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C HD ext. > Thyroid - Thyroid Nodules and Thyroid Cancer > Flashcards

Thyroid - Thyroid Nodules and Thyroid Cancer Flashcards

1
Q

Are thyroid nodules mostly benign or malignant?

A

Benign

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2
Q

What two features are suggestive of the nodule being within the thyroid?

A
  • It moves on swallowing

- It is painless

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3
Q

If a nodule is in the thyroid, what type of fascia will it be invested in?

A

Pretrachial fascia

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4
Q

When will a thyroid nodule be painful?

A

If a cyst has formed which is bleeding and expanding

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5
Q

What are the two most important questions in a history of a thyroid nodule?

A
  • Has there been neck irradiation?

- Is there a family history of thyroid cancer?

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6
Q

What are two important things to look/assess for on examination of a thyroid nodule?

A
  • Lymphadenopathy in the neck

- Hoarseness of the voice

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7
Q

If lymph nodes are found in the neck along with a thyroid nodule, what is this until proven otherwise?

A

Papillary thyroid cancer

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8
Q

What is hoarseness of the voice suggestive of?

A

Recurrent laryngeal nerve palsy- an aggressive cancer

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9
Q

What are the most important investigations for a thyroid nodule?

A
  • TSH levels

- US and FNA

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10
Q

What are the different FNA/US stages and what does each signify?

A 
Thy1- inadequate
Thy2/U2- benign
Thy3 (a/f)/U3- atypical
Thy4/U4- probably malignant
Thy5/U5- malignant
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11
Q

Thy3a FNA staging has what % chance of being malignant?

A

30%

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12
Q

Where do most thyroid tumours arise from?

A

Follicular cells

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13
Q

What is the most common tumour of the thyroid?

A

Follicular adenoma

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14
Q

What type of tumours are follicular adenomas?

A

Benign, glandular

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15
Q

Follicular adenomas are encapsulated. What does this mean?

A

They are surrounded by a band of collagen within which there are closely packed thyroid follicles

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16
Q

Are follicular adenomas functioning or non-functioning?

A

Normally non-functioning but can sometimes secrete thyroid hormones

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17
Q

If a follicular adenoma was to secrete thyroid hormones, is this TSH dependent or independent?

A

TSH independent

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18
Q

What genetic mutations are associated with follicular adenoma?

A

Ras oncogene

TSHR signalling pathway

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19
Q

As well as follicular adenoma, what are some other causes of a benign solitary nodule?

A
  • Cyst
  • Colloid nodules
  • Hyperplastic nodules
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20
Q

Most thyroid cancers are what type?

A

Carcinomas

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21
Q

What are carcinomas?

A

Malignant epithelial tissue

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22
Q

Which types of thyroid carcinomas can be differentiated?

A

Papillary and follicular

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23
Q

What thyroid carcinoma is the most common?

A

Papillary

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24
Q

What does it mean for a cancer to be differentiated?

A

They look and behave very similarly to normal cells

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25
Q

What is the main advantage and main disadvantage of differentiated cancer?

A

D: can be hard to spot/diagnose
A: very good prognosis

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26
Q

Most differentiated cancers take up X, secrete Y and are Z driven?

A 
X= iodine
Y= thyroglobulin
Z= TSH
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27
Q

Which sex is more commonly affected by thyroid cancers?

A

Females

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28
Q

How do the rates of thyroid cancer vary with age in both men and women?

A

Women- rates increase from age 15-40 and then plateau

Men- rate steadily increases with age

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29
Q

Thyroid cancers have a lower incidence in what race?

A

Afro-Americans

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30
Q

Thyroid cancers have a strong association with what environmental factor?

A

Exposure to radiation

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31
Q

How soon after a nuclear incident do effects start to show?

A

Exactly 25 years

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32
Q

What 3 things does thyroid cancer have a weak association with?

A
  • Thyroid adenoma
  • Chronic elevation of TSH
  • More children a woman has had
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33
Q

What factors does thyroid cancer have NO association with, that are common risk factors for other cancers?

A

Diet, other malignancies, smoking

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34
Q

What do most thyroid cancer patients present with?

A

A palpable nodule, most likely to be an enlarged lymph node

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35
Q

A pathological fracture is most likely to be caused by what type of thyroid cancer?

A

Follicular

36
Q

How does papillary cancer tend to spread? This makes what a common presentation?

A

Spreads via lymphatics- cervical lymphadenopathy is a common presentation

37
Q

Does cervical lymphadenopathy with papillary thyroid cancer alter the prognosis?

A

No

38
Q

If papillary cancer was to spread haematogenously, where are some areas it may spread to?

A
  • Bones
  • Liver
  • Lungs
  • Brain
39
Q

What two factors is papillary thyroid cancer associated with?

A

Hashimoto’s thyroiditis and ionising radiation

40
Q

What is the prognosis for papillary and follicular differentiated cancer?

A

10 year mortality < 5%

41
Q

What are some local effects of papillary thyroid cancer?

A

Hoarseness, dysphagia, cough, dyspnoea

42
Q

What age group does papillary thyroid cancer tend to affect?

A

30-40

43
Q

What genetic features are associated with papillary thyroid cancer?

A

BRAF and RAS mutations

44
Q

What type of nuclei is seen in papillary thyroid cancer?

A

Orphan Annie eye- clear and grooved

45
Q

How does follicular cancer tend to spread? This makes what more common?

A

Haematogenously, making distal metastases more common

46
Q

What is the peak age for follicular cancer?

