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Questions and Answers
Which clinical finding in a patient presenting with a thyroid nodule is least suggestive of malignancy?
Which clinical finding in a patient presenting with a thyroid nodule is least suggestive of malignancy?
- Fixed nodule to adjacent structures
- Vocal cord paralysis
- Rapid nodule growth
- Nodule tenderness on palpation (correct)
A 55-year-old woman presents with a thyroid nodule and a history of long-standing iodine deficiency. Which type of thyroid cancer is most likely?
A 55-year-old woman presents with a thyroid nodule and a history of long-standing iodine deficiency. Which type of thyroid cancer is most likely?
- Medullary thyroid carcinoma
- Follicular thyroid carcinoma (correct)
- Papillary thyroid carcinoma
- Anaplastic thyroid carcinoma
A patient diagnosed with medullary thyroid carcinoma (MTC) should undergo testing for mutations in which gene?
A patient diagnosed with medullary thyroid carcinoma (MTC) should undergo testing for mutations in which gene?
- PIK3CA
- RET (correct)
- PTEN
- BRAF
A 70-year-old patient presents with a rapidly enlarging thyroid mass, hoarseness, and difficulty swallowing. Surgical intervention is typically avoided in which of the following thyroid cancer types?
A 70-year-old patient presents with a rapidly enlarging thyroid mass, hoarseness, and difficulty swallowing. Surgical intervention is typically avoided in which of the following thyroid cancer types?
Which of the following thyroid carcinoma types is least likely to be associated with a history of radiation exposure?
Which of the following thyroid carcinoma types is least likely to be associated with a history of radiation exposure?
A patient with follicular thyroid carcinoma develops distant metastases. Which of the following sites is most likely to exhibit hormonally active metastases leading to hyperthyroidism?
A patient with follicular thyroid carcinoma develops distant metastases. Which of the following sites is most likely to exhibit hormonally active metastases leading to hyperthyroidism?
In the context of thyroid nodules, which feature is most indicative of an increased risk of associated lymphadenopathy?
In the context of thyroid nodules, which feature is most indicative of an increased risk of associated lymphadenopathy?
A patient is diagnosed with a neuroendocrine tumor arising from the parafollicular cells of the thyroid. Which laboratory finding would be most consistent with this diagnosis?
A patient is diagnosed with a neuroendocrine tumor arising from the parafollicular cells of the thyroid. Which laboratory finding would be most consistent with this diagnosis?
Considering the anatomical relationships, what is the most likely consequence of inadvertently ligating the superior thyroid artery too close to the thyroid gland during a thyroidectomy?
Considering the anatomical relationships, what is the most likely consequence of inadvertently ligating the superior thyroid artery too close to the thyroid gland during a thyroidectomy?
A patient presents with a thyroid nodule and difficulty swallowing. Fine needle aspiration (FNA) is inconclusive. Which of the following factors would MOST strongly suggest the need for surgical excision rather than continued monitoring?
A patient presents with a thyroid nodule and difficulty swallowing. Fine needle aspiration (FNA) is inconclusive. Which of the following factors would MOST strongly suggest the need for surgical excision rather than continued monitoring?
Following a total thyroidectomy for papillary thyroid cancer, a patient's postoperative calcium level is low, and they are experiencing perioral tingling and muscle cramps. What is the MOST likely cause of these symptoms?
Following a total thyroidectomy for papillary thyroid cancer, a patient's postoperative calcium level is low, and they are experiencing perioral tingling and muscle cramps. What is the MOST likely cause of these symptoms?
A 60-year-old patient undergoes a thyroidectomy for a large multinodular goiter. Postoperatively, the patient's voice is hoarse. Laryngoscopy reveals paralysis of the left vocal cord. What is the MOST likely cause?
A 60-year-old patient undergoes a thyroidectomy for a large multinodular goiter. Postoperatively, the patient's voice is hoarse. Laryngoscopy reveals paralysis of the left vocal cord. What is the MOST likely cause?
A patient with Graves' disease is being considered for definitive treatment. Which of the following factors would MOST strongly favor total thyroidectomy over radioactive iodine ablation?
A patient with Graves' disease is being considered for definitive treatment. Which of the following factors would MOST strongly favor total thyroidectomy over radioactive iodine ablation?
In the management of differentiated thyroid cancer, what is the PRIMARY rationale for administering high-dose radioactive iodine (RAI) post-thyroidectomy?
