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ORAL BOARDS > Endocrine > Flashcards

Endocrine Flashcards

1
Q

Whipple’s triad

A 
Insulinoma
Includes:
Fasting hypoglycemia
Symptoms of hypoglycemia
Relief with sugar
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2
Q

C peptide levels in insulinoma

A

High

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3
Q

When to enucleate vs resect in insulinoma

A

If <2 cm can enucleate

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4
Q

Insulinoma seen in which MEN?

A

Type 1

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5
Q

MEN 1

A

Pancreas
Pituitary
Parathyroid

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6
Q

MC pancreas tumor in MEN1

A

Gastrinoma

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7
Q

MC pancreas neuroendocrine tumor

A

Insulinoma

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8
Q

Check for pheo - lab

A

urine metanephrines

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9
Q

MEN 2A

A

Parathyroid
Medullary thyroid CA
Pheo

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10
Q

Preop prep for pheo

A

Alpha blockade with phenoxybenzamine
Adequate hydration
If pressures still uncontrolled, beta blocker added

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11
Q

R adrenal v drains into

A

IVC

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12
Q

L adrenal v drains into

A

L renal v

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13
Q

MEN 2B

A

Mucosal neuromas
Marfanoid
Medullary thyroid CA
Pheo

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14
Q

Apple green birefringent in medullary thyroid

A

Amyloid deposits

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15
Q

Recs for thyroidectomy in MEN 2A

A

5 yo

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16
Q

Gene for MEN 2

A

RET

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17
Q

Gene for MEN 1

A

Menin

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18
Q

Every medullary thyroid CA should be screened for

A

Pheo

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19
Q

Rule of 10s for pheo

A

10% bilateral, malignant, extra-adrenal, pediatric, asymptomatic

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20
Q

Thyroglossal cyst tx

A

Sistrunk procedure

Surgical excision of cyst and resection of central portion of hyoid bone

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21
Q

Thyroglossal cyst PE

A

Swallowing does not move it
Protrusion of tongue does
Midline mass

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22
Q

Thyroglossal cyst infected - tx

A

I&D

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23
Q

When to resect thyroglossal cyst in baby

A

1 year

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24
Q

Branchial cleft cysts are located where?

