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ENDOCRINE Flashcards

1
Q

Painful thyroid + thyrotoxicosis

A

subacute granulomatous thyroiditis

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2
Q

Phases of subacute granulomatous thyroiditis

A

Initial hyperthyroid (similar to influenza) and low uptake on RAI uptake scans.

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3
Q

RAI uptake with Graves disease

A

Increased

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4
Q

RAI uptake with postpartum thyroiditis

A

Hyperthyroid phase

Decreased RAI uptake

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5
Q

Riedel thyroiditis

A

Rare chronic inflamm disease of thyroid that causes fibrosis of thyroid –> hard, nontender thyroid

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6
Q

Antibodies assoc with Graves disase

A

Thyroid stimulating hormone receptor antibodies

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7
Q

1.8 cm thyroid nodule –> FNA shows follicular lesion. Next stop?

A

Diagnostic lobectomy and/or molecular testing

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8
Q

Central neck LN

A

Level VI

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9
Q

Lateral neck LN

A

Level II-V

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10
Q

Primary hyperPTH + medullary thyroid CA should raise suspicion for?

A

MEN 2A - look for pheo!

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11
Q

For pts with highest risk mutation RET proto-oncogene (Men IIB) when should thyroidectomy be performed?

A

Before age 1 or at time of dx. Also check calcitonin, US and r/o pheo.

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12
Q

Bacteria in suppurative thyroiditis

A

Staph aureus or strep pyo

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13
Q

Calcitonin levels after thyroidectomy in MEN 2A

A

Slowly decrease and may not reach nadir for several months

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14
Q

Follicular neoplasm on FNA

A

Thyroid lobectomy

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15
Q

Rapidly growing thyroid mass with FNA showing large irregular lymphoid cells

A

Thyroid lymphoma - give chemoXRT (CHOP).

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16
Q

Bethesda III - next step?

A

Repeat FNA or lobectomy atypica of undetermined significance or FLUS

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17
Q

Signs that lymph node is mets

A

Malignant LN may demonstrate increased size, round shape, loss of central fatty hilum/thinning of hilum, peripheral or mixed vascualrity, presence of microcalcifications, or ill-defined margins

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18
Q

Tumor marker for PTC

A

Thyroglobulin

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19
Q

Preoperative SSKI/Lugol iodine before thyroidectomy reduces?

A

Intraoperative blood loss (decreases vascularity of thyroid gland)

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20
Q

Level III LN location

A

Middle internal jug chain
Inferior margin of hyoid to inferior margin of cricoid, anterior to posterior border of SCM, lateral to medial margin of common carotid a

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21
Q

Which medications can increase hepatic metabolism of thyroid hormone?

A

Antiepileptics (including phenobarb, carbamazepine and phenytoin). Pts on these meds often require higher than normal doses of thyroxine

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22
Q

In Men 2a, what surgery comes first?

A

Adrenalectomy

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23
Q

What size nodules do not require routine sonographic follow up

A

If purely cystic/low suspicion on US and <1 cm

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24
Q

ANtibodies assoc with Hashimoto thyroiditis

A

Antithyroid peroxidase antibodies

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25
Q

Child under 14 with thyroid nodule

A

Nearly 50% chance of malignancy

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26
Q

Increased risk of hypothyroidism after hemithyroidectomy

A

Preoperate Hashimoto dz (anti TPO antibodies)

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27
Q

How does follicular thyroid CA spread?

A

Hematogeneously

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28
Q

What size MTC warrants a CLND?

A

> 1 cm

Also: clinically positive LN, bilobe disease

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29
Q

Where do parafollicular cells derive from?

A

4th pharyngeal pouch

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30
Q

Large crowded nuclei with folded and grooved margins, intranuclear cytoplasmic inclusions

A

Papillary thyroid CA

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31
Q

Solid sheets of cells that do not contain colloid

A

Follicular CA

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32
Q

Hypercellularity and presence of eosinophilic cells

A

Hurthle cell CA

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33
Q

Sheets of infiltrating neoplastic cells heterogenous in shape and size

A

Medullary thyroid CA

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34
Q

Spindle, polygonal, giant multinucleated cells with occasional foci of undifferentiated cells

A

Anaplastic thyroid CA

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35
Q

Tx of subacute thyroiditis

A

NSAIDs or steroids

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36
Q

Child with MEN2A - when thyroidectomy?

