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thyroid/neck mass Flashcards

1
Q

etiologies for neck mass

A

-squamous cell carcinoma (SCC) - >90%
-alcohol and tobacco- 75%
-HPV (16), betel quid, occupational wood dust, or asbestos, EBV
-pts can develop further associated (secondary) malignancies within following years - 9-23% -> very common
-complications after head/neck cancer: dysphagia, pharyngocutaneous fistula, injury to accessory, vagus, hypoglossal, mandibular nerves
-mocositis or xerostomia (dry mouth) from radiotherapy

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2
Q

diagnosing neck mass

A

-biopsy
-flexible nasendoscopy (FNE) for direct visualization
-if only presenting with lymphadenopathy -> U/S FNA
-MRI is the imaging of chocie
-CT of neck and chest to look for spreading -> Stages
-PET-CT- first line choice if primary tumor location is unknown

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3
Q

child neck mass

A

-more likely congenital, inflammatory, infectious
-adults- neck masses > 2cm have >80% malignant

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4
Q

thyroid cancer

A

-lumps are common- cancer is not
->4cm has increased risk
-lumps are more common in women -> if you find one in men its more chance of cancer
-family hx- 10x increased risk
-usually asymptomatic, compressive sx
-MEN2? past radiation?
-painful? -> most likely an infection
-papillary
-follicular
-medullary
-anaplastic

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5
Q

papillary thyroid cancer

A

-MC thyroid cancer 75%
-40-50 yo women > men
-multiple lesions
-spread via lymph (bilateral cervical)
-Psammona bodies
-Pupil nuclei - orphan annie eyes- cell
-good prognosis
-tx- total or near total thyroidectomy

5 P’s:
- popular: MC
- psammona bodies
- palpable LNs
- pupil nuclei (orphan annie eyes)
- positive prognosis

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6
Q

follicular carcinoma

A

-40-60yo women>men
-2nd MC thyroid cancer
-focal encapsulated lesions
-usually hematogenous spread to bones and lungs
-iodine deficiency
-tx- lobectomy
-older pts with >4cm -> total thyroidectomy
-poor prognosis:
-age > 50
-size >4cm
-vascular invasion
-extrathyroidal invasion
-distant metastases

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7
Q

medullary carcinoma

A

-3% of thyroid cancer
-usually painful
-elevated calcitonin levels !!!
-20% are MEN 2A and 2B syndromes cases
-spread via lymph (cervical) and medullary routes
-monitor calcitonin post op
-distant metastatic ds -> liver, bone, lung
-screen for pheochromocytoma
-tx- total thyroidectomy -> its multicentric

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8
Q

anaplastic thyroid cancer

A

-rare
-undifferentiated
-painful, hoarse, dyspnea, cough
-skin is warm and discolored over
-older pts (>65) women >men
-very aggressive
-spread by time of presentation 90%
-do neck and chest CT at time of dx
-tx- resection or debulking, chemo

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9
Q

red flags of neck lump

A

-rapid growth or pain
-pressure symptoms- dysphagia
-cough, hoarse voice, stridor
-multiple enlarged cervical lymph nodes
-tether of lump surrounding structures
-cold nodule (can also be benign)

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10
Q

non-cancerous neck lumps

A

-benign thyroid adenoma or thyroid cyst
-toxic multi-nodular goiter - hyperthyroidism sx
-non-toxic multi-nodular goiter
-thyroglossal duct cyst*- will move superiorly as pts sticks out tongue

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11
Q

thyroid lump work up

A

-TFTs- TSH (normal in cancer) and thyroglobulin (used post op- should be undetectable after total)
-toxic/hot nodule- low TSH and high T3/T4 -> low chance of cancer
-high calcitonin- can be medullary carcinoma (use to monitor)
-1. U/S- microcalcifications, hypoechogenicity, irregular margins, increased vascularity -> Red flags
-2. FNA- >1cm, suspicious US, family hx
-radioiodine imaging- tells you if nodule is hot or cold
-bone scintigraphy to further look for metastasis
-1 year after surgery -> fu with serum thyroglobulin level and US

