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FRCS General Section 1/2 > Endo/Neuroendo/Urol > Flashcards

Endo/Neuroendo/Urol Flashcards

1
Q

How should patients with suspected pheochromocytoma be initially investigated?

A

Plasma free metanephrines (from supine position) and/or urinary fractionated metanephrines

Note this is not vanillymandelic acid (VMA) - which has a high false positive rate

(Endocrine Society Clinical Practice Guidelines 2014)

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2
Q

When is a MIBG scintigraphy indicated in management of phaeo/paraganglioma?

A

With metastatic disease when radiotherapy using I-MIBG is planned, otherwise use PET-CT

(Meta-iodobenzylguandidine)
(Endocrine Society Clinical Practice Guidelines 2014)

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3
Q

What germline mutation should be tested for in patients with Paragangliomas?

A

Succinate dehydrogenase (SDH) - about 50% prevalence if present

(Endocrine Society Clinical Practice Guidelines 2014)

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4
Q

How should functional phaeochromocytomas/paragangliomas be managed in the preoperative setting?

A

A-adrenergic blockers first choice, allowing 7-14 days prep.
Advice re high sodium/fluid diet (to combat intravascular depletion post op)

(Endocrine Society Clinical Practice Guidelines 2014)

A blockers - phenoxybenzamine (irreversible), phentolamine, doxazosin

Often give beta blockade after establishing alpha blockade (labetolol)

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5
Q

How should patients with resected PPGL be monitored?

A

Annual plasma/urine metanephrines

(Endocrine Society Clinical Practice Guidelines 2014)

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6
Q

When should an open approach be taken to resection of pheochromocytoma?

A

Large >6cm, invasive tumours - minimise rupture, complete margins

Most paraganlgiomas

Partial can be considered rarely

(Endocrine Society Clinical Practice Guidelines 2014)

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7
Q

How does a phaeochromocytoma differ from a Paraganglioma?

A

Phaeo is tumour arising adrenomedullary chromatin cells (producing one or more of epinephrine, norepinephrine and dopamine) - about 80-85%.

Paraganglioma 15-20% - extra-adrenal chromatin cells of sympathetic paraveterbral ganglia of thorax, abdomen and pelvis. Can also arise from parasympathetic ganglia along IX and X nerves and base of skull - do not produce catecholamines

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8
Q

What is the prevalence of PPGL among adult hypertensive outpatients?

A

0.2-0.6% — 1.7% children

5% of incidental adrenal masses

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9
Q

Which syndromes are associated with PPGL?

A

MEN2a - MTC, HPTH, lichen amyloidosis
MEN2b - MTC, neuromas, intestinal gangliomas (Hirschprungs)
vHL - HAemangiomblasoma, retinal angioma, clear cell RCC, pancreatic NETs and cyst adenomas, papillary cyst adenomas of epididymis
NF1 - neurofibromas, cafe-au-lait spots, freckling, iris harmartomas (Lisch nodules)

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10
Q

What proportion of phaeochromocytomas are bilateral?

A

10%

10% children, 10% malignant, 10% not hypertensive

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11
Q

How are appendiceal neuroendicine neoplasms most frequently detected?

A

Incidentally during appendicectomy

(ENETS consensus guidelines 2016)

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12
Q

Which patients with incidentally identified neuroendocrine tumours at appendicectomy do not require further treatment?

A

<1cm size
Invasion up to subserosa or up to 3mm in mesoappendix
clear surgical margins

Those at base or larger also more likely to recur

(ENETS consensus guidelines 2016)

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13
Q

Where do appendiceal NENs most often appear?

A

70% at tip

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14
Q

What tumour markers are useful in appendiceal NEN?

A

Chromogranin A (CgA) - useful to differentiate from goblet cell carcinoma, follow up with metastatic

urinary 5-HIAA in rare patients with carcinoid

(ENETS consensus guidelines 2016)

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15
Q

How are Neuroendocrine tumours graded?

A

WHO 2010 classification

Ki67 Index (%) and Mitotic Rate (HPF)

G1 NET - Ki ≤2%, MR <2/10
G2 NET - KI 3-20%, MR 2-20/10
G3 NET - KI >20, MR >20

G3s - either poorly differentiated or carcinoma

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16
Q

What is the metastatic rate for appendiceal NETS >2cm?

A

about 40%

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17
Q

When should a right hemicolectomy be considered with appendiceal NETs 1-2cm in size?

A

if Base or R1,

or if risk factors - V1,L1, G2/3

(ENETS consensus guidelines 2016)

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18
Q

How often do small intestinal NETs present with metastasis?

A

50%

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19
Q

How do metastatic small intestinal NETs usually present?

A

With vague nonspecific symptoms - the carcinoid syndrome is still rare

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20
Q

What symptoms are associated with Carcinoid syndrome?

A

Secretory diarrhoea (60-80%)
Flushing (60-85%)
Intermittent bronchial wheezing (<10%)
Right heart valve fibrosis - Carcinoid Heart disease, Hedinger syndrome (20%)

Seen with liver metastatic disease bypassing hepatic clearance of serotonin

5% of patients can have retroperitoneal/ovarian tumours/metastases

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21
Q

How should patients be optimally investigated for small intestinal NET?