A

Before age of 5 should have total with CLND

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37
Q

Men 2B

A

Medullary thyroid CA + Marfans + pheo + mucosal neuromas

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38
Q

MEN 2A

A

Medullary thyroid CA + primary hyperPTH + pheo

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39
Q

First mx of MEN 2A/B

A

MTC

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40
Q

What adrenal location produces most cortisol?

A

Zona fasciculata (glucocorticoids)

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41
Q

Pt with MEN1 dx with parathyroid adenoma. What is operative plan?

A

Bilateral cervical exploration with resection of 3 and 1/2 glands as well as bilateral thymectomy (higher propensity for ectopic as well as thymic tumors)

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42
Q

Pathogenesis of FHH as well as diagnosis

A

Inactivating mutations in the calcium-sensing receptor in the parathyroid glands and the kidneys –> high serum ca
-reduction in urinary Ca excretion

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43
Q

What is the CCCR ratio and what is the diagnostic value in FHH?

A

24 hr urinary creatinine excretion and serum calcium and creatinine concentrations
If <0.01 (in a vitamin D replete individual) diagnostic of FHH

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44
Q

Elevated serum cortisol and low ACTH

A

Adrenal adenoma (ACTH independent Cushing syndrome)

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45
Q

Secondary hyperPTH

A

Secondary hyperparathyroidism occurs due to chronic renal failure. Phosphate retention and hyperphosphatemia leads to the decrease in serum calcium levels. This effect is aggravated by the reduction in 1-hydroxylase activity in the kidney which is necessary for the activation of vitamin D3. The secondary increase in PTH levels to compensate for the hypocalcemic effects is exacerbated by aluminum accumulation in bone.

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46
Q

Central neck dissection: Borders

A

Superior: horizontal line at the inferior border of the cricoid and RLN insertion point
Inferior: plane on level with the innominate artery
Lateral: Common carotid artery
Medial: Medial edge of contralateral strap muscles

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47
Q

Central neck dissection: level VI borders

A

defined superiorly by the hyoid bone, inferiorly by the sternal notch, laterally by the medial aspect of the carotid sheath, posteriorly by the prevertebral fascia, and anteriorly by the superficial layer of the deep cervical fascia.

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48
Q

Central neck dissection: level VII borders

A

Level VII lymph nodes are those associated with the brachiocephalic vein and innominate artery. The inferior boundary of level VII, included as the lowest portion of the ATA-defined CND, is defined by the innominate artery on the right (at its point of tracheal crossing) and the corresponding axial plane on the left.

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49
Q

Mgmt of recurrent parathyroid CA

A

re-exploration and resection. little value in chemo or XRT as its pretty radioresistant

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50
Q

First line for intraoperative HTN in pheo

A

Nitroprusside

51
Q

Where do the inferior PTH glands arise from?

A

3rd branchial pouch

52
Q

Basal fasting gastrin levels indicative of gastrinoma

A

An increase in gastrin levels of more than 120 pg/mL over basal fasting levels is positive. Serum gastrin levels usually peak by 10 minutes.

53
Q

Dfif between stage I and II ACC

A

Size - tumor > or < 5 cm

54
Q

After hypercortisolism has been diagnosed by a low-dose dexamethasone suppression test and/or a 24-hour urine cortisol collection, an adrenocorticotropic hormone (ACTH) level should be obtained. If the ACTH value is low (< 10 pg/mL)?

A

Adrenal lesion should be suspected

55
Q

Discharge plan after aldosteronoma resection

A

All antihypertensive medications should be withheld unless it is necessary to wean patients off them. Carvedilol requires weaning to avoid rebound hypertension. A high-salt diet can help blunt the rebound hyperkalemia that occurs due to reversal of chronic suppression of the renin-angiotensin-aldosterone axis. Patients should return in 1 week for blood pressure monitoring and a chemistry panel to evaluate potassium levels.

56
Q

How to test for dx of insulinoma

A

72 hour fast
Blood tested for serum glucose and immunoreactive insulin concentration every 6 hours and when symptoms develop. If develops neuroglycopenic sx the nserum levels of glucose, insulin, C-peptide and proinsulin are drawn and the fast is terminated. Dx made if develops neruoglycopenci symmptoms, serum glucose <45 mg/dL, concomitant serum level of insulin higher than 5 microU/L. Elevated levels of C-peptide (>0.7) and proinsulin are confirmatory and exclude factitious hypoglycemia

57
Q

Where are insulinomas found in the pancreas?

