20531600
Descrição
FlashCards por Kiranya Tipirneni, atualizado more than 1 year ago
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Criado por Kiranya Tipirneni
quase 5 anos atrás
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| Questão | Responda |
| Thyroid Cancer Risk Factors | - hx of H&N XRT - hx of total body XRT (ie for BMT) - familial thyroid ca (MEN, familial papillary) - older age (>55 yrs) - contralateral nodules *consider total thyroidectomy if +RFs |
| FNA Guidelines | 1. nodules > 2cm w/ v. low suspicion (<3% risk) 2. nodules > 1.5 cm if low suspicion (5-10%) 3. nodules > 1cm w/ suspicious (70-90%) or intermediate suspicion (10-20%) 4. PET-avid nodules >1 cm [30% risk malignant] (not diffuse uptake) |
| Suspicious US Findings (70-90% risk of malignancy) | 1. solid nodule 2. hypoechogenicity 3. microcalcifications 4. irregular borders (microlobulated, infiltrative) 5. taller than wide 6. rim calcifications 7. evidence of ETE *TI-RADS scoring |
| Suspicious US Findings for Lymph Nodes | 1. microcalcifications 2. cystic aspect 3. peripheral vascularity 4. hyperechogenicity 5. round (vs oval) shape 6. loss of fatty hilum FNA if suspicious LNs >8-10 mm in smallest dimension |
| Benign Pattern | 0% risk - completely cystic nodules w/ well-defined walls |
| Very Low Suspicion Pattern | <3% risk - spongiform nodules & nodules with interspersed cystic spaces |
| Low Suspicion Pattern | 5-10% risk 1. isoechoic or hyperechoic nodule 2. partially cystic nodule 3. solid component 4. none of the following features: - microcalcifications (see other points below) - irregular margins - extrathyroidal extension - taller than wide |
| Intermediate Suspicion Pattern | 10-20% risk 1. hypoechoic solid nodule with smooth margins 2. no malignant features |
| High Suspicion Pattern | >70-90% risk 1. solid hypoechoic nodule (or solid hypoechoic component of a partially cystic nodule), with at least one of these features: - microcalcifications (see other points below) - irregular margins (infiltrative, microlobulated) - extrathyroidal extension - taller than wide - rim calcifications with an extrusive soft tissue component lymphadenopathy |
| Bethesda Classification FNA (Estimated Risk of Malig) | |
| 2017 Bethesda Classification | |
| T Staging (Papillary, follicular, poorly ddx, Hurthle cell, anaplastic) | MACIS calculator (PTC, prognostic) |
| T Staging (Medullary) | |
| Differentiated Thyroid Cancer Staging (AJCC 8th Ed., < 55 yrs) | |
| Differentiated Thyroid Cancer Staging (AJCC 8th Ed., >/= 55 yrs) | |
| Anaplastic Carcinoma Staging | Stage IVa: confined to thyroid Stage IVb: gross extrathyroidal extension or regional mets Stage IVc: distant mets |
| Surgical Mgmt Well-Differentiated Thyroid Carcinoma | 1. T >4cm or w/ ETE (T4) or +nodal or metastatic disease...total thyroid +/- LN dissection 2. 1 cm< T <4 cm w/o ETE or nodal mets...total or lobectomy 3. if T <1 cm w/o ETE or nodal mets... lobectomy only (if no adverse RFs) 4. if multifocal (>5) microcarcinoma, consider total |
| Indications for RAI | 1. primary tumors > 4cm 2. distant mets 3. gross extrathyroidal extension 4. age > 45 yrs 5. elevated post op thyroglobulin levels >5-10 ng/ml 6. bulky or >5 LNs on path 6. high risk features: vascular invasion (follicular only), poorly ddx subtypes, multifocal dis - cytomel & thyrogen may reduce hypothyroidism/TSH withdrawal prior to RAI |
| Lymph Node Dissection ? | 1. consider elective level VI neck if T3 or T4 or if clinically involved involved lateral neck nodes (cN1b) [weak evidence] 2. no elective neck for T1/T2 unless +LNs 3. for lateral neck, ATA recommends level IIa-V, excl IIb |
| Workup for WDTC & Nodules | |
| Surgical Mgmt & RAI Flowchart | |
| Pre-op NPL for thyroidectomy? | ATA recommends NPL pts w/: 1. preop voice abnormalities 2. hx of cervical/chest sx 3. extensive posterior ETE or nodal disease |
