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Endocrine > Thyroid Neoplasms > Flashcards

Thyroid Neoplasms Flashcards

1
Q

Name benign nodules of the thyroid

A
  • cyst
  • colloid nodule
  • follicular nodule
  • hyperplastic nodule
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2
Q

What percentage of nodules will be malignant?

A

5%

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3
Q

Who are follicular adenomas most common in?

A

Women >30 years old

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4
Q

Describe the histology of follicular adenomas

A

Discrete solitary mass. Composed of thyroid follicles & encapsulated by collagen

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5
Q

Are adenomas generally functional or non-functional?

A

Non-functional

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6
Q

When are adenomas most likely to be functional?

A

If there is a mutation involved in TSH signalling, increasing cAMP and therefore thyroid hormone production

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7
Q

What percentage of all cancers are thyroid cancers?

A

1.5%

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8
Q

Which gender is mainly affected by thyroid carcinoma?

A

Female

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9
Q

State the two cancers which are part of DTC

A
  • papillary

- follicular

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10
Q

What hormone drives differentiated thyroid cancer?

A

TSH

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11
Q

What do most DTC take up and secrete?

A

Take up - iodine

Secrete - thyroglobulin

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12
Q

Describe the aetiology of DTC

A

Environment associations - ionising radiation and iodine deficiency
Genetic features

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13
Q

Where are mutations often found in papillary carcinomas?

A

MAP kinase pathway

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14
Q

Where are mutations often found in follicular carcinomas?

A

P13K/AKT pathway

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15
Q

Where are mutations often found in anaplastic carcinoma?

A

MAP kinase/P13K/AKT/p53/ beta catenine

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16
Q

What mutations are associated with medullary thyroid cancer?

A

Multiple endocrine neoplasm type 2

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17
Q

Describe the appearance of a papillary carcinoma

A

Usually a solitary nodule in the thyroid often cystic and may be calcified

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18
Q

What is the name given to the parts of a tumour that have calcified?

A

Psammoma bodies

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19
Q

What are the local effects of a papillary carcinoma?

A

Hoarseness, dysphagia, cough, dyspnoea

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20
Q

Where do papillary carcinomas usually spread to?

A

Lymphatics

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21
Q

If papillary carcinomas spread haematological where will it go to?

A

Lung

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22
Q

What disease is papillary carcinoma associated with?

A

Hashimoto’s thyroiditis

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23
Q

What is the 10 year survival of papillary carcinoma?

A

95%

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24
Q

What areas of the world have a higher incidence of follicular carcinoma?

A

Regions of iodine deficiency

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25
Q

If a follicular carcinoma is minimally invasive what will it look like?

A

Follicular architecture, may have surrounding capsule but difficult to distinguish from adenoma

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26
Q

If a follicular carcinoma is widely invasive what will it look like?

A

More solid architecture, less follicular and more mitotic

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27
Q

How do follicular carcinomas usually spread?

A

Haematogenous

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28
Q

What is the 10 year survival of follicular carcinoma?

A

Ranges from 50-100%

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29
Q

Where do medullary thyroid carcinomas arise from?

A

C cells that secrete calcitonin

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30
Q

Describe the aetiology of medullary thyroid carcinoma

A

Young patients - MEN

40-50 year olds - sporadic/familial

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31
Q

How will a sporadic MTC appear?

A

Solitary nodule

32
Q

How will a familial MTC appear?

A

Multi-centric/bilateral due to C cell hyperplasia

33
Q

Describe the histology of MTC

A

Composed of spindle/polygonal cells arranged in nests/trabeculae/follicles, necrosis, small cell morphology, often very aggressive

34
Q

What is MTC often associated with?

A

Amyloid deposition - abnormal folded protein (calcitonin)

35
Q

What is the typical presentation of an MTC?

A

Neck mass with local effects

36
Q

What is the key risk associated with MTC?

A

Paraneoplastic syndrome

37
Q

State the two checks that are important to determine the cause of MTC

A
  • urinary metenephrines

- genetics

38
Q

Describe anaplastic carcinoma

A

Undifferentiated aggressive tumours, usually in older patients with a history of DTC. Rapid growth, involvement of neck structures and death.

39
Q

State two important questions in a suspected thyroid cancer history

A
  • neck irradiation

- family history of thyroid cancer

40
Q

What is the significance of the patient sticking out their tongue during examination?

A

Thyroglossal cyst will move - also will cause supra-hyoid midline swelling

41
Q

What investigations should be carried out on a suspected solitary thyroid nodule?