A

Evenly distributed throughout

58
Q

Arterial supply of adrenal gland

A

Superior adrenal a from inferior phrenic, middle adrenal from aorta, and inferior adrenal a from renal a

59
Q

Where does the left adrenal vein drain into

A

Left renal vein after joining with left inferior phrenic vein

60
Q

Dx of Conn syndrome

A

Due to lack of autoregulation by renin, a plasma aldosterone-to-renin ratio >25-30 (make sure you discontinue ACE inhibitors, diuretics, and beta adrenergic blockers)

61
Q

Mechanism of aldosterone

A

Increases sodium retention in exchange for hydrogen in the cortical collecting tubules and potassium in the gut, salivary and sweat glands. Therefore in hyperaldosteronism pts have low serum K, high urinary K, low urinary Na and metabolic alkalosis

62
Q

Sx of prolactinoma

A

Menstrual cycle dysfunction (amenorrhea), decreased bone density and osteopenia, galactorrhea, decreased libido, infertility, ED, and impaired vision.

63
Q

Vision impairment in pituitary prolactinoma

A

Bitemporal hemianopsia

64
Q

Possible gene mutation seen in some cases of ACC

A

somatic mutations in p53 (Li Fraumeni)

65
Q

ectopic inferior parathyroid

A

thymus or thyroid. Undescended glands may be located anywhere within carotid sheath. Can also be located intra-thyroidally with greater frequency than superior glands

66
Q

ectopic superior parathyroid

A

tracheoesophageal groove and retroesophageal region. May be intrathyroidal or, if undescended, located at piriform sinus

67
Q

Cortisol elevated and ACTH is low

A

Cortisol secreting lesion (adrenal adenoma or adrenal hyperplasia)

68
Q

RET oncogene

A

protooncogene that encodes a receptor tyrosine kinase protein. Mutations are inherited in an AD fashion.

69
Q

Next step if pt with biochemical evidence of primary hyperaldosteronism and CT scan showing either no abnormalities or bilateral abnormalities

A

Bilateral adrenal venous sampling

70
Q

What are sx of VIPoma

A

WDHA syndrome - watery diarrhea, hypokalemia, achlorhydria or acidosis

71
Q

How to confirm dx of VIPoma

A

elevated fasting serum VIP level

72
Q

First step in left adrenalectomy

A

Mobilization of splenic flexure of colon from left retroperitoneum

73
Q

Diabetes, gallstones and steatorrhea

A

Somastinoma

74
Q

Resection is indicated for all adrenal incidentalomas if they are?

A

functioning

75
Q

First step in right adrenalectomy

A

Dividing right triangular ligament to mobilize right lobe of the liver

76
Q

First line for bilateral adrenocortical hyperplasia

A

Spironolactone

77
Q

Location of most somatostatinomas

A

Head or periampullary region

78
Q

Which endocrine pancreatic tumors located in distal pancreas?

A

VIPoma, glucagonoma

79
Q

MC cancer that spreads to adrenal

A

Lung. Then GI tract, breast, kidney, pancreas and skin

80
Q

Confirmatory of somatostatinoma

A

Fasting plasma somatostatin leves >100 pg/mL

81
Q

Most impt predictor of survival in ACC

A

adequacy of resecction

82
Q

Dx of glucagonoma

A

Fasting glucagon >1000 mg/mL

83
Q

Mixed presentation of Cushing syndrome and virilization should make you suspicious for

A

Adrenocortical carcinomma

84
Q

postnatal congenital adrenal hyperplasia due to 21 hydroxylase enzyme deficiency

A 
virilization, hirsutism
polycystic ovaries
irreg menses
HYPOcortisolism
HYPOaldosteronism
85
Q

PTH increaess calcium by what 3 mechanisms

A

1) stim of Ca reabsorption in distal convoluted tubule
2) stimulation of osteoclasts and release of Ca from bone mineral stores
3) stimulation of formation of calcitriol (vit D) which incrases dietary absorption of calcium

86
Q

MCC hyperaldosteronism

A

Bilatera ladrenal hyperplasia

87
Q

Where do inferior parathyroid glands lie in association with RLN?

A

Anterior

*superior parathyroid glands lie posterior to RLN

88
Q

Superior laryngeal nerve lcoation and function

A

Near superior pole of thyroid near trunk of superior thyroid a. Injury causes subtle voice changes and voice projection compromise

89
Q

Cricothyroid muscle innervation

A

External branch of the superior laryngeal nerve

90
Q

Blood supply of parathyroids

A

Inferior thyroid artery which is a branch of the thyrocervical trunk from the subclavian artery

91
Q

Where are the superior parathyroid glands usually found in relatioon to the inferior thyroid arteries?

