Thyroid nodules and cancer

Question 1

What are the types of benign nodules

Answer 1

Multinodular
hashimotos thyroiditis
cysts
follicular adenomas

Question 2

What are the malignant nodules (less common)

Answer 2

papillary, follicular, medullary, anaplastic carcinoma
primary thyroid lymphoma
metastatic carcinoma (breast, renal)

Question 3

When you feel a thyroid nodule, ask yourself these two questions

Answer 3

Are they cancer?

Are they causing thyroid dysfunction?

Question 4

What can indicate that a nodule is cancerous

Answer 4

Kids, men, adults <30 or >60 
Hx head/neck radiation 
Hx hematopoietic stem cell transplant 
FHx thyroid cancer 
Size

Question 5

What approach can you take if you find a nodule

Answer 5

1. test TSH. If elevated (more likely cancer), do a thyroid scan
   - hot nodule: high uptake, still making hormones (good)
   - cold: not active, worrisome
2. If hot, ablate and resect. DO NOT BIOPSY! this will send you into thyroid STORM
3. If cold, do FNA do determine composition
   - non-diagnostic: repeat bx
   - benign: monitor by US (surgery if it grows or is susp.)
   - susp/follicular neoplasm: consider thyroid scan and if hot, ablate, if cold, surgery
   - malignant: surgery

Question 6

What is your procedure of choice for evaluating nodules

Answer 6

Fine Needle Aspiration ; by palpation or US guided
can be done in office 
If large (>4 cm), need multiple samples

Question 7

Indications for FNA are

Answer 7

What makes you more worried about cancer!
>5mm
abn cervical lymph nodes
microcalcifications >1cm

Question 8

FNA is not indicated if

Answer 8

purely cystic nodule

Question 9

How do you manage FNA results

Answer 9

Benign: repeat US in 6-18 months. if it grows >20%, repeat FNA
other findings depend on lesion type and are followed by specialist

Question 10

Epidemiology of thyroid cancer

Answer 10

Increases with age
MC in females
Worse prognosis if <20, >45, or male

Question 11

RF for thyroid cancer are

Answer 11

Hx of childhood head/neck radiation
FHx (1st degree) thyroid cancer
Large nodule (4+ cm)

Question 12

What are the types of thyroid cancer

Answer 12

papillary (MC, best prognosis)
follicular
anaplastic (least common, worst prognosis)
Medullary (MC familial)- test for RET mutation (gene marker)
Primary thyroid lymphoma
Mets from other site

Question 13

How do you treat thyroid cancer

Answer 13

near total thyroidectomy
Levothyroxine (thyroid suppression)
Radioiodine ablation
chemotherapy, radiotherapy

Question 14

What do you need to monitor post thyroid cancer Tx

Answer 14

serum TG and TSH 
anti-TG antibodies 
neck US 
\+/- whole body radioiodine scan 
MRI, CT, PET as appropriate