Carcinoma Of Thyroid Management

CARCINOMA OF THYROID MANAGEMENT

Q. 1

True regarding ligation of inferior thyroid artery during thyroidectomy:  

September 2005

 A

Ligated maximally away from the gland

 B

Ligated close to the gland

 C

Ligated midway between the options a and b

 D

None

Q. 1

True regarding ligation of inferior thyroid artery during thyroidectomy:  

September 2005

 A

Ligated maximally away from the gland

 B

Ligated close to the gland

 C

Ligated midway between the options a and b

 D

None

Ans. A

Explanation:

A: Ligated maximally away from gland

Inferior thyroid artery is NOT routiney ligated, but if they have to be ligated, they are ligated away from the gland The inferior thyroid arteries are not routinely ligated to preserve the parathyroid blood supply

Main steps of Thyroidectomy:

  • Exposure – Curved neck incision, +/- raising of flaps, +/- division of strap muscles
  • Identification of essential structures – Recurrent and external branch of superior laryngeal nerve, parathyroid glands
  • Devascularization

Superior thyroid artery-It splays over the upper pole and hence ligated individually

–        Inferior thyroid artery are not routinely ligated so protecting the supply to the parathyroids

–        Thyroid ima if present

  • Resection
  • Exploration of other pathology – e.g. contralateral lobe, lymph nodes
  • Closure

Complications

  • Hypothyroidism/Thyroid insufficiency in up to 45% of patients after ten years
  • Thyrotoxic crisis/ Thyroid storm
  • Laryngeal nerve injury in about 1% of patients, in particular the recurrent laryngeal nerve:

– Unilateral damage results in a hoarse voice.

– Bilateral damage presents as laryngeal obstruction on removal of the tracheal tube and is a surgical emergency

  • Hypoparathyroidism temporary (transient) in many patients, but permanent in about 1-4% of patients
  • Respiratory obstruction-may be due to collapse or kinking of trachea (tracheomalacia)
  • Infection
  • Stitch granuloma

Haemorrhage/ Hematoma

This may compress the airway, becoming life-threatening. A suture removal kit should be kept at the bedside throughout the postoperative hospital stay.

  • Surgical scar/ keloid

Q. 2

Thyroxine can be given in which thyroid carcinoma:

September 2009

 A

Papillary

 B

Medullary

 C

Anaplastic

 D

Undifferentiated

Q. 2

Thyroxine can be given in which thyroid carcinoma:

September 2009

 A

Papillary

 B

Medullary

 C

Anaplastic

 D

Undifferentiated

Ans. A

Explanation:

Ans. A: Papillary

On the basis that most of the tumours are TSH depedent it is a standard practice to prescribe thyroxine for all patients after operation for differentiated thyroid carcinoma (papillary and follicular type) to suppress endogenous TSH production.


Q. 3

After thyroidectomy for medullary carcinoma of thyroid, which is important for determining recurrence of tumour:

September 2009

 A

Thyroglobulin

 B

TSH

 C

Carcinoembryonic antigen

 D

Thyroxine levels

Q. 3

After thyroidectomy for medullary carcinoma of thyroid, which is important for determining recurrence of tumour:

September 2009

 A

Thyroglobulin

 B

TSH

 C

Carcinoembryonic antigen

 D

Thyroxine levels

Ans. C

Explanation:

Arts. C: Carcinoembryonic antigen

Unlike papillary and follicular thyroid cancers which arise from thyroid hormone producing cells, medullary cancer of the thyroid originates from the parafollicular cells (also called C cells) of the thyroid.

These C cells make a different hormone called calcitonin.

High levels of serum calcitonin and carcinoembryonic antigen are produced by many medullary tumours.

Levels falls after resection and rise again with recurrence making it a valuable tumour marker in the follow-up of patients with this disease

This cancer has a much lower cure rate than does the “well differentiated” thyroid cancers (papillary and follicular), but cure rates are higher than they are for anaplastic thyroid cancer.


