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https://upload.medbullets.com/topic/120414/images/thyroid-cancer.jpg
https://upload.medbullets.com/topic/120414/images/hot_thyroid_nodule.jpg
https://upload.medbullets.com/topic/120414/images/medullary_us.jpg
Snapshot
  • A 36-year-old woman complains of several weeks of hoarseness and difficulty swallowing. She also feels a sense of fullness in her neck. On physical exam there is a palpable, nontender swelling in the front of her neck that moves with swallowing. There is no cervical lymphadenopathy. Lab studies show decreased TSH. Ultrasound of the neck reveals a 2.5 cm hypoechoic thyroid nodule with calcifications and thyroid scintigraphy shows decreased iodine uptake of the nodule compared to surrounding tissues. 
Introduction
  • Overview
    • primary malignancy of thyroid gland
    • secondary metasteses can occur from other cancers
      • breast, colon, renal, and melanoma
  • Epidemiology
    • incidence
      • increasing in past 15 years
      • papillary thyroid cancer (most common) has incidence of 15 per 100,000
    • demographics
      • papillary more common in women
      • anaplastic more common in elderly
    • risk factors
      • < 30 or > 70 years of age
      • history of radiation to head/neck
      • family history of
        • medullary thyroid cancer
        • multiple endocrine neoplasia (MEN) syndrome type 2 
        • Cowden syndrome
        • familial adenomatous polyposis 
  • Prognosis
    • papillary
      • very good prognosis
    • anaplastic
      • very poor prognosis
Classification
  • Papillary 
    • overview
      • 85% of all thyroid cancers 
      • female dominance
      • often multifocal
      • risk factors include radiation exposure to the head and neck
      • spreads via lymphatics
      • very good prognosis
    • histology
      • psammoma bodies (calcifications) 
        • also seen in ovarian dysgerminomas and meningiomas
      • ground glass/empty nuclei/"orphan Annie nuclei"
        • nuclear grooves
      • cells organized into papillary "fingers" 
  • Follicular carcinoma
    • overview
      • usually unifocal
      • small number evolved from a benign follicular adenoma
        • requires surgical excision to differentiate between adenoma and carcinoma
          • follicular carcinoma shows invasion into capsule and vessels  
      • spreads hematogenously
        • lungs most common location of metastasis
      • good prognosis
    • histology
      • preservation of normal thyroid follicular architecture but with proliferation
        • uniform follicles
  • Medullary
    • overview
      • derived from calcitonin-synthesizing C cells
        • may present with hypocalcemia
        • may produce ACTH
      • 10% of cases associated with MEN syndrome type 2a or 2b 
        • associated with a RET mutation 
      • typically unifocal thyroid nodule
      • patients have elevated serum calcitonin (tumor marker)
      • risk factors
        • previous radiation to neck
        • family history
    • histology
      • amyloid (consisting of calcitonin)
  • Anaplastic
    • overview
      • more common in elderly
      • can be superimposed on multinodular goiter or follicular cancer
      • very poor prognosis
Presentation
  • Symptoms
    • dysphagia and hoarseness
      • can be due to direct compression by mass
      • can indicate tumor invasion/nerve involvement
  • Physical exam
    • neck mass or palpable thyroid nodule
    • +/- cervical lymphadenopathy
      • suggests metastasis
Imaging
  • Thyroid scintigraphy (radioactive iodine uptake test)
    • indications
      • patients with decreased thyroid stimulating hormone (TSH) levels
    • findings
      • "hot" nodule 
        • increased uptake of iodine compared to surrounding thyroid tissue
        • suggests autonomously functioning thyroid
          • typically benign
          • no fine needle aspiration (FNA) required 
      • "cold" nodule
        • less uptake of iodine compared to surrounding thyroid tissue
        • concern for malignancy
        • perform FNA
  • Ultrasonography
    • indications
      • all patients with thyroid nodule
    • findings
      • hypoechoic nodule >1 cm more likely to be malignant
      • high suspicion of malignancy if
        • hypoechoic nodule > 1cm and has ≥ 1 suspicious features such as
          • irregular margins
          • microcalcifications 
          • rim calcifications
          • extrathyroidal extension
      • intermediate suspicion of malignancy if
        • hypoechoic nodule > 1cm with smooth margins
Studies
  • TSH levels
    • decreased TSH more concerning for malignancy
      • follow up with thyroid scintigraphy (radioactive iodine uptake test)
    • normal/elevated TSH less concerning for malignancy
      • follow up with ultrasound
  • Serum calcitonin
    • tumor marker for medullary thyroid cancer
  • Fine needle aspiration (FNA)
    • indications
      • all "cold" nodules on radioactive iodine uptake scan
      • nodules that meet high or intermediate suspicion criteria based on ultrasound
      • nodules that are low suspicion on ultrasound but have all of the following properties
        • isoechoic, hyperechoic solid nodule, or partially cystic nodule
        • has eccentric solid areas
        • size > 1.5 cm
Differential
  • Benign thyroid nodule 
    • key distinguishing factors
      • more likely to be tender
      • associated hypo- or hyperthyroidism
      • typically "hot" on radioactive iodine uptake test
Treatment
  • Medical
    • iodine radiotherapy
      • indications
        • papillary thyroid cancer
        • following surgical management in high-risk and some intermediate-risk patients
    • thyroid hormone supplementation
      • indications
        • almost all patients following initial medical/surgical management
        • prevents hypothyroidism
        • minimizes potential TSH stimulation of tumor growth
      • modalities
        • daily oral levothyroxine
  • Surgical
    • thyroidectomy
      • indications
        • FNA findings that either confirm malignancy or are suspicious for malignancy
      • risk of damage to recurrent laryngeal nerve during surgery
        • persistent hoarseness
Complications
  • Metastasis to other organs
  • Death
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.ON.16.37) A 45-year-old woman comes into your office with complaints of "lump" she found on her neck while showering. She denies any other symptoms and states that she has not gained any weight. On exam, you notice a 2 cm nodule on her anterior neck. Her TSH level is normal and radionucleotide scan reveals a cold nodule. Fine needle aspiration biopsy (FNAB) reveals follicular architecture suspicious for malignancy. What is the next best step? Review Topic | Tested Concept

QID: 104579
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Punch biopsy

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Surgical excision

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3

Thyroxine administration

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Ultrasound

14%

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CT scan

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