Flashcards
Thyroid/Endocrine
Flashcards do conjunto (42)
- 1Thyroid Cancer Risk Factors- hx of H&N XRT
- hx of total body XRT (ie for BMT)
- familial thyroid ca (MEN, familial papillary)
- older age (>55 yrs)
- contralateral nodules
*consider total thyroidectomy if +RFs - 2FNA Guidelines1. nodules > 2cm w/ v. low suspicion (<3% risk)
2. nodules > 1.5 cm if low suspicion (5-10%)
3. nodules > 1cm w/ suspicious (70-90%) or intermediate suspicion (10-20%)
4. PET-avid nodules >1 cm [30% risk malignant] (not diffuse uptake) - 3Suspicious US Findings (70-90% risk of malignancy)1. solid nodule
2. hypoechogenicity
3. microcalcifications
4. irregular borders (microlobulated, infiltrative)
5. taller than wide
6. rim calcifications
7. evidence of ETE
*TI-RADS scoring - 4Suspicious US Findings for Lymph Nodes1. microcalcifications
2. cystic aspect
3. peripheral vascularity
4. hyperechogenicity
5. round (vs oval) shape
6. loss of fatty hilum
FNA if suspicious LNs >8-10 mm in smallest dimension - 5Benign Pattern0% risk
- completely cystic nodules w/ well-defined walls - 6Very Low Suspicion Pattern<3% risk
- spongiform nodules & nodules with interspersed cystic spaces - 7Low Suspicion Pattern5-10% risk
1. isoechoic or hyperechoic nodule
2. partially cystic nodule
3. solid component
4. none of the following features:
- microcalcifications (see other points below)
- irregular margins
- extrathyroidal extension
- taller than wide - 8Intermediate Suspicion Pattern10-20% risk
1. hypoechoic solid nodule with smooth margins
2. no malignant features - 9High Suspicion Pattern>70-90% risk
1. solid hypoechoic nodule (or solid hypoechoic component of a partially cystic nodule), with at least one of these features:
- microcalcifications (see other points below)
- irregular margins (infiltrative, microlobulated)
- extrathyroidal extension
- taller than wide
- rim calcifications with an extrusive soft tissue component
lymphadenopathy - 10Bethesda Classification FNA (Estimated Risk of Malig)
- 112017 Bethesda Classification
- 12T Staging (Papillary, follicular, poorly ddx, Hurthle cell, anaplastic)MACIS calculator (PTC, prognostic)
- 13T Staging (Medullary)
- 14Differentiated Thyroid Cancer Staging (AJCC 8th Ed., < 55 yrs)
- 15Differentiated Thyroid Cancer Staging (AJCC 8th Ed., >/= 55 yrs)
- 16Anaplastic Carcinoma StagingStage IVa: confined to thyroid
Stage IVb: gross extrathyroidal extension or regional mets
Stage IVc: distant mets - 17Surgical Mgmt Well-Differentiated Thyroid Carcinoma1. T >4cm or w/ ETE (T4) or +nodal or metastatic disease...total thyroid +/- LN dissection
2. 1 cm< T <4 cm w/o ETE or nodal mets...total or lobectomy
3. if T <1 cm w/o ETE or nodal mets... lobectomy only (if no adverse RFs)
4. if multifocal (>5) microcarcinoma, consider total - 18Indications for RAI1. primary tumors > 4cm
2. distant mets
3. gross extrathyroidal extension
4. age > 45 yrs
5. elevated post op thyroglobulin levels >5-10 ng/ml
6. bulky or >5 LNs on path
6. high risk features: vascular invasion (follicular only), poorly ddx subtypes, multifocal dis
- cytomel & thyrogen may reduce hypothyroidism/TSH withdrawal prior to RAI - 19Lymph Node Dissection ?1. consider elective level VI neck if T3 or T4 or if clinically involved involved lateral neck nodes (cN1b) [weak evidence]
2. no elective neck for T1/T2 unless +LNs
3. for lateral neck, ATA recommends level IIa-V, excl IIb - 20Workup for WDTC & Nodules
- 21Surgical Mgmt & RAI Flowchart
- 22Pre-op NPL for thyroidectomy?ATA recommends NPL pts w/:
1. preop voice abnormalities
2. hx of cervical/chest sx
3. extensive posterior ETE or nodal disease - 23Other Mgmt PearlsATA Recommendations
1. recommend against routine preop TG levels
2. recommend post-op TG monitoring