Q. 4

A patie-tt has undergone total thyroidectomy for papillary carcinoma of thyroid. Marker for follow-up of such a patient is:           

March 2011

 A

Thyroglobulin

 B

Calcitonin

 C

TSH

 D

Serum iodine levels

Q. 4

A patie-tt has undergone total thyroidectomy for papillary carcinoma of thyroid. Marker for follow-up of such a patient is:           

March 2011

 A

Thyroglobulin

 B

Calcitonin

 C

TSH

 D

Serum iodine levels

Ans. A

Explanation:

Ans. A: Thyroglobulin

The measurement of serum thyroglobulin is of value in the follow-up and detection of metastatic disease in patients who have undergone surgery for differentiated thyroid carcinoma

Differentiated thyroid carcinoma includes follicular and papillary neoplasms

Thyroid carcinoma which is:

  • MC type: Papillary
  • Least common type: Anaplastic
  • Best prognosis: Papillary
  • Worst prognosis: Anaplastic
  • Developing in thyroglossal cyst: Papillary
  • Spreading by lymphatics: Papillary
  • Psammoma bodies: Papillary
  • Least malignant: Papillary
  • Hurthle cell variant: Follicular
  • Arising from parafollicular/ C cells: Medullary
  • Associated with MEN II: Medullary
  • Secrete calcitonin: Medullary
  • Associated with RET proto-oncogene: Medullaryy

Q. 5

In treatment of papillary carcinoma thyroid, radioiodine destroys the neoplastic cells predominantly by:

 A

X-rays

 B

ri rays

 C

7 rays

 D

a particles

Q. 5

In treatment of papillary carcinoma thyroid, radioiodine destroys the neoplastic cells predominantly by:

 A

X-rays

 B

ri rays

 C

7 rays

 D

a particles

Ans. B

Explanation:

Ans. ri rays


Q. 6

 Identify the Type of Thyroidectomy shown in Photograph 

 A

 Total thyroidectomy 

 B

 Sub-total thyroidectomy

 C

 Thyroid lobectomy

 D

Hartley Dunhill Operation

Q. 6

 Identify the Type of Thyroidectomy shown in Photograph 

 A

 Total thyroidectomy 

 B

 Sub-total thyroidectomy

 C

 Thyroid lobectomy

 D

Hartley Dunhill Operation

Ans. C

Explanation:

Ans is Thyroid lobulectomy

This operation involves removing the half of the thyroidgland that has the nodule. It is sometimes called a “diagnostic lobectomyLobectomy – removal of half thethyroid” because the preoperative diagnosis may be uncertain and part of the reason for the operation is to make a diagnosis of cancer or no cancer.


Q. 7

Treatment of choice for thyroid carcinoma shown in the photograph is ? 

 A

Thyroid lobectomy.

 B

Hemi-thyroidectomy.

 C

Sub-total thyroidectomy.

 D

Total thyroidectomy.

Q. 7

Treatment of choice for thyroid carcinoma shown in the photograph is ? 

 A

Thyroid lobectomy.

 B

Hemi-thyroidectomy.

 C

Sub-total thyroidectomy.

 D

Total thyroidectomy.

Ans. D

Explanation:

The thyroid carcinoma shown in the photograph above represents medullary carcinoma thyroid.

Treatment of choice for medullary thyroid carcinoma is total thyroidectomy.


Q. 8

A female presented with severe secretory diarrhea and the thyroid carcinoma as represented in the photomicrograph below. Treatment of the same is ? 

 A

Surgery and Radiotherapy.

 B

Radiotherapy and Chemotherapy.

 C

Surgery only.

 D

Radioiodine ablation.

Q. 8

A female presented with severe secretory diarrhea and the thyroid carcinoma as represented in the photomicrograph below. Treatment of the same is ? 

 A

Surgery and Radiotherapy.

 B

Radiotherapy and Chemotherapy.

 C

Surgery only.

 D

Radioiodine ablation.

Ans. C

Explanation:

The thyroid carcinoma shown in the picture above represents medullary thyroid carcinoma (MTC).

In MTC there is a high propensity for bilateral disease in both the sporadic and familial forms and, therefore, the usual treatment istotal thyroidectomy with central neck compartment dissection in all patients. 

In unilateral sporadic disease, if the primary tumor is greater than 1 cm or central compartment disease is present, strong consideration should be given to ipsilateral modified radical neck or mediastinal dissections, or both.



Q. 9

Identify the type of thyroidectomy shovrn in the photograph below ? 

 A

Total thyroidectomy.

 B

Sub-total thyroidectomy.

 C

Thyroid lobectomy.

 D

Hartley Dunhill Operation.

Q. 9

Identify the type of thyroidectomy shovrn in the photograph below ? 

 A

Total thyroidectomy.

 B

Sub-total thyroidectomy.

 C

Thyroid lobectomy.

 D

Hartley Dunhill Operation.