A

TSH

Ultrasound +/- Fine needle aspiration

42
Q

Describe the categories of USS FNA

A 
Thy 1 - inadequate only blood cells seen
Thy 2 - benign - U2
Thy 3 - atypical/follicular - U3
Thy 4 - probably malignant - U4
Thy 5 - malignant - U5
43
Q

Who is a low risk group?

A

Age <50 years old, tumour<4cm

44
Q

How are low risk groups managed?

A

Lobectomy - aim to keep TSH low and monitor baseline thyroglobulin

45
Q

Who is a high risk group?

A

Palpable lymph nodes, >50 years old, >4cm tumour

46
Q

How are high risk groups managed?

A

Total thyroidectomy - keep TSH low, monitor thyroglobulin, may need to use radio iodine

47
Q

What do thyroglobulin levels help indicate?

A

Increases help to diagnose recurrent disease

48
Q

State the T categories of TNM

A

T1 - = 2cm
T2 2-4cm
T3 - >4cm
T4a - any size extending beyond capsule within tracheal fascia
T4b - advanced disease involves pre vertebral fascia

49
Q

State the N categories of TNM

A

N0 - no lymph nodes
N1a - regional lymph nodes
N1b - cervical/retropharyngeal/superior mediastinal lymph nodes

50
Q

What condition is thyroid lymphoma associated with?

A

Hashimoto’s thyroiditis - B cell lymphoma

51
Q

How does thyroid lymphoma present?

A

Rapidly expanding mass usually in women aged 70-80 years old

52
Q

How is thyroid lymphoma diagnosed?

A

Core biopsy

53
Q

What is the treatment for thyroid lymphoma?

A

Chemotherapy, radiotherapy, steroids

54
Q

What are the investigations for a multi-nodular goitre?

A

Assess TSH

CT scan

55
Q

What respiratory symptoms can a multi-nodular goitre cause and how can they be investigated?

A

Retrosternal extension/tracheal compression will cause stridor or choking when lying flat.
Volume loops can help identify the cause of respiratory symptoms

56
Q

How are multi-nodular goitres managed?

A

Most can be left alone
Radioactive iodine if significant hyperthyroidism
Surgery if respiratory problems/cancerous/impacting life

57
Q

What are the three types of surgery for thyroid nodules?

A
  • thyroid lobectomy with isthmusectomy
  • sub-total thyroidectomy
  • total thyroidectomy
58
Q

What risk assessment tool is used for risk stratification?

A

Age
Metastases
Extent of primary tumour
Size of primary tumour

59
Q

Who is classed as a low risk?

A

Younger patients with no evidence of mets
Older patients with an intrathyroidal papillary lesion or minimally invasive follicular lesion where the primary tumour is <5cm with no distant mets

60
Q

What is the 20 year survival for low risk patients?

A

99%

61
Q

Who is classed as high risk?

A

All patients with distant mets, extra thyroidal disease in papillary carcinoma or significant capsular invasion in follicular carcinoma. Primary tumour >5cm

62
Q

What is the 20 year survival for high risk patients?

A

61%

63
Q

What surgery is used for AMES low risk patients?

A

Lobectomy and isthmusectomy

64
Q

Describe a thyroid lobectomy and isthmusectomy

A

The gland is exposed 2-3cm above the sternal notch by separation of the strap muscles. The lobe is mobilised by diving the vessels supplying each part

65
Q

Describe a sub/total thyroidectomy

A

?

66
Q

What lymph node surgery is carried out in papillary tumours?

A

Central compartment clearance and lateral lymph node sampling

67
Q

What lymph node surgery is carried out in follicular cancer?

A

Central node clearance

68
Q

What should be checked within 24 hours of a thyroid operation?

A

Calcium - replacement initiated if levels are below 2mmol/l, if below 1.8 IV calcium is required

69
Q

Name the investigation carried out usually 3-6 months post thyroid operation

A

Iodine scan

70
Q

Describe the radio iodine scan

A

TSH >20 for best results
Monday/Tuesday - rhTSH injection
Wednesday - Iodine injection
Friday - Scan

71
Q

What is the purpose of a radio iodine scan?

A

In order to view any residual thyroid tissue

72
Q

If residual tissue is present on iodine scan what is done?

A

Thyroid remnant ablation

73
Q

Describe thyroid remnant ablation

A

Patient is admired to a lead lined room with main sewage, pre-treated with rhTSH and 2-3 units of iodine are administered. Stay in the room until they are less radioactive (80% excreted in first 24 hours)

74
Q

What is the aim of thyroid remnant ablation?

A

Suppress TSH and destroy remnant cells and mircofoci

75
Q

What are the short and long term side effects of remnant ablation?

A

Short term - sialadenitis

Long term - increased incidence of AML

Endocrine (17 decks)

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