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12
Q

FNA-bethesda scaling

A

-bethesda scaling
-B1- non diganostic -> repeat in 4-6 weeks
-B2- benign
-B3-4- case by case basis
-B5- surgery
-B6- cancer -> surgery aspa

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13
Q

postoperative complication of thyroid surgery:

A

Every patient that has a neck surgery TRACHEOSTOMY KIT AT BEDSIDE open the wound and evacuate the hematoma (delayed hemorrhage)

Must measure serial serum calcium levels post-surgery -> check for parathyroid injury

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14
Q

thyroid cancer management

A

-chemo, radio, radio-iodine
-ultimately surgical resection
-hemi-thyroidectomy
-total thyroidectomy
-neck dissection- removes lymph nodes

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15
Q

neck surgery complications

A

-damage to parathyroid -> hypocalcium
-symptoms: paraesthesia or tetany
-check calcium levels after always
-thyroid storm
-hematoma -> airway obstruction
-reopen the wound
-drain and stop bleeding
-ARDS
-cervical sympathetic nerve damage -> horners syndrome - ptosis, miosis (constricted), anhidrosis
-cellulitis, infection
-hypothyroidism and recurrent hyperthyroidism
-ALWAYS HAVE A TRACHEOSTOMY KIT

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16
Q

neck surgery laryngeal nerve injury

A

-recurrent laryngeal nerve damage -> IPSILATERAL vocal cord paralysis
-unilateral- hoarse voice
-paramedian vocal cords- normal or weak voice
-abducted position- hoarse and ineffective cough
-bilateral- life threatening stridor -> tracheostomy may be needed
-inferior thyroid artery crosses the recurrent laryngeal nerve
-suspensory ligament (ligamentum berry) is near the tubercle of zuckerkandl (lateral part of thyroid gland) -> identifies where inferior thyroid artery feeds in -> and therefore where the recurrent laryngeal
-external laryngeal nerve -> NO hoarseness, difficulty projecting sound, problem for singers
-superior recurrent laryngeal
-2b is most common to cause injury
-nerve injurys can heal

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17
Q

thyroid lymph nodes

A

-malignant lymph nodes fixed and have tissue in them

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18
Q

cretinism

A

-failure of thyroid from birth
-intellectual disability
-short stature
-thickening of facial features

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19
Q

thyroid cancer: radioiodine therapy

A

-mainly used for papillary or follicular
-only effective after TOTAL thyroidectomy (4-6 weeks)
-used in cases of higher risk of occurrence
-ablates remnant thyroid tissue and distant metastases
-PO
-graves, hot nodules, cancers

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20
Q

graves ds

A

Diffuse thyroid enlargement with autoantibodies TSI
- Ocular sx: exopthalmos, lid lad, proptosis, diplopia

Tx:
- Metimazole - first line but category X
- Proptlthioracil: first trimester in pregnancy
- Propranolol for palpitations
RAI:
- Before RAI, thyroid hormone levels should be normalized with thionamides to prevent acute thyrotoxicosis or thyroid storm
- CI: pregnancy, signficant orbitopathy, compressive sx

Thyroidectomy: CI to other tx, compressive sx, thyroid nodules suspicious for cancer

21
Q

thyroid: external beam radiotherapy

A

-primary or adjunctive therapy
-routine for anaplastic
-dont use if you can resect

22
Q

hot nodules

A

-toxic nodules
-initial tx- thionamides to tx hyperthyroidism
-preferred tx- lobectomy
-beta blockers for symptomatic therapy
-toxic multinodular goiter- Plummer’s Disease -> total thyroidectomy

23
Q

toxic multinodular goiter

A

MC in older pts in iodine deficient areas
- goiter with compressive sx
-plummer’s disease
-T3 toxicosis
-can cause afib, CHF
-hyperthyroidism
-can be precipitated by iodide containing drugs (contrast media and antiarrhythmic agent amiodarone -> Jod-Basedow hyperthyroidism)

tx:
- subtotal/total thyroidectomy** Total thyroidectomy is tx of choice
Always prep pt with meth/PTU to normalize hormone levels before surgery to prevent thyroid storm
- NOT RAI: high risk of recurrence
-PTU short term if urgent