3. calcitonin: for MTC (more specific in detecting residual or recurrent disease than CEA) - 24Genetic Testing for Thyroid Cancer1. Afirma gene expression classifier- NPV 93%
2. ThyroSeq - NPV 95%
3. ThyGenX/ThyrMIR ("rule in") - 66% PPV - 25Indications for Parathyroidectomy1. serum Ca > 1 mg/dL above ULN
2. CrCl decr by >30%
3. age <50 yrs
4. 24hr urinary Ca > 400 mg/dL
5. bone density >2.5 std devs by T-score
6. Pt requests sx - 26Mutations Assoc with Thyroid Carcinoma
- 27Mutations Assoc with Thyroid Carcinoma (contd)papillary - RET (peds), BRAF (adults), RAS
follicular - RAS, PPARG
poorly ddx - RAS, BRAF, TP53
anaplastic - TP53, RAS, BRAF, PIK3CA
medullary - RET - 28MACIS ScoreMetastasis
Age at diagnosis
Completeness of surgical rx
Invasion of extrathyroidal structures
Size of tumor - 29Metastatic Thyroid Disease- lymphatic mets: PTC >> FTC
- distant mets: Hurthle cell > FTC (hematogenous) > PTC (lymphatic)
- bone, liver, lung (MC), brain
NB: children more commonly present w/ advanced disease & cervical & distant thyroid mets (esp to lungs) - 30Mets to Thyroidkidney
breast
lung
skin (melanoma, SCCa) - 31Mgmt of MTC- if primary > 1 cm (> 0.5 cm for MEN2B), elective ipsilateral II-IV SND indicated
- ATA recommends elective SND according to serum calcitonin levels
> 20 pg/ml - ipsilateral SND
> 200 pg/ml - bilateral SND - 32Mgmt of MTC cont'd1. preop serum CEA (more predictive of survival), calcitonin (more sensitive for persistent/recurrent disease)
2. genetic eval; RET muts screened for pheo & HPTH
3. CT thorax/mediastinum, US
4. total thyroidectomy + bilat central ND + level VII
NB: do not respond to radioiodine tx or TSH; no CTX & EBRT is controversial
OS: familial MTC > MEN-2A > sporadic - 33MEN 11. parathyroid hyperplasia (95% by age 50)
2. pituitary adenoma
3. pancreatic tumors - 34MEN 2A1. parathyroid adenomas (30%)
2. pheochromocytoma (70%)
3. MTC (100%) - ATA recommends total thyroidectomy prior to age 5
RET-associated - 35MEN 2B1. MTC - ATA recommends total thyroidectomy + central neck dissection within 1st year of life (more aggressive than MEN2A)
2. pheochromocytoma
3. mucosal neuromas
+Marfanoid habitus - 36Parathyroid Hormone- secr by parathyroid chief cells
- half life: 3-5 mins
- targets: (1) kidney, (2) skeletal system, (3) intestine
(1) incr Ca resorption, decr Phos resorption, converts 25-OH D3 to 1,25-OH D3 (calcitriol)
(2) indirectly stimulates OCs via OBs
(3) incr Ca absorption via vit D - 37Superior Parathyroids- 4th branchial pouch
- cricothyroid junction, 1 cm cranial to intersection of RLN + inf thyroid art.
- deep (dorsal) to RLN
- unlike thyroid nodules, paras can move freely as they are encapsulated w/in pseudocapsule - 38Inferior Parathyroids- 3rd branchial pouch w/ thymus
- inf pole of thyroid & along thyrothymic ligament
- superficial (ventral) to RLN
- 28% found in thymus (thyrothymic ligament) or anterior superior mediastinal thymic gland
- other locations: intrathyroidal (1-3%), carotid sheath, retroesophageal, submandibular region - 39Risk Factors for Aggressive WDTC- demographics: age <20 or >55; M>F; FHx; hx of XRT
- variant: tall cell variant, diffuse sclerosing, Hurthle cell, follicular carcinoma
- size >4cm
- ETE
- LVI
- mets - 40ATA Guidelines for MTCafter initial dx, obtain:
1. US neck
2. baseline CEA, calcitonin (if Ctn >500pg/ml, work up for mets with staging CT or MRI)
3. DNA testing for RET germline mutation (if +, evaluate for pheo & treat first) - 41ATA Guidelines for treatment MTCtotal thyroidectomy with CND +/- SND II-IV (depending on US, serum CTn, intraop findings)
in patients with clinically positive nodes of the ipsilateral neck, contralateral SND should be performed if CTn >200 pg/ml - 42ATA Guidelines for MTC in patients with MENMEN2a - total thyroid by age 5 years
MEN2b - total thyroid by 12 months