5 - Surgical Endocrine Flashcards by E *

Important thyroid stuff

Highly vascular

Zone 2 of the neck

Important surrounding structures (arteries, veins, recurrent laryngeal nerve, vagus nerve, trachea)

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Complication of thyroid surgery

Thyroid storm with excessive manipulation

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Common patient type for thyroid stuff

Women (most are benign)

CA risk higher if in men

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Workup for solitary thyroid nodules

H and P
Imaging  - ultrasound preferred
Tissue Dx - FNA
- Surgical Bx if suspicious 
Blood - TSH, T4, T3

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Risk factors for malignant nodule

Irradiation (baby boomers given radiation txt for various conditions)

Radiation txt for Hodgkins lymphoma

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MEN 1 (Werner’s)

Hyperparathyroidism (Calcium problems)

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MEN 2a (Sipple)

Medullary thyroid carcinoma

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MEN 2b

Ganglioneuromatosis of GI tract

Marfnaoid appearance

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Obstructive signs include (enlarged thyroid)

Stridor (inspiratory)
Tracheal deviation
JVD

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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

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Scintigraphy?

Nuclear study

Can tell you if nodule is hot (hormonally active) or cold

Most nodules are cold

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TSH low with high T3, T4 means you’ve got:

A functioning nodule

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Indications for thyroid surgery

Suspected or proven CA on FNA

Hormonally active nodules

Functionally malignant

Recurrent cystic nodules

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What is a follicular adenoma

Benign tissue hyperplasia surrounded by fibrous capsule

May be hot or cold

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Toxic adenoma

Hyperfunctioning thyroid tissue

Kicking out a lot of extra thyroid hormones

Txt c iodine if < 4cm

txt c surg if > 4 cm

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Thyroidectomy - now you need

Lifelong synthroid

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Malignant thyroid nodules

More common in females

Papillary and follicular are most common

Medullar and anaplastic less common

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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

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Follicular neoplasms tissue diagnosis?

Pathologist makes diagnosis

frozen section sent for immediate diagnosis
permanent section can be preserved in formalin for later diagnosis

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How to determine between frozen or preserved specimen?

Coordinate w pathology dept

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Papillary thyroid carcinoma is more common to:

Iodine deficiency, children, and post-XRT

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Medullary thyroid carcinoma is part of which MEN syndrome?

MEN 2

Cut it out

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Adjuvant therapy for thyroid CA

Thyroxine - replace hormone and suppress mets

Radioactive iodine - after thyroidectomy

XRT - local invasion, recurrent, mets, or unresectable

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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