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DEMS Unit 4 > Thyroid Nodules--Clinical/Pathologic/Pathophys Correlates > Flashcards

Thyroid Nodules--Clinical/Pathologic/Pathophys Correlates Flashcards

1
Q

how common are thyroid nodules

A

30-60%;

  • 25 year old - 10%
  • 70 year old 55%
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2
Q

risk of cancer in thyroid nodule

A

small (10-15%) but not insignificant

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3
Q

how are most thyroid nodules detected

A

noted by pt, noted by third party, detected by other tests,

- 1/3 via testing: US > CT > PET

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4
Q

normal thyroid structure

A
  • butterfly shaped organ in neck; L and R lobes
  • follicular cells with parafollicular/C cells
  • follicles round, dark, uniform, and filled with colloid
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5
Q

what does a nodule look like

A

well circumscribed, different color from surroundign thyroid

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6
Q

types of thyroid neoplasms

A
  • benign - adenoma (most common)
  • malignant- papillary, carcinoma, follicular/Hurthle, anaplastic, medullary
  • lymphoma, sarcoma
  • metastatic
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7
Q

rank the malignant thyroid tumors from most to least common

A

papillary (85-90%)
Follicular/Hurthle (5%)
Medullary (5%)
Anaplastic (

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8
Q

Thyroid adenoma

A

benign neoplasm, solitary nodule

  • composed of follicular cells/Hurthle cell
  • smaller follicles
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9
Q

how do you distinguish between adenoma and carcinoma

A

have to look at specimen

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10
Q

Follicular/Hurthle cell Carcinoma

A
  • 2 types (minimally invasive - vascular or capsular invasion, widely invasive - more extensive invasion)
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11
Q

Papillary carcinoma

A
  • most common malignant
  • well differentiated
  • multifocal– often will take out whole gland since often multifocal
  • lymphatic spread
  • excellent prognosis
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12
Q

features of papillary carcinoma

A
  • papillae with vascular core
  • optically clear nuclei; “open eyed nuclei”– have dark nucleus pushed to outside
  • nuclei tend to be large
  • nuclear pseudoinclusions
  • nuclear grooves, rare or absent mitoses
  • Psammoma Bodies (calcification)
  • Have follicular variant that aren’t forming papillary fronds by trying to form follicular structures– still have odd nuclear features
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13
Q

Anaplastic carcinoma

A
  • older age group (poor survival)
  • rapidly growing– often will have lump for months to years without changes then suddenly starts growing rapidly
  • 3 patterns (spindle cell, giant cells, squamoid cells
  • necrosis and hemorrhage
  • anaplastic– undifferentiated, ugly look – not looking like thyroid
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14
Q

Medullary Carcinoma

A
  • solid proliferation of cells with granular cytoplasm (C cells)
  • highly vascular stroma
  • hyalinized collagen and/or amyloid
  • may have Psammoma bodies (calcification)
  • Immunostains: Thyroglobulin -, Calcitonin +, Chromogranin +
  • can’t tell difference with other thyroid tumors
  • Note chromogranin from neuroendocrine
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15
Q

Lymphomas

A
  • can arise in thyroid
  • background autoimmune thyroiditis can eventually lead to lymphoma with chronic inflammation
  • large, fleshy masses
  • DDx- anaplastic ca of thyroid
  • positive LCA, usually B cell
  • gene rearrangement
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16
Q

Metastatic cancers to thyroid

A

melanoma, lung, head and neck, renal, breast, colon

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17
Q

Things to look for in hx

A

growth, pain, cough/voice change, irradiation, family hx (about 10% familial)

18
Q

what to look for on physical exam

A

size, consistency (rock hard more concerning), fixation (nl thyroid should move with swallowing), lymphadenopathy

19
Q

3 key tests for thyroid

A

TSH, US, fine needle aspiration biopsy (if meets criteria)

20
Q

if FNAB suspicious/indeterminate

A

will only do scan if low TSH

21
Q

Dip quick stain

A

Dip fine needle aspiration int his too see if good biopsy

22
Q

Hurthle cells

A
  • have more pink, grainy cytoplasm

- follicular cells with different microscopic appearance

23
Q

papillary carcinoma of thyroid cytologic features

A 
- highly cellular, 
\+/- colloid
- nuclear enlargement, elongation
- nuclear grooves, pseudoinclusions
- multiple small  to large nucleoli
- Psammoma bodies (rarely seen)
- papillary cellular aggregate
24
Q

anaplastic cancer cytology

A

large, wacky cells, huge nucleoli, multinucleated

25
Q

lympnoma cytology

A

very uniform, really no cytoplasm

26
Q

Bethesda diagnostic categories for thyroid nodules

A

non-diagnostic, benign, ACUS(indeterminate), suspicious for follicular neoplasm, suspicious for malignancy, malignant

27
Q

management for malignant nodules

A

remove thyroid, +/- LN depending on US

28
Q

management for nodule suspicious for malignancy

A

thyroidectomy +/- LN depending on US

29
Q

management for nodule suspicious for follicular neoplasm

A

lobectomy–look at capsule to determine if foll. carcinoma or just adenoma

30
Q

proto-oncogene

A

normal gene which codes for a protein that promotes normal cell division

31
Q

oncogene

A

mutated gene which codes for a protein that causes unregulated cell division

32
Q

tumor suppressor gene

A

normal gene which codes for a protein that restrains cell division or that promotes cell differentiation, DNA repair or apoptosis

(example: p53)

33
Q

most common genetic pathway messed up in thyroid cancer

A
  • MAP kinase

- usually signals through Ras to BRAF and to MEK-ERK system– stimulates cell growth and division

34
Q

tumors result from

A

oncogene activation or tumor suppressor gene loss

  • cancers result from multiple sequential genetic mutations
  • cells transformed by genetic mutations likely to develop more mutations
35
Q

Most common mutations in Papillary Ca

A
  • proto-oncogene RET/PTC (20%)– rearrangement–now becomes expressed
  • pt mutation in Ras (20%)
  • BRAF point mutation (40%)
  • can have p53 inactivating point mutation
36
Q

most common mutation in thyroid cancer

A

BRAF point mutation

37
Q

do thyroid tumors have multiple mutations

A

usually just one but can have more

38
Q

Follicular Carcinoma mutations

A
  • pt mutation in RAS
  • PI3 kinase pathway or Map kinase
  • Pax8-PPARgamma rearrangement (20-40%)– get fusion protein
39
Q

what has to happen to get anaplastic carcinoma

A

need to have activating mutation and also inactivating of tumor suppressor (p53 or beta catenin)

40
Q

which cancer has highest 2- year outcome

A

papillary thyroid carcinoma

DEMS Unit 4 (16 decks)

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