A

CT/MRI followed by Ga-DOTATOC PET or SRS Spect

For G3 a FDG PET may be useful

(ENETS consensus guidelines 2016)

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22
Q

What biochemical tests are useful in SI NETs?

A

Serum Chromogranin A
Urinary 5-HIAA (product of serotonin metabolism) highly sensitive

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23
Q

What are the types of well differentiated gastroduodenal NETs? (3)

A

Type 1 - ECLoma (Enterochromaffin like cell) - chronic atrophic gastritits
Type 2 - ECLoma -Zollinger Ellison
Type 3 - rare, sporadic, often high grade

If <1cm - endoscopic resection

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24
Q

How should rectal NETs be managed?

A

If <1cm - Endoscopic resection (unless G3)
>2cm - Anterior resection
1-2cm variable

(ENETS consensus guidelines 2016)

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25
Q

How is Zollinger Ellison syndrome diagnosed?

A

Elevated fasting serum gastrin (x10 normal) in the presence of hypergastrinaemia when gastric pH<2

60-80% in duodenum (90-100% in those with MEN1)

(ENETS consensus guidelines 2016)

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26
Q

How is an insulinoma diagnosed? (4)

A

Plasma glucose <3mmol
Plasma insulin ≥3uU
C-peptide ≥0.6ng
Proinsulin ≥5pmol

For non-functioning p_NETs Chromogranin A can be useful

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27
Q

How should pNETs be localised?

A

68GA labelled somatostatin analog

PET-CT is better than SR SPECT, except for insulinoma - GLP1-receptor analogue scintigraphy or intra-arterial injection and measurement of some gradient

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28
Q

What surgical approach can frequently be used for insulinoma?

A

Enucleation

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29
Q

When should non-functioning P-nets be excised?

A

≥2cm when major pancreatic resection required

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30
Q

What are the types of appendiceal neoplasm?

A

1) Mucinous epithelial neoplasm
-Serrated polyp
-Low grade Mucinous neoplasm (LAMN)
-High grade mucinous neoplasm (HAMN)
-Mucinous adenocarcinoma

2) Non-mucinous epithelial neoplasm (adenoma/adenocarcinoma)
3) Epithelial with neuroendocrine features (NET or Goblet cell)
4) Mesenchymal neoplasms

(Peritoneal Surface Oncology Group International (PSOGI) Guidelines 2021)

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31
Q

What are the types of appendiceal neoplasm?

A

1) Mucinous epithelial neoplasm
-Serrated polyp
-Low grade Mucinous neoplasm (LAMN)
-High grade mucinous neoplasm (HAMN)
-Mucinous adenocarcinoma

2) Non-mucinous epithelial neoplasm (adenoma/adenocarcinoma)
3) Epithelial with neuroendocrine features (NET or Goblet cell)
4) Mesenchymal neoplasms

(Peritoneal Surface Oncology Group International (PSOGI) Guidelines 2021)

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32
Q

What tumour markers should be measured in appendiceal PMP?

A

CEA + CA19-9 +/- CA125

(Peritoneal Surface Oncology Group International (PSOGI) Guidelines 2021)

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33
Q

What is the risk of synchronous tumours when colonic cancer is diagnosed?

A

3-5%

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34
Q

When should a right hemicolectomy be performed for goblet cell carcinoma of the appendix?

A

Any of:

Not Tang A
Tumour ≥20mm
Involved margins
Mesoappendix invasion ≥3mm
V1/L1
Ki62>2%

If perforated consider adjuvant CRS/HIPEC

(Peritoneal Surface Oncology Group International (PSOGI) Guidelines 2021)

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35
Q

If a pseudomyxoma is suspected as an incidental finding at surgery, how should it be managed?

A

Appendicectomy (?caecetomy?lymph node resection) + sampling of mucin

Avoid right hemicolectomy

(Peritoneal Surface Oncology Group International (PSOGI) Guidelines 2021)

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36
Q

In patients where pseudomyxoma is suspected who are undergoing a laparoscopy, where should trocars be placed?

A

In the midline, so incisions can be excised

(Peritoneal Surface Oncology Group International (PSOGI) Guidelines 2021)

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37
Q

When is CRS/HIPEC indicated with a completely excised LAMN?

A

pM1a/pM1b - acellular/cellular mucin PCI≤3

A right hemicolectomy is not indicated

(Peritoneal Surface Oncology Group International (PSOGI) Guidelines 2021)

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38
Q

When should a right hemicolectomy be performed with a HAMN?

A

Probably in all cases, definitely if perforated.

Similar for CRS and HIPEC

Also for mucinous adenocarcinoma and GCC

(Peritoneal Surface Oncology Group International (PSOGI) Guidelines 2021)

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39
Q

What defines complete cytoreduction?

A

CC0 - no visible disease or
CC1 - remaining nodules <2.5mm

achieved in 73.8% –> 87.4% 5 year survival

(Peritoneal Surface Oncology Group International (PSOGI) Guidelines 2021)

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40
Q

What are the absolute (2) and relative (6) contraindications to cytoreductive surgery?

A

Absolute:
- Extensive small bowel serosal involvement
- Mesenteric involvement causing retraction

Relative:
- Age>75
- Aggressive histologies - high grade with signet ring, mucinous, GCC, PCI>20
- Involvement of liver hilum
- Infiltration of anterior pancreatic surface
- Ureteric obstruction
- Need for total gastrectomy

(Peritoneal Surface Oncology Group International (PSOGI) Guidelines 2021)

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41
Q

How should ovaries be managed in patients with appendiceal PMP?

