398.2 📚 國考版醫垫國考 / PGY OSCE

398.2.0.1 📌 Cram Sheet

398.2.0.1.1 🔥 高 yield 18
  1. Workup: TSH → US (TI-RADS) → FNA (Bethesda)
  2. TSH 抑 → scan first (hot 䞍 FNA)
  3. TI-RADS 1-5 + size threshold 決定 FNA
  4. Bethesda 6 categories with malignancy risk
  5. PTC 85%: best prognosis; lymphatic; BRAF V600E
  6. FTC 5-10%: hematogenous; capsular + vascular invasion; RAS, PAX8/PPARγ
  7. MTC 3-5%: C cells, calcitonin, MEN2 RET, pre-op pheo rule out
  8. Anaplastic 1-2%: 老人, aggressive, BRAF V600E → dabrafenib + trametinib
  9. Lymphoma: Hashimoto background
  10. Total thyroidectomy + RAI for differentiated (high-risk)
  11. TSH suppression with LT4 post-op (high-risk < 0.1)
  12. Tg + Tg-Ab + neck US surveillance
  13. MTC 䞍 RAI (no NIS)
  14. Selpercatinib (RET), larotrectinib (NTRK), dabrafenib (BRAF V600E)
  15. Pregnancy/lactation: ¹³¹I 絕對犁忌
  16. Pre-op MTC: pheo rule out (catecholamine + metanephrine)
  17. Lobectomy acceptable for low-risk PTC < 1 cm
  18. TI-RADS TR1-2 䞍 FNA
398.2.0.1.2 🔢 必背
TI-RADS FNA size F/U size
TR1 None None
TR2 None None
TR3 ≥ 2.5 cm 1.5-2.4
TR4 ≥ 1.5 cm 1.0-1.4
TR5 ≥ 1.0 cm 0.5-0.9
Bethesda 名皱 Risk
I Non-diagnostic varies
II Benign < 3%
III AUS/FLUS 6-18%
IV Follicular neoplasm 10-40%
V Suspicious 45-60%
VI Malignant 94-99%
項目 æ•žå­—
TSH 抑 hot 侍癌 < 1%
Cold nodule 癌 5-15%
PTC 10-yr survival > 95%
Anaplastic 6-mo mortality > 90%
TSH suppression high-risk < 0.1
TSH suppression intermediate 0.1-0.5
TSH replacement low-risk 0.5-2.0

398.2.0.2 ⭐ 高 yield

398.2.0.2.1 Risk Factors for Malignancy
  • 頭頞郚 RT 史 (兒童期最匷)
  • HSCT 党身 RT
  • Family Hx (MEN2, FAP, Cowden, DICER1)
  • 幎霡 < 20 或 > 60
  • 男性
  • 快速生長 / hard / fixed
  • 聲音改變 (RLN)
  • 頞郚 LN
  • 吞嚥困難 / dyspnea
398.2.0.2.2 TI-RADS Features (ACR 2017)
Category Points
Composition: spongiform 0
Composition: solid 2
Echogenicity: hyper/iso 1
Echogenicity: very hypo 3
Shape: taller-than-wide 3
Margin: lobulated/extrathyroidal 2-3
Foci: microcalcifications 3
398.2.0.2.3 Mutation by Cancer Type
Cancer Mutations
PTC BRAF V600E (~50%), RET/PTC, RAS
FTC RAS, PAX8/PPARγ, PTEN
MTC RET (germline MEN2 + somatic)
Anaplastic TP53, BRAF V600E, RAS
398.2.0.2.4 Drug Quick by Mutation
Mutation Drug
BRAF V600E Dabrafenib + trametinib
RET fusion Selpercatinib, pralsetinib
NTRK Larotrectinib, entrectinib
ALK Crizotinib
Multikinase (RAI-refractory) Lenvatinib, sorafenib
MTC RET (any) Vandetanib, cabozantinib (older); selpercatinib (newer)
398.2.0.2.5 MEN2A vs 2B
MEN2A MEN2B
MTC Yes Yes (more aggressive)
Pheo Yes Yes
Parathyroid Yes No
Mucosal neuroma No Yes
Marfan habitus No Yes
Prophylactic thyroidectomy by 5 yr by 1 yr
398.2.0.2.6 Surveillance Quick (Diff Thyroid CA)
  • Tg + Tg-Ab + neck US q6-12 mo
  • TSH for replacement
  • Stimulated Tg + WBS at 1 yr post-RAI
  • PET-CT if Tg ↑ but imaging negative

398.2.0.3 🎯 自我檢枬

  1. Workup steps? → TSH → US → TI-RADS → FNA → Bethesda
  2. TSH 抑 next step? → Scan first (hot 䞍 FNA)
  3. TR4 FNA threshold? → 1.5 cm
  4. Bethesda V malignancy risk? → 45-60%
  5. PTC mutation? → BRAF V600E ~50%
  6. FTC spread? → Hematogenous
  7. FTC vs adenoma 區分? → Capsular + vascular invasion (histology)
  8. MTC marker? → Calcitonin
  9. MTC syndrome? → MEN2 (RET)
  10. Pre-op MTC rule out? → Pheo (catecholamine, metanephrine)
  11. Anaplastic 6-mo mortality? → > 90%
  12. Anaplastic BRAF V600E drug? → Dabrafenib + trametinib
  13. Lymphoma background? → Hashimoto
  14. Selpercatinib indication? → RET fusion
  15. MTC RAI? → 侍 (C cells lack NIS)
  16. TSH suppression high-risk? → < 0.1
  17. RAI 犁忌? → Pregnancy + lactation
  18. MEN2B prophylactic thyroidectomy? → by 1 yr

⚠ AI 草皿。