24
Q

toxic adenoma

A

-single hyperfunctioning nodule
-pts are younger
-hyperthyroidism once nodule reaches at least 3cm
-tx- Meth or PTU for initial management with beta blockers
-lobectomy with isthmectomy for younger pts -> bc of cost

25
Q

primary hyperparathyroidism

A

-usually benign adenoma secretes PTH
-high calcium as a result
-MEN1
-stones, bones, groans (PUD), psychiatric undertones
-can cause pancreatitis
-osteitis fibrosa cystica salt and pepper skull, brown tumors of long bones
-renal failure can happen
-24-hour urine calcium excretion -> used to rule out familial hypocalciuric hypercalcemia -> does NOT need resection
-Weakness
-Fatigue
-Polydipsia
-Polyuria
-Nocturia
-Bone and Joint Pain
-Constipation
-Decreased Appetite
-Nausea
-Heartburn
-Pruritus
-Depression
-Memory Loss
-DX:
-high vitamin D
-24 hours urine- calcium will be high
-dual energy x-ray absorptiometry (DEXA)
-bone scans, imaging for kidneys
-parathyroidectomy for everyone unless risks are prohibitive
- successful tx: PTH level: decreases over 50% from the preoperative baseline and into the normal range within ten minutes of gland excision

26
Q

secondary hyperparathyroidism

A

All 4 parathyroid glands are overreacting due to chronic hypocalcemia
-due to vitamin D deficiency, malabsorptive conditions, CKD!!!!!!!!!
-PTH is high but Ca is low or normal
-osteomalacia
-osteitis fibrosa cystica
tx
- Cinacalcet: *** activates calcium sensing receptor in parathyroid gland -> reduces PTH secretion
-prevent with- vitamin D replacement and phosphorus binders
- dialysis: CKD
-if refractory -> surgery: Subtotal or total parathyroidectomy with autotransplantation -> transplant into a muscle; for pts who dont respond to medicine/intolerant to calcimimetics

27
Q

hypoparathyroidism

A

-tetany, convulsions
-hypothyroidism sx- dry skin, nails
-chvostek’s sign- percussion of ipsilateral facial muscle anterior to ear -> facial muscle contraction
-trousseau’s sign- carpal spasm after 3min of occlusion with blood pressure cuff
-low PTH, low Ca
-can be a result of thyroidectomy issue
-can be autoimmune
-can be caused by hypomagnesemia
-CKD
-tx- calcium gluconate, vitamin D, magnesium

28
Q

hypercalcemia of malignancy

A

-high PTH and PTHrP

29
Q

thyroid storm

A

-a fib/shock
-hyperpyrexia >104
-CNS findings
-psychomotor agitation
-depression
-cardiovascular collapse
-GI dysfunction
-hepatic failure
-hypertension -> hypotensive
-AMS
-can be caused by illness, injury (during surgery), withdrawal of meds

tx-
-cooling blanket
-oxygen
-antipyretic drugs - tylenol (1g every 6 hrs- 4g a day)
-beta blockers (prevents T4 -> T3 too)
-lugol’s solution- decrease iodine uptake
-glucocorticoids: hydrocortisone to lower inflammation
-thionomaides -> PTU** or methimazole

30
Q

thyroglossal duct cyst

A

-MC congenital
-midline
-moves up with swallowing or tongue protrusion
-dx- CT/MRI/US
-FNA- definitive dx (not often done)
-if there is symptoms or is complicated by infection
-US!!!! -> see if only functioning thyroid tissue may be attached to cyst
-1% of pts can have papillary thyroid cancer (NEVER medullary)
-can form fistula
-tx- surgical excision unless this is the only thyroid tissue the pt has ->
-sistrunk procedure- sedate pt and push down on epiglottis -> body of hyoid bone is removed -> recurrence if medial portion of hyoid bone not removed
-OR sublingually to floor of mouth endoscopically