A

Lateral

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25
Which neck mass moves with swallowing
Thyroid mass
26
Gastrinoma triangle
the confluence of the cystic and common bile duct superiorly, the second and third portions of the duodenum inferiorly, and the neck and body of the pancreas medially, both dorsally and ventrally
27
CT is negative for gastrinoma - what next?
EUS | Then octreotide scan
28
D2 gastrinoma 2 cm in size
Enucleate
29
Gastrinoma closely approximated to pancreas parenchyma
Antimesenteric duodenotomy and excise from lumen
30
Long term recs for gastrinoma
PPI - taper off Re-EGD and ensure clearance of ulcers Annual eval first 5 years with serial CT scans
31
<1 cm thyroid CA
lobectomy
32
>4 cm thyroid CA
thyroidectomy
33
Margin goals in GIST
Negative
34
Adjuvant imatinib recs
``` High mitotic rate >5 cm Positive margins High grade Recurrence ```
35
Recurrent GIST recs - resectable
``` Endoscopy +/- EUS Restage - CT C/A/P Discuss at MDC Re-resect Adjuvant imatinib ```
36
Medullary thyroid CA - OR
total thyroidectomy + CND + ipsilateral neck dissection
37
F/u for medullary thyroid CA
Serial calcitonin
38
Adrenal incidentaloma - biochemical workup
CBC, CMP, 1 mg low dose dexamethasone suppression cortisol test, ACTH, renin, DHEA-sulfate, aldosterone, plasma metanephrines
39
Incidental pancreatic mass - hyperdense on arterial phase
GI neuroendocrine tumor
40
Pancreatic mass in young pt - rule out?
MEN syndromes Pancreatic adenoCA Functional vs non functional neuroendocrine tumors
41
Metastatic disease in neuroendocrine tumors test
Dotatate PET scan
42
Asymptomatic neuroendocrine tumor - resection?
If small can observe up to 1 cm Resect if >2 cm Can always re-image short interval
43
How can you biopsy GIST
EUS with FNA
44
History taking in adrenal incidentaloma
Symptoms of hormone excess! Cortisol excess - HTN, hyperglycemia, weight gain, muscle weakness Pheo - palpitations, HTN, anxiety Aldosteronemia - hypoK, HTN diff to control
45
Low dose dexamethasone suppression test
``` 1 mg dexa 10 pm Cortisol check following AM Normal: suppression to <1.8 Result >5 is positive Indeterminate --> confirmatory test as late night salivary cortisol vs 24 hr urine collection ```
46
DHEA sulfate can be elevated in
adrenocortical carcinoma
47
Adrenal mass concerning for malignancy - imaging
>10 hounsfield units on non con - mets, primary adrenal tumors, or pheo >4 cm should have higher suspicion
48
Indeterminate adrenal mass on CT
Can get PET or do adrenalectomy
49
Non functional small adrenal adenoma - followup?
Repeat biochemical workup and imaging in 1 year (to be safe)
50
Lap left adrenalectomy
Ports along costal margin, lateral decubitus position Assess for mets if CA Incise lateral attachments to spleen and begin mobilizing spleen and pancreas medially to develop avascular plane ID left renal vein and trace medially until adrenal v encountered - ligate and divide between clips Mobilize off kidney and away from diaphragm Place in endocatch Ensure hemostasis prior to closure
51
Meds that may cause hypercalcium, hyperPTH, or interefere with PTH assays
HCTZ, Lithium, Biotin
52
Low vitamin D, normal Ca, mildly elevated PTH
PTH activation of 1 alpha hydroxylase | Correct vitamin d levels and recheck PTH
53
Asymptomatic primary hyperparathyroidism - indications for surgery
``` Ca >1 mg above upper normal Dexa t score <2.5 or vertebral fx by imaging Cr clearance <60 Kidney stones 24 urine Ca >400 Age <50 Neurocognitive/neuropsych sx ```
54
Can't find inferior parathyroid - where to look?
Thymus
55
Parathyroidectomy - OR
``` Large bore IV access Intubate with ETT with RLN monitoring Draw baseline PTH Collar incision, subplatysmal flap Midline raphe to retract strap mm and gain access to thyroid gland Retract thyroid medially to develop plane between thyroid and prevertebral fascia Find and ligate middle thyroid v Begin looking for parathyroid gland ```
56
4 gland parathyroid exploration - OR
Begin by ID superior PTH on ipsilateral side - send small frozen to confirm parathyroid, mark with clip Inf and superior PTH on contralateral side, confirm with frozen, place clips Don't excise until found all 3 If any abnormal, resect that one only If all appeared normal, subtotal parathyroidectomy leaving 1/2 of para as remnant
57
RA iodine in Grave's disease - when to avoid?
Ocular Graves
58
Prep for OR for Graves
Repeat thyroid function tests 2 weeks prior to ensure normal free T3 Lugols iodine solution for 1 week prior to OR to decrease vascularity of thyroid gland
59
OR - thyroidectomy
Collar incision, subplatysmal flap Midline raphe to retract strap mm and gain access to thyroid gland Retract thyroid medially to develop plane between thyroid and prevertebral fascia Find and ligate middle thyroid v Upper and lower poles of thyroid, taking vessels with energy device Preserve parathyroids on vascular pedicle ID RLN in TE groove Complete thyroid mobilization by taking ligament of Berry Contralateral side Check hemostasis, viability of para glands and autotransplant any that appear compromised
60
Concern for intra op RLN injury
Paralyzed from traction or accidentally transected Complete exposure and check if intact If transected, perform primary anastomosis of nerve w/o tension and call neurosurg or plastics to help with repair Terminate procedure and plan to rescope pt Completion thyroidectomy once nerve recovers
61
Total thyroid in papillary CA - indications
``` >4 cm Evidence of extrathyroidal extension on US or intraop Metastatic LN ID pre op Contralateral nodules Need for adjuvant radioiodine therapy ```
62
Advantages of thyroid lobectomy in papillary CA
Decrease QOL impact Equivalent survival No need for thyroid supps
63
Concerning LN with dx of thyroid CA
FNA prior to OR | Send to cytology and thyroglobulin aspirate washout (elev --> diagnostic for mets)
64
Thyroid nodule workup - first step
Thyroid US + TSH level
65
FNA not recommended for thyroid nodules under what size
1 cm
66
Features to look for on thyroid nodule US
``` Size Irregular borders Microcalcs Hypoechogenicity Peripheral vascularity Taller greater than wide ```
67
Steps of FNA
Use US to locate nodule Anesthetize the skin Under US guidance, multiple passes using 25 gauge needle Cytopathology on site to confirm sample adequacy
68
Bethesda classification
II - benign, interval US III 15% IV 40% V and VI - malignancy
69
Indeterminate thyroid nodule - next steps?
Repeat FNA with molecular testing vs diagnostic lobectomy | If negative molecular testing, <5% chance of malignancy
70
When would you ever biopsy an adrenal mass
Pt that has hx of CA and wanting to r/o mets
71
Open left adrenalectomy
Subcostal laparotomy Mobilize splenic flexure and spleen and tail of pancreas medially En bloc excision of left adrenal mass and surrounding RP adipose tissue If inv of upper pole of kidney, nephrectomy also performed AVOID RUPTURE OF CAPSULE Any suspicious LN removed
72
Addisonian crisis s/p adrenalectomy - tx
IV hydrocortisone post op Transition to PO steroids at discharge Taper slowly over 6-12 months
73
How is adrenal venous sampling performed
Cannulation of R and L adrenal vv along with systemic aldosterone levels in IVC Comparison between levels may show unilateral hypersecretion --> candidate for adrenalectomy even if no mass on imaging
74
Lap right adrenalectomy
LLD Mobilize R lobe of liver by dividing posterior peritoneal attachments of the triangular ligament and the coronary ligament to expose bare area of liver Dissect RP posterior to R lobe of liver to expose IVC and continue along lateral and anterior aspects until ID R adrenal v, then clip and divide Mobilize R adrenal gland away from RP adipose tissue, diaphragm, and posterior musculature using an energy device Ligate fatty attachments of adrenal gland to upper pole of kidney, avoiding renal hilar vessels Place in endocatch Confirm hemostasis Close incisions
75
Avulsion of R adrenal vein - next steps
Alert anesthesia Maintain pressure with lap instruments Retract R lobe of liver medially, remove packs Suture ligate hole with figure of 8 or clamp orifice of adrenal vein with vascular clamp followed by closure of venotomy Confirm hemostasis Assess for narrowing of IVC **can use allis clamp**
76
Concern for Cushing Syndrome - labs
``` BMP Glucose ACTH Cortisol Dexamethasone suppression test ```
77
Causes of hypercortisolism
Exog steroids ACTH dependent - pituitary, ectopic Adrenal source
78
Hypercortisolism - medical mgmt
Metyrapone Mifepristone Ketoconazole

ORAL BOARDS (11 decks)

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