endocrine Flashcards
adrenal blood supply (arterial and venous)
- arterial: 1) superior from inf phrenic 2) middle from aorta 3) inferior from renal artery)
- venous: Right –> IVC, Left –> left renal v
normal adrenal echogenicity
- oreo
- smooth
NB US appearance
- enlarged
- hyperechoic (or anechoic)
- Ca
trauma related adrenal hemorrhage
adults
R>L
adrenal hyperplasia app, causes
- enlarged (>20mm), one limb thickness >4mm
- cerebriform
- can sometimes lose central bright layer
- causes-21 hydroxylase deficiency (90% of neonatal HP), Cushing disease (not syndrome!)
BL solid testicular masses + congenital adrenal HP
adrenal rests
adrenal lesions
- adenoma
- adrenal carcinoma
- collision tumors
- pheo
- cysts
- mets
- hyperplasia
adrenal adenoma washout equations
- absolute: (Enhanced-Delayed)/Enhanced-Unenh x 100. >60% = adrenal adenoma
- relative: (Enh-delayed)/Enh x 100, > 40%=adenoma
pheo appearance
- same as adenoma (homogeneously enhancing lesion with washout) BUT >120HU on arterial/venous
- large >3cm
- var (hem, cysts, Ca, sometimes fat) or homog
- T2+++
- enh +++
- usually cystic appearing
-what should make you think an adrenal mass is not an adenoma?
> 120 HU on arterial/venous (pheo or met-RCC, HCC)
- Ca, necrosis, hem
- size >4cm = 70% cancer, >6cm=85%
- BL large=pheo or met (lung cancer)
are most adenomas functional or non functional
non-functional
MCC Conn’s syndrome
adenoma
-carcinoma more rare and usually acc by hypercorticalism
what nukes scan for pheo
MIBG (ocreotide taken up by kidneys)
Pheochromocytoma rule of 10s
- 10% not active
- 10% extradrenal (MC IMA)
- 10% children
- 10% BL
- 10%hereditary
syndromes ass w/ pheo
- VHL
- MEN 2a, 2b
- less tested: NF1, SW, TS
Carney triad
1) GISTs
2) pulmonary chondromas (hamartomas)
3) extra adrenal pheos
carney triad ≠ carney complex!
triad:
1) GISTs
2) pulmonary chondromas (hamartomas)
3) extra adrenal pheos
complex: cardiac myxoma, skin pigmentation
myelolipoma img
- bulk fat +/- Ca
- hem if >4cm
- herecho –> speed displacement artifact on US (discon’t diaphragm)
speed displacement artifact myelolipoma
-sound travels slower in fat relative to soft tissue –> confuses machine and results in discon’t diaph
adrenal tumors with Ca
- Nb
- myelolipoma
- cortical Ca
- Melanoma mets (known to Ca)
adrenal Ca
- trauma
- inf (tb)
- tumors
- woman dx
mets to adrenal glands
- lung, breast, melanoma
- can looks like lipid poor adenomas
Cortical carcinoma appearance
- large (4-10cm) (v unlikely to be <5cm)
- Ca (20%)
- nasty looking _ mets (dir invasion!)
wolman dx
BL enlarged Ca adrenals
*fat metabolism error –> death bf 1yo
MEN syndromes
*Multiple Endocrine Neoplasia
1) Piter Pan Parts from Menhood-pituitary, pancreas (gastrinoma MC), para HP (90%)
2A) Adrenal (pheo), Aggressive thyroid (medullary), A lot of Ca (parathyroid)
2B) it’s a wanaBe, so it’s the same But it has Beef with Ca so instead of parathyroid it decided to Be a Gangster (ganglioneuroma)
how common is carcinoid syndrome
10%
Urine test for carcinoid
5-HIAA
nukes test of choice for carcinoid
ocreotide (MIBG also positive but <25%), Gallium+ but not spect
Carcinoid effect on heart
serotonin degrades R heart valves
thyroid nodule micro vs macro Ca ass tumors
micro=HM for papillary
macro=medullary
mal vs benign vascularity patterns thyroid nodules
- per=benign
- central=mal
utlility of zyckerkandl tubercle (pst nodular extension of thyroid)
locate recurrent laryngeal n (n is medial to it)
is size predictive of thyroid mal
No but mal tumors >1.5cm
comet tail artifact
colloid thyroid cyst
etiology of acute suppurative thyroiditis in a kid
infection of 4th brachial cleft anomaly (usually L) travel via pyriform fistula –> thyroid
thyroid conditions to consider
- nodule (benign, mal)
- goiter (MN, graves, Hashimoto, low iodine in 3rd world)
- subacute thyroiditis/de quervains thyroiditis
- acute suppurative thyroiditis
- reidels thyroiditis
- thyroglassal duct cyts
- ectopic lingual thyroid
subacute thyroiditis/de quaervains thyroiditis
- young woman, painful s/p URI
- pregnant, painless
TGDC locations to to hyoid
- suprahyoid 25%
- at the hyoid 30%
- infrahyoid 45%
risk of cancer ectopic/lingual thyroid
- papillary
- 3%
hashimotos appearance
1) giraffe skin
2) white knights (hyperechoic nodules that are actually regenerative nodules)
Features vary with different stages of disease and extent of involvement (i.e., diffuse vs. focal)
1) Acute, focal: Discrete nodules occur in equal frequency against normal or altered background thyroid parenchyma
2) Acute, diffuse: Diffuse, hypoechoic, heterogeneous, micronodular echo pattern involving entire gland
* diffuse gland enlargement/hypoecho w/ micronodular pattern + bright linear fibrous septa
3) Chronic: Enlarged, hypoechoic, micronodular gland with lobulated outlines; diffuse, hypoechoic, parenchymal echoes (ghost-like thyroid) ± echogenic fibrous septa
4) Atrophic/end stage: Small, hypoechoic gland with heterogeneous echo pattern
delphian nodes
- nodes ant to thyroid
- enlarged w/ Hashimoto
- sick looking=laryngeal met
thyroid cancer type breakdown
1) papillary
2) follicular
3) medullary
4) anapestic
5) Hurthle cell
thyroid cancer type breakdown
1) papillary- microCa, Lymph spread
2) follicular-Hematog spread resp less to I-131, but still good.
