

A

sorafenib multikinase inhibitor

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29
Q

Poorly differentiated
Aggressive
Poor prognosis die within 6 mos

A

Anaplastic thyroid cancer

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30
Q

Anaplastic thyroid tx

A

Chemo: paclitaxel and anthracycline (daunorubicin, doxo)
EBRT
Use of checkpoint inhibition therapy

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31
Q

Background of Hashimoto’s thyroiditis
Rapidly expanding thyroid mass
Sensitive to RT

A

Thyroid lymphoma

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32
Q

Most common thyroid lymphoma

A

Diffuse large b cell lymphoma

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33
Q

5% of thyroid cancer

3 familial forms

A

Medullary thyroid

Men2A
Men2B - more aggressive

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34
Q

Non tender palpable solitary neck mass

First dx

A

TSH
High
UTZ
Detectes on UTZ -> FNAB w cytology

TSH LOW
radionucleotide scanning
Hyperfuxn nodule

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35
Q

Thyroid cytology done by

A

Bethesda classification

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36
Q

Hyperthyroidism from single hyperfunctioning nodule
RAI scanning shows hot nodule with suppression of rest of thyroid gland
Rarely malignant
Smaller nodule - antithyroid med and RAI
lobectomy and isthmusectomy - larger nodule

A

Plummer’s disease

Toxic adenoma

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37
Q

Notorious for causinf hypo or hyper

A

Amiodarone

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38
Q

Most common location of cancer in esophagus

A

Middle third

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39
Q

Most common malignancy in iodine deficient region

A

Follicular TC

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40
Q

Calcitonin producing TC

A

Medullary thyroid

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41
Q

Carcinoma assoc with Hashimoto’s

A

Thyroid lymphoma

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42
Q

Thyroid lymphoma is thought to arise from

A

Chronic antigenic stimulation leading to proliferation of lymphoid tissue, somatic mutation, clonal proliferation, lymphoma

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43
Q

Thyroid lymphoma is thought to arise from

A

Hashimoto’s thyroiditis

as rapidly expanding thyroid mass

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44
Q

Most cases of thyroid carcinoma present with

A

a thyroid nodule

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45
Q

CLADs in thyroid carcinoma signify

A

local progression

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46
Q

Most common metastases of thyroid cancer

A

Lung

Bone

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47
Q

Rapidly enlarging thyroid mass

Regional or distant metasteses

A

Anaplastic TC

48
Q

MTC may present with paraneoplastic secretion of ectopic

A

adrenocorticotropic hormone ACTH

49
Q

Most common symptoms of Medullary TC

A

Diarrhea
Flushing

due to calcitonin

50
Q

Diagnosis made on basis of cytologic features from FNA or surgical pathology

Multifocal
Invade locally within thyroid gland and through thyroid capsule into adjacent structures in the neck

Grows slowly

A

Papillary TC

51
Q

PTC has propensity to spread via

A

Lymphatics

but may spread hematogenously particularly to bone and lung

significant burden of pulmonary metastases may accumulate sometimes with few symptoms

52
Q

Diagnosis is made on the bases of characteristic cytologic features on specimens from SURGICAL PATHOLOY

Difficult to diagnose by FNA nor cytopathology nor frozen section

A

Follicular TC

53
Q

Distinction between benign and malignant Follicular TC rests on evidence of

A

invasion into vessels, nerves, capsules and adjacent structures

54
Q

Follicular TC tends to spread

A

Hematogenously to bone, lung and CNS

55
Q

Diagnosis is made on the basis of cytologic features on specimen from FNA or surgical pathology

Poorly differentiated and aggressive arising from differentiated thyroid carcinoma due to V600E alteration in BRAF as with papillary

Uptake of radioiodine negligible

A

Anaplastic TC

56
Q

Definitive diagnosis made on the basis of cytologic features on specimens from FNA or surgical pathology