In the management of differentiated thyroid cancer, what is the PRIMARY rationale for administering high-dose radioactive iodine (RAI) post-thyroidectomy?
A surgeon is performing a thyroid lobectomy. During the procedure, they encounter significant scarring and inflammation in the area of the recurrent laryngeal nerve due to previous thyroiditis. What is the MOST appropriate course of action to minimize the risk of nerve injury?
A surgeon is performing a thyroid lobectomy. During the procedure, they encounter significant scarring and inflammation in the area of the recurrent laryngeal nerve due to previous thyroiditis. What is the MOST appropriate course of action to minimize the risk of nerve injury?
Which of the following pathological findings in a thyroid nodule obtained via fine needle aspiration (FNA) would be MOST indicative of malignancy and warrant surgical excision?
Which of the following pathological findings in a thyroid nodule obtained via fine needle aspiration (FNA) would be MOST indicative of malignancy and warrant surgical excision?
In the context of MEN 2, which genetic mutation is most closely associated with the development of this syndrome?
In the context of MEN 2, which genetic mutation is most closely associated with the development of this syndrome?
A patient presents with medullary thyroid carcinoma, pheochromocytoma, and hyperparathyroidism. Which type of MEN syndrome is most likely?
A patient presents with medullary thyroid carcinoma, pheochromocytoma, and hyperparathyroidism. Which type of MEN syndrome is most likely?
Which combination of ultrasound (US) and Thy classification would be most indicative of a high suspicion for thyroid malignancy?
Which combination of ultrasound (US) and Thy classification would be most indicative of a high suspicion for thyroid malignancy?
What characteristics from a thyroid nodule would classify it as a U4 based on ultrasound findings?
What characteristics from a thyroid nodule would classify it as a U4 based on ultrasound findings?
Which of the following factors is least likely to be associated with a poorer prognosis in papillary thyroid cancer?
Which of the following factors is least likely to be associated with a poorer prognosis in papillary thyroid cancer?
In managing thyrotoxicosis, which scenario would most strongly favor thyroidectomy over medical management?
In managing thyrotoxicosis, which scenario would most strongly favor thyroidectomy over medical management?
A patient with a history of toxic multinodular goiter is planning to undergo thyroidectomy. Which clinical finding would be the strongest indication for surgical intervention?
A patient with a history of toxic multinodular goiter is planning to undergo thyroidectomy. Which clinical finding would be the strongest indication for surgical intervention?
A patient is diagnosed with a thyroid nodule. Post-FNA, the pathology report returns a Thy3f result. What is the most appropriate next step in management?
A patient is diagnosed with a thyroid nodule. Post-FNA, the pathology report returns a Thy3f result. What is the most appropriate next step in management?
Flashcards
Thyroid gland anatomy
Thyroid gland anatomy
The thyroid gland is an endocrine organ located in the neck that regulates metabolism.
Differentiated thyroid cancer
Differentiated thyroid cancer
Types of thyroid cancer that respond well to treatment, including papillary and follicular carcinoma.
Common presentation of thyroid cancer
Common presentation of thyroid cancer
The most frequent symptom of thyroid cancer is a solitary thyroid nodule.
Indications for thyroid surgery
Indications for thyroid surgery
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Recurrent laryngeal nerve
Recurrent laryngeal nerve
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Thyroid nodule types
Thyroid nodule types
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Radioactive iodine role
Radioactive iodine role
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Surgical complications of thyroid surgery
Surgical complications of thyroid surgery
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Papillary Thyroid Carcinoma
Papillary Thyroid Carcinoma
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Follicular Thyroid Carcinoma
Follicular Thyroid Carcinoma
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Medullary Thyroid Carcinoma
Medullary Thyroid Carcinoma
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Anaplastic Thyroid Carcinoma
Anaplastic Thyroid Carcinoma
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Risk Factors for Thyroid Cancer
Risk Factors for Thyroid Cancer
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Thyroid Malignancy Presentation
Thyroid Malignancy Presentation
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Metastatic Thyroid Cancer
Metastatic Thyroid Cancer
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Multiple Endocrine Neoplasia (MEN)
Multiple Endocrine Neoplasia (MEN)
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RET Gene Mutation
RET Gene Mutation
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MEN 2A
MEN 2A
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MEN 2B
MEN 2B
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Thyroid Nodule Evaluation
Thyroid Nodule Evaluation
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Fine Needle Aspiration (FNA)
Fine Needle Aspiration (FNA)
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Thyroid Nodule Classification
Thyroid Nodule Classification
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Poor Prognostic Factors in Thyroid Cancer
Poor Prognostic Factors in Thyroid Cancer
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Indications for Thyroidectomy
Indications for Thyroidectomy
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Study Notes
Thyroid Surgery - Overview
- Course: Surgery
- Year: 2024-2025
- Class: Year 2
- Topic: Thyroid Surgery
Learning Objectives
- Recall the anatomy of the thyroid gland and surrounding structures, including its blood supply.
