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Endocrine: The Thyroid > Thyroid Neoplasms > Flashcards

Thyroid Neoplasms Flashcards

1
Q

benign causes of nodules

A

cyst
colloid nodule
benign follicular adenoma
hyperplastic nodules

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2
Q

malignant causes of nodules

A 
papillary
follicular
medullary
lymphoma
poor differentiated (anaplastic)
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3
Q

how to check whether a nodule is on the thyroid?

A

check it moves on swallowing as the thyroid is invested in the pre-tracheal fascia

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4
Q

what is an uncommon feature in a nodule?

A

pain but can be caused by an intra-thyroidal bleed into a cyst

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5
Q

diagnosis of neoplasm

A
  • history: neck irradiation and FH of thyroid carcinoma
  • examination: neck nodes and hoarseness
  • investigation: TSH and USS-FNA for cytology or core biopsy for morphology (lymphoma)
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6
Q

what investigations are not used in neoplasms

A

isotope thyroid scan

CT/MRI

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7
Q

USS-FNA classification

A 
thy1= inadequate sample
thy2/U2= bengin
thy3/U3= atypical
thy4/U4= probably malignant
thy5/U5= malignant
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8
Q

staging that can be used?

A

TNM

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9
Q

low risk thyroid tumours

A

under 50

tumour <4cm

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10
Q

follow-up for low risk nodules

A

TSH and thyroglobulin measured every 6 months for first 5 years, then annually for next 5

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11
Q

predictors of malignancy

A
  • new thyroid nodule age <20 or >50
  • lesion >4cm in diameter and size increasing
  • male
  • history of head and neck radiation
  • vocal cord palsy
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12
Q

define adenoma

A

this is a benign discrete solitary mass that is often an incidental finding, but if large can cause local symptoms

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13
Q

what is an adenoma comprised of?

A

neoplastic thyroid follicles (follicular adenoma)

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14
Q

what is an adenoma difficult to distinguish from?

A

nodule in goitre

follicular carcinoma

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15
Q

what do some adenomas do?

A

secrete thyroid hormones causing thyrotoxicosis, due to mutation in TSHR signalling pathway that activates G proteins and cAMP

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16
Q

what age groups is thyroid carcinoma more common in?

A

females 15-40
males more common with age
uncommon in children

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17
Q

causes of carcinomas

A

environment

genetics

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18
Q

which carcinoma is associated with radiation

A

papillary

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19
Q

which carcinoma is associated with iodine deficiency

A

follicular

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20
Q

what are differentiated thyroid cancers driven by?

A

TSH

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21
Q

which is the most common carcinoma?

A

papillary

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22
Q

presentation of papillary carcinoma?

A

usually a solitary nodule
lymph node metastasis common
haematogenous spread rare, but usually to lung
associated with Hashimoto’s thyroiditis

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23
Q

survival rates from papillary carcinoma

A

good

24
Q

buzzword for pathology of papillary carcinoma

A

orphan Annie eye nuclei psammoma bodies

25
Q

who is follicular carcinoma most common in?

A

females 40-50s (older than papillary)

26
Q

presentation of follicular carcinoma

A

slow growing
painless
non-functional nodule
haematogenous spread to bone, lungs and liver
lymph node spread rare
invasive growth pattern of vasculature/capsle

27
Q

management of follicular carcinoma

A

thyroid lobectomy, but if significant invasion then total thyroidectomy

28
Q

where are incident rates higher for follicular carcinoma?

A

regions of iodine deficiency

29
Q

what is medullary thyroid carcinoma derived from?

A

C cells so can secrete calcitonin

30
Q

what can MTC be associated with?

A

MEN2a/b

amyloid deposition of abnormally folded calcitonin

31
Q

presentation of MTC

A

neck mass

paraneoplastic syndrome e.g. diarrhoea (VIP production) and Cushing’s (ACTH production

32
Q

management of MTC

A

total thyroidectomy

33
Q

describe anaplastic carcinoma

A

undifferentiated, aggressive tumours

rapid growth and involvement of neck structures

34
Q

who does anaplastic carcinomas present in?

A

older patients usually

35
Q

five types of thyroid carcinoma

A 
papillary carcinoma
follicular carcinoma
medullary thyroid carcinoma
anaplastic carcinoma
lymphoma
36
Q

risk associations with lymphoma

A

background of AI hypothyroidism on T4

37
Q

presentation of lymphoma

A

rapid onset mass

usually women 70-80

38
Q

diagnosis of lymphoma

A

core biopsy

39
Q

management of lymphoma

A

R-CHOP chemo
radio
steroids

40
Q

management of DTC

A

surgery is first line, options include:

  • thyroid lobectomy with isthmusectomy
  • sub-total thyroidectomy
  • total thyroidectomy
41
Q

risk stratification post-op

A 
AMES
age
metastasis
extent of primary
size of primary tumour
42
Q

AMES low risk

A
  • younger patients (men <40 and women <50) with no metastasis
    -older patients with minimally invasive lesion, tumour <5cm
    add no distant metastasis
43
Q

management of AMES low risk

A

thyroid lobectomy with isthmusectomy

44
Q

AMES high risk

A

all patients with distant metastases
extrathyroidal disease in patients with papillary cancer
significant capsular invasion with follicular carcinoma
primary tumour >5cm in old patients

45
Q

when sub-total or total thyroidectomy used in DTC?

A 
extra-thyroidal spread
bilateral/multifocal DTC
DTC with distant metastasis
nodal involvement
AMES high risk
46
Q

lymph node surgery

A

central lymph node clearance

47
Q

post-op care

A

check calcium and give replacement if below 2mmol/L

discharge on T3/4

48
Q

when is whole body iodine scanning used

A

patients who have undergone sub-total or total thyroidectomy usually 3-6 months post-op

49
Q

what happens to medications before the scan?

A

T4 stopped 4 weeks prior to the scan
T3 stopped 2 weeks prior to the scan
rhTSH is better as no need to stop T3/T4

50
Q

what level should TSH be for best results in total body iodine scanning

A

more than 20

51
Q

lead up to whole body iodine scanning

A

rhTSH injections Monday/Tuesday and mCi capsule on Wednesday and patients return for imaging on Friday
results of scan inform treatment decision

52
Q

describe thyroid remnant ablation

A
  • admitted to a lead-lined room with mains sewerage
  • pre-treated with rhTSH
  • 2 or 3 GBq capsule of I-131 administered
53
Q

side effects of thyroid remnant ablation

A

sialadenitis
sore throat
use disposable cutlery and no contact until no longer radioactive
discharge when count rate <500cps at 1m (Geiger counter) and post-therapy scan prior to discharge
patients maintained on T4 (below 25)

54
Q

recurrent disease

A
  • detected clinically through rising Tg or by imaging
  • recurrence in cervical lymph nodes is often papillary
  • haematogenous spread to lungs, bone or brain more common in follicular
  • patients undergo whole body scan to determine ability of disease to take up iodine (difficult if this is negative)
  • PET
55
Q

systemic anti-cancer therapy (SACT)

A
  • sorafenib and lenvatinib for patients DTC refractory to radioactive iodine therapy

Endocrine: The Thyroid (15 decks)

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