| Other Mgmt Pearls | ATA Recommendations 1. recommend against routine preop TG levels 2. recommend post-op TG monitoring 3. calcitonin: for MTC (more specific in detecting residual or recurrent disease than CEA) |
| Genetic Testing for Thyroid Cancer | 1. Afirma gene expression classifier- NPV 93% 2. ThyroSeq - NPV 95% 3. ThyGenX/ThyrMIR ("rule in") - 66% PPV |
| Indications for Parathyroidectomy | 1. serum Ca > 1 mg/dL above ULN 2. CrCl decr by >30% 3. age <50 yrs 4. 24hr urinary Ca > 400 mg/dL 5. bone density >2.5 std devs by T-score 6. Pt requests sx |
| Mutations Assoc with Thyroid Carcinoma | |
| Mutations Assoc with Thyroid Carcinoma (contd) | papillary - RET (peds), BRAF (adults), RAS follicular - RAS, PPARG poorly ddx - RAS, BRAF, TP53 anaplastic - TP53, RAS, BRAF, PIK3CA medullary - RET |
| MACIS Score | Metastasis Age at diagnosis Completeness of surgical rx Invasion of extrathyroidal structures Size of tumor |
| Metastatic Thyroid Disease | - lymphatic mets: PTC >> FTC - distant mets: Hurthle cell > FTC (hematogenous) > PTC (lymphatic) - bone, liver, lung (MC), brain NB: children more commonly present w/ advanced disease & cervical & distant thyroid mets (esp to lungs) |
| Mets to Thyroid | kidney breast lung skin (melanoma, SCCa) |
| Mgmt of MTC | - if primary > 1 cm (> 0.5 cm for MEN2B), elective ipsilateral II-IV SND indicated - ATA recommends elective SND according to serum calcitonin levels > 20 pg/ml - ipsilateral SND > 200 pg/ml - bilateral SND |
| Mgmt of MTC cont'd | 1. preop serum CEA (more predictive of survival), calcitonin (more sensitive for persistent/recurrent disease) 2. genetic eval; RET muts screened for pheo & HPTH 3. CT thorax/mediastinum, US 4. total thyroidectomy + bilat central ND + level VII NB: do not respond to radioiodine tx or TSH; no CTX & EBRT is controversial OS: familial MTC > MEN-2A > sporadic |
| MEN 1 | 1. parathyroid hyperplasia (95% by age 50) 2. pituitary adenoma 3. pancreatic tumors |
| MEN 2A | 1. parathyroid adenomas (30%) 2. pheochromocytoma (70%) 3. MTC (100%) - ATA recommends total thyroidectomy prior to age 5 RET-associated |
| MEN 2B | 1. MTC - ATA recommends total thyroidectomy + central neck dissection within 1st year of life (more aggressive than MEN2A) 2. pheochromocytoma 3. mucosal neuromas +Marfanoid habitus |
| Parathyroid Hormone | - secr by parathyroid chief cells - half life: 3-5 mins - targets: (1) kidney, (2) skeletal system, (3) intestine (1) incr Ca resorption, decr Phos resorption, converts 25-OH D3 to 1,25-OH D3 (calcitriol) (2) indirectly stimulates OCs via OBs (3) incr Ca absorption via vit D |
| Superior Parathyroids | - 4th branchial pouch - cricothyroid junction, 1 cm cranial to intersection of RLN + inf thyroid art. - deep (dorsal) to RLN - unlike thyroid nodules, paras can move freely as they are encapsulated w/in pseudocapsule |
| Inferior Parathyroids | - 3rd branchial pouch w/ thymus - inf pole of thyroid & along thyrothymic ligament - superficial (ventral) to RLN - 28% found in thymus (thyrothymic ligament) or anterior superior mediastinal thymic gland - other locations: intrathyroidal (1-3%), carotid sheath, retroesophageal, submandibular region |
| Risk Factors for Aggressive WDTC | - demographics: age <20 or >55; M>F; FHx; hx of XRT - variant: tall cell variant, diffuse sclerosing, Hurthle cell, follicular carcinoma - size >4cm - ETE - LVI - mets |
| ATA Guidelines for MTC | after initial dx, obtain: 1. US neck 2. baseline CEA, calcitonin (if Ctn >500pg/ml, work up for mets with staging CT or MRI) 3. DNA testing for RET germline mutation (if +, evaluate for pheo & treat first) |
| ATA Guidelines for treatment MTC | total thyroidectomy with CND +/- SND II-IV (depending on US, serum CTn, intraop findings) in patients with clinically positive nodes of the ipsilateral neck, contralateral SND should be performed if CTn >200 pg/ml |
| ATA Guidelines for MTC in patients with MEN | MEN2a - total thyroid by age 5 years MEN2b - total thyroid by 12 months |
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