A

In postmenopausal women bilateral salpingoophrectomy, probably in premenopausal too

(Peritoneal Surface Oncology Group International (PSOGI) Guidelines 2021)

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42
Q

What imaging is indicated for patients with suspected primary hyperparathyroidism?

A

Usually Ultrasound and Sestamibi scan.

SPECT may be useful, particularly if reoperation is being considered

If not localised or scans discordant, consider 4 gland exploration anyway, no need for further scans first.

NICE (2019)

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43
Q

How can primary hyperparathyroidism be differentiated from familial hypocalciuric hypercalcaemia?

A

24 hour urinary calcium excretion or
random renal calcium:creatinine excretion ratio
Random serum calcium:creatinine clearance ratio (>0.01)

NICE (2019)

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44
Q

When should surgery be considered in patients with primary hyperparathyroidism?

A

adjusted Ca>2.85 or

symptoms of hypercalcaemia or
end organ disease (renal stones, fragility fractures or osteoporosis - t score -2.5 or less

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45
Q

How should patients be followed up after parathyroidectomy?

A

adjusted Ca and PTH before discharge
adjusted Ca at 3-6 months and then annually if normal

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46
Q

When is cinacalcet indicated for primary hyperparathyoidism?

A

If surgery failed or inappropriate and:

aCa>2.85 + symptomatic
aCa>3 regardless

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47
Q

Why does a thyroglossal cyst move on extension of tongue?

A

Arises from descent from foramen cecum of tongue

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48
Q

What are the likely positions of the superior parathyroid gland?

A

1) In fat pad on thyroid surface caudal to inferior thyroid artery
2) Inferiorly behind inferior thyroid artery and oesophagus
3) behind upper pole

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49
Q

What are the likely positions of the inferior parathyroid gland?

A

1) Along thyrothymic axis (30%)
2) Under capsule of lower thyroid pole (50%)
3) down to accessible mediastinal thymus
4) within carotid sheath
5) intrathymic
6) within thyroid lobe

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50
Q

What is the recommended first line treatment for Graves disease?

A

If mild and uncomplicated –> Carbimazole (12-18months) or radioiodine
If severe radio iodine

Surgery, only if concerns re compression, malignancy or others unsuitable

NICE (2019)

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51
Q

What is the recommended first line treatment for toxic nodular goitre?

A

Radioactive iodine.

If unsuitable, total thyroidectomy or antithyroid drugs

NICE (2019)

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52
Q

When should propylthiouracil be considered over carbimazole?

A
  • patients with allergy to carbimazole
  • pregnant or within 6 months
  • history of pancreatitis

Do not use either if history of agranulocytosis

NICE (2019)

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53
Q

What is Conns syndrome?

A

Primary aldosteronism - 33% adenoma, 66% bilateral adrenal hyperplasia
For adenoma –> surgery, bilateral –> spironolactone

Present with hypertension, depressed renin-angiotensin axis, hypokalaemia (increased urinarly losses)

Plasma aldosterone:renin ratio is diagnostic

about 5-10% of hypertensive patients

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54
Q

What is the embryological origin of the inferior parathyroids?

A

Third pharyngeal pouch, along with the thymus

Supplied by glossopharyngeal nerve (IX)

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55
Q

What is the embryological origin of the superior parathyroids?

A

Fourth pharyngeal pouch, along with parafollicular thyroid C-cells + larynx

supplied by superior laryngeal nerve (vagus derivative)

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56
Q

What is the staging peculiarity for patients with differentiated thyroid cancer?

A

Patients under 45 are all stage 1 if M0 and stage 2 if M1.

Stages 1-3 have a 10 year survival of >98%

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57
Q

What is the incidence of permanent recurrent laryngeal nerve injury after total thyroidectomy?

A

0.2%

2% risk of permanent hypocalcaemia

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58
Q

What proportion of patients with sporadic hyperparathyroidism have a single adenoma to explain their symptoms?

A

85%

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59
Q

What is the most useful biomarker of medullary thyroid disease?

A

Calcitonin - derived from the parafollicular C-cells

Can be used to screen in familial cases and monitor for metastatic disease

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60
Q

What proportion of patients with an adrenal nodule <4cm will have a carcinoma?

A

2%

25% >6cm

Age, sex, FH and functional studies are not a reliable indicator of malignancy

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61
Q

What is the incidence of pheochromocytoma in adrenal incidentalomas?

A

about 5%

30% of phaeos are diagnosed in this fashion

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62
Q

What is the genetic abnormality in Li-Fraumeni syndrome?

A

Autosomal dominant p53 mutation
- Sarcoma
- Breast cancer
- Leukaemia
- Adrenocortical adenocarcinoma

SBLA syndrome

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63
Q

What are the common manifestations of MEN-1?

A

Parathyroid, pituitary and pancreatic tumours, foregut carcinoids

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64
Q

What are the common manifestations of MEN2a?

A

Parathyroid adenomas, Medullary thyroid cancer, pheochromocytoma

RET oncogene mutation

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65
Q

What are the common manifestations of MEN2b?

