Podcast
Questions and Answers
Which type of thyroid cancer is characterized by its neuroendocrine origin and production of calcitonin?
Which type of thyroid cancer is characterized by its neuroendocrine origin and production of calcitonin?
Which type of thyroid cancer is most likely to spread through the lymphatic system?
Which type of thyroid cancer is most likely to spread through the lymphatic system?
A patient presents with a rapidly growing thyroid nodule, hoarseness, and is known to have a family history of thyroid cancer. Which of the following clinical indicators would also be suggestive of a higher risk of malignancy?
A patient presents with a rapidly growing thyroid nodule, hoarseness, and is known to have a family history of thyroid cancer. Which of the following clinical indicators would also be suggestive of a higher risk of malignancy?
A 55-year-old patient is diagnosed with a thyroid cancer that has metastasized to the bones, presenting as lytic lesions. Which type of thyroid cancer is most likely?
A 55-year-old patient is diagnosed with a thyroid cancer that has metastasized to the bones, presenting as lytic lesions. Which type of thyroid cancer is most likely?
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Which of the following is a risk factor that is specific to follicular thyroid carcinoma and not shared with papillary thyroid carcinoma?
Which of the following is a risk factor that is specific to follicular thyroid carcinoma and not shared with papillary thyroid carcinoma?
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A patient with medullary thyroid cancer is being evaluated for associated conditions. What genetic syndrome should be investigated?
A patient with medullary thyroid cancer is being evaluated for associated conditions. What genetic syndrome should be investigated?
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Which of the following is true regarding Anaplastic Thyroid Cancer?
Which of the following is true regarding Anaplastic Thyroid Cancer?
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What clinical feature is most suggestive of lymphoma in a patient presenting with a thyroid nodule?
What clinical feature is most suggestive of lymphoma in a patient presenting with a thyroid nodule?
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Which of the following is a differentiated thyroid cancer?
Which of the following is a differentiated thyroid cancer?
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What is the most common clinical presentation of thyroid cancer?
What is the most common clinical presentation of thyroid cancer?
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Which of the following is generally considered an indication for thyroid surgery?
Which of the following is generally considered an indication for thyroid surgery?
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Which nerve is most at risk of being injured during thyroid surgery due to its proximity to the gland?
Which nerve is most at risk of being injured during thyroid surgery due to its proximity to the gland?
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Where does the recurrent laryngeal nerve typically lie in relation to the thyroid gland?
Where does the recurrent laryngeal nerve typically lie in relation to the thyroid gland?
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A patient presents with hoarseness after a thyroidectomy. Which nerve was most likely injured during the procedure?
A patient presents with hoarseness after a thyroidectomy. Which nerve was most likely injured during the procedure?
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Which of these thyroid conditions is considered benign?
Which of these thyroid conditions is considered benign?
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Which of these is NOT typically considered a risk factor for thyroid cancer?
Which of these is NOT typically considered a risk factor for thyroid cancer?
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What does the RET gene mutation primarily lead to in MEN 2 syndromes?
What does the RET gene mutation primarily lead to in MEN 2 syndromes?
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Which factor is NOT considered a poor prognostic factor for papillary cancer?
Which factor is NOT considered a poor prognostic factor for papillary cancer?
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What is the primary action recommended when a thyroid nodule is suspicious of malignancy?
What is the primary action recommended when a thyroid nodule is suspicious of malignancy?
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In the evaluation of thyroid nodules, which pathology result indicates a non-diagnostic outcome?
In the evaluation of thyroid nodules, which pathology result indicates a non-diagnostic outcome?
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What clinical situation may warrant a thyroidectomy due to benign disease?
What clinical situation may warrant a thyroidectomy due to benign disease?
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Which of the following is an indication for thyroidectomy in cases of thyroid disease?
Which of the following is an indication for thyroidectomy in cases of thyroid disease?
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What characteristic of a thyroid nodule would classify it as U3 on ultrasound assessment?
What characteristic of a thyroid nodule would classify it as U3 on ultrasound assessment?
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Which of the following conditions is indicated for thyroidectomy when planning a pregnancy?
Which of the following conditions is indicated for thyroidectomy when planning a pregnancy?
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What is the primary function of the external laryngeal nerve in the context of thyroid surgery?
What is the primary function of the external laryngeal nerve in the context of thyroid surgery?
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If a patient presents with dysphagia (difficulty swallowing) alongside a confirmed diagnosis of a thyroid condition, what is the most likely cause?
If a patient presents with dysphagia (difficulty swallowing) alongside a confirmed diagnosis of a thyroid condition, what is the most likely cause?
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During a thyroidectomy, which anatomical relationship places the recurrent laryngeal nerve at greatest risk of injury?