High serum calctonin and CEA can be indicative

Radioiodine scans not helpful since they do not accumulate radioiodine

A

Medullary TC

57
Q

Routine measurement of calcitonin is not recommended to detect MTC or in a patient with thyroid nodule

and should be tested instead only in persons presenting with

A

Diarrhea

Flushing

58
Q

Diagnosis of primary thyroid lymphoma rests on demonstration of

A

sheets of lymphoid cells in FNA

core biopsy specimen

59
Q

Can aid distinction of lymphoma from small cell lung cancer or Anaplastic TC

A

Immunophenotyping

60
Q

Most common Primary Thyroid Lymphoma

A

Diffuse Large Cell Non-Hodgkin Lymphoma

61
Q

Reed Sternberg Cells

A

Hodgkins B Lymphoma

62
Q

Starry sky appearance

A

Burkitt lymphoma

63
Q

TSH level in 95% of TC patients

64
Q

Marker for residual, recurrent or metastatic disease in WELL-DIFFERENTIATED TC

in patients with complete excision/ablation

A

Thyroglobulin Tg

Sensitivity of Tg increases when TSH is elevated

Interference of 20% can invalidate serum Tg assay

65
Q

Tg measurement suggests persistent ir recurrent thyroid carcinoma

66
Q

Tg level is increased in most metastatic

A

Papillary

Follicular

67
Q

Serum calcitonin level associated with cancer

A

500-2000 pg/mL

CEA

68
Q

Should be performed in sporadic cases of MTC to evaluate possibility of MEN2

A

RET mutational analysis

69
Q

Useful to aid in accurate needle placement in FNA

Used preoperatively in pathologically confirmed thyroid cancer to identify potential metastatic nodes and assist in planning the appropriate nodal dissection during surgical resection

Also useful to monitor for/identify sites of recurrent disease

A

Ultrasonography of neck

70
Q

Radioactive iodine uptake is significant in these types of TC in areas of residual or recurrent disease including bone and soft-tissue metastases

A

Papillary

Follicular TC

71
Q

Used to identify sites of distant metastases

A

18-Fluoro-deoxyglucose FDG positron emission tomography PET

72
Q

Good sensitivity and specificity

Accurate for detecting Papillary TC

73
Q

Nondiagnostic biopsies occur because

A

Fibrotic reaction with few cells available for aspiration
Cyst in which cellular components reside along cyst margin
Nodule too small for aspiration

74
Q

Additional preop diagnositc imaging after positive FNA

A

Chest radiography
Preoperative neck ultrasonography
CT or MRI of the neck, for fixed or substernal lesions
Evaluation of vocal cord mobility

75
Q

Papillary TC variant

A

Pure papillary
Follicular
Diffuse sclerosing
Tall-cell, columnar-cell

76
Q

Folicullar TC variant

A

Minimally invasive
Widely invasive
Hurthle Cell Carcinoma (oncocytic)
Insular carcinoma

77
Q

T1 staging

A

= 2 cm

limited to thyroid

78
Q

T2 staging

A

2-4cm

limited to thyroid

79
Q

T3 staging

A

> 4cm limited to thyroid or minimal extrathyroidal extension

80
Q

T4a

A

any size extending beyong capsule to soft tissue, larynx, trachea, esophagus or recurrent laryngeal nerve

81
Q

T4b

A

Tumor invades prevertebral fascia
Encases carotid artery
Mediastinal vessels

82
Q

N1

A

Regional lymph node metastasis

83
Q

N1a

A

Metastasis to level VI (pre, paratracheal, Delphian)

84
Q

N1b

A

Metastasis to unilateral, bilateral or contralateral cervical or superior mediastinal lymph nodes

85
Q

Stage grouping for PTC or FTC in <45

Stage I

Stage II

A

Any T, N, M0

Any T, N, M1

86
Q

Stage grouping for PTC or FTC >/= 45 or MTC any age

Stage IVc

A

Any T, Any N, M1

only M1

87
Q

Stage grouping for anaplastic carcinoma

A

All stages are considered stage IV

88
Q

Primary mode of therapy for well-differentiated thyroid carcinoma and MTC

A

Total thyroidectomy

89
Q

Total thyroidectomy is indicated as primary mode of treatment for well differentiated TC because

A

Removes primary lesion
Allows accurate histologic diagnosis and staging
Allows assessment of lymph node involvement and spread
Allows post-therapeutic surveillance using Tg as tumor marker

90
Q

Thyroidectomy + Postsurgical radioablation is performed in

A 
Age <15 >45
History of radiation
Known distant metastases
Bilateral disease
Extrathyroidal invasion
Tumor >4cm 
Cervical lymph node metastases
Family history of thyroid cancer
91
Q

Used for postsurgical ablation of residual thyroid tissue
Treatment of residual or recurrent TC

Reduction in recurrence rates
Improved monitoring with whole-body scanning and serial Tg

