Thyroid Nodules and Cancer

Question 1

What is a thyroid nodule?

1 - malignant mass that forms in the thyroid
2 - hyperplasia of thyroid cells
3 - hypertrophy of thyroid cells

Answer 1

2 - hyperplasia of thyroid cells

• not normally cancerous but can become malignant

Question 2

What % of adults in the UK have thyroid nodules?

1 - 0.4 - 0.7%
2 - 4-7%
3 - 40-70%

Answer 2

2 - 4-7%

• highest incidence in men >60 y/o

Question 3

4-7 % of adults in the UK have thyroid nodules. What % of these become malignant?

1 - 0.5 - 1.0%
2 - 5-10%
3 - 15-30%
4 - >75%

Answer 3

2 - 5-10%

Question 4

Are women or men more likely to develop thyroid nodules?

Answer 4

• females

Question 5

Although thyroid nodules are normally benign, there are occasions that are concerning. Which of the following is NOT a concern for a thyroid nodules?

1 - >65 y/o
2 - single nodule getting bigger
3 - family history of thyroid cancer
4 - previous radiation to neck
5 - stridor
6 - cervical lymphadenopathy
7 - unexplained hoarseness
8 - weight loss

Answer 5

8 - weight loss

Question 6

If we are suspicious about a thyroid nodule, we need to do the CRP (triple assessment). Which one of this is not part of this?

1 - clinical examination/history
2 - class II thyroids exam
3 - radiology
4 - pathophysiology

Answer 6

2 - class II thyroids exam

Question 7

When we measure bloods in a patient with a thyroid nodule, which of the following is the least important?

1 - thyroid stimulating hormone
2 - thyroxine (T4)
3 - triiodothyronine (T3)
4 - reverse T3

Answer 7

4 - reverse T3

Question 8

In hyperthyroidism, what would we expect to see in TSH, T3 and T4?

Answer 8

• TSH is low or normal
• T3 and T4 are high

Question 9

In hypothyroidism, what would we expect to see in TSH, T3 and T4?

Answer 9

• TSH is high
• T3 and T4 are low

Question 10

If someone has a thyroid nodule, what is often the first line imaging that is used?

1 - ultrasound
2 - CT scan
3 - PET scan
4 - iodine 123 scan

Answer 10

1 - ultrasound

Question 11

If someone has a thyroid nodule and they have hyperthyroidism, what scan do they need?

1 - ultrasound
2 - CT scan
3 - PET scan
4 - iodine 123 scan

Answer 11

4 - iodine 123 scan

• iodine would be found in high levels in the nodule
• this is called a hot nodule

Question 12

If a patient has a nodule but is hypothyroidism, what can be done?

1 - surgery
2 - iodine therapy
3 - levothyroxine
4 - Carbimazole or Propylthiouracil

Answer 12

3 - levothyroxine

Question 13

If a patient has a nodule but is euthyroid, we need to identify if a nodule is dominant or is just diffusely swollen. If it is a dominant nodule we would do 3 of the following, which one is incorrect?

1 - fine needle aspiration biopsy
2 - ultrasound
3 - iodine 123 scan
4 - FDG-PET

Answer 13

3 - iodine 123 scan

Question 14

Which of the following is not a typical sign of hyperthyroidism?

1 - Nervousness
2 - Sweating
3 - Palpitations
4 - Fatigue
5 - Weight gain
6 - Diarrhoea
7 - Increased appetite
8 - Tachycardia
9 - Tremor

Answer 14

5 - Weight gain

• typically lose weight due to increased metabolism

Question 15

Which of the following is not a typical sign of hypothyroidism?

1 - Weakness and lethargy
2 - Dry skin
3 - Slow speech
4 - Sensitivity to cold
5 - Constipation
6 - Weight loss
7 - Loss of appetite
8 - Memory impairment

Answer 15

6 - Weight loss

• normally weight gain due to lowered metabolism

Question 16

If a patient has a nodule and is euthyroid they will require a fine needle aspiration biopsy guided by ultrasound. This can be analysed by cytology and scored out of 5 as in the image. What levels requires surgery based on the biopsy to confirm diagnosis?

1 - all
2 - >2
3 - >3
4 - 5 only

Answer 16

3 - >3

Question 17

What is the gold standard for diagnosing a patient who has a nodule and is euthyroid?

1 - core biopsy
2 - ultrasound
3 - fine needle aspiration biopsy
4 - iodine 123 scan

Answer 17

3 - fine needle aspiration biopsy

• needs to be ultrasound guided

Question 18

How many cases of thyroid cancer are there each year?

1 - 4
2 - 40
3 - 400
4 - 4000

Answer 18

4 - 4000

• approx 400 deaths
• deaths are mainly in older patients

Question 19

What is the peak incidence of thyroid cancer in women?