Ans. B

Explanation:

The type of thyroidectomy shovrn in the photograph above represents Subtotal thyroidectomy.

Subtotal thyroidectomy is a surgical procedure, in which the surgeon leaves a small thyroid remnant in situ to preserve thyroid function, thereby preventing lifelong thyroid hormone supplementation therapy.


Q. 10

Identify the type of thyroidectomy shovrn in the photograph below ? 

 A

Total thyroidectomy.

 B

Sub-total thyroidectomy.

 C

Thyroid lobectomy.

 D

Hartley Dunhill Operation.

Q. 10

Identify the type of thyroidectomy shovrn in the photograph below ? 

 A

Total thyroidectomy.

 B

Sub-total thyroidectomy.

 C

Thyroid lobectomy.

 D

Hartley Dunhill Operation.

Ans. C

Explanation:

The type of thyroidectomy shovrn in the photograph above represents Thyroid lobectomy.

This operation involves removing the half of the thyroid gland that has the nodule. It is sometimes called a “diagnostic lobectomyLobectomy – removal of half the thyroid” because the preoperative diagnosis may be uncertain and part of the reason for the operation is to make a diagnosis of cancer or no cancer.


Q. 11

Identify the type of thyroidectomy shovrn in the photograph below ? 

 A

Total thyroidectomy.


 B

Sub-total thyroidectomy.


 C

Thyroid lobectomy.

 D

Hartley Dunhill Operation.

Q. 11

Identify the type of thyroidectomy shovrn in the photograph below ? 

 A

Total thyroidectomy.


 B

Sub-total thyroidectomy.


 C

Thyroid lobectomy.

 D

Hartley Dunhill Operation.

Ans. A

Explanation:

The type of thyroidectomy shovrn in the photograph above represents Total thyroidectomy.

total thyroidectomy is the complete removal of the thyroid gland. The thyroid gland is situated in the lower part of the front of the neck. There are different reasons for performing a total thyroidectomy.

1) Hyperthyroidism – a condition where the thyroid gland is producing too much thyroid hormone.

2) Suspected or Confirmed thyroid cancer. 

3) Compression – The thyroid may enlarge to such an extent that surrounding structures are compressed in the neck. These structures may include the trachea (windpipe) or oesophagus (gullet). 

4) Cosmetic – an enlarged thyroid may cause a lump on the front of the neck that a patient may consider unsightly. 


Q. 12

A patient has undergone the procedure for papillary carcinoma of thyroid as shown in the picture below. Marker for follow-up of such a patient is ? 

 A

Thyroglobulin.

 B

Calcitonin.

 C

TSH.

 D

Serum iodine levels.

Q. 12

A patient has undergone the procedure for papillary carcinoma of thyroid as shown in the picture below. Marker for follow-up of such a patient is ? 

 A

Thyroglobulin.

 B

Calcitonin.

 C

TSH.

 D

Serum iodine levels.

Ans. A

Explanation:

The type of thyroidectomy shovrn in the photograph above represents total thyroidectomy.

The measurement of serum thyroglobulin is of value in the follow-up and detection of metastatic disease in patients who have undergone surgery for differentiated thyroid carcinoma

Differentiated thyroid carcinoma includes follicular and papillary neoplasms

Thyroid carcinoma which is:

  • MC type: Papillary
  • Least common type: Anaplastic
  • Best prognosis: Papillary
  • Worst prognosis: Anaplastic
  • Developing in thyroglossal cyst: Papillary
  • Spreading by lymphatics: Papillary
  • Psammoma bodies: Papillary
  • Least malignant: Papillary
  • Hurthle cell variant: Follicular
  • Arising from parafollicular/ C cells: Medullary
  • Associated with MEN II: Medullary
  • Secrete calcitonin: Medullary
  • Associated with RET proto-oncogene: Medullary.

Q. 13

Complications of the type of thyroidectomy shown in the photograph below include all except ? 

 A

Hoarseness.

 B

Airway obstruction.

 C

Hemorrhage.

 D

Hypercalcaemia.

Q. 13

Complications of the type of thyroidectomy shown in the photograph below include all except ? 

 A

Hoarseness.

 B

Airway obstruction.

 C

Hemorrhage.

 D

Hypercalcaemia.

Ans. D

Explanation:

The type of thyroidectomy shovrn in the photograph above represents total thyroidectomy.