- Discuss the indications for lobectomy versus total thyroidectomy.
- Discuss the role of radioactive iodine in managing thyroid cancer.
- Describe surgical approaches, associated complications, and recent advancements.
Test Your Knowledge - Differentiated Thyroid Cancer
- Papillary carcinoma of the thyroid is a differentiated thyroid cancer.
Test Your Knowledge - Commonest Clinical Presentation
- The commonest clinical presentation of thyroid cancer is a solitary thyroid nodule.
Test Your Knowledge - Indications for Thyroid Surgery
- Cosmesis: True
- Thyroid cancer: True
- Toxic thyroid nodule: True
- Grave's disease (in certain settings): True
- Difficulty swallowing: True
Test Your Knowledge - Nerves at Risk
- Superior laryngeal nerve
- Recurrent laryngeal nerve
- Accessory nerve
- Vagus nerve
- Phrenic nerve
Anatomy of the Thyroid
- Diagrams illustrate the location of the thyroid gland, including the common carotid artery, thyroid cartilage, superior/inferior thyroid arteries and veins, and the trachea among other structures.
- The recurrent laryngeal nerve is in a groove between the trachea and esophagus, emerging medial to the inferior part of the gland.
- The external laryngeal nerve runs medial to the superior part of the gland to innervate the cricothyroid.
Thyroid Nodule - Differential Diagnosis
- Benign nodules are more common.
- The different types of benign and malignant nodules were listed in the slide (Multi-nodular Goitre, Follicular Adnoma, Thyroiditis, Graves, Colloid Goitre, Papillary, Follicular, Medullary, Anaplastic carcinomas, Lymphoma, Metastatic thyroid cancer)
Types of Thyroid Cancers
- Papillary thyroid carcinoma
- Follicular thyroid carcinoma
- Medullary thyroid carcinoma
- Anaplastic thyroid carcinoma
- Lymphoma
- Sarcoma
- Metastasis (breast, colon, kidney, melanoma)
Papillary Thyroid Cancer
- Peak onset: 30-50 years old
- Female:Male ratio: 3:1
- Risk factors: radiation exposure, family history
- Typically spreads through lymphatic systems
- Rare metastases: lung, bone (brain, kidneys, liver)
Thyroid Malignancy
- Frequent presentation: a solitary thyroid nodule
- Risk factors: age under 20 or over 60, firmness on palpation, rapid growth, fixation to adjacent structures, hoarseness/vocal cord paralysis, associated lymphadenopathy, history of neck radiation, family history of thyroid cancer, or a history of Hashimoto's thyroiditis (for lymphoma).
Follicular Thyroid Cancer
- Second most common thyroid cancer
- Peak onset: 40-60 years old
- Female:Male ratio: 3:1
- Risk Factors: radiation exposure, family history, iodine deficiency
- Typically spreads via hematogenous route (bloodstream) to bone, lungs, brain, liver, etc.
- Metastases can be hormonally active (hyperthyroidism).
Medullary Thyroid Cancer
- Neuroendocrine tumor of parafollicular C cells
- Normal thyroid function tests (TFTs)
- Calcitonin production is a feature.
- Can occur sporadically or with hereditary syndrome (e.g., MEN-2)
- Presents with single nodule or with lymph nodes in the neck
- Familial cases are part of MEN-2
- Patient evaluations are required pre-surgery for neuroendocrine tumors.
Anaplastic Thyroid Cancer
- Undifferentiated tumors of the thyroid follicular epithelium
- Highly aggressive, mortality nearing 100%.
- Signs of local invasion (hoarseness, difficulty swallowing), usually presented by older adults.
- Early palliative care is important.
- Surgery typically not indicated.
- Chemotherapy and radiation may be helpful for some cases.
