0%
Topic
Review Topic
0
0
N/A
N/A
Questions
0 4
0
0
100%
0%
Evidence
0 2
0
0
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
 

Please rate topic.

Average 4.3 of 3 Ratings

Questions (4)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(M2.ON.16.37) A 45-year-old woman comes into your office with complaints of a "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? Tested Concept

QID: 104579
1

Punch biopsy

0%

(0/7)

2

Surgical excision

71%

(5/7)

3

Thyroxine administration

0%

(0/7)

4

Ultrasound

14%

(1/7)

5

CT scan

14%

(1/7)

M 6 E

Select Answer to see Preferred Response

Evidences (2)
Topic COMMENTS (6)
Private Note