During a thyroidectomy, which anatomical relationship places the recurrent laryngeal nerve at greatest risk of injury?
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A patient undergoing thyroid surgery experiences a postoperative hoarse voice, what is the most likely cause?
A patient undergoing thyroid surgery experiences a postoperative hoarse voice, what is the most likely cause?
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A thyroid nodule is determined to be malignant. Which of the following is NOT considered a common malignancy within the thyroid?
A thyroid nodule is determined to be malignant. Which of the following is NOT considered a common malignancy within the thyroid?
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In the management of thyroid cancer, what specific role does radioactive iodine primarily play?
In the management of thyroid cancer, what specific role does radioactive iodine primarily play?
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Which of these is a likely reason for a patient to undergo a thyroid lobectomy, as opposed to a total thyroidectomy?
Which of these is a likely reason for a patient to undergo a thyroid lobectomy, as opposed to a total thyroidectomy?
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During a thyroidectomy, which of the following conditions would necessitate a more meticulous dissection to avoid damage and postoperative complications?
During a thyroidectomy, which of the following conditions would necessitate a more meticulous dissection to avoid damage and postoperative complications?
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Which feature most strongly distinguishes anaplastic thyroid cancer from other thyroid malignancies?
Which feature most strongly distinguishes anaplastic thyroid cancer from other thyroid malignancies?
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A patient, age 45, diagnosed with follicular thyroid cancer, presents with hyperthyroidism symptoms. What is the most likely explanation?
A patient, age 45, diagnosed with follicular thyroid cancer, presents with hyperthyroidism symptoms. What is the most likely explanation?
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A patient is diagnosed with medullary thyroid cancer. Further evaluation should have a heightened focus on which potential comorbid condition?
A patient is diagnosed with medullary thyroid cancer. Further evaluation should have a heightened focus on which potential comorbid condition?
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A 62 year old male presents with a thyroid nodule. Which clinical feature, if present, would MOST strongly suggest that it could be a malignancy?
A 62 year old male presents with a thyroid nodule. Which clinical feature, if present, would MOST strongly suggest that it could be a malignancy?
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A 35-year-old female patient is diagnosed with papillary thyroid cancer. Which is the most typical route of metastasis?
A 35-year-old female patient is diagnosed with papillary thyroid cancer. Which is the most typical route of metastasis?
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A patient with a history of medullary thyroid cancer and a marfanoid habitus requires evaluation for other potential conditions. Which of the following is most likely to be associated with these findings?
A patient with a history of medullary thyroid cancer and a marfanoid habitus requires evaluation for other potential conditions. Which of the following is most likely to be associated with these findings?
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What distinguishes familial medullary thyroid cancer from its sporadic counterpart?
What distinguishes familial medullary thyroid cancer from its sporadic counterpart?
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A thyroid nodule characterized by a solid, hypoechoic structure with disrupted peripheral calcification and a lobulated outline on ultrasound would be classified as which of the following?
A thyroid nodule characterized by a solid, hypoechoic structure with disrupted peripheral calcification and a lobulated outline on ultrasound would be classified as which of the following?
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Which combination of risk factors would most significantly elevate suspicion for follicular thyroid cancer in a patient with a thyroid nodule?
Which combination of risk factors would most significantly elevate suspicion for follicular thyroid cancer in a patient with a thyroid nodule?
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A patient with a thyroid nodule is found to have cytological atypia of uncertain significance upon fine-needle aspiration. Based on the classification provided, what is the approximate risk of malignancy?
A patient with a thyroid nodule is found to have cytological atypia of uncertain significance upon fine-needle aspiration. Based on the classification provided, what is the approximate risk of malignancy?
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Which of the following statements regarding the management of anaplastic thyroid cancer is MOST accurate?
Which of the following statements regarding the management of anaplastic thyroid cancer is MOST accurate?
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Which of these thyroid pathologies would be most likely to be classified as a 'Thy 4' result from a FNA?
Which of these thyroid pathologies would be most likely to be classified as a 'Thy 4' result from a FNA?
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A 40-year-old patient is diagnosed with papillary thyroid cancer. Which of these factors would NOT be considered to be a poor prognostic indicator in this patient?
A 40-year-old patient is diagnosed with papillary thyroid cancer. Which of these factors would NOT be considered to be a poor prognostic indicator in this patient?
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A patient with a toxic multinodular goitre requires a thyroidectomy. Which of the follow conditions could also warrant a thyroidectomy, in addition to the aforementioned goitre?
A patient with a toxic multinodular goitre requires a thyroidectomy. Which of the follow conditions could also warrant a thyroidectomy, in addition to the aforementioned goitre?
