Surgery Marrow Pg 91-100 (Endocrine)

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Questions and Answers

What is the half-life of radioiodine used in ablation?

3-4 days

7-8 days (correct)

14-15 days

10-12 days

High levels of S. Thyroglobulin are always reliable for diagnosing recurrence of PTC.

False

What are the main treatment options for radioiodine resistant DTC?

Immunotherapy, External beam radiotherapy, Chemotherapy

___ is the second most common thyroid cancer.

Follicular thyroid carcinoma Signup and view all the answers

Match the following terms with their descriptions:

PTC = Papillary Thyroid Carcinoma Tg = Thyroglobulin RIA = Radioiodine Ablation FTC = Follicular Thyroid Carcinoma Signup and view all the answers

What is a common characteristic of Hurthle cell carcinoma compared to follicular thyroid carcinoma (FTC)?

More aggressive Signup and view all the answers

Females have a lower incidence of thyroid issues compared to males.

False Signup and view all the answers

What type of thyroid surgery is indicated when there is a need for diagnosis during surgery?

Hemithyroidectomy Signup and view all the answers

Hurthle cell carcinoma is characterized by the presence of ______ which is rich in mitochondria.

oxyphilic Hurthle cell Signup and view all the answers

Match the following conditions with their characteristics:

Follicular Carcinoma = Identical treatment to Papillary Thyroid Carcinoma Thyroid Adenoma = No surgical management indicated Hurthle Cell Carcinoma = Presence of oxyphilic cells Multinodular Goitre = Long-standing risk factor for thyroid issues Signup and view all the answers

What is the primary treatment for localized thyroid disease?

Total thyroidectomy + Central neck dissection + Modified radical neck dissection Signup and view all the answers

The incidence of thyroid lymphoma primarily occurs in individuals in their 5th to 7th decades of life.

True Signup and view all the answers

What is the first line treatment regimen for thyroid lymphoma?

R-CHOP Signup and view all the answers

The most common type of thyroid lymphoma is _____ .

Diffuse large B cell lymphoma (DLBCL) Signup and view all the answers

Match the following treatments with their descriptions:

Dabrafenib = Tyrosine kinase inhibitor used in advanced disease Rituximab = Monoclonal antibody against CD20 Cyclophosphamide = Chemotherapy agent in R-CHOP Total thyroidectomy = Surgical treatment for localized disease Signup and view all the answers

What is the primary use of the AGES system in thyroid cancer prognosis?

Assessing histologic grade and extrathyroidal invasion Signup and view all the answers

Anaplastic carcinoma of the thyroid is the most common type of thyroid cancer.

False Signup and view all the answers

What is the most common site for distant metastases in anaplastic thyroid carcinoma?

Lungs Signup and view all the answers

The MACIS system evaluates the __________ of original surgical resection.

completeness Signup and view all the answers

Match the clinical features with their corresponding descriptions:

Neck swelling = Rapid increase in size, hard in consistency Stridor = Difficulty breathing due to airway compression Hoarseness = Changes in voice due to recurrent laryngeal nerve involvement History of multinodular goiter = Previous thyroid enlargement condition Signup and view all the answers

Which of the following tumors is most commonly associated with MEN I Syndrome?

Pituitary adenomas Signup and view all the answers

MEN 2B Syndrome is characterized by more aggressive Medullary Thyroid Carcinoma compared to MEN 2A.

True Signup and view all the answers

What gene is involved in MEN I Syndrome?

menin gene Signup and view all the answers

In MEN 2A, parathyroid abnormalities are most often seen as _____ rather than hyperplasia.

adenoma Signup and view all the answers

Match the following features to the correct syndrome:

Megacolon/Hirschsprung disease = MEN 2A Exon 634 mutation = MEN 2A Marfanoid features = Both MEN 2A and 2B Exon 918 mutation = MEN 2B Signup and view all the answers

What is the most common type of thyroid cancer?