  • Hypocalcemia, not hypercalcemia is a complication of thyroidectomy.
  • Complications of thyroidectomy include

1)         Haemorrhage

Is usually due to slipping of ligature on the superior thyroid art.

Hematomas may cause airway compromise and must be evacuated immediately.

Hematomas may occur immediately or later on. An immediate bleed occurs after or shortly before extubation when the pt. lightens from anaesthesia and may begin to cough, causing a vessel to open. Delayed hemorrhage may develop slowly and therefore may not be recognized at first.

2)         Respiratory obstruction

Causes includes

Tension hematoma.

Laryngeal oedema (by anesthetic intubation)

Bilateral recurrent laryngeal nerve paralysis.

3)         Recurrent laryngeal nerve paralysis

– May be unilateral or bilateral, transient or permanent.

– Bilateral causes respiratory obstruction – Dyspnea, stridor.

4) Injury to other nerves

– External branches of superior laryngeal nerve

– Cervical sympathetic trunk – may cause Homer’s syndrome.

5) Parathyroid insufficiency.

– Is due to removal of the parathyroid glands or infarction due to vascular injury.

Vascular injury is more important.

– Cases usually present 2-5 days after operation with symptoms of hypocalcemia (circumoral and fingertip numbness and tingling tetany, carpopedal spasm and laryngeal stridor.

Treatment with oral calcium and vitamin supplements.

IV calcium gluconate may be required in severe cases.

6)         Thyroid insufficiency.

7)         Thyrotoxic crisis

– Occurs if the thyrotoxic patient has been inadequately prepared for thyroidectomy.


Q. 14

The drug used in the management of medullary carcinoma thyroid is

 A

Cabozantinib

 B

Rituximab

 C

Tenofovir

 D

Anakinra

Q. 14

The drug used in the management of medullary carcinoma thyroid is

 A

Cabozantinib

 B

Rituximab

 C

Tenofovir

 D

Anakinra

Ans. A

Explanation:

Ans.is ‘a’ i.e., Cabozantinib

Medullary thyroid cancers (MTCs) are neuroendocrine tumors of thyroid paraf011icular cells that do not concentrate iodine.

  • The primary treatment for MTC is extensive and meticulous surgical resection.
  • There is a limited role for external-beam radiotherapy.

For patients with asymptomatic metastatic tumors generally less than 1 to 2 cm in diameter, growing in  diameter less than 20 percent per year

  • Systemic therapy is not required
  • Such patients should be monitored for disease progression. Known sites of metastatic disease should be imaged by CT or MRI every 6 to 12 months, and potential new sites of disease should be imaged every 12 to 24 months.
  • For patients with metastatic tumors at least 1 to 2 cm in diameter, growing by at least 20 percent per year, or Or patients with symptoms related to multiple metastatic foci that cannot be alleviated with surgery or external beam radiotherapy
  • Administer systemic treatment as part of a clinical trial.

 

  • Forpatients with metastatic tumors at least I to 2 cm in diameter, growing by at least 20 percent per year, or

for patients with .symptoms related to multiple metastatic foci who cannot participate in a clinical trial

 

  • An oral tyrosine kinase inhibitor (TKI) is suggested, rather than traditional cytotoxic chemotherapy.
  • For initial TKI therapy
  • Cabozantinib or vandetanib rather than sorafenib or sunitinib.
  • Cytotoxic chemotherapy, of which dacarbazine-based regimens such as cyclophosphamide-vincristine­dacarbazine are preferable, is an alternative option for patients who cannot tolerate or who fail multiple TKIs

Drugs used in medullary carcinoma thyroid

Tyrosine kinase inhibitors

Cvtotoxic chemotherapy

Cabozanitib

Cyclophosphamide
Vandetanib Vincristine
Sorafenib Dacarbazine
Sunitinib  

Q. 15

A 27-year-old female presented with long-standing nodule in right lobe of size 2 cm x 2 cm and underwent right hemithyroidectomy. Histopathological findings are suggestive of:

 A

Adenomatous goiter

 B

Papillary carcinoma

 C

Follicular adenoma

 D

Graves disease

Q. 15

A 27-year-old female presented with long-standing nodule in right lobe of size 2 cm x 2 cm and underwent right hemithyroidectomy. Histopathological findings are suggestive of:

 A

Adenomatous goiter

 B

Papillary carcinoma

 C

Follicular adenoma

 D

Graves disease

Ans. B

Explanation:

Ans. b. Papillary carcinoma



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