A

Mucosal neuromas, marfinoid habitus, Medullary thyroid cancer, pheochromocytoma

RET oncogene mutation

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66
Q

How is malignant phaeochromocytoma diagnosed?

A

Requires presence of distant metastases

Likelihood is increased by 3+ of Weiss criteria.

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67
Q

What is the other name for Chronic Lymphocytic thyroiditis?

A

Hashimotos disease (hypothyroidism, elevated thyroid autoantibodies)

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68
Q

What is deQuervain’s thyroiditis?

A

Post viral thyroiditis - treat with NSAIDs +/- beta blockers if necessary

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69
Q

What is Reidel’s thyroiditis?

A

Woody hard swelling of thyroid as an isolated abnormality
F>M
Usually treat with high dose steroids

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70
Q

Which type of thyroid cancer characteristically metastasises by the haematogenous route?

A

Medullary

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71
Q

When does tertiary hyperparathyroidism require surgery?

A

If persists >12 months beyond resolution of CRF - about 40%

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72
Q

How are thyroglossal cysts best treated?

A

Due to recurrent infection, formal excision with part of hyoid bone (Sistrunk procedure)

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73
Q

What is the gender disparity of thyroid nodules?

A

5:1 F:M

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74
Q

What are risk factors for a thyroid nodule being malignant?

A
  • Age <20 or >60
  • ‘Firmness’
  • Rapid growth
  • Fixation to adjacent structures
  • Vocal cord paralysis
  • Lympadenopathy
  • History of neck irradiation
  • History of Hashimotos (lymphoma)
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75
Q

When should a core biopsy of a thyroid lump be performed?

A

If lymphoma is suspected, otherwise FNAC

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76
Q

How are USS findings for thyroid nodules graded?

A

U1-U5

FNAC for 3-5, discharge 1-2 unless other risk factors

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77
Q

How are thyroid nodule FNACs categorised?

A

Thy 1 - non diagnostic –> repeat
Thy 2 - benign –> no follow up
Thy 3F - follicular lesion –> hemithyroidectomy (with isthmus) or total thyroidectomy
Thy 3A - atypia -> repeat, if still present –> hemithyroidectomy
Thy 4 - suspicious –> diagnostic hemithyroidectomy
Thy 5 - malignant –> total thyroidectomy

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78
Q

In PTC/FTC, when is hemithyroidectomy sufficient?

A

<4cm, age <45, no other high risk factors (inc not pT3/T4a)

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79
Q

When should a level 6 lymph node dissection be conducted in PTC?

A

High risk cancers, or if lateral or other nodes confirmed to be involved

Cervical lymph nodes should be managed by selective node dissection

For FTC, only conduct level 6 nodal dissection if nodes are clinically involved

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80
Q

What treatment do patients require after total thyroidectomy for cancer?

A

Suppressive doses of levothyroxine 20ug/kg or liothyronine
Calcium check within 24 hours

Thyroglobulin >6weeks post surgery and then 6-12 monthly

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81
Q

When is I131 ablation performed after total thyroidectomy for cancer?

A

In all cases, unless tumour <1cm or minimally invasive with either no high risk papillary forms or medullary

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82
Q

What proportion of cases of medullary thyroid cancer are familial?

A

25% (MEN2a, MEN2b, Familial MTC) - therefore screening for RET mutation

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83
Q

Where MTC is suspected what preoperative investigations are required?

A

Calcitonin, CEA
Urinary metanephrines (24hr)
Calcium and PTH
CT/MRI/USS neck
RET (?after surgery)

84
Q

What is the recommended surgical treatment of medullary thyroid cancer?

A

Total thyroidectomy with central compartment node clearance (level 6), even in the presence of disseminated metastasis

If there are central lymph node metastasis, ipsilateral neck dissection should be performed (70% involved)

All T2-T4 tumours also have bilateral selective neck dissections (IIa-Vb)

85
Q

What USS features are suggestive of thyroid malignancy?

A

Hypoechoity
Microcalcifications
Lymphadenopathy
Loss of halo
Irregular margins

86
Q

What are the histological features of papillary thyroid cancers?

A

Most common sub type

Psammoma bodies (microcalfication)
Orphan Annie Nuclei

Metastasise via lymphatics

87
Q

What are the skin manifestations of Glucagonoma?

A

Necrolytic migratory erythema (70%)
(erythematous blisters of abdomen/buttocks with irregular border and intact/ruptured vesicles)

Serum glucagon of >1000pg/ml
produced by alpha cells

90% malignant

88
Q

How should incidental adrenal lesions be managed?

A

75% non-functioning adenomas
Risk of malignancy related to size - if >4cm, 25% malignant
If suspected metastasis then biopsy as long as not phaeo
Otherwise excise or monitor

Also needs:

Cortisol (morning/midnight)
1mg overnightDexamethasone suppression test - Cushing?
24 hour urinary cortisol and metnephrines - Phaeo
Serum potassium (low) aldosterone (high) and renin (low) levels - Conns

89
Q

What is the risk of hypocalcaemia following thyroidectomy?

A

5% requiring treatment, 80% resolve over 12 months (therefore 1-2% at 12 months)

90
Q

Which tumour type is most likely to metastasise to the thyroid?

A

Renal cell carcinoma - clear cell morphology

91
Q

How does PTH cause its effects?

