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Endocrine > Thyroid/Neck lumps > Flashcards

Thyroid/Neck lumps Flashcards

1
Q

What is a goitre?

A

Any enlargement of the thyroid gland. Most often due to lack of dietary iodine

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2
Q

What TFT results would you expect in low dietary iodine?

A

reduced fT3/4 production & high TSH (-> gland enlargement)

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3
Q

List some substances that limit T3/4 production.

A

broccoli, cauliflower, cabbage

lithium, amiodarone

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4
Q

Who would typically present with a diffuse goitre?

A

sporadic; F>M, puberty & young adults.

usually present with cosmetic issue since usually euthyroid

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5
Q

what TFTs would you expect for a sporadic diffuse goitre?

A

T3/4 normal but TSH high/upper limit normal

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6
Q

What developmental condition can result in babies if they have dyshormonogenesis relating to thyroid hormones?

A

cretinism - absence of T4 after 3months -> permanent developmental delay

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7
Q

What cellular disruption would you see in a multi-nodular goitre?

A

rupture of follicles, haemorrhage, scarring, calcification

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8
Q

A patient presents with a discrete solitary mass that they reckon they have had for a while now but have only noticed recently since they have been having trouble swallowing. Differentials?

A

Follicular Adenoma
Dominant nodule in a multi-nodular goitre
Follicular carcinoma

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9
Q

Describe the architecture of a follicular adenoma.

A

encapsulated by a surrounding collagen cuff

composed of neoplastic thyroid follicles (i.e. follicular adenoma)

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10
Q

What is a Differentiated Thyroid Cancer?

A

Differentiated refers to histological appearance but also physiological characteristic:
most take up Iodine and secrete thyroglobulin
DTCs are TSH driven
if ‘differentiated’ features = good prognosis compared to other solid tumours (i.e. anaplastic)

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11
Q

Who typically gets DTC?

A

uncommon in children
F: rates increased from 15-40 but plateau
M: steady increase with age

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12
Q

DTC are associated with diet, smoking, other proven malignancies, FH… true or false?

A

false - only strong assoc. is radiation exposure

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13
Q

Name the types of DTCs

A

papillary
follicular
medullary

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14
Q

How does papillary DTC spread?

A

via lymphatics

haematogenous spread uncommon but if it does happen -> lungs

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15
Q

Describe a papillary DTC (key features) and its prognosis.

A

usually solitary nodule, often cystic, may be calcifications in cytoplasm (psammoma bodies) and enlarged nuclei with clear centres + dark edges = Orphan Annie nuclei
good prognosis

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16
Q

Papillary thyroid cancer is associated with Grave’s disease. True or false?

A

false - associated with Hashimoto’s thyroiditis

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17
Q

How might a papillary DTC present?

A

lesion in thyroid gland or cervical lymph node
hoarseness, dysphagia, cough, dyspnoea
if PC is lymph node mets & thyroid tissue / psammoma body in lymph node -> search for occult papillary carcinoma

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18
Q

What is the 2nd commonest DTC and who gets it?

A

Follicular carcinoma
F>M; older age group than papillary (40-50s)
incidence slight raised in areas of iodine deficiency

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19
Q

Describe a Follicular DTC and how it spreads.

A

usually single nodule - slowly enlarging, painless, non-functional
haematogenous spread; lymphatic spread rare THEREFORE no lymph node enlargement

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20
Q

Describe the types of growth pattern of follicular DTC.

A

Widely invasive: more solid architecture, less follicular architecture, more mitotic activity

Minimally invasive: follicular architecture (= well-differentiated), may have surrounding capsule

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21
Q

How do you differentiate a follicular adenoma from a follicular carcinoma if they both have follicular architecture?

A

carcinoma will have vascular/capsular invasion, adenoma will not

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22
Q

Name the DTC that is a neuroendocrine tumour and list its associations.

