Thyroid Nodules/Surgery Flashcards
what % of nodules are malignant?
15% - though they are present in about 5% of adults
- Incidence of thyroid cancer increasing, but mortality rate remains stable
hx of more malignant nodules?
- increased malignancy in**
- men
- ages60
- hx of radiation
- family hx of thyroid cancer (FAP, MEN, multiple hamartoma syndrome)
- voice sx, visual sx, fatigue, anxiety (sx of hypo/hyperthyroidism)
when is FNA indicated?
nodules >1cm that are suspicious on US (hypoechoic, irregular, intranodular vascularity, calcifications, nodal mets )
FNA results:
- benign: (has 5% false negative rate) need to do 6-12 mos follow up
- malignant: requires surgery
- indeterminant (follicular lesion): usually contains follicular cells/hurthle cells - malignancy determined by invasion of capsule into surrounding blood vessels
solitary nodule algorithm for elevated Thyroid function tests?
- thyroid function tests
- if elevated do RAI scan - RAI scan:
- if hot, use RAI Rx or surgery
- if diffuse uptake or negative: follow patient
solitary nodule algorithm w/ normal thyroid function tests?
- do thyroid fn testing
- if normal, do ultrasound - Ultrasound shows cystic:
- do aspirate cytology
- if positive –> surgery
- if negative- follow and repeat US in 6 mos. - US shows solid/heterogenous
- do FNA
- if malignant then do surgery
- if intermediate then repeat FNA or follow closely for 3 mos.
- if follicular cells, do surgery or follow closely
- if benign then follow closely
what do you see with papillary carcinoma FNA?
Little Orphan Annie cells, intra-nuclear grooving, papillary projections, psammoma bodies
tx for papillary carcinoma?
total thyroidectomy +/- lymph node dissection
high risk papillary carcinoma
- age >40
- male
- capsular invasion, extrathyroidal extension to lymph nodes
- regional/distant mets
- size > 4cm (<2 cm is low-risk)
- poorly differntiated
long term survival is 50-99%
Hurthle cells
follicular carcinoma
FNA of follicular nodules?
if malignant, then do total thyroidectomy, no lymph node dissection needed
what is seen on FNA of medullary carcinoma?
see large bi-lobed nuclei w/ intense staining - indicating parafollicular C- cells
“C cells” secrete calcitonin
75% are sporadic
25% are familial (MEN2A, 2B or familial)
- always screen for PTH and adrenal disease as well
- follow up using serum calcitonin levels
tx: total thyroidectomy, +/- lymph node dissection
FNA of anaplastic carcinomas?
~ 1% of thyroid cancers
Very aggressive and often presents as a rapidly enlarging, painful mass with obstructive symptoms
Can be diagnosed with FNA
Palliative care only, doesn’t respond well to surgery, radiation therapy, or chemotherapy
follow up of thyroid cancers?
Most well-differentiated epithelial thyroid cancer treated with post-op radioactive iodine to ablate subclinical disease or mets
- Thyroid replacement
- Monitor physical exam and thyroglobulin levels to look for recurrent disease
- Medullary cancers followed with calcitonin and family evaluation
when is surgery performed for HyperTH
“Hot” nodule
Toxic nodular goiter
Grave’s Disease, especially in pregnant patient
Multinodular goiter
when is surgery not performed for HyperTH
thyroiditis - b/c its usually self limiting