A

Secreted by parathyroid chief cells
Increases calcium level by:

Bone - Osteoblast binding –> osteoclasts –> bone resorption
Kidney - active reabsorption of ca and mg from distal convoluted tubule
Intestine via kidney - increasing activated Vitamin D

Increases activity of 1-a-hydroxylase enzyme (converts 25-hydroxycalciferol to 1,25-dihydroxycholecalciferol)

92
Q

Which antibiodies are seen in patients with Hashimotos and Graves disease?

A

Hashimotos - Thyroid peroxidase (100%)
Graves - Thyroid peroxidase (70%), TSH receptor (95%)

93
Q

For patients with suspected parathyroid cancer on USS, what is the optimum treatment?

A

Straight to surgery, no tissue diagnosis.
Hemithyroidectomy + gland - 89% 5 year survival

Gland only 53% 5 year survival

94
Q

How does Aldosterone exert its effects?

A

Produced by Zona glomerulosa of adrenal

Controls sodium reabsorption in distal renal tubule via Na+/K+ and H+ pumps

95
Q

Where are thyroglossal cysts most commonly found?

A

Immediately Inferior to hyoid bone

96
Q

What are the types of Cushings syndrome?

A

ACTH dependent - pituitary (Cushing disease) or ectopic (mostly lung ca)
ACTH independent - adenoma/carcinoma of adrenal

97
Q

How is Cushings disease investigated?

A

24 hour urinary cortisol
Dexamethasone suppression test (CT/MRI)

98
Q

What medical treatment is effective for advanced/mestastatic adrenal cortical cancers?

A

Mitotane

99
Q

What histological findings are often seen in Follicular carcinoma of the thyroid?

A

Hurthle cells (adverse prognosis)

100
Q

What is the most common presentation of Cushing syndrome?

A

Obesity 95%
Hirsuitism/hypertension 80%
Myopathy 60%
Buffalo hump 55%
Easy bruising 40%

101
Q

Which thyroid tumour type is most common after non- therapeutic irradiation?

A

Papillary

102
Q

What morphological charactestics on CT suggest a benign adrenal lesion?

A

Homogenous and lipid rich

HU<10 and less than 4cm, no further imaging

103
Q

In patients with indeterminate adrenal lesions, what are indications for excision?

A

Increase in size by >20% + at least 5mm in 6-12 months

104
Q

What additional tests should be performed for patients with bilateral adrenal nodules?

A

17-hydroxyprogesterone (exclude CAH)

105
Q

What is the most common aetiology of an adrenal incidentaloma?

A

80% Adenoma (75% non functioning, 12% cortisol secreting, 2.5% aldosterone)
7% Phaeochromocytoma
8% Adrenocortical carcinoma
5% Metastasis

106
Q

What are the chraracteristic findings of benign adrenal lesions on CT?

A

<4cm, <10Hu, >60% contrast washout

107
Q

What enzymes are affected in CAH?

A

11a hydroxlase - aldo/test
17a hydroxylase - aldo
21ahydroxylase - test

108
Q

What is the chloride to phosphate ratio in hyperparathyroidism?

A

Elevated, at >33

109
Q

Which neuroendocrine tumours tend to present at youngest age?

A

Appendiceal - median 39 (39% male)

Most others are mid-late 60s

110
Q

What is the most frequent type of NET?

A

Lung > SB > Appendix

111
Q

Which NETs are more common in women (3)?

A

Appendix, caecum and lung

Women have a globally much better prognosis than males? why

112
Q

What are the causes of diarrhoea in patients with NET (6)?

A

Pancreatic malabsorption
short bowel
drug related
bile salt related
bacterial overgrowth
hormonal (gastrin or 5-HT)

113
Q

How should patients with NETS be managed perioperatively?

A

Consider octreotide IV/infusion

If non functioning - IV if major surgery
If history carcinoid will need IV for minor surgery (inc biopsies) and preop infusion for major

114
Q

Where can NETs occur (3)?

A

1) Isolated neuroendocrine cells (bronchopulmonary, GI tract, skin)

2) Aggregates of neuroendocrine cells (pancreatic islets)

3) Classic endocrine glands (adrenal, pituitary)

115
Q

What proportion of gastrointestinal NETSs are ‘functioning’?

A

about 30%

This is a difficult distinction though because they often release hormones when handled anyway

116
Q

What proportion of patients with Small bowel NETs have carcinoid disease?

A

20% - 20% of these have carcinoid heart disease (check pro-BNP)

117
Q

How long should patients with small bowel NETs be followed up for?

A

Minimum of 8 years - life

118
Q

What is the differential diagnosis of an adrenal incidentaloma?

A

Functional
-cortex - adenoma, nodular hyperplasia, carcinoma
-medulla - phaeochromocytoma, ganglioneuroma/blastoma

Non-functional
-Adrenal masses - lipoma, cyst, haematoma, harmartoma, teratoma, amyloid, neurofibroma
-Metastases - breast, lung, lymphoma, renal
-Leukaemia

119
Q

What investigations should be performed for an adrenal incidentaloma?

A

-Standard bloods
-Urinary/plasma metanephrines
-Overnight dexamethasone suppression test
-If hypertensive renin/aldosterone levels
-If virilised plasma sex steroids

120
Q

What are the characteristics of a benign adrenal lesion on CT?