Multiple Endocrine Neoplasia
- MEN 1: Autosomal dominant, RET gene mutation - involves parathyroid, pituitary, and pancreatic endocrine tumors (e.g., gastrinomas/insulinomas).
- MEN 2: Autosomal dominant, RET gene mutation
- MEN 2a: Medullary Thyroid, Phaeochromocytoma, hyperparathyroidism
- MEN 2b: Medullary Thyroid, Phaeochromocytoma, ganglioneuromas, marfanoid habitus.
Evaluation of Thyroid Nodules
- Clinical history, physical exam, blood tests (e.g. Thyroid function, T4, T3) are fundamental to diagnosis
- Radiology (e.g. ultrasound, CT, MRI and isotope scans)
- Pathology (Fine-needle aspiration - FNA)
Thyroid Lobectomy vs Total Thyroidectomy – Indications (Malignant Disease)
-
Total Thyroidectomy:
- High-risk differentiated thyroid cancers (≥ 4 cm tumors or extensive spread outside the thyroid gland).
- Clinically apparent distant metastases (spread to lymph nodes).
- Medullary thyroid cancer.
- History of head and neck radiation, or family history of thyroid cancer.
-
Thyroid Lobectomy:
- Low-risk differentiated thyroid cancers (1–4 cm, no widespread spread).
- Unifocal cancers (< 1 cm, no history of radiation).
Thyroid Lobectomy /Total Thyroidectomy – Indications (Benign Disease)
- Thyroid Lobectomy/Total Thyroidectomy:
- Goitre: - Compression of adjacent structures. - Cosmetic concerns.
- Toxic conditions (e.g., hyperthyroidism, Graves’disease, toxic multinodular goitre or toxic adenoma):
- unresponsive to medical treatment
Surgical Approach to Thyroidectomy
- Elective surgery, generally under general anesthesia.
- Patient positioned supine with neck extended.
- Transverse incision commonly used.
Thyroidectomy - Steps
- Identify and protect important structures (nerves).
- Adequate exposure of thyroid gland.
- Dissect and remove the thyroid gland.
- Control bleeding (haemostasis).
- Closure with absorbable sutures.
Post-operative Management
- Usual inpatient stay: 1–2 days.
- Routine monitoring and pain management (analgesia).
- Potential complications: identified in slide 31.
Thyroidectomy – Complications
- Early: Hematoma, nerve injuries (laryngeal), transient hypoparathyroidism, hypocalcemia, seroma formation, thyroid storm
- Intermediate: infection
- Late: Permanent hypoparathyroidism, Horner's syndrome, and recurrence
Strap Hematoma
- High vascular organ, often due to venous bleeding.
- Can lead to airway compromise (stridor).
- Immediate senior review and intervention required.
- Treatment: immediate opening of the clips and sutures in the skin and deeper layers of the neck.
Post-operative Hypocalcemia
- Immediate: IV calcium often needed in symptomatic patients.
- Monitor hypomagnesemia.
- Medium/long term: Oral calcium, active vitamin D (calcitriol) may be required
- If refractory to treatment, consider calcium replacement and thiazides to aid urinary calcium loss.
- Parental PTH only used if treatment for hypocalcaemia is not effective.
Recurrent Laryngeal Nerve Injury
- Symptoms include: asymptomatic, voice changes, hoarseness, bilateral breathing difficulty.
Radioactive Iodine (Iodine-131) in Thyroid Cancer
- First approved in 1971.
- Often used after surgery to destroy remaining thyroid tissue.
- Can be given orally or intravenously.
- A multidisciplinary decision on use, depending on recurrence/persistent risks.
- Not routinely used for patients with unifocal tumors of 1 cm or less. Not recommended for low-risk patients who have no other high-risk features.
Contraindications to Radioactive Iodine
- Pregnancy
- Breastfeeding
Summary Points for Thyroid Cancer and Surgery
- Differentiated vs. Undifferentiated thyroid cancers
- Common presentation and indications for thyroid cancer surgery
- Importance of considering different types of cancers (papillary, medullary, follicular, anaplastic), their common presentations, and possible treatments
- Potential complications associated with thyroidectomy and their management
- The role of radioactive iodine in thyroid cancer treatment
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Description
This quiz covers key aspects of thyroid cancer, including clinical findings suggestive of malignancy, genetic mutations, and treatment strategies. It addresses diagnosis, risk factors, and management of thyroid cancer.
