Thyroid Nodules/Surgery

Question 1

what % of nodules are malignant?

Answer 1

15% - though they are present in about 5% of adults

• Incidence of thyroid cancer increasing, but mortality rate remains stable

Question 2

hx of more malignant nodules?

Answer 2

• • increased malignancy in**
• men
• ages60
• hx of radiation
• family hx of thyroid cancer (FAP, MEN, multiple hamartoma syndrome)
• voice sx, visual sx, fatigue, anxiety (sx of hypo/hyperthyroidism)

Question 3

when is FNA indicated?

Answer 3

nodules >1cm that are suspicious on US (hypoechoic, irregular, intranodular vascularity, calcifications, nodal mets )

FNA results:

• benign: (has 5% false negative rate) need to do 6-12 mos follow up
• malignant: requires surgery
• indeterminant (follicular lesion): usually contains follicular cells/hurthle cells - malignancy determined by invasion of capsule into surrounding blood vessels

Question 4

solitary nodule algorithm for elevated Thyroid function tests?

Answer 4

1. thyroid function tests
   - if elevated do RAI scan
2. RAI scan:
   - if hot, use RAI Rx or surgery
   - if diffuse uptake or negative: follow patient

Question 5

solitary nodule algorithm w/ normal thyroid function tests?

Answer 5

1. do thyroid fn testing
   - if normal, do ultrasound
2. Ultrasound shows cystic:
   - do aspirate cytology
   - if positive –> surgery
   - if negative- follow and repeat US in 6 mos.
3. US shows solid/heterogenous
   - do FNA
   - if malignant then do surgery
   - if intermediate then repeat FNA or follow closely for 3 mos.
   - if follicular cells, do surgery or follow closely
   - if benign then follow closely

Question 6

what do you see with papillary carcinoma FNA?

Answer 6

Little Orphan Annie cells, intra-nuclear grooving, papillary projections, psammoma bodies

Question 7

tx for papillary carcinoma?

Answer 7

total thyroidectomy +/- lymph node dissection

Question 8

high risk papillary carcinoma

Answer 8

• age >40
• male
• capsular invasion, extrathyroidal extension to lymph nodes
• regional/distant mets
• size > 4cm (<2 cm is low-risk)
• poorly differntiated

long term survival is 50-99%

Question 9

Hurthle cells

Answer 9

follicular carcinoma

Question 10

FNA of follicular nodules?

Answer 10

if malignant, then do total thyroidectomy, no lymph node dissection needed

Question 11

what is seen on FNA of medullary carcinoma?

Answer 11

see large bi-lobed nuclei w/ intense staining - indicating parafollicular C- cells

“C cells” secrete calcitonin
75% are sporadic
25% are familial (MEN2A, 2B or familial)
- always screen for PTH and adrenal disease as well
- follow up using serum calcitonin levels
tx: total thyroidectomy, +/- lymph node dissection

Question 12

FNA of anaplastic carcinomas?

Answer 12

~ 1% of thyroid cancers

Very aggressive and often presents as a rapidly enlarging, painful mass with obstructive symptoms

Can be diagnosed with FNA

Palliative care only, doesn’t respond well to surgery, radiation therapy, or chemotherapy

Question 13

follow up of thyroid cancers?

Answer 13

Most well-differentiated epithelial thyroid cancer treated with post-op radioactive iodine to ablate subclinical disease or mets

• Thyroid replacement
• Monitor physical exam and thyroglobulin levels to look for recurrent disease
• Medullary cancers followed with calcitonin and family evaluation

Question 14

when is surgery performed for HyperTH

Answer 14

“Hot” nodule
Toxic nodular goiter
Grave’s Disease, especially in pregnant patient
Multinodular goiter

Question 15

when is surgery not performed for HyperTH

Answer 15

thyroiditis - b/c its usually self limiting

Question 16

when is surgery used for goiter?

Answer 16

when it produces obstructive/pressure sx

if its rapidly growing, might do an FNA

Question 17

complications of thyroid surgery?

Answer 17

• Recurrent laryngeal nerve injury
• Superior laryngeal nerve injury
• Hypoparathyroidism
• Hypothyroidism
• Extensive blood loss
• infections are rare

Question 18

Look back over the cases

Answer 18

do it now.

Question 19

what tx is done with papillary carcinoma w/ projections?

Answer 19

total thyroidectomy b/c they are multifocal!!!