Thyroid Nodules and Cancers

enlargement, benign, adenomas, incidentally, painless

Thyroid Nodule

• Can be present without overall thyroid _____________

• Majority are ________, but 5-10% malignant

• Can result from ___________, cysts, or malignancy

• Frequently found ___________ on imaging from another issue

• Typically ___________, but painful if hemorrhage of thyroid cyst

TSH, suppressed, ultrasound, microcalcifications, margins, biopsy

Nodule Work Up

• ___ in all patients

  • _____________ TSH suggest Graves Disease or Toxic Nodule

• Check thyroid-focused ____________ in all patients with clinically or incidentally found nodules

• Concerning ultrasound results include ______________, hypoechoic and irregular __________, large anterior-posterior than transverse dimension → fine needle _________ (FNA)

  • TIRADS classification

composition, echogenicity, shape, margin, echogenic

TIRADS Classification

• ___________

  • Cystic, spongiform, mixed cystic and solid, solid

• ____________

  • anechoic, hyperechoic or isoechoic, hypoechoic, very hypoechoic

• ______

  • wider than tall, taller than wide

• ________

  • smooth, ill-defined, lobulated or irregular, extra-thyroidal extension

• ____________ foci

  • none or large comet-tail artifacts, macrocalficiations, peripheral calficiations, punctate echogenic foci

scintigraphy, low, high, compressive, contrast

Nodule Work Up

• Thyroid ___________ (radionuclide scan, radioactive iodine) in case of ___ TSH with one or more nodules

  • If ____ uptake (hot), the nodule is less likely to be malignant

• CT or MRI only needed if larger goiter and/or _____________ symptoms but avoid __________ to avoid overdose of iodine

biopsy, 6, Bethesda, molecular, indeterminate

When to do more for thyroid nodules

• Fine needle _________

  • An adequate sample consists of _ groups of well visualized cells

  • Uses ____________ reporting system for classification

  • Uses _____________ diagnostic testing in case of inadequate results

• Molecular testing helps avoid unnecessary surgery in _______________ nodules

no, 12-24, negative, indeterminate, surgery, FNA, malignancy, molecular, surgery

Thyroid Nodule Treatment Options

• Benign → __ treatment necessary, typically monitored to check for growth q__-__ months based on suspicion. If two __________ FNA, no further imaging needed

• If ___________ (stage AUS/FLUS) → __________ based on pt preference, risk factors, and appearance on ultrasound

  • May also repeat ___, try molecular testing, or monitor ultrasound for sizing

• Indeterminate (stage FN/SFN) → higher risk of ____________, tend to be surgical pts, but can try _____________ testing

• Malignant or SUSP → ___________

females, family, low, radiation, firm, painful, FNA

Thyroid Cancer

• Increased risk with _________ 3:1 ratio, middle-aged, _________ history, ___-iodine diet, head or neck ___________ exposure

  • 7th most common type of cancer in women

• Typically presents with _____, palpable nodule on thyroid. Typically not __________

• Dx with ___ with cytologic assessment

tender, iodine, papillary, slow, follicular, aggressive, lung

Thyroid Cancer

• Differentiated Thyroid Carcinomas

  • Non-________, no signs of hypo or hyperthyroidism

  • Tend to behave like normal thyroid cells → take up _________ and synthesize thyroglobulin

    • _____________ thyroid carcinoma

      • ____ growing, cervical node involvement, most common, can happen at any age, about 80% of all thyroid cancers

    • ___________ thyroid carcinoma

      • More ___________, metastasize to bone and _____, can go to cervical lymph nodes but not as often as PTC, about 14% of all thyroid cancers

    • Sometimes mix of papillary and follicular, but behave like papillary

poorly, metastatic, iodine, anaplastic, extrathyroid, older, core, thyroidectomy, palliative, medullary, parafollicular, RET, extrathyroid, FNA

Thyroid Cancer

• __________ Differentiated are more aggressive with higher _____________ rates → do not take up ________ or secrete thyroglobulin

  • ____________ → about 2% progressive, median survival is 6 months

    • ____________ and lymph node involvement common at diagnosis

    • ________ patient with rapidly enlarging mass

    • _____ biopsy preferred, not FNA

    • ____________ if good margins can be obtained

    • __________ chemo

  • ___________ carcinoma of Thyroid → 2-3%, about 1/3 sporadic cases, 1/3 familial, and 1/3 neuroendocrine and part of multiple endocrine neoplasia (MEN)

    • Arise from thyroid ______________ cells

    • 10 year survival is 75-85%

    • MEN screening is indicated

    • Now testing for ___ mutations to be able to use targeted RET inhibitors in treatment regimen

    • Common to have lymph node involvement, not ____________ → also adjacent muscle and trachea

    • ___ preferred

ultrasound, FNA, resection, surgery, lobectomy, extrathyroid, full, dissection, total, thyroglobulin, iodine, levothyroxine, cytomel

Thyroid Cancer Treatments

• Prior to treatment, perform repeat _____________ to further exam lymph node involvement

  • May need another ___ if suspicious lymph nodes, will need ___________ if positive

• ___________ is recommended treatment

  • < 1 cm, confined nodule, no lymphadenopathy

    • ____________

  • 1-4 cm nodule

    • lobectomy as long as no ____________ involvement

  • > 4 cm nodule and/or extrathyroid involvement

    • ____ thyroidectomy

  • Lymph node ____________ based on extent of involvement

  • Any size with hx of childhood radiation

    • _______ thyroidectomy

• Measure _____________ 4 weeks post op to see if thyroid is still functional, then q 6-12 months

• Radioactive __________ to follow surgery based on risk for reoccurrence → will need to stop ______________ 6 weeks prior to RAI. Can sub ____________ for 4 weeks, but then no meds 2 weeks prior to surgery

replacement, goals, high, intermediate, low, kinase, antiresorptive

Thyroid Cancer → Post-Surgery/RAI Treatment

• All post-thyroidectomy and RAI pts will likely need thyroid hormone _________________ but with different TSH _______ individualized by age and comorbidities

  • ______ risk pts = <0.1 mU/L

  • ___________ risk = 0.1 to 0.5

  • ____ risk pts = 0.5 to 2.0

• If RAI-refractory DTC, __________ inhibitors approved but with high side effects

• Bone-directed _____________ agents in patients with diffuse RAI-refractory bone metastases

• Lenvatinib and sorafenib for RAI-refractory disease; RET/NTRK inhibitors if mutation-positive

thyroglobulin, regrowing, ultrasound, papillary, follicular, differentiated

Thyroid Cancer Monitoring and Prognosis

• ____________ (Tg) 1 6-12 months → goal is to suppress to show that gland is not ____________ and increasing risk of reoccurence

• Neck ____________ 1 6-12 months

• Prognosis

  • __________ Thyroid cancer = 98% survival rate at 10 years

  • ___________ Thyroid cancer = 85-95%, variable based on age, size of tumor, extrathyroid

  • Poorly _______________ thyroid cancer = 47% survival rate at 10 years