1 - 20-30
2 - 44-49
3 - 50-70
4 - 70-74

Answer 19

2 - 44-49

• women are more likely to develop thyorid cancer

Question 20

What is the peak incidence of thyroid cancer in men?

1 - 20-30
2 - 44-49
3 - 50-70
4 - 70-74

Answer 20

4 - 70-74

Question 21

In patients with thyroid cancer, survival depends on 3 key factors. Which of the following is NOT one of these factors?

1 - age
2 - diabetes
3 - pathological subtype
4 - metastatic disease

Answer 21

2 - diabetes

• thyroid cancer is the only cancer where age is included in the TNM staging

Question 22

There are 4 different types of thyroid cancer pathology. Which one of the following is NOT a subtype?

1 - papillary
2 - follicular
3 - medullary
4 - anaplastic
5 - carcinoma in-situ

Answer 22

5 - carcinoma in-situ

Question 23

There are 4 different types of thyroid cancer pathology. Which one of the following is most common?

1 - papillary
2 - follicular
3 - medullary
4 - anaplastic

Answer 23

1 - papillary

• accounts for 50-60% of all thyroid cancers
• excellent prognosis if no metastasis

Question 24

Papillary cancers are the most common cause of thyroid cancers. Which of the following is NOT true about these tumours?

1 - caused by RET and BRAF gene mutations
2 - linked with childhood ionising radiation
3 - contain high protein and DNA in their cells
4 - name comes from appearance like papillae (finger like projections)

Answer 24

3 - contain high protein and DNA in their cells

• they have LOW proteins and DNA and are called Orphan Annie Eye Nucleus

Question 25

Follicular thyroid cancers are the 2nd most common type of thyroid cancer. Which of the following is NOT true about these cancers? 1 - linked with mutations in RAS (oncogene) and PTEN (tumour suppressor gene) 2 - develops from follicular cells, breaking-out of fibrous capsule 3 - invade near by blood vessels and lymph nodes 4 - spread to the lungs, liver, bone, and brain 5 - cannot be distinguished from adenocarcinomas

Answer 25

3 - invade near by blood vessels and lymph nodes - do not typically spread to lymph nodes

Question 26

Medullary thyroid cancer grows from a specific cell type and account for approx 10% of all thyroid cancers. What do these tumours originate from? 1 - C cells 2 - B cells 3 - follicular cells 4 - follicular capsule

Answer 26

1 - C cells - C cells produce calcitonin that controls plasma Ca2+ - these tumours have a good prognosis

Question 27

Anaplastic tumours have odd cell appearance, which is where they get their name from. Which of the following is NOT true about these tumours? 1 - they are rare 2 - have a poor prognosis 3 - locally invade 4 - always cause hyperthyroidism

Answer 27

4 - always cause hyperthyroidism

Question 28

When we decide which patients need treatment there are a number of specific cases that do. Which of the following would NOT need surgery? 1 - Cancer 2 - Pressure symptoms (stridor, tracheal deviation) 4 - Grave’s disease 5 - Cosmesis 6 - Hashimoto's thyroiditis 7 - Diagnostic uncertainty

Answer 28

6 - Hashimoto's thyroiditis - this would be treated with levothyroxine

Question 29

The following are different types of surgery. If a patient has a solitary toxic nodule with diagnostic uncertainty, which surgery would generally be performed? 1 - hemi-thyroidectomy 2 - total thyroidectomy 3 - radioiodine 4 - Carbimazole or Propylthiouracil

Answer 29

1 - hemi-thyroidectomy

Question 30

The following are different types of surgery. If a patient has graves disease, proven cancer and/or multi nodular goitre, which surgery would generally be performed? 1 - hemi-thyroidectomy 2 - total thyroidectomy 3 - radioiodine 4 - Carbimazole or Propylthiouracil

Answer 30

2 - total thyroidectomy

Question 31

In thyroid surgery blood vessels can be damaged. Which 2 of the following could be damaged leading to oedema and obstruction of the upper airway? 1 - external carotid artery 2 - superior thyroid artery 3 - inferior thyroid artery 4 - right subclavian artery

Answer 31

2 - superior thyroid artery 3 - inferior thyroid artery

Question 32

In thyroid surgery nerves can be damaged. Which 2 of the following could be damaged leading to hoarse voice, stridor or even laryngeal obstruction? 1 - left recurrent laryngeal nerve 2 - vagus nerve 3 - superior laryngeal nerve 4 - right recurrent laryngeal

Answer 32

1 - left recurrent laryngeal nerve 4 - right recurrent laryngeal

Question 33

When removing the thyroid gland in surgery we must ensure we do not remove what? 1 - C cells 2 - parathyroid 3 - pituitary gland 4 - superior thyroid artery

Answer 33

2 - parathyroid - only need one to function