Papillary thyroid carcinoma Signup and view all the answers

DTC has a better prognosis for individuals over 55 years of age.

False Signup and view all the answers

Name one genetic mutation commonly associated with papillary thyroid carcinoma.

BRAF Signup and view all the answers

The ratio of female to male incidence of differentiated thyroid cancer is ______.

3:1 Signup and view all the answers

Match the risk factors for PTC with their descriptions:

Radiation exposure = Includes nuclear fallout and post radiotherapy. Family History = Increased risk due to hereditary factors. Obesity = Associated with a higher incidence of thyroid cancer. Signup and view all the answers

What is a prerequisite for performing a whole body iodine scan post-surgery?

TSH > 20 Signup and view all the answers

Total thyroidectomy requires different criteria than hemithyroidectomy.

False Signup and view all the answers

What surgery is indicated for patients with PTC involving Level 6 and other neck lymph nodes?

Total thyroidectomy + CND + modified radical neck dissection Signup and view all the answers

A minimum total thyroidectomy is indicated for patients with ________ spread.

No extrathyroidal Signup and view all the answers

Match the type of thyroid surgery with its description:

Hemithyroidectomy = Indicated for unilateral low-risk cases Total thyroidectomy = Complete removal of the thyroid gland Total thyroidectomy + CND = Includes removal of level 6 lymph nodes Total thyroidectomy + CND + modified radical neck dissection = Used when PTC involves multiple lymph nodes in the neck Signup and view all the answers

Which substance is primarily secreted by medullary thyroid carcinoma (MTC)?

Calcitonin Signup and view all the answers

Sporadic medullary thyroid carcinoma is usually more aggressive than familial medullary thyroid carcinoma.

False Signup and view all the answers

What is the most common site for hematogenous spread of medullary thyroid carcinoma?

Liver Signup and view all the answers

MTC arises from ___________ cells in the thyroid.

parafollicular/C Signup and view all the answers

Match the following symptoms with their causes:

Diarrhoea = Serotonin Cushing syndrome = ACTH Flushing = Histamine Hypocalcemia = Calcitonin Signup and view all the answers

Which of the following microscopic features is associated with Papillary Thyroid Carcinoma (PTC)?

Coffee bean nuclei Signup and view all the answers

Psammoma bodies are only observed in Papillary Thyroid Carcinoma.

False Signup and view all the answers

What is the primary diagnostic procedure used for thyroid nodules?

FNAC Signup and view all the answers

The most common site for haematogenous metastases in thyroid carcinoma is the __________.

lungs Signup and view all the answers

Match the following tumors with their associated features:

Papillary Thyroid Carcinoma = Orphan Annie eyed nuclei Serous Cystadenoma = Dystrophic calcifications (psammoma bodies) Meningioma = Common brain tumor with distinct cellular architecture Papillary RCC = Renal cell carcinoma histology Signup and view all the answers

Which type of surgical procedure involves the complete removal of the thyroid gland along with neck dissection?

Total thyroidectomy + CND Signup and view all the answers

Medullary thyroid cancer (MTC) can absorb iodine during whole body scanning.

False Signup and view all the answers

What is monitored through calcitonin levels during follow-up for thyroid cancer?

MTC (Medullary Thyroid Cancer) Signup and view all the answers

The most common type of thyroid cancer is _____ .

Papillary Signup and view all the answers

Match the following types of thyroid cancer with their associated characteristics:

Papillary = Most common Follicular = Hematogenous metastasis Medullary = Associated with MEN2 Syndrome Anaplastic = Worst prognosis Signup and view all the answers

Which of the following is a risk factor for follicular thyroid cancer?

Iodine deficiency Signup and view all the answers

Radiotherapy is not considered in the management of advanced thyroid cancer.

False Signup and view all the answers

What type of hereditary syndrome is associated with Medullary thyroid cancer (MTC)?