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A patient tests positive for a RET gene mutation, suggesting a MEN 2 syndrome. Which of the following presentations would most strongly suggest MEN 2B rather than MEN 2A?
A patient tests positive for a RET gene mutation, suggesting a MEN 2 syndrome. Which of the following presentations would most strongly suggest MEN 2B rather than MEN 2A?
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A patient with hyperthyroidism secondary to Graves' disease is considering pregnancy. Which of the following scenarios would most strongly support the need for a thyroidectomy?
A patient with hyperthyroidism secondary to Graves' disease is considering pregnancy. Which of the following scenarios would most strongly support the need for a thyroidectomy?
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Study Notes
Thyroid Surgery Overview
- Course: Surgery
- Year: 2024-2025
- Class: Year 2
- Title: Thyroid Surgery
Learning Objectives
- Recall the anatomy of the thyroid gland and its surrounding structures, including the vascular supply.
- Discuss the indications for lobectomy versus total thyroidectomy.
- Discuss the role of radioactive iodine in the management of thyroid cancer.
- Describe the surgical approach, its complications, and recent advances.
Test Your Knowledge - Differentiated Thyroid Cancer
- Papillary carcinoma of the thyroid is a differentiated thyroid cancer.
Test Your Knowledge - Commonest Clinical Presentation
- A solitary thyroid nodule is the most common clinical presentation of thyroid cancer.
Test Your Knowledge - Indications for Thyroid Surgery
- Cosmesis: T/F (answer not provided)
- Thyroid cancer: T/F (answer not provided)
- Toxic thyroid nodule: T/F (answer not provided)
- Grave's disease (certain settings): T/F (answer not provided)
- Difficulty swallowing: T/F (answer not provided)
Test Your Knowledge - Nerves at Risk During Thyroid Surgery
- Superior laryngeal nerve
- Recurrent laryngeal nerve
- Accessory nerve
- Vagus nerve
- Phrenic nerve
Anatomy of the Thyroid
- Diagram showing the location of the thyroid gland, common carotid artery, internal jugular vein, superior thyroid artery, superior thyroid vein, inferior thyroid artery, inferior thyroid vein, etc.
Important Nearby Anatomical Structures
- The recurrent laryngeal nerve sits in a groove between the trachea and esophagus.
- It emerges medially to the inferior part of the thyroid gland.
- The external laryngeal nerve passes medially to the superior portion of the gland. This innervates the cricothyroid.
Thyroid Nodule - Differential Diagnosis
- Most thyroid nodules are benign.
- Benign conditions include multinodular goitre, follicular adenoma, thyroglossal cyst, Graves' disease, colloid goitre, and thyroiditis.
- Malignant conditions include papillary carcinoma, follicular carcinoma, medullary carcinoma, anaplastic carcinoma, lymphoma, and metastasis (rare).
Types of Thyroid Cancers
- Differentiated thyroid cancers include papillary and follicular thyroid carcinoma.
- Other types include medullary, anaplastic, lymphoma, and sarcoma.
- Metastasis (from another cancer) is also possible.
Papillary Thyroid Cancer
- Peak onset between 30-50 years old.
- Female:male ratio is 3:1.
- Risk factors include radiation exposure and family history.
- Typically spreads through lymph nodes.
- Lung, bone, brain, kidneys, and liver are infrequent/rare metastasis sites.
Thyroid Malignancy
- Often presents as a solitary thyroid nodule.
- Features associated with higher malignancy risk include age <20 or >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, history of Hashimoto's thyroiditis.
Follicular Thyroid Cancer
- Second most common type of thyroid cancer.
- Peak onset between 40-60 years old.
- Female:male ratio is 3:1.
- Risk factors: radiation exposure, family history, iodine deficiency.
- Usually spreads via the bloodstream (haematogenous route) to bone, lungs, brain, liver, bladder, and skin.
- Metastases can be hormonally active (hyperthyroidism).
Medullary Thyroid Cancer
- Neuroendocrine tumor of parafollicular cells (C cells).
- Thyroid function tests (TFTs) are usually normal.
- Calcitonin production is a feature and is used as a tumor marker.
- May arise sporadically or as part of an inherited syndrome (MEN-2).
- Often presents with a single nodule and cervical lymph node enlargement.
Anaplastic Thyroid Cancer
- Undifferentiated tumor of thyroid follicular epithelium.
- Aggressive disease; mortality is high.
- Usually presents with signs of local invasion (hoarseness, difficulty swallowing).
- Typically occurs in older patients.
- Early palliative care is important.
- Surgical intervention is usually not indicated.