A

1-2 cm superior to inferior thyroid arteries

92
Q

First endocrine mx in MEN1

A

hyperPTH

93
Q

first endocrine mx in MEN2A

A

MTC

94
Q

von Hippel Lindau characteristic tumors

A

CNS and retinal hemangioblastomas, clear cell RCC, pheo, pancreatic cystadenomas and neuroendocrine tumors, endolymphatic sac tumors and papillary cystatednomas of epididymis and broad ligament

95
Q

Surveillance for VHL disease

A
  • screen for signs of neuro sx, nystagmus, strabismus and white pupil
  • age 1-4 years: eye/retinal exam using indirect ophthalmoscope
  • 5-15 yrs: audiology assessment every 2-3 years
  • 16+ quality US of abdomen and MRI +/- contrast every other year
  • age 16: MRI of nervous system every 2-3 years and audiology exam by audiologist
  • annual test for fractionated metanephrines (especially NE) using blood or urine test starting at 5 years old
96
Q

If suspicious for ZES but gastrin level between 150-1000

A

Most sensitive test is secretin stimulated gastrin level. Positive test will show increase in gastrin of >200 pg/mL

97
Q

What else causes increasd gastrin?

A

PPI use
H.pylori
Renal failure

98
Q

Relative potency of hydrocortisone

A

1

99
Q

Relative potency of prednisone

A

4

100
Q

Relative potency of methylprednisone

A

5

101
Q

Relative potency of dexamethasone

A

30

102
Q

What if you cannot localize a gastrinoma despite all efforts?

A

Highly selective vagotomy

103
Q

Most important determinant of survival in pts that undergo resection of adrenal met

A

Disease free interval between initial CA and mets (>6 months)

104
Q

Total parathyroidectomy more commonly performed in which MEN syndrome

A

MEN1

Selective parathyroidectomy of abnormal glands is more often oeperformed in pts with MEN2

105
Q

Conn syndrome is most commonly caused by

A

bilateral adrenal hyperplasia

106
Q

FEV1 of how much from contralateral lung required to proceed with pneumonectomy

A

800mL

107
Q

tx of unlocalized gastrinoma despite all efforts

A

highly selective vagotomy

108
Q

small <3 cm, sporadic pancreatic head gastrinomas - tx?

A

enucleation + regional LN dissection

109
Q

5 infections that require negative pressure room isolation

A 
measles
COVID
varicella
tuberculosis
SARS
110
Q

single most impt RF for development of heart disease in US

A

Coronary heart disease

111
Q

> 10 mg daily prednisone and minor procedure

A

25 mg of hydrocortisone at induction

112
Q

> 10 mg daily prednisone dose in last 3 months and moderate surgery (hemicolectomy, open chole, hysterectomy)

A

usual preop steroids + 25 mg hydrocortisone at induction + 100 mg hydrocortisone/day for 24 hours

113
Q

> 10 mg daily predinosone and major surgery

A

usual preop steroids + 25 mg hydrocortisone at induction + 100 mg hydrocortisone/day for 2-3 days
resume normal PO tx when GI function returned

114
Q

TEF and anastomotic leak

A

most heal spontaneously

if you see a leak or suspect one, leave retropleural chest tube in place, keep NPO and abx may be administered

115
Q

anti arrhythmic that can cause hypothyroidism

A

amiodarone

116
Q

how soon are effects seen after calcitonin administration

A

6 hours

117
Q

how does cinacalcet correct hypercalcemia

A

decreases production of PTH

118
Q

what is mitotane used for

A

adrenal-lytic

residual, recurrent or metastatic ACC

119
Q

what is metyrapone used for

A

adrenal hyperplasia - it blocks cortisol synthesis

120
Q

what is metyrosine used for

A

inhibits tyrosine hydroxyalse causing decreased synthesis of catecholamines
given pre op in adrenalectomy (pheo) or in case of unresectable disease

121
Q

simultaneous tumors in MEN 1 - what do you treat first?

A

hyperparathyroidism (4 gland resection with autotransplantation plus bilateral thymectomy)

122
Q

Pheochromocytoma in MEN 2 - unilateral or bilateral? benign or malignant?

A

often bilateral

nearly always benign

123
Q

Likelihood of malignancy when thyroid lights up on PET CT

A

21%

124
Q

Long term vitamin D deficiency leads to

A

secondary hyperPTH

ABS (23 decks)

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