MEN2 Syndrome Signup and view all the answers

Study Notes

Active Space

Whole body scan to check for residual disease or metastasis

Radioiodine Ablation (RIA)

Uses β rays
Half-life is 7-8 days
Indicated for residual disease, metastases, positive lymph nodes, and persistently high thyroglobulin following surgery

TSH Suppression

Suppresses TSH levels to the lower limit of normal with thyroxine
Reduces the recurrence of papillary thyroid carcinoma
Requires lifelong follow-up
Involves regular neck ultrasound scans and monitoring thyroglobulin levels
If thyroglobulin levels are elevated, suspect papillary thyroid carcinoma recurrence and perform a whole body iodine scan

Radioiodine Resistant DTC

May necessitate different treatment approaches
Immunotherapy with sorafenib or lenvatinib
External beam radiotherapy
Chemotherapy with doxorubicin

Follicular Thyroid Carcinoma (FTC)

2nd most common thyroid cancer
Most common thyroid cancer in iodine-deficient areas
Genetic factors include upregulation of miRNA-197 and 346, and mutations in PTEN and BAX genes

Hurthle Cell Carcinoma

Separate entity from FTC
Occurs predominantly in the 6th and 7th decade of life
Distinguished by the presence of oxyphilic Hürthle cells rich in mitochondria
More aggressive than FTC
Less radioactive avid than other differentiated thyroid cancers
Treatment is similar to papillary thyroid carcinoma
Prognosis is poorer than FTC

Thyroid Lymphoma

Rare
Occurs most often in the 5th and 7th decade
Risk factor is long-standing Hashimoto's or lymphocytic thyroiditis
Clinical presentation: thyroid swelling, weight loss, fever, night sweats, itching
Diagnosis involves core or Trucut biopsy as FNAC is insufficient
Treatment is primarily chemotherapy
First-line chemotherapy regimen is R-CHOP
Surgery is only indicated for residual or recurrent disease
Most common type is diffuse large B-cell lymphoma (DLBCL)

Prognostic Indicators for Well-Differentiated Thyroid Cancers

AGES System
- Considers age, histologic grade, extrathyroidal invasion, size, and tumor size
MACIS System
- Factors in age, metastasis, completeness of original surgical resection, extrathyroidal invasion, and size

Anaplastic Thyroid Carcinoma

Least common type
Worst prognosis
Occurs most frequently in the 5th and 7th decade of life
Genetic features: upregulation of miRNA 17-9a and mutations in p53 and β-catenin genes
Clinical presentation: rapidly expanding hard neck swelling, history of multinodular goiter, pressure symptoms, stridor, dyspnea, hoarseness
Differential diagnosis includes Riedel thyroiditis
Commonly metastasizes to the lungs
Investigations include FNAC and ultrasound-guided core biopsy

MEN (Multiple Endocrine Neoplasia) Syndromes

Inherited disorders characterized by the development of tumors in multiple endocrine glands
MEN 1 Syndrome
- Related to mutations in the menin gene on chromosome 11
- Features include pituitary adenomas (prolactinoma is most frequent), parathyroid abnormalities, pancreatic endocrine tumors, collagenomas, adrenocortical tumors, and thymic tumors
MEN 2 Syndrome
- Caused by mutations in the RET proto-oncogene on chromosome 10
- Types: MTC only, MEN 2A, and MEN 2B
- MEN 2A
  - Most commonly associated with MTC
  - Parathyroid abnormalities with adenoma or hyperplasia
  - Can also present with megacolon or Hirschsprung disease
  - Mutation is found in exon 634 of the RET proto-oncogene
- MEN 2B
  - Distinguished by more aggressive MTC
  - Manifests with medullated corneal fibers, mucosal neuromas, and megacolon
  - Mutation occurs in exon 918 of the RET proto-oncogene

Differentiated Thyroid Cancer (DTC)

