5 - Surgical Endocrine Flashcards
Important thyroid stuff
Highly vascular
Zone 2 of the neck
Important surrounding structures (arteries, veins, recurrent laryngeal nerve, vagus nerve, trachea)
Complication of thyroid surgery
Thyroid storm with excessive manipulation
Common patient type for thyroid stuff
Women (most are benign)
CA risk higher if in men
Workup for solitary thyroid nodules
H and P Imaging - ultrasound preferred Tissue Dx - FNA - Surgical Bx if suspicious Blood - TSH, T4, T3
Risk factors for malignant nodule
Irradiation (baby boomers given radiation txt for various conditions)
Radiation txt for Hodgkins lymphoma
MEN 1 (Werner’s)
Hyperparathyroidism (Calcium problems)
MEN 2a (Sipple)
Medullary thyroid carcinoma
MEN 2b
Ganglioneuromatosis of GI tract
Marfnaoid appearance
Obstructive signs include (enlarged thyroid)
Stridor (inspiratory)
Tracheal deviation
JVD
Ultrasound can help you do what with the thyroid?
Define the nodule
Solitary or multiple
Cystic or multinodular
Not adequate to determine benign vs malignant
Can guide the FNA - send aspirate to pathology
Scintigraphy?
Nuclear study
Can tell you if nodule is hot (hormonally active) or cold
Most nodules are cold
TSH low with high T3, T4 means you’ve got:
A functioning nodule
Indications for thyroid surgery
Suspected or proven CA on FNA
Hormonally active nodules
Functionally malignant
Recurrent cystic nodules
What is a follicular adenoma
Benign tissue hyperplasia surrounded by fibrous capsule
May be hot or cold
Toxic adenoma
Hyperfunctioning thyroid tissue
Kicking out a lot of extra thyroid hormones
Txt c iodine if < 4cm
txt c surg if > 4 cm
Thyroidectomy - now you need
Lifelong synthroid
Malignant thyroid nodules
More common in females
Papillary and follicular are most common
Medullar and anaplastic less common
Follicular neoplasms
Most are benign, but FNA cannot differentiate between benign and malignant
Requires surgery
Grab sample, look at sample, make decision based on sample
Adenoma? No further resection
Carcinoma? Cut the whole thyroid out
Follicular neoplasms tissue diagnosis?
Pathologist makes diagnosis
- frozen section sent for immediate diagnosis
- permanent section can be preserved in formalin for later diagnosis
How to determine between frozen or preserved specimen?
Coordinate w pathology dept
Papillary thyroid carcinoma is more common to:
Iodine deficiency, children, and post-XRT
Medullary thyroid carcinoma is part of which MEN syndrome?
MEN 2
Cut it out
Adjuvant therapy for thyroid CA
Thyroxine - replace hormone and suppress mets
Radioactive iodine - after thyroidectomy
XRT - local invasion, recurrent, mets, or unresectable
Thyroglossal duct cyst ?
Benign
Kids, young adults
Can get infected
Txt with ABX prior to elective surgery
NO I and D
Goiter
Less common now thanks to iodine supplementation
Simple - euthyroid (iodine deficient)
Toxic - graves dz
Management of goiter
Medical - thyroid replacement to reduce TSH stimulation to bring to euthyroid
Surgical - if refractory, airway compromise, dysphagia/odynophagia
Surgical complications (goiter)
Bleeding
Injury to surrounding structures
Infection
Respiratory obstruction
Clinical features of thyrotoxicosis
Clinical features • Palpitations • Diarrhea • Irritable • Sweating/heat intolerance • Menstrual changes • Fatigue/weight loss • Physical exam • Tachycardia • Ophthalmic signs • Tremors • Pretibial myxedema
Txt for thyrotoxicosis
Control HR c BB’s first
Suppress thyroid function with PTU
Radioactive iodine reduces vascularity
Surgery once pt is euthyroid
Primary care responsibilities for thyroid nodules
TSH / T3 / T4 / CBC / CMP
US of thyroid
CXR
Refer
Parathyroid gland
4 glands embedded in the posterior lobes of the thyroid
Primary hypercalcemia
Parathyroid glands excrete excess PTH
2/2 adenoma or hyperplasia
Secondary (malignant) hypercalcemia
Tumors produce PTH mimicking hormone or other CA has metastasized to the bone
If Ca is high, what do we do?
Order PTH
If the PTH is high, hyperparathyroidism
MC - parathyroid adenoma
Secondary hyperparathyroidism
Decreased serum CA -> elevated PTH
Chronic renal failure
Malabsorption
Clinical presentation of hyperparathyroidism
Stones, bones, groans, blah blah
MEN1
Hyperparathyroidism
MEN2
Medullary thyroid CA
Subperiosteal bone resorption (pits) seen on CXR
Hyperparathyroidism
Causes increased osteoclastic activity, hence increased bone resorption
W/U for parathyroid problems
CMP
PTH
Plain films (bone resorption)
US preoperatively to find offending gland
Parathyroid gland - surgical indications
Renal stones
Osteoporosis
Hypercalcemic crisis
Surgical complications of parathyroid surg
Bleeding
Injury to surrounding structures
Hypoparathyroidism - hypocalcemia
Tetany, Chvosteks, Trousseau, seizure
Prolonged QT onECG
Txt with Ca++
Primary care responsibilities for hypercalcemia
Order CMP / PTH / CXR
Refer
Zones of adrenal cotex
Zona glomerulosa - aldosterone
Zone fasiculata - cortisol
Zona reticularis - testosterone
Medulla of cortex produces
Catecholamines
What is an incidentaloma?
Mass discovered INCIDENTALLY during a scan
Most are benign
Increased suspicion for malignant mass:
> 5cm
Mets site for breast, lung, renal, melanoma, lymphoma
Can present as adrenal failure (Adisonian crisis)
Pheo triad
HA
Palpitations
Diaphoresis
Pheo found in 50% of pts with
MEN2
How do you control pheo?
Alpha blockade THEN beta blockade
Remember, thyroid is BB
Adrenal cortical hyperplasia = malignant tumor of:
Zona fasciculata
Pituitary adenoma - excess production of:
ACTH
Leads to Cushing’s disease
Surgical removal of pituitary adenoma
Sites of ectopic ACTH production
Small cell CA of the lung
Carcinoid tumors
Medullar carcinoma of the thyroid
When would you suspect sepsis-induced adrenal failure?
Critically ill patient that does not respond to fluid resuscitation
If adrenal mass if hormonally active?
Take it out
If its a pheo - be really careful - those catecholamines will be released - be ready to alpha block
Hormonally inactive adrenal mass
If encroaching on the kidney or other structures, cut it out
If it’s > 5cm, cut it out
If it’s < 5cm, reassess in 3-6 mos
Primary care duties for adrenal mass
CBC CMP (pay attention to electrolytes) PTH Dexamethasone test Urine catecholamines Serum VMA and metanephrines
CXR to check for metastasis
Consider special imaging
refer (medicine, endo, surgery)
What Wallace said about soldiers and thyroid disease
Hilarious