A

HU<10 and 60% contrast washout at 15 minutes

121
Q

What are the indications for completion thyroidectomy after lobectomy for T3F?

A

If confirmed follicular carcinoma and any of:

Large tumour >4cm
Extracapsular extension/angioinvasion
Hurthle cell (secretes thyroglobulin)

122
Q

What proportion of Insulinomas are benign?

A

About 90% therefore can be treated with enucleation. CF glucagonomas, which are usuallyy malignant

Best diagnostic test is EUS
5-10% have MEN1
75% of those with MEN1 will have Pancreatic Islet tumours

123
Q

How should adrenal incidentalomas be assessed for cortisol excess?

A

1mg overnight Oral Dexamethasone test

If Cortisol <50 - normal
51-138 - possible
>138nmol/L probable (low ACTH)

124
Q

What additional treatment will patients receiving Mitotane require?

A

Steroids - as lyses normal side as well

125
Q

What proportion of U5 thyroid lesions are malignant?

A

80%

126
Q

In which situations is monitoring of thyroglobulin inaccurate?

A

Remaining thyroid
Positive thyroid antibodies (can monitor trend)

127
Q

What proportion of patents with Graves disease have eye signs?

A

30% - chemises, proptosis, opthalomplegia

(nb lid lag present in all thyrotoxicosis)

128
Q

What are the broad indications for surgery in primary hyperparathyroidism?

A

Any <50
>50 if symptomatic or end organ damage

129
Q

How often are Thy3f malignant on final histology?

A

About 20%

130
Q

From which thyroid cells does thyroglobulin originate?

A

Follicular

131
Q

Where is the largest store of body Calcium?

A

Bones!

132
Q

What are the effects of PTH?

A

-To increase Ca and decrease PO4
-Immediate action on osteoblasts to increase Ca, also they signal the osteoclasts to resorb bone
-Increase renal tubular absorption of caclium
-Increased synthesis of 1,25(OH)2D –> bowel absorption
-Decreased renal phosphate

133
Q

Where is Calcitonin made?

A

C- cells of thyroid

134
Q

Which type of parotid malignancy has the worst outcomes?

A

Adenoid cystic (5 year 35%)

Acinic cell 80%, Adenocarcinoma up to 75%

135
Q

Between which muscles does a pharyngeal pouch occur?

A

Thyropharyngeus and cricopharyngeus

136
Q

From which branchial structure do branchial cysts originate?

A

2nd branchial cleft

137
Q

What proportion of CO goes to the kidney?

A

About 25%

138
Q

How is the GFR calculated?

A

(Conc of solute in urine x volume of urine/min)/plasma conc

Total volume of plasma leaving capillaries –> Bowman’s capsule

139
Q

What substances are absorbed in the proximal convoluted tubule?

A

-Glucose, amino acid, phosphate co-transported with Na+ and water
- Up to 2/3 of water

140
Q

What substances are regulated at the distal convoluted tubule?

A

Sodium
Potassium
H+
Calcium

141
Q

Describe the physiology of the Loop of Henle?

A

-Isotonic fluid enters LoH
-Thin descending limb permeable to water but not Na/CL
-Thin ascending limb impermeable to water but permeable to ions
-Thick ascending limb active resorption of na and cl ions

142
Q

What factors stimulate renin release?

A

From juxtaglomerular cells –> angiotensinogen to angiotensin 1

-Hypotension (reduced RPP)
-Hyponatraemia
-Sympathetic nerve stimuation
-Catecholamines
-Erect posture

143
Q

What drugs reduce renin secretion?

A

Beta blockers
NSAIDs

144
Q

What factors are likely to make postoperative renal failure more likely?

A

-Elderly
-PVD
-High BMI
-COPD
-Vasopressors
-Nephrotoxic medication
-Emergency surgery

145
Q

What are the characteristics of prerenal renal failure?

A

Kidneys retain sodium,

Therefore

Urine sodium low (<20mmol/l)
Urine concentrated (>1.5 osmolality ratio) with high SG

146
Q

What are the types of testicular cancer?

A

95% Germ cell tumours
- Seminoma (commonest)
-NSGT (42% - teratoma, yolk sac, choriocarcinoma, mixed germ cell)

147
Q

What are the features of testicular seminoma?

A

Normal AFP
HCG/LDH elevated in 10-20%

Advanced disease 5- year 73%

Sheet like lobular patterns of cells with fibrous component and septa.

148
Q

What are the features of testicular NSGT?

A

Younger (20-30)
Worse prognosis
May need retroperitoneal lymph nod dissection

AFP raised in 70%
40% HCG

Heterogenous texture

149
Q

What drug can characteristically cause epididymitis?

A

Amiodarone

150
Q

What is the peak incidence of testicular torsion?

A

13-15 years

151
Q

What is the most common cause of acute epidiymo-orchitis?

A

Chlamydia

152
Q

What are indications for commencement of dialysis?

A

Intractable hyperkalaemia
Acidosis
Uraemia symptoms (nausea, pruritus, malaise)
Therapy resistant fluid overload
CKD 5

153
Q

What are the borders of the anterior triangle of the neck?

A

Anterior border of SCM
Lower border of Mandible
Anterior midline

154
Q

What sub triangles are contained within the anterior triangle?