A

Around 50

47
Q

What are some genetic features associated with follicular thyroid cancer?

A

Mutations in P13k/AKT pathways or the RAS family

48
Q

Most follicular thyroid cancer patients present with what FNA score?

A

Thy3f

49
Q

Can you tell if there has been capsular invasion with an FNA?

A

No

50
Q

When a new thyroid nodule presents, what are some clinical indicators of malignancy?

A
  • New nodule aged < 20 or > 50
  • Increasing in size
  • > 4cm diameter
  • History of head/neck irradiation
  • Vocal cord palsy
51
Q

What investigation is most effective at showing lymph nodes? What should be done if these are found?

A

Ultrasound- should be taken out completely

52
Q

What investigation should be performed if there is a suspected vocal cord palsy?

A

Pre-operative laryngoscopy

53
Q

What investigations are there no role for in thyroid cancer?

A

Isotope scans, CT, MRI

54
Q

What are some features of a low risk group?

A

< 40
No metastases
Cancer confined to the thyroid

55
Q

What are some features of a high risk group?

A

Age > 40

Any metastases

56
Q

What do T1/2/3 mean in TNM staging of thyroid cancer?

A

T1- size 2cm or less
T2- size greater than 2cm up to 4cm (limited to thyroid)
T3- size greater than 4cm , limited to the thyroid or with minimal extension

57
Q

What do T4a and T4b in TNM staging of thyroid cancer?

A

T4a- moderately advanced disease, tumour extending beyond the capsule to subcutaneous tissues

T4b- very advanced disease, tumour invades pre vertebral fascia or vessels

58
Q

What do N0 and N1 mean in TNM staging of thyroid cancer?

A

N0- no regional node metastases

N1- regional node metastases

59
Q

What do N1a and N1b mean in TNM staging of thyroid cancer?

A

N1a- metastases to level VI (pre tracheal, paratracheal or pre laryngeal nodes)

N1b- metastases to unilateral, bilateral or contralateral cervical, retropharyngeal or superior mediastinal nodes

60
Q

What do M0 and M1 mean in TNM staging of thyroid cancer?

A

M0- no metastases

M1- distal metastases present

61
Q

What level of the neck are thyroid cancers mostly seen?

A

Levels 3/4

62
Q

What is the treatment of choice for thyroid cancers?

A

Surgery

63
Q

What are the pros and cons of a lobectomy?

A

Less invasive and lower morbidity

The other lobe is then prone to cancer and investigations are difficult

64
Q

When are lobectomies used?

A

Very low risk patients

65
Q

What is the deal with Ca++ and post-operative care after a thyroidectomy?

A

Ca++ checked in first 24 hours

Ca++ replaced if < 2mmol/l (IV if < 1.8mmol/l or the patient is symptomatic)

66
Q

What test is performed 3-6 months post-op of a thyroidectomy?

A

Whole body iodine scanning

67
Q

What must happen to T3 and T4 treatment before a patient undergoes a whole body iodine scan?

A

T4 stopped 4 weeks before

T3 stopped 2 weeks before

68
Q

What is used as a tumour marker for differentiated cancer?

A

Thyroglobulin

69
Q

How can you get rid of any leftover thyroid tissue following a thyroidectomy?

A

Thyroid remnant ablation

70
Q

What are some side effects of thyroid remnant ablation?

A

Sialadenitis, sore throat, increased risk of acute myeloid leukaemia

71
Q

Does thyroid remnant ablation have any effect on increased incidence of other tumours, infertility or genetic abnormalities of offspring?

A

No

72
Q

After completion of therapy and follow up for thyroid cancer, patients are maintained on X therapy, with the aim of suppressing TSH to Y and have a fT4 level of Z?

A 
X= T4
Y= < 0.1 U/l
Z= < 25
73
Q

How can recurrent disease be detected?

A

Rising thyroglobulin or imaging

74
Q

Recurrence in cervical lymph nodes is mostly seen in what cancer?

A

Papillary

75
Q

Recurrence to distal sites is mostly seen in what cancer?

A

Follicular

76
Q

Recurrent disease is seen within how long of the first cancer?

A

2 years

77
Q

What is the recurrence rate for differentiated thyroid cancer? Are these treated successfully?

A

30%- with most being treated successfully

78
Q

If thyroglobulin is rising but there is a negative whole body iodine scan, what test could be done?

A

PET

79
Q

What can be used as a tumour marker for medullary thyroid carcinoma?

A

Calcitonin

80
Q

What type of tumours are medullary thyroid carcinomas? Where are they derived from and what do they secrete?

A

Neuroendocrine- derived from C-cells (parafollicular) and secrete calcitonin

81
Q

What genetic factor is related to medullary thyroid cancer?

A

MENIIa and MENIIb, familial medullary carcinoma

82
Q

What should always be checked when there is a medullary thyroid cancer with suspicion of MEN?

A

24h urinary metanephines and genetics

Screen family

83
Q

Medullary thyroid cancer is associated with deposition of what? What does this represent?

A

Amyloid deposition- represents abnormally folded calcitonin

84
Q

Who does anaplastic thyroid carcinoma occur in?

A

Older patients, maybe with a PMH of differentiated thyroid cancer

85
Q

What genetic factors are involved in anaplastic thyroid cancer?

A

p53 and B-catenin mutations

86
Q

Who does thyroid lymphoma occur in?

A

Those with a background of autoimmune hypothyroidism on T4

C HD ext. (5 decks)

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