Thyroid Surgery (Tieman) - MT

Question 1

If you find a 1.5 cm soft, movealbe L thyroid nodule in an asymptomatic patient, what lab/procedure would you use to evaluate them next?

Answer 1

Thyroid panel to measure T3, T4

Question 2

If a patient’s thyroid nodule is found to be hyperthyroid by a thyroid panel (elevated T3,T4), what would this indicate about the functionality of the nodule and what test should be done next?

Answer 2

• there may be a functional tumor
• Thyroid scan with iodine uptake

Question 3

If a patient is found to have a euthyroid with the thyroid nodule, what diagnostic test should be undertaken next?

What aspects of the nodule is examined by this test?(x5)

Answer 3

• Ultrasound of they thyroid
• Cystic or solid quality, Number of nodules, Size of nodules, Vascularity of nodules, invasion into adjacent structures.

Question 4

What general wideness and deepness of a thyroid nodule would indicate a malignancy?

Answer 4

• might be malignancy if nodule is deeper than it is wide

Question 5

If Ultrasound visualization showed a smooth walled solid nodule that is well defined, what is the next step in management?

Answer 5

FNA

Question 6

What condition do the cells in this thyroid FNA?

What are the histologic changes seen in these cells? (2x)

Where do these cells originate from?

Answer 6

• Thyroid medullary carcinoma
• bi lobed nuclei, stippling of hypochromatic cytoplasm
• Parafollicular C cells

Question 7

If Thyroidectomy and Lymph node biopsy on a patient with thyroid medullary carcinoma yields several LN containing cancer, what are some useful ways to monitor the patient? (x3)

Answer 7

1. Serum Calcitonin (assess effectiveness of surgery)
2. Thyroid hormone replacement
3. MEN2 syndrome surviellance

Question 8

What condition must you check for before undertaking a thyroidectomy in a patient with suspected MEN syndrome?

What test would you use to check for the condition?

Answer 8

• Pheochromocytoma
• Urine metaneprhine levels (vanyllic) (will be high in pt. with pheo)

Question 9

Why are Serum thyroglobulin and Radioactive iodine ablation not useful diagnostic study and management in thyroid medullary carcinomas thyroidectomy?

Answer 9

• Thyroglobulin not useful because from parafollicular cells
• Parafollicular cells will not take up Iodine (can’t use radioactive iodine to ablate tumor left over)

Question 10

What is one increased lab measurement that would signify high likely hood of metastatic medullary thyroid carcinoma?

Answer 10

Elevated serum Calcitonin

Question 11

Why would you perform RET proto oncogene study on a patient with thyroid medullary carcinoma’s children?

(type of mutation)

Answer 11

RET is a germline mutation and marker for thyroid medullary carcinoma

Question 12

What types of cells can be seen in this FNA and what kind of tumor do they characterize?

Answer 12

• Orphan annie optically clear cells
• papillary carcinoma

Question 13

What is the appropriate treatment for a papillary carcinoma?

Answer 13

• Total thyroidectomy f/u with Radioactive iodine ablative therapy

Question 14

How do papillary carcinomas of the thyroid spread?

Answer 14

• lymphatic spread

Question 15

prognosis for papillary carcinoma of the thyroid

Answer 15

good

Question 16

What tumor type does this histologic slide show?

what are the characteristics that indicate the tumor type?

Answer 16

• Papillary carcinoma
• Multiple mitotic cells, vaascular invasion, papillary extensions

Question 17

In the absence of growth or suspicious clinical or radiologic findings, thyrid nodules with a benign finding on FN can be managed by what?

Answer 17

observation

Question 18

Patients with thyroid nodule FNAs that are interpreted as suspicious for malignancy or malignant should be referred for what?

Answer 18

a total thyroidectomy

Question 19

If an FNA is non diagonistic on the biopsy what do you do?

If an FNA is benign on the first biopsy what do you do?

Answer 19

• repeat FNA with US guidance (non diagnostic)
• repeat US in 1-2 years (benign)

Question 20

Risks of a thyroidectomy procedure would include? (x2)

Answer 20

1. Risk of damaging recurrent laryngeal nerve in TE recess (if cut hoarse voice)
2. Bleeding

Question 21

If a thyroid lobectomy frozen section was reported as a low grade well differentiated follicularcarcinoma w/o thyroidal extention, what surgery should be undertaken in the patient?

Answer 21

• total thyroidectomy

* lobectomy would negate the effectiveness of radioactive iodine ablation post-op treatment