Includes papillary, follicular, and Hurthle cell carcinomas
Arise from thyroid epithelial cells
Accumulate iodine
Poor prognosis in those diagnosed over 55 years old
Stages are similar to those of anaplastic cancer
Diagnosis is made through histopathology

Papillary Thyroid Carcinoma (PTC)

Most prevalent type of thyroid cancer
Best prognosis among thyroid cancers

Risk Factors for PTC

Radiation exposure: nuclear fallout, head and neck radiotherapy, radioiodine ablation therapy at a young age
Family History
Obesity
Genetic predispositions
- BRAF mutations (most frequent)
- GDNF mutations (glial-derived neurotrophic factor)
- RET/PTC mutations

Incidence of PTC

Female to male ratio is 3:1
Most commonly diagnosed in the 3rd and 5th decades of life

Clinical Presentation of PTC

Thyroid swelling (most common)
Often bilateral and multicentric
Management: total thyroidectomy

Surgical Management of Papillary Thyroid Carcinoma

Decisions about the extent of surgery depend on factors like tumor size, location, and spread
Hemithyroidectomy: Removal of one lobe of the thyroid gland
- Considerations: low-risk tumors, unilateral tumors, tumors less than 4 cm, no extrathyroidal spread, radiation-induced DTC, familial non-medullary thyroid cancer, multifocal bilateral DTC, extrathyroidal extension, T3 or T4 tumors, and positive level 6 lymph nodes
Minimum Total Thyroidectomy:
- Indicated for the same criteria as hemithyroidectomy
Total Thyroidectomy + Central Neck Dissection (CND): Removal of the entire thyroid gland and dissection of lymph nodes at level 6
- Considerations: same criteria as hemithyroidectomy
Total Thyroidectomy + CND + Modified Radical Neck Dissection (MRND): Includes the removal of the whole thyroid and a more extensive neck dissection
- Considerations: PTC involving level 6 and other neck lymph nodes

Strategies for Whole Body Iodine Scan

Postoperative procedures to detect residual disease or metastasis
Prerequisite: TSH greater than 20 for enhanced iodine uptake
Traditional method: waiting 4-6 weeks after surgery and withholding thyroxine supplementation (patient experiences hypothyroidism during this period)
Recombinant TSH injections: alternative approach to raising TSH levels

Medullary Thyroid Carcinoma (MTC)

Originates from parafollicular or C cells
Secretes:
- Calcitonin
- CEA (carcinoembryonic antigen): indicates dedifferentiation
- Chromogranin A

###Types of MTC

Sporadic
- Most common
- Typically diagnosed in the 4th to 6th decade of life
- Less aggressive
Familial
- Less frequent
- Diagnosed in the 2nd to 4th decade of life
- Often associated with MEN 2A and MEN 2B, which are characterized by more aggressive and multifocal disease

Clinical Features of MTC

Thyroid swelling (most common)
Atypical symptoms

Investigations for MTC

Fine needle aspiration cytology

Symptoms Associated with MTC

Diarrhea: due to excessive serotonin secretion
Cushing syndrome: caused by ACTH secretion
Flushing: associated with histamine release

Spread of MTC

Lymphatic: involves level 6 lymph nodes
Hematogenous: most frequently metastasizes to the liver

Lateral Aberrant Thyroid

Enlargement of level 6 lymph nodes due to papillary thyroid carcinoma, even if the thyroid is not palpable

Thyroid Incidentaloma

Incidentally diagnosed
Size is less than 1cm

Investigations for Lateral Aberrant Thyroid and Thyroid Incidentaloma

Fine needle aspiration cytology

Haematogenous Spread of Papillary Thyroid Carcinoma

Lungs (most common)

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Description

This quiz covers essential treatments and management strategies for thyroid cancers, specifically focusing on Radioiodine Ablation, TSH suppression, and the approaches for different types of differentiated thyroid carcinoma. Learn about the indications, methods, and follow-up requirements crucial for managing thyroid cancer effectively.