A 
Medullary thyroid cancer (MTC)
arises from C-cells (calcitonin cells)
70% sporadic
assoc. with MEN 2A or 2B
familial medullary carcinoma
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23
Q

Describe a typical patient MTC patient with MEN2A/B / a familial case

A

very young patient - most have prophylactic thyroidectomy in 1st 6months of life

familial case seen in adults; 40-50s

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24
Q

In which cases of MTC would you see a solitary nodule and a bilateral/multi-centric nodule?

A 
solitary = sporadic case
bilateral = familial case
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25
Q

Which DTC is associated with amyloid deposition?

A

MTC since amyloid represents deposition of an abnormally folded protein and in MTC case the protein is calcitonin

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26
Q

In which DTC would there be apple green birefringence / stain congo red?

A

MTC

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27
Q

Name some common paraneoplastic syndromes due to MTC.

A

Cushing’s - ACTH production

Diarrhoea - VIP production

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28
Q

What is the prognosis of MTC and which drugs are used to treat it?

A

rapid progression so moderate prognosis

tyrosine kinase inhibitors used (-inib)

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29
Q

What is the undifferentiated form of thyroid carcinoma? Who gets it and what is the prognosis?

A

anaplastic carcinoma
usually older patients - may have Hx of DTC
aggressive tumours - rapid growth & involvement of neck structures - normally fatal soon after diagnosis (if cut out -> grows back)

30
Q

What is the first line investigation of a neck lump /suspected thyroid cancer?

A

USS guided Fine Needle Aspiration (FNA) of the lesion

= thyroid cytology

31
Q

Why are FNA interpreted without architecture? And in which DTC does this cause an issue?

A

provides minimally invasive assessment of the likelihood of malignancy
Follicular lesions can be difficult to interpret as relationship to capsule not assessed

32
Q

What is the grading system for FNA?

A 
Thy1 = uninterpretable
Thy2 = benign
Thy3 = atypic probably benign/some questionable features
Thy4 = atypic suspicious of malignancy
Thy5 = malignant
33
Q

Which FNA result would make you repeat the test?

A

Thy3

34
Q

Which FNA result would make you send the patient straight to surgery for removal?

A

Thy4 or 5

35
Q

At which grade are follicular lesions automatically graded?

A

Thy3

36
Q

What other investigations might you do/not do regarding a thyroid neoplasm?

A

can do excision biopsy of lymph node
no role for isotope thyroid scan or CT/MRI
pre-op laryngoscopy if suspected vocal card palsy

37
Q

List some clinical predicators of malignancy.

A 
new thyroid nodule <20 or >50
male
nodule increase in size
lesion >4cm diameter
Hx of head &amp; neck irradiation
vocal cord palsy
38
Q

What are the 2 surgical options for thyroid cancers?

A

Thyroid lobectomy with isthmusectomy

Sub-total thyroidectomy (+ total thyroidectomy)

39
Q

Removal of unilateral thyroid nodule; involves exposure of tracheosophageal grooves = ?

A

thyroid lobectomy + isthmusectomy

40
Q

Surgical option for papillary micro carcinoma (<1cm diameter) or a minimally invasive follicular carcinoma with capsular invasion only?

A

thyroid lobectomy

+ patients with a low AMES risk

41
Q

What risk stratification score is used post-op and what does it include?

A 
AMES 
Age
Metastases
Extent of primary tumour
Size of primary tumour
42
Q

<50 y/o female patient /<40 y/o male patient with no evidence of metastasis - AMES group?

A

low risk AMES

43
Q

older patient with intra-thyroidal papillary lesion; primary tumour is <5cm & no distant metastases - AMES group?

A

low risk AMES

44
Q

older patient with minimally invasive follicular lesion; primary tumour <5cm & no distant metastases - AMES group?

A

low risk AMES

45
Q

What is the 20-year survival predicted for a low risk and high risk AMES patient?

A

low risk = 99%

high risk = 61%

46
Q

A patient with distant metastases - AMES group?

A

high risk AMES

47
Q

Patient with extra-thyroidal disease & papillary cancer - AMES group?

A

high risk AMES

48
Q

Patient with follicular carcinoma showing significant capsular invasion - AMES group?