31
Q

ectopic thyroid tissue

A

-MC spot is thyroglossal duct
-can compress, cause breathing problems
-can be anywhere from base of the tongue (foramen cecum ) (MC!!!) to superior anterior mediastinum
-can cause hyperthyroidism

dx:
-US
-scintigraphy to identify if tissue is functioning -> differentiates
-TSH, T3/T4- tell if level it is functioning
-FNA- if concerned for malignancy
-monitor, meds, surgery based on pt
- remove if sx of obstruction or malignant

32
Q

pheochromocytoma

A

-tumor that secrete catecholamines (epinephrine)
-paroxysmal headaches, tachycardia, sweating
-HTN
-MEN2
-prior to medullary thyroid cancer surgery screen for this!!!!
-Plasma metanephrines high -> confirms dx
-tumor follows paraganglionic tissue
-CT, MRI, MIBG -> meta-iodobenzylguanidine (nuclear medicine) -> scan for metastasis
-pre-op tx- alpha-adrenergic blocking agents FIRST (phenoxybenzamine, doxazosin), CCB, BB SECOND
-Use high dose magnesium sulfate → controls BP
-tx- laparotomy surgery, resection
-tie off inferior suprarenal, middle suprarenal a, and superior (inferior phrenic) -> veins too bc once you manipulate the gland it can release catecholamines and cause HTN crisis during surgery
-can cause severe hypotension -> volume replacement, shock, renal failure, seeding of tumor
-control glucose -> can have hypoglycemia
-insufficient cortisol
-bleeding
-infections, UTI, lung infection
-blood clot in leg
-Adverse reaction to anesthesia:
-give Cortisol -> upregulates alpha receptors → without this BP drops
-If resistant to pressures – give steroids –> replace what they are not getting (mineralocorticoids like aldosterone)

33
Q

pheochromocytoma flow chart

A
34
Q

adrenal gland anatomy

A

Suprarenal comes off the inferior phrenic arteries
Them middle suprarenal supply comes off of the aorta
The inferior suprarenal comes off the renal artery

35
Q

Waterhouse-Friderichsen Syndrome

A

Neisseria meningitidis Infection:
- septicemia -> widespread inflammation -> disseminated intravascular coagulation (small blood clots throughout bloodstream)
- Waterhouse-Friderichsen Syndrome: hallmark findings is massive b/l adrenal hemorrhage***
- causes acute adrenal insuffiency: severe fatigue, ab pain, rapid deterioration

tx:
- immediate abx for gram neg: ceftriaxone
- corticosteroid replacement: high dose hydrocortisone
- address DIC with FFP, platelets

36
Q

hyperthyroidism

A

-low TSH, high T3/T4
-pretibial myxedema
-exophthalmos- lid lag
-hyperreflexia
-proximal myopathy
-tx- thioureylene: propylthiouracil (PTU), methimazole
-BB
-radioactive 131-iodine (ablation) for high risk pts, avoids surgery, lower cost
-total or near thyroidectomy if needed

37
Q

radioactive 131 iodine (RAI) contrindications

A

-confirmed cancer or suspicious nodules
-young pts
-desire to conceive soon (<6 months)
-had reactions to antithyroid meds
-large goiters (>80g) causing compressive symptoms
-reluctant to under RAI

38
Q

hypothyroidism

A

-hoarse voice
-paresthesias
-myxedema
-high TSH, low T4
-fatal complication- myxedema coma -> AMS, hypothermia, hypoventilation, hypotension, edema
-tx- levothyroxine

39
Q

complex thyroid nodule found on US

A

-most likely malignant
-cystic and solid
-heterogenic- tumors in various states

40
Q

thyroiditis

A

-acute (supurative)
-subacute- self limiting
-chronic- hashimotos

41
Q

causes of hypercalcemia

A

-PTHrP: SCC in lung cancer
-Malignancy
-Humoral Hypercalcemia of Malignancy: tumors of the lung, breast, kidney, head and neck, and ovary
-Thiazide Diuretics
-Sarcoidosis
-Pheochromocytoma

