Thyroid nodules (E&M)

Question 1

Define thyroid nodules.

Answer 1

Abnormal growths within the thyroid glands - they are usually non-functioning

Question 2

Which groups do thyroid nodules happen more commonly in? (2)

Answer 2

• F>M
• incidence increases with age

Question 3

What are some benign causes of thyroid nodules? (4)

Answer 3

• multinodular goitre
• Hashimoto’s thyroiditis
• thyroid adenoma
• thyroid cyst

Question 4

What are types of thyroid cysts (benign thyroid nodules)? (3)

Answer 4

• colloid - overgrowths of normal thyroid tissue (most common type of thyroid nodules)
• simple - growths that are filled with fluid/partly solid and partly filled - pose low risk for cancer = monitored/biopsies if >2cm
• haemorrhagic

Question 5

What are some malignant causes of thyroid nodules? (3+3)

Answer 5

• thyroid carcinoma:
  
  • papillary carcinoma
  • follicular carcinoma
  • medullary carcinoma
• anaplastic carcinoma
• lymphoma

Question 6

What are the three types of thyroid carcinoma (malignant thyroid nodules)?

Answer 6

• papillary carcinoma - most common, 30-40y
• follicular carcinoma - second most common, 30-60y
• medullary carcinoma

Question 7

Where can papillary carcinoma metastasise to?

Answer 7

Cervical lymph nodes

Question 8

What can you use as a tumour marker for papillary carcinoma?

Answer 8

Thyroglobulin

Question 9

What do you see on light microscopy in papillary carcinoma?

Answer 9

Orphan Annie eyes

Question 10

What is the prognosis of papillary carcinoma like?

Answer 10

Very good

Question 11

When is follicular carcinoma more common?

Answer 11

In areas of low iodine and in women (30-60y)

Question 12

Where does follicular carcinoma metastasise to?

Answer 12

Lung and bones

Question 13

What can you use as a tumour marker for follicular carcinoma?

Answer 13

Thyroglobulin

Question 14

What is medullary carcinoma?

Answer 14

Cancer of parafollicular cells, secretes calcitonin

Question 15

What hereditary condition is medullary carcinoma a part of?

Answer 15

MEN-2 (Multiple Endocrine Neoplasia Type 2):

• medullary carcinoma
• parathyroid hyperplasia
• phaeochromocytoma

Question 16

What are the risk factors for thyroid cancer? (4)

Answer 16

• radiation
• family Hx
• rapid enlargement/compression
• lymphadenopathy

Question 17

What are some different types of neck lumps? (7)

Answer 17

• reactive lymphadenopathy - tender LNs, Hx of local infection/viral illness
• lymphoma - rubbery and painless lymphadenopathy, B symptoms (fever, WL, night sweats), splenomegaly
  
  • thyroid lymphoma linked with Hashimoto’s thyroiditis
• thyroid swelling - hypo/hyper/euthyroid Sx, moves upwards on swallowing
• thyroglossal cyst - mass that develops from tissues that remains after formation of thyroid gland
• pharyngeal pouch - part of pharyngeal lining herniates through pharyngeal wall
• branchial cyst - embryonic remnant
• carotid aneurysm

Question 18

What are the clinical features of lymphoma (thyroid nodules)? (3)

Answer 18

• rubbery and painless lymphadenopathy
• B symptoms - fever, WL, night sweats
• splenomegaly

Question 19

What are the clinical features of thyroid swelling (thyroid nodules)? (2)

Answer 19

• hyper/hypo/euthyroid symptoms
• lump moves upwards on eating

Question 20

What are the clinical features of a thyroglossal cyst (thyroid nodules)? (4)

Answer 20

• age <20y
• midline
• moves upwards on protrusion of tongue
• painful if infected

Question 21

What are the clinical features of a pharyngeal pouch? (7)

Answer 21

• older men
• not seen usually but if large, then midline mass
• gurgles on palpation
• dysphagia
• regurgitation
• aspiration
• chronic cough

Question 22

What are the clinical features of a branchial cyst (thyroid nodules)? (4)

Answer 22

• oval, mobile, cystic mass
• between SCM and pharynx
• presents in early adulthood
• contains cholesterol crystals

Question 23

What are the clinical features of carotid aneurysm (thyroid nodules)? (3)

Answer 23

• pulsatile
• lateral neck mass
• does not move on swallowing

Question 24

How do most thyroid nodules present?

Answer 24

Asymptomatic

Question 25

Which type of thyroid nodule is most likely to be malignant?

Answer 25

Single isolated nodule

Question 26

What is a red flag for thyroid cancer?

Answer 26

Radiation to head or neck

Question 27

What is the first-line imaging for thyroid nodules?

Answer 27

Ultrasonography to check for features of malignancy

Question 28

What other investigation would we do if we suspect malignancy (thyroid nodules)?

Answer 28

Fine needle aspiration biopsy (alongside ultrasound)

Question 29

What bloods do we do for thyroid nodules?

Answer 29

TFTs

Question 30

What scan can we do for thyroid nodules?

Answer 30

Radioiodine uptake scan

Question 31

What different results could there be of a radioiodine uptake scan? (5)

Answer 31

- Graves disease - diffuse uptake throughout enlarged gland - toxic adenoma - single hot nodule - toxic multinodular goitre - multinodular gland with single hot nodule, patchy uptake - thyroid cancer - diffuse uptake with single cold nodule - de Quervain's (viral) thyroiditis - no uptake

Question 32

How would Grave's disease present on radioiodine uptake scan?

Answer 32

Diffuse uptake throughout enlarged gland

Question 33

How would toxic adenoma present on radioiodine uptake scan?

Answer 33

Single hot nodule

Question 34

How would toxic multinodular goitre present on radioiodine uptake scan?

Answer 34

Multinodular gland with single hot nodule + patchy uptake

Question 35

How would thyroid cancer present on radioiodine uptake scan?

Answer 35

Diffuse uptake with single cold nodule

Question 36

How would de Quervain's (viral) thyroiditis present on radioiodine uptake scan?

Answer 36

No uptake

Question 37

Describe the diagnostic flowchart for thyroid nodules.

Answer 37

- history and examination - TSH + ultrasound of neck - TSH subnormal --> thyroid scintigraphy - functioning (hot) nodule = evaluation for hyperthyroidism (T3/4) - non-functioning (cold) nodule OR if TSH normal/elevated --> criteria for FNA met? (suspicious nodule >1cm, large nodule >1.5-2cm, RFs for malignancy) --> if Y = FNA + cytology, if N = monitor with ultrasound

Question 38

What is the main form of management for thyroid nodules?

Answer 38

Thyroid surgery

Question 39

How do we manage papillary and follicular carcinoma (thyroid nodules)?

Answer 39

Total thyroidectomy followed by radioiodine to kill residual cells After - give thyroxine and do yearly thyroglobulin levels check to detect early recurrent disease

Question 40

How do we treat hyperthyroidism? (2)

Answer 40

- beta blockers - anti-thyroid drugs (carbimazole)