A

Digastric Triangle (Submandibular gland/nodes, facial vessels, IX)
Muscular triangle (Straps, EJV)
Carotid Triangle (carotid sheath, ansa cervicali)

155
Q

What is the blood supply of the parathyroids?

A

Inferior thyroid artery, inserting medially

156
Q

What is the blood supply to the thyroid?

A

-Arterial
Superior thyroid artery - 1st branch from external carotid artery (Superior Laryngeal Nerve)
Inferior thyroid artery - thyrocervical trunk (RLN)

-Venous
Superior thyroid vein - IJV
Middle thyroid vein - IJV
Inferior thyroid vein - brachiocephalics

157
Q

How does parasympathetic and sympathetic stimulation affect the parotid gland?

A

Para - water saliva
Symp - enzymatic

158
Q

What muscles are controlled by Trochlear and Abducens CNs?

A

SO 4 LR 6

159
Q

Which is the largest cranial nerve?

A

Trigeminal
- ophthalmic
- maxillary
- mandibular (sensory/motor)

160
Q

What nerves supply taste to the tongue?

A

Anterior 2/3 - Facial
Posterior 1/3 - Glossopharyngeal

161
Q

What are the borders of the posterior triangle of the neck?

A

Anterior - post SCM
Posterior - anterior Trap
Base - middle 1/3 of clavicle

162
Q

What are the contents of the posterior triangle of the neck?

A

-Nerves
Accessory nerve
Phrenic nerve
Three trunks of brachial plexus
- Vessels
EJV
SCA
-Muscles
Inferior belly of omohyoid
Scalene

163
Q

Which embryological structures does the vagus supply?

A

4th/6th pharyngeal arches (fore/midgut sections of embryonic gut tube)

164
Q

What is the lymphatic drainage of the tongue?

A

Anterior 2/3 ipsilateral submental –> deep cervical
Posterior 1/3 bilateral submandibular –> deepcervical

165
Q

From which structures are the coverings of the spermatic cord formed?

A

Internal spermatic fascia –> Transversalis
Cremastic fascia –> IO
External spermatic fascia –> EOA

166
Q

What are the contents of the spermatic cord?

A

Three vessels
- Testicular artery
- cremasteric artery
- artery to vas

Three other
- vas deferens
- pampiniform plexus
- lymphatics

Three nerves
- genital branch of genitofemoral
- sympathetic
- ilioinguinal (on outside)

167
Q

What are the four parts of the male urethra?

A

Pre-prostatic
Prostatic
Membranous (narrowest, external sphincter)
Penile (longest)

Transitional urothelium –> squamous distally

168
Q

What are the histological findings for anaplastic thyroid carcinoma?

A

Rhabdoid cells, multi nucleation, nuclear pleomorphism

169
Q

what is the most common pancreatic tumour in MEN1?

A

Gastrinoma > Insulinoma

170
Q

On which bones is a DXA scan performed?

A

Radius
Upper Lumbar spine
Lower Lumbar spine
Hip

171
Q

What can increase 5 HIAA levels?

A

-Food
Avocados
Bananas
Kiwi
Plantains
Tomatoes
-Medicines
Paracetamol

172
Q

What can decrease 5HIAA levels?

A

Heparin
MAOIs
Aspirin

173
Q

What is the agent of choice for metastatic medullary thyroid cancer?

A

Vandetanib (TKI) also cabozantinib

174
Q

How should patients with adrenal cancer be followed up?

A

3 monthly CT for 2 years

175
Q

What adjuvant treatment should be considered for adrenal cancers?

A

Mitotane if Ki67>10%
+ Radiotherapy if Stage 3/R1

176
Q

In thyroidectomy, what factors increases the risk of postoperative hypocalcaemia?

A

Central node dissection (20–>35%)

177
Q

What is the result of a low dose dexamethasone suppression test in Cushings?

A

Lack of suppression of cortisol

178
Q

How are the results of the high dose dexamethasone suppression test interpreted?

A

If suppresses
- Pituitary tumur (CD)

If not then:
-Ectopic ACTH
-Adrenal adenoma

179
Q

What is the most common presentation of hyperparathyroidism?

A

Fatigue (>stones/asymptomatic)

180
Q

What happens to potassium with Cushings?

A

Hypokalaemia - weak mineralocorticoid effect

181
Q

What is the most common cause of Cushings after steroids?

A

Pituitary adenoma

182
Q

How frequently is a serum calcium of <2.1 on POD 1 seen after thyroidectomy?

A

25%

183
Q

When should a paediatric hydrocele be fixed?

A

IF not going by 2-3 years

184
Q

How should Thy1 results be managed?

A

Repeat FNAC, usually after 3 months to allow inflammation to settle

185
Q

With a normal calcium on POD 1 after thyroidectomy, what supplemental calcium is required?

A

None

186
Q

How should patients be prepared for radio iodine remnant ablation post thyroidectomy?

A

Suppression of TSH, so:

-Levothyroxine (e.g. 100mcg OD) then stop 4 weeks prior
-Liothyronine (e.g. 20mcg TDS) then stop 2 weeks prior
-Low iodine diet post stopping
-Could have levo followed by Lio if timings work
-Could continue Levo then give recombinant TSH at 48/24hours prior

187
Q

How do the parathyroids relate to the RLN?

