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Thyroid - Coggle Diagram

- - - - RET +
        
        Genetic councelling, evaluate for hyperparathyroidism - Calcium, PTH, pheochromocytoma - 24 hr urine metanephrines and catecholamines
  - - - rare variant called PTC, oxyphilic type
    - - Histologic variants: Oxyphilic (hurthle) , clear cell
    - - TT: post op thyroid supression, unresponsive to I-131 but radiosensitive
- - - - PTU, Meth, I-131 ablation, b-blockers, Iodide.
- - - - ATA
        
        High suspicion pattern: Solid hypoechoic or solid hypoechoic compontnet of cystic nodule with ≥ of (MITRE): Microcalcifications, taller, than wide, Irregular margins, rim calcifications, ETE. Biopsy > 1 cm
        
        Bathesda cytology: Need 6 groups of well visualized follicular cells - each group containing 10 well preserved epithelial cells
        
        Non-diagnostic (1-4% malignant)
        
        Repeat FNA
        
        If repeatedly non -diagnostic without high risk US features - active surveillance or diagnostic hemithyroidectomy.
        
        Benign (0-3%)
        
        No sx
        
        Still managed surgically If: Large nodule > 4 cm, compressive sx, concerning us/clinical features or cosmesis
        
        Molec testing + and high risk US features = TT
        
        AUS/FLUS (5-15%)
        
        Molecular testing: BRAF has high specificity for Ca - low sensitivity
        
        Molec testing + = total thyroid
        
        Molec testing - = observe / diagnostic hemi
        
        can manage by: repeat FNA, molecular testing, surveillance, diagnostic hemi
        
        surveillance : High susp on u/s = FNA In 12 months, low = repeat US In 12-24 months, very low = repeat us In 24 months
        
        Follicular neoplasms/FSN 15-30 %
        
        Molecular testing
        
        +. = oncologic thyroid
        
        -. = diagnostic hemi
        
        gold stand: diagnostic hemi
        
        Suspicious 60-75%
        
        Molecular testing
        
        Hemi or TT (choice dependent on us findings, clinical features and molecular testing)
        
        Malignant (97-99%)
        
        sx : TT always In > 4 cm tum, t4, > n1 M1
        
        active surveillance option If: Papillary microcarcinoma < 1 cm without mets, local Invasion or cytologic evidence of disease, high surgical risk, limited life span, other medical Issues.
        
        Hemi If: 1-4 cm, no ETE, n0 m0 no adverse us feautres. Should ALWAYS do hemi If < 1 cm, unifocal, Intrathyroidal , no H& N rads, No familial thyroid ca.
        
        Didnt meet size criteria for biopsy
        
        High risk: repeat US In 6-12 mnths
        
        Int/low risk: repeat us In 12-24 months
        
        very low > 1 cm = repeat us In 24 months, very low < 1 cm - no follow. If > 20% growth In 2 dimensions or Increase In 2 mm or 50% volume , FNA
        
        Intermediate suspicion: solid hypoechoic nodule without above features. Biopsy > 1 cm
        
        Low suspsicion: Isoechoic or hyperechoic nodule without high risk features. Biopsy > 1.5 cm
        
        Very low suspicion: spongiform or partially cystic nodules without high suspicion patterns Biopsy > 2 cm
        
        Benign pattern: cystic purely. No biopsy
      - TI-RADS (SCEME)
        
        composition
        
        cystic 0
        
        spongiform 0
        
        mixed cystic and solid 1
        
        solid 2
        
        echogenecity
        
        anechoic 0
        
        hyperechoic or Isoechoic 1
        
        hypoechoic 2
        
        very hypoechoic 3
        
        shape
        
        WtT 0
        
        TtW 3
        
        margin
        
        smooth 0
        
        ill defined 0
        
        lobulated or Irregular 2
        
        ETE 3
        
        Echogenic foci
        
        none or large comet-tail artifacts 0
        
        macro cal 1
        
        rim cal 2
        
        punctate echogenic foci 3
        
        T1 = 0
        
        No FNA
        
        t2 = 2
        
        No FNA
        
        T3 = 3
        
        ≥ 2.5 cm FNA > 1.5 cm follow
        
        bathesda
        
        T4 = 4-6
        
        ≥ 1.5 cm FNA , ≥ 1 cm follow
        
        T5 ≥7
        
        ≥ 1 cm FNA , 0.5 cm follow