Endo Flashcards
At what size do you start getting symptoms tracheal narrowing from goitre
Exertions dyspnoea at less than 8mm
Stridor/wheeze at less than 5mm
indications for surgery in thyrotoxic nodule or TMNG
6 M's Malignancy Medical therapy failure Massive goitre (compressive symptoms) Mediastinal extension Menacing consequences of radioactive iodine - pregnancy, allergey, severe orbitopathy Mechanical compression
advice while taking radioactive iodine
Takes 3-5 days to pass through system
Takes upto 12 weeks to work
Dependant on the dose
Need to avoid close personal contact - radioactive iodine can be released in saliva, urine, sweat, no sharing saliva, bed, stay away from children for upto 5 days,
no pregnancy for at least 6 months - probably 12 best
Treatment of thyroid storm
B blocker Cooling cares (+ paracetamol) Icu Carbimazole Iodine Steroids
Amiodarone induced hyperthyroidism types
Type 1 - from iodine in amiodaronetype2 from destructive thyroiditis
How is the ti rads comprised
Echogenicity Margins Shape Composition (solid v cyst v spongiform) Echogenic foci (calcs, peripheral calcs, punctuate echogenic foci)
Ti rads
1- benign (0 points)
2 - benign (2 points)
3 - mildly suspicious - fna greater than 2.5cm and follow 1.5cm
4- moderately suspicious (4-6) fna 1.5cm and follow 1cm
5- highly suspicious - fna 1cm follow 0.5cm
What is the implication of negative localisation studies for PHPTH
Should do 4 grand exploration
Single gland still most likely
But remember multigland disease/hyperplasia
CT differentiation of incidentaloma
<10 HU - benign
<4 cm likely benign (90% malignant tumour >4cm)
< -40 HU myelolipoma
Washout - fast washout is consistent with adenoma. Delayed washout >10 mins in phaeo and ACC
Margins
Increased vascularity in phaeo
High intensity T2 on MRI FOR phaeo
Cystic and haemorrhagic changes in phaeo
>20 HU in malignancy and phaeo
What is the proportion of incidentaloma that are functional
90% non funxtuons
- 4 Cushing
- 1 phaeo
- 6 conns
What is mitotaine used for
Adrenocortical carcinoma
Incomplete resection or unresectable
High risk disease
Mitotaine is an adrenolytic agent that suppresses the adrenal Cortex and alters the peripheral metabolism of steroids
Commonest sites for neuroendocrine rumours
Small bowel 45% Rectum 20% Appendix 16% Colon 11% Stomach 7%
Describe the grading of NET
G1- mitoses <2, ki67 upto 2%
G2- m 2-20, k 3-20%
G3 - m>20, k >20 (=NEC)
Describe staging of NET
generally not for tumour <1-2cm and type 1 and 2 gastric NETs
CT CAP
+ somatostatin receptor based imaging “octreoscan” or Dotate PET scan - important to assess if octreotide would work
cernea classification
1 - nerve passes >1cm above superior lobe (60% of normal sized thyroid, 20% of large goitre)
2a - <1cm of superior lobe (20% of large and normal gland)
b - crosses superior lobe (60% large goitre, 20% small)
suspicious USS of involved lymph nodes
loss of fatty hilum calcifications non compressible round vs oval hyperechoic >8mm size
thyroglobulin measurement post total and hemi thyroidectomy
total <5ng/ml
hemi <30ng/ml
intermediate/high risk categories of thyroid cancer
>4cm ETE (microscopic) (macroscopic = high risk) Clinically lymph node involved Gross residual tumour (high risk) Node >3cm (high risk)
follicular cancer with >4 foci of vascular invasion + well differentiated + no capsular invasion
Papillary - high risk variant (tall cell, hurthle cell, hobnail, insular)
Outline the roles for RAI
Used in adjuvant setting- I-131
Ablate residual thyroid tissue
Adjuvant treatment of subclinical mets
Treatment of residual/metastatic disease
Used in diagnostic purposes - I-123
Staging
Assessment of hyperthyroidism
Treatment of metastatic thyroid cancer
RAI is curative in a minority of patients
Combination of RAI + TSH helps to minimise disease burden
Kinase inhibitors VEGRF targets can be trialled for non-responsive disease -
Genetics of papillary vs follicular
papillary - MAPK pathway - RET oncogen
follicular - RAS
rates of single vs double vs diffuse hyperplasia for HPTP
85% vs 5% vs 10%
what age to consider MEN2 a possibility with HPTH
<30 year old male
what type of pet ct for pth adenoma?
methionine PET CT
cancer syndromes associated with adrenal cortical carcinoma
Li Farumeni
MEN1
Histology of Adrenal cortical carcinoma
Weiss histological criteria for cancer Note its difficult to diagnose cancer in the absence of metastatic disease 5 criteria >6 mitoses/50 HPF, Ki67% <25% clear tumour cells abnormal mitoses necrosis capsular invasion
phaeo associated familial syndromes
MEN2
VHL
NF1
Carney triad
when to familial test for phaeo/paraganglioma
consider for all paraganglioma
bilateral phaeo
family history
unilateral phaeo <45 years old
Phaeo triad
Headaches, palpitations sweats (+hypertension on examination)
Conn’s triad
hypokalemia, alkalosis, hypertension
PNET characteristic presentations
Insulinoma - whipple’s triad - hypoglycemic symptoms (confusion, visual changes, diaphoresis) + recorded hypoglycemia + symptoms settle with sugar intake
Gastrinoma - zollinger-ellison syndrome (PUD + Diarrhoea)
Glucagonoma - necrolytic migratory erythema, diabetes, diarrhoea, VTE, neuropsych
VIPoma - diarrheoa, hypokalemia, hypochlorhydria
Somatostatinoma - steatorrhoea, cholelithiasis
how to confirm ZES
Fasting serum gastrin level high
Low stomach pH (<2) (ensure not on acid suppression) - if higher pH and not on suppression consider atrophic gastritis/h.pylori
exclude other causes of high gastrin (e.g. retained antrum syndrome)
secretin suppresion test if FSG<10x increased
if >10 FSG then confirms ZES
what is the ASVS
arterial calcium stimulation with hepatic venous sampling used to help localised insulinoma + gastrinoma
carcinoid syndrome
flushing diarrhoea wheezing
Bethesda + risk of malignancy
1 - non diagnostic 2- benign - 2% 3- atypia of undetermined significant or follicular lesion of undetermined significance - 5-15% 4 -follicular neoplasm - 15-30% 5- Suspicious for malignancy - 60-75% 6- Malignant - 99%