- hyper echo + hypoechoic rim
- no Ca
3) Hurthle cell (follicular variant)-elderly. doesn’t respond well to I-131 (FDG-PET for surveillance)
- indist from follicular. Can be more hypo echo (unlike other follicular)
4) medullary- MEN (calcitonin). Local invasion, L/H. Doesn’t respond well to I-131.
- macroCa
5) anaplastic-elderly s/p Rad rx. Fast growing. Lymph spread. Doesn’t respond well to I-131.
- diffuse, avascular/necrotic, ugly
thyroid metastasis to other orgns
- microCa in a LN
- hyperechoic, hyerenchancing, T1+
- miliary pattern in lungs (pulmonary fibrosis is a risk of treating w/ I-131 if you have diffuse mets)
parathyroid anatomy-org of sup and inf glands
- super: 4th branchial pouch
- inf: 3rd branchial pouch. Most likely to be ectopic
HyperPTH causes
- hyperfunctioning parathyroid (90%)
- Hyperplasia (8-10%)
Parathyroid on ct enhanced scan
-early arterial wash in and delayed wash out
parathyroid adenoma vs carcinoma
carcinoma uncommon (1% hyperPTH) -looks v sim to adenoma BUT cervical adenopathy, invasion of adjacent structure
hashimotos- MOA
anti thyroid peroxidase (TPO) and anti thyroglobulin
char US of papillary thyroid cancer
hypoechoic
solid
microCa
char US of follicular thyroid CA
hyperechoic
thick irregular halo
ø Ca
char US of thyroid lymphoma
hypoecho
ø Ca
staging thyroid CA via lymph nodes
N1a=level 6=central/visceral
N1b=all others
MC location extra-adrenal myelolipoma
pre-sacral (indistinguishable from liposarcoma)
cervical ca staging
T1-uterus
T2-parametrium, upper 2/3 vag
T3-lower 3rd vag or pelvic wall
T4-rectum, bladder mucosa
colloid cyst
- benign lesion w.o malignant potential
- unilocular thin walled cyst w/ comet-tail artifact
- thicker wall/multiseptated if debris/hemorrhage
anapplastic thyroid cancer app
Invasive hypoechoic thyroid mass, ± focal calcification, ± necrosis against background of multinodular goiter (MNG) in elderly female patient, ± nodal or distant metastases
- Ill-defined, hypoechoic tumor diffusely involving entire lobe or gland
- Background of MNG or differentiated thyroid carcinoma (DTCa)
-Necrosis (78%), dense amorphous calcification (58%)
Extracapsular spread with infiltration of trachea, esophagus, and perithyroid soft tissues and nerves
Thrombus in internal jugular vein (IJV) and carotid artery (CA), causing expansion and occlusion of vessels
Nodal or distant metastases in 80% of patients
Color Doppler shows prominent, small, chaotic intratumoral vessels
de quervians
Acute phase: Focal, ill-defined, nodular, hypoechoic, avascular/hypovascular area in subcapsular region
Subacute phase: Diffuse enlargement of 1 lobe or entire thyroid gland with multifocal, patchy/confluent, ill-defined, hypoechoic, avascular/hypovascular areas
Radioactive iodine uptake test or Tc-99m pertechnetate thyroid scan: Focal defect or large area of ↓/absent uptake due to failure of iodine trapping
Hemorrhagic Thyroid Cyst
Ddx de quervians
- rapid-onset painful goiter ± preceding history of URI with repeated coughing
- Well-defined, predominantly cystic nodule with internal debris and fluid level ± thick, avascular septa
- FNAC for decompression invariably yields altered blood
follicular adenoma vs follicular carcinoma vs Hurthle vs adenomatous nodule
*follicular lesions tend to be iso/hyper
True adenoma: Benign neoplasm of thyroid glandular epithelium with fibrous encapsulation
-Solid, homogeneous, noncalcified, well-defined, haloed, isoechoic or hyperechoic; hypoechoic is less common and has ↑ risk of malignancy
Adenomatous nodule: Focal adenomatous hyperplasia with incomplete capsule; cold nodule
US features that raise suspicion of malignant FN: Ill-defined, hypoechoic component in otherwise iso-/hyperechoic nodule, thick irregular capsule
Hürthle cell neoplasms have similar imaging characteristics to follicular nodule (FN)
parathyroid adenoma on US
oval (or flat developing long in fascial planes)
hypoecho to thyroid +/-cystic
thin echo capsule