42
Q

indications for adrenal surgery

A

-Conn syndrome.
-Cushing syndrome.
-Pheochromocytoma.
-Large myelolipoma.
-Metastatic tumors- lung cancer pt -> chest CT that includes upper abdomen CT -> upper pole of kidneys to see adrenals
-septic with Neisseria -> Waterhouse-Friderichsen syndrome- adrenal necrosis/bleeding -> adrenal insufficiency -> shock
-check for this with lung cancer metastasis ^
-Adrenocortical carcinoma.
-Neuroblastoma (pediatric population)- posterior aspect of abdominal cavity or mediastinum -> Adrenal tissue can be found anywhere along the ganglions of the retroperitoneum

43
Q

1% of thyroglossal duct cells are what type of cancer

A

papillary cancer
- never medullary

44
Q

thyroid gland artery anatomy

A

Inferior thyroid artery CROSSES the recurrent laryngeal nerve
- If you injure one: ipsilateral hoarseness/ vocal cord -> maramedian abducted will cause hoarseness
- B/L recurrent laryngeal nerve injury : airway obstruction -> tracheostomy

thyroid:
- superior thyroid: from external carotid; close to the external laryngeal nerve -> difficulty projecting sound (singers)
- inferior thyroid: from thyrocervical trunk -> close to the RECURRENT LARYNGEAL

variations in anatomy:
- type B variants the nerve crosses the artery < 1 cm away; dont accidentally injure recurrent nerve or inferior thyroid artery

45
Q

Neuromuscular signs of hypocalcemia›

A

Chvostek’s sign: Tapping the facial nerve just anterior to the ear causes twitching of the facial muscles in patients with hypocalcemia.
Trousseau’s sign: Inflation of a blood pressure cuff above systolic pressure for several minutes induces carpal spasm in patients with hypocalcemia.
Hypocalcemia is most often seen postoperatively in patients who undergo parathyroidectomy, particularly after total removal of all four parathyroid glands, which can cause transient or permanent hypoparathyroidism.

46
Q

tubercle of zuckerkandi

A

lateral outgrowth of the thyroid gland
- found on the posterior aspect of the thyroid gland
- anatomical landmark to locate the recurrent laryngeal nerve (RLN).

47
Q

chemo man:

Cisplatin + Carboplatin (Ca):

Cyclophosphamide + Ifosfamide:

5-Fluorouracil (5-FU):

6-Mercaptopurine:

Methotrexate:

Cytarabine:

Bleomycin + Busulfan:

Doxorubicin + Daunorubicin:

Trastuzumab (Herceptin):

Vincristine:

Taxanes (e.g., Paclitaxel):

Vinblastine:

A

Cisplatin + Carboplatin (Ca): like aminoglycosides
- Ototoxicity (ears)
- Nephrotoxicity (kidneys)

Cyclophosphamide + Ifosfamide:
- Hemorrhagic cystitis (bladder)
- neutropenia

5-Fluorouracil (5-FU):
- Myelosuppression
- Gastrointestinal upset

Methotrexate:
- Myelosuppression
- Mucositis
- Liver fibrosis

Cytarabine:
- Conjunctivitis
- Keratitis (eye)

Bleomycin + Busulfan:
- Pulmonary fibrosis (lungs)

Cardiotoxicity (heart):
- Doxorubicin + Daunorubicin: need echo before tx
- Trastuzumab (Herceptin): monitor EF (HER 2 + monoclonal ab)

Peripheral neuropathy (nerves)
- Taxanes (ex: Paclitaxel - breast cancer triple neg)
- Vincristine

myelosuppression: VM 56
- Vinblastine
- Methotrexate
- 5-Fluorouracil (5-FU)
- 6-Mercaptopurine

48
Q

MEN Syndrome

A

surgery (6 decks)

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