Multiple Endocrine Neoplasia
- MEN 1: Autosomal dominant, RET gene mutation, affects parathyroid, pituitary, and pancreatic endocrine glands (gastrinomas/insulinomas)
- MEN 2: Autosomal dominant, RET gene mutation. Includes sub-types 2a and 2b. - 2a: medullary thyroid, phaeochromocytoma, hyperparathyroidism - 2b: medullary thyroid, phaeochromocytoma, ganglioneuromas, marfanoid habitus
Evaluation of Thyroid Nodule
- Diagnosis involves clinical history, physical examination, blood tests, radiology (ultrasound, isotope scan, CT/MRI), and pathology (fine-needle aspiration - FNA).
Clinical Examination, Radiology, and Pathology of Thyroid Nodules
- A detailed table describing different ultrasound (U1-U5) categories with their respective pathology findings (Thy 1 - Thy 5)
Poor Prognostic Factors for Thyroid Cancer
- Older age
- Large tumor size
- Soft tissue invasion
- Distant metastasis
Indications for Thyroidectomy - Benign Diseases
- Goitre (compression of adjacent structures or for cosmetic reasons)
- Toxic multinodular goitre
- Toxic adenoma
- Graves' disease (not responsive to medical treatment, or if pregnancy is planned).
Indications for Thyroidectomy - Malignant Diseases
- High-risk differentiated thyroid cancer (tumour ≥ 4cm or gross extrathyroidal extension).
- Clinically apparent metastatic lymph nodes or distant metastases.
- Medullary thyroid cancer.
- Thyroid cancer after prior head/neck radiation or family history of differentiated thyroid cancer in a first degree relative (due to high recurrence risk).
- Low-risk differentiated thyroid cancer, tumour between 1-4 cm without gross evidence of extrathyroidal extension or clinical lymph node metastases.
- Unifocal differentiated thyroid cancers <1cm with no history of head/neck radiation or family history
Surgical Approach
- Thyroid surgery is usually elective.
- Performed under general anesthesia.
- Supine patient positioning and neck extended.
- Transverse incision.
- Steps include identification/protection of vital structures, adequate exposure, dissection/removal of gland, haemostasis, and closure with absorbable sutures.
Post-Operative Management
- In-patient stay (typically 1-2 days).
- Routine observations and analgesia.
- Potential complications.
Thyroidectomy Complications
- Early: strap haematoma, laryngeal nerve injury, vocal cord paresis, transient hypoparathyroidism, hypocalcaemia, seroma formation, thyroid storm
- Intermediate: infection
- Late: permanent hypoparathyroidism, Horner's syndrome, recurrence (if surgery was for thyroid malignancy)
Strap Haematoma
- High vascularity of the thyroid strap muscles.
- Often due to venous bleeding.
- Potential for airway compromise (stridor).
- Treatment: immediate opening of incisions, senior review and intervention; don't leave patient unattended.
Post-Operative Hypocalcaemia
- Symptoms: perioral numbness, paraesthesia of the hands and feet.
- Signs: Chvostek sign, Trousseau sign.
- Immediate management: IV calcium, correction of hypomagnesemia, monitor plasma calcium for potential hypo or hypercalcemia.
- Long-term management options include oral calcium, vitamin D (calcitriol), and thiazides to reduce calcium loss.
Recurrent Laryngeal Nerve Injury
- Symptoms: asymptomatic on initial presentation, voice changes, hoarseness, bilateral breathing difficulty possible.
Radioiodine (I-131) for Thyroid Cancer
- First approved in 1971 as a therapeutic agent.
- Uses:
- Treats papillary and follicular thyroid cancer in postoperative patients with residual or recurrent disease/metastasis
- High-risk patients to lower recurrence risk.
- Treats hyperthyroidism
- Causes permanent destruction of thyroid tissue (or remaining tissue).
- It can be taken orally or intravenously.
Radioiodine Therapy Decision
- Multidisciplinary decision made based on recurrence/persistent disease risk.
Three Primary Goals of Radioiodine Therapy
- Ablation of tissue remnants after thyroidectomy in low-risk patients.
- Treatment to lower recurrence risk in selected postoperative patients
- Treatment of known disease including residual cancer, recurrent structural/biochemical disease, or metastatic disease
Contraindications and Complications of RAI therapy
- Contraindications: pregnancy and breastfeeding
- Complications: nausea, vomiting, acute gastritis/enteritis, acute sialadenitis, xerostomia, dysgeusia, bone marrow suppression (high doses)
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Description
Test your knowledge on various types of thyroid cancer, their characteristics, risk factors, and clinical presentations. This quiz covers topics such as medullary thyroid cancer, anaplastic thyroid cancer, and metastasis. Perfect for medical students and professionals seeking to enhance their understanding of endocrinology.
