Thyroid Tumours

Question 1

The incidence of papillary and follicular tumours are falling?

Answer 1

False

Incidence is increasing as the mortality falls

Question 2

What in papillary and follicular tumours is there a strong association with?

Answer 2

Radiation exposure

Question 3

Are follicular and papillary tumours TSH Independent?

Answer 3

False they are TSH dependant

Most take up iodine and secrete thyroglobulin

Question 4

What ways are follicular and papillary tumours found?

Answer 4

Palpable lump
Small chance findings from thyroidectomy
5% present the pathological Metastatic disease

Question 5

What are follicular tumours strongly linked to?

Answer 5

Iodine deficiency

Question 6

How do papillary tumours prefer to spread?

Answer 6

Lymph

Question 7

How do follicular tumours prefer to spread?

Answer 7

Haematogenous

Question 8

What is the main investigation for thyroid tumours?

Answer 8

Ultrasound with fine needle aspiration

+/- excision biopsy of lymph nodes

Question 9

What isn’t used in the investigation of thyroid tumours?

Answer 9

No CT, MRI or thyroid scan

Question 10

What are some clinical predictors of malignancy?

Answer 10

Thyroid nodule is <20 or over >50
Head and neck irradiation
Rapidly growing

Question 11

What is the mainstay of treatment in thyroid tumours?

Answer 11

Thyroidectomy and RAI

Question 12

What is RAI

Answer 12

Radioactive Iodine therapy

Question 13

What is the scale used for determining severity of disease?

Answer 13

AMES

Question 14

What factors determine the AMES score?

Answer 14

Age
Metastasis
Extent of primary tumour
Size of primary tumour

Question 15

What would be a stereotypical low AMES score?

Answer 15

Young with no metastatic disease

Old with a minimally invasive primary

Question 16

What would be a stereotypical high AMES score?

Answer 16

Distant metastasis
Extra-thyroid disease
Capsular invasion (follicular)

Question 17

What is the surgery usually used in a low AMES risk?

Answer 17

Thyroid lobectomy with isthmus

Question 18

What would indicate a lobectomy?

Answer 18

Papillary Microcarcinoma <1cm

Minimally invasive follicular

Question 19

What is the surgery usually used in a high risk AMES score?

Answer 19

Sub or total thyroidectomy

Question 20

What would indicate a sub or total thyroidectomy?

Answer 20

Differentiated thyroid cancer + extra thyroidal spread
- distant mets or nodal involvement
Bilateral or multifocal tumours

Question 21

In papillary cancer what is the nodal clearance?

Answer 21

Central compartment clearance

Lateral node sampling

Question 22

In follicular cancer what is the nodal clearance?

Answer 22

Central compartment clearance

Question 23

What is done acutely in post operative care?

Answer 23

Calcium is checked 24 hours post surgery

Question 24

At what level is the calcium meant to be above?

Answer 24

2 mmol/l

Question 25

What level of calcium requires urgent treatment?

Answer 25

1.8 mmol/l | IV calcium

Question 26

What is done 3-6 months post operatively ?

Answer 26

Whole body iodine scan

Question 27

In what circumstances is a whole body iodine scan completed?

Answer 27

High AMES risk | Sub or total thyroidectomy

Question 28

What is key in a whole body iodine scan?

Answer 28

Must have high TSH level to drive iodine uptake

Question 29

How are high TSH levels ensured in whole body iodine scan?

Answer 29

T3/4 injection are stopped weeks before | rhTSH is injected

Question 30

If the scan as taking place in a week what is the timeline?

Answer 30

rhTSh administered on the Monday and Tuesday | Iodine capsule is given on the Wednesday

Question 31

What iodine isotope is used?

Answer 31

I-131

Question 32

Why do the tumours take up the iodine?

Answer 32

Synthetically induced high TSH levels and the fact the tumours are TSH dependant

Question 33

What does the scan show?

Answer 33

Any thyroid remnants | Any tumour which takes up the iodine

Question 34

In Thyroid remnant ablation therapy how many capsules are given?

Answer 34

2 or 3 | 200x more radiation than diagnostic

Question 35

How are patients prepared for ablation therapy?

Answer 35

Same as in whole body iodine scan

Question 36

What precautions are taken in ablation therapy?

Answer 36

Lead lined room Sewage connected directly to the mains Disposable cutlery clothes and bedding Minimal/ no nurse and family contact

Question 37

What level can patients be discharged?

Answer 37

radiation must be below 500 cps at 1 metre

Question 38

How long does the level take to drop to a safe level?

Answer 38

usually 48 hours

Question 39

What are the side effects of ablation therapy?

Answer 39

Sore throat

Question 40

What is key in the follow up post ablation therapy?

Answer 40

Maintained in T4 | Suppress TSH to prevent growth

Question 41

What can be used a tumour marker post ablation?

Answer 41

Thyroglobulin levels

Question 42

What should TSH levels be kept below?

Answer 42

<0.1 mU/l

Question 43

Why should TSH levels be suppressed?

Answer 43

TSH drives the growth of the tumour, by reducing levels you can inhibit the growth of the tumour

Question 44

List long term effects of ablation therapy

Answer 44

Small increased risk of acute myeloid leukemia

Question 45

Does ablation therapy increase your risk of tumour developmen?

Answer 45

No

Question 46

In what time period is recurrence most likely to occur?

Answer 46

Within the first two years

Question 47

Which tumour caries the greatest risk of recurrence in the same sight?

Answer 47

Pappiliary

Question 48

If a follicular tumour where to recur where would it be most likely to?

Answer 48

Lung Bone Brain

Question 49

If there is a rising thyroglobulin level but the whole body iodine scan is negative what might have occurred and what is the correct corse of action?

Answer 49

Tumour has become anaplastic | PET scan the entire body