A

high risk AMES

49
Q

Older patient with primary tumour >5cm - AMES group?

A

hight risk AMES

50
Q

What are the indications for a sub-total/total thyroidectomy?

A

DTC with extra-thyroidal spread
bilateral/multi-focal DTC
DTC with distant metastasis ± nodal involvement
Patient in AMES high risk group

51
Q

What is the controversial treatment associated with a patient with DTC + nodal involvement?

A

lymph node surgery (clearance) controversial since long-term survival unclear

52
Q

A patient with macroscopic lymphadenopathy -> ?

A

nodal clearance

53
Q

Patient with papillary lymph node metastasis -> ?

A

central compartment clearance AND lateral lymph node SAMPLING

54
Q

Patient with follicular lymph node metastases -> ?

A

central lymph node clearance

55
Q

What is checked within 24hrs of thyroid surgery?

A

calcium levels
replacement initiated if <2mmol/l
IV calcium for levels <1.8 or if symptomatic

56
Q

What are some symptoms of hypocalcaemia?

A

muscle tetany, pins & needles

extreme case - difficulty breathing due to unrelieved contraction of respiratory muscles

57
Q

What is Chovstecks sign?

A

tapping over facial nerve -> facial muscle spasm

sign of hypocalcaemia

58
Q

What is Trousseau sign?

A

carpo-pedal spasm; inflate BP cuff on arm to 20 mmHg above systolic BP -> carpal spasm due to ulnar nerve ischaemia

59
Q

What might you see on ECG in hypocalcaemia?

A

prolonged QT

60
Q

After which surgery would a patient get a whole-body iodine scan? And how long after the surgery is it?

A

total or sub-total thyroidectomy

3-6 months post-op

61
Q

When doing a whole-body iodine scan, which of the patients drugs need to be stopped and how long before the scan?

A

T4 stopped 4 weeks before scan

T3 stopped 2 weeks before scan

62
Q

What is rhTSH and when is it given?

A

recombinant human TSH - given when T3/4 has to be stopped for tests (e.g. whole-body iodine scan) so that patient won’t have episodes of symptomatic hypothyroid

63
Q

What level should TSH be pre whole-body scan for optimum results?

A

> 20

64
Q

What is the typical week-long schedule for a whole-body iodine scan?

A

Mon/Tues = rhTSH injection
Wed = 2-4 mCi I-131 capsule given
Fri = patient returns for imaging
scan will show any thyroid hormone activity

65
Q

What is thyroid remnant ablation (TRA)?

A

Patient is pre-treated with rhTSH
2/3 GBq capsule of i-131 administered
admitted to Lead-lined room
Patient uses disposable cutlery, sheets and clothing is stored until safe; little or no contact with nurses or visitors
Discharged when count rate <500 cps at 1m

66
Q

What is the follow-up for TRA?

A

post-therapy scan prior to discharge
Patient is maintained on T4 - aim to suppress TSH <0.1 mU/l and fT4 < 25
thyroglobulin can be used as a “tumour marker”

67
Q

Why can Tg (thyroglobulin) be used as a “tumour marker” post-TRA?

A

raised TSH is associated with elevation of Tg levels

anti-thyroglobulin antibodies should be measured at same time as they can affect the interpretation of results

68
Q

What is the long-term effect of TRA?

A

small but significant increase in incidence fo AML (acute myeloid leukaemia) in patients with cumulative i-131 disease >800mCi and repeated doses within 12 months

69
Q

How is recurrent thyroid cancer detected?

A

clinically by rise in Tg or imaging

70
Q

Where/how do papillary and follicular DTCs recur?

A

papillary - in cervical lymph nodes

follicular recurrence is more common - haematogenous spread to lungs, bone or brain

71
Q

In which group of patients would yo consider a PET scan to check for recurrence?

A

Those with rising Tg but negative whole-body iodine scan

PET scan in these patients can help identify sites of disease and allow surgery/radiotherapy to be targeted

Endocrine (6 decks)

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