A

Superior above and lateral
Inferior below and medial

188
Q

In which patients after thyroidectomy is hypocalcaemia most common?

A

Hungry bone syndrome - screen with ALP (also check and replace Vit D)

189
Q

What is the blood supply to the adrenal?

A

Superior adrenal artery from inferior phrenic
Middle adrenal artery from aorta
Inferior adrenal artery from renal artery

Right –> IVC
Left –> Renal vein

190
Q

What preoperative treatment should patients undergoing pituitary surgery receive?

A

Steroids

191
Q

What history and examination findings are relevant in patients with adrenal incidentilomas?

A

Phaeo - anxiety, palpitations, headaches, hypertension
Hyperaldosteronism - hypokalaemia, hypertension
Hypercortisolism - diabetes, weight gain, hypertension

FH - Endocrinopathy (MEN)

Examination - obesity, facial plethora, hirsutism, proximal muscle weakness

192
Q

How may adrenal incidentalomas be classified?

A

Functional
Medulla- phaeo
Cortex - adenoma, carcinoma

Non-functional
Metastasis, lipoma, cyst, haematoma

193
Q

What features are important in a history and examination of thyroid goitre?

A

History
–Upper airway symptoms (Cough, stridor, SOB, change in voice)
–Dysphagia
–Rapid growth
–History of irradiation
–Thyroid symptoms (heat/cold intolerance, weight loss/gain, insomnia/tiredness)
–FH of MEN
Examination
- Dominant nodule
- Cervical lymphadenopathy
- retrosternal extension
- bruit
- tracheal deviation, signs of SVC/thoracic outlet obstruction
- thyroid eye signs

194
Q

How Is a thyroid uptake scan helpful in acute thyrotoxicosis?

A

Uptake bilateral - Graves
Uptake unilateral - toxic nodule/adenoma
No uptake - thyroiditis

Carbimazole for 6 weeks, if urgent need then potassium iodide and propranolol for 7-10 days

195
Q

What is Ki-67?

A

Marker of cell proliferation

196
Q

What is the differential diagnosis of a parotid lump?

A

Benign
–Pleomorphic adenoma
–Warthin tumour
–Lipoma
–Neuroma

Malignant Primary
– Adenoid cystic
– Adenocarcinoma
– Mucoepidermoid
– SCC
– Acinic cell carcinoma

Malignant Secondary (SCC, Lymphoma)

197
Q

How is MEN1 hyperparathyroidism characterised?

A

–Multigland disease, hyperplasia and adenomas.
–Often ectopic and supernumerary
–Subtotal/total + cervical thymectomy

198
Q

What is the risk of complications after thyroidectomy?

A

Hypoparathyroidism/hypocalcaemia 20% transient, 4% permanent
RLN damage 5-10% temporary, 2% permanent, 0.5% bilateral
((can treat with injection of vocal cords with autologous fat))
Superior laryngeal N. 0.5%
Haemorrhage –> theatre 1-2%

199
Q

How is recurrent Medullary Thyroid cancer managed?

A

Surgery if feasible
Chemotherapy and radiotherapy can be used but less effective

Tyrosine Kinase inhibitors e.g. Cabozantinib and Vandetinib now licensed

200
Q

How is recurrent differentiated Thyroid cancer managed?

A

Papillary or follicular

Surgery if feasible
Chemotherapy or radio-iodine

Can use Lenvatinib (VEGFR)/ sorafenib, then cabozantinib

201
Q

What are the complications of adrenalectomy?

A

Overall about 10%
Mortality <0.5%
Major haemorrhage requiring transfusion 5%
Damage to viscera - pancreas, liver, kidneys, diaphragm 2%
Addisonian crisis <1%

202
Q

What are the subdivisions of the anterior triangle of the neck?

A

Muscular
Carotid
(posterior belly of digastric)
Submandibular
Submental

203
Q

What are the boundaries of level 6 neck nodes?

A

Inf- manubrium
Sup - hyoid
Ant - platysma
Post - prevertebral fascia/trachea

204
Q

What are branchial cleft cysts?

A

Anomalies arising from 1-4th branchial clefts
Most common is 2nd (anteromedial to superior SCM), may be associated with IX and XII
1 - Parotid area, 3-middle SCM, 4 lower SCM

Present as cysts, sinuses or fistulae
Do USS +/- CT
Excise (infection, malignancy), can do blue dye or fistula probes

205
Q

What is the mechanism of carbimazole and how can it cause agranulocytosis?

A

Thyroid peroxidase inhibition (iodination of tyrosine residues in thyroglobulin)

Causes agranulocytosis via direct toxicity with reactive oxygen species and possibly by immune reactions with ANCA

206
Q

What are the types of nerve injury?

A

Sunderland Classification
Grade 1 - neuropraxia
Grade 2 - axontmesis
Grade 3-5 - neurotmesis

207
Q

How should you examine a neck?

A

–Inspection
General – scars, cachexia, dyspnoea/stridor/hoarseness/exophthalmos
Neck Lump – anterior/posterior triangle, movement on swallowing or tongue protrusion
–Assessment of lump
Site, size, shape, consistency, mobility/fixity
Pulsatility/bruit, tenderness, transillumination
–Palpate all lymph node basins
–Examine thyroid from behind – general, tongue, swallow

FRCS General Section 1/2 (13 decks)

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