A

Radioiodine treatment

Most stage 1 PTC primary tumor <1.5 can be managed safely with thyroxine supression

92
Q

Patients who generally require thyroid ablation and radioiodine treatment

A

Larger papillary carcinomas adjacent lymph node involvement or extrathyroidal invasion
FTC
Evidence of metastases

93
Q

Strategy for postop radioiodine remnant ablation

A

2 weeks of liothyronine T3 25ug and then
Complete thyroid withdrawal for 2 weeks

Avoid pretreatment of scanning dise 131I to avoid stunning thyroid cells

Proceed directly to ablation unless suspicion that anount of residual tissue will alter therapy

94
Q

To increase radioiodine uptake patient must be placed on this diet

A

Low iodine <50 ug/d urinary iodine

Alternate strategy: Recombinant human TSH (rhTSH) to enhance 131 uptake for post surgical ablation

95
Q

Used to treat specific metastatic lesions when they cause bone pain or threaten neurologic injury (vertebral metastases)

A

External-beam radiotherapy

96
Q

Anaplastic TC therapy

A

Multimodal

Chemotherapy: cisplatin, bleomycin, 5-fu, cyclophosphamide

EBRT if responsive

97
Q

Thyroid lymhpoma is highly sensitive to

A

External-beam radiation

Avoid surgical resection

98
Q

Primary mode of therapy in MTC

Radioiodine treatment not indicated

A

Total thyroidectomy

EBRT for extensive local metastasis

Chemotherapy: doxorubicin, vincristine, cyclophosphamide, dacarbazine

99
Q

Monitoring of Well-differentiated TC

A

TSH supression (0.1-0.5 mU/L)

If high risk of recurrence or metastatic, complete supression <0.1

FT4 monitored to avoid excessive treatment

100
Q

Monitoring for recurrence 2

Primary technique

A

Imaging 131I whole body scanning and/or thyroid ultrasonography
Serum Tg

101
Q

Initial whole body scan following post therapy scan should be performed after how long post surgery/thyroid ablation

A

6-12 months

102
Q

For patients at low risk of recurrence Tg <2 ng/ml this may be used as an alternative to thyroid hormone withdrawal to stimulate Tg 131I uptake after ablation

Avoids symptoms of hypothyroidism and risk of prolonged TSH stimulated growth tumor

A

Recombinant human TSH

103
Q

Residual disease or metastases is treated with

A

Therapeutic 131I

Continue surveillance measures if there is no apparent disease

104
Q

PE should be done in differentiated TC

A

every 3-6 months for 2 years

annually if disease-free

105
Q

TSH and Tg antibodies in differentiated TC should be done

A

at 6 and 12 months

Anually if disease free

106
Q

Radioiodine scan in differentiated thyroid carcinoma every

A

12 months until 1 negative scan if undergone total thyroidectomy and ablation

107
Q

Surveillance protocol for differentiated TC

A

Periodic neck UTS and chest radiograph
Additional FDG PET or CT if Tg >10 ng/mL if 131I are negative and stimulated Tg level is >2-5 ng/mL
Consider rhTSh stimulated Tg in low risk patients with negative neck ultrasonography

108
Q

MTC surveillance

A

Annual measurement of basal calcitonin and CEA
Periodic neck ultrasonography
Ocreotide scanning to localize

109
Q

Complications specific to MTC

A

Secretion of serotonin and prostaglandin causing Flushing, diarrhea
Secretion of ACTH or CRH
Cushing’s

110
Q

Complications of 131I ablation

A

Sialodenitis
Radiation thyroiditis
Nausea
Dysgeusia and metallic taste sensation
Infertility and chromosomal abnormalities in offspring occur very rarely after exposure to high doses
Radiation fibrosis or lung (very high cumulative doses)

111
Q

<20 years >45 years

Prognosis

112
Q

Male sex

Prognosis

113
Q

Mortality is markedly increased in stage IV disease (1%)

114
Q

Poor prognostic factors in Follicular TC

A 
Distant metastases
Age >50 years
Primary tumor size >4 cm
Hurthle cell histology
Presence of marked vascular invasion
115
Q

Medullary TC may be prevented in patients known to harbor a germline mutation of

A

RET protooncogene MEN2

By early prophylactic thyroidectomy
Men2A 10 years
Men2B 4 years

Medicine (29 decks)

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