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ABSITE > Endocrine > Flashcards

Endocrine Flashcards

1
Q

mc pituitary adenoma?

A

prolacitnoma.

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2
Q

`prolactin dx?

A

> 150 (symptomatic)

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3
Q

sx of prolactinoma?

A

galactorrhea, irregular menses, decreased libido, infertility

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4
Q

mgmt prolactinoma?

A

asx and <1 cm, follow with MRI.
if sx or if >1cm, bromocriptine (if pregnant) or cabergoline&raquo_space;> transsphenoid resection if failed mgmt

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5
Q

what is deadly about acromegaly?

A

cardiac sx (valve dysfunction, cardiomyopathy).

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6
Q

acromegaly GH dx?

A

elevated IGF-1 > 10 in 90%; MRI

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7
Q

mgmt acromegaly?

A

transsphenoid resection, XRT, bromocriptine, octreotide, pegvisomant (GH-R antagonist)

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8
Q

Sheehan’s syndrome?

A

postpartum lactation issues, amenorrhea, AI, hypothyroid
anterior pit ischemia after peripartum hemorrhage

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9
Q

mgmt sheehan’s?

A

steroids, hormone replacement

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10
Q

pituitary apoplexy

A

bleeding into pituitary tumor with gland destruction; acute bleeding sx

treat: steroids emergently; hormone replacement

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11
Q

craniopharyngioma origin?

A

rathke’s pouch; benign calcified cyst.grows along stalk to suprasellar anterior pituitary

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12
Q

mgmt craniopharyngioma?

A

resection (endocrine abnormalities, bitemporal hemianopsia, HA, hydrocephalus, etc.)

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13
Q

complication of craniopharyngioma resection

A

DI

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14
Q

Nelson’s syndrome?

A

after b/l adrenalectomy; increased CRH (enlarged pituitary).

sx: amenorrhea, bitemporal hemianopia, hyperpigmentation (B-MSH byproduct of ACTH)

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15
Q

mgmt Nelson’s

A

steroids.

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16
Q

Waterhouse Friderichsen syndrome?

A

adrenal gland hemorrhage after meningococcal sepsis leading to AI.

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17
Q

arterial supply to adrenals?

A

superior: inferior phrenic
middle: aorta
inferior: renal.

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18
Q

venous drainage from adrenals?

A

left: left renal
right: cava.

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19
Q

innervation to the adrenals?

A

cortex: none
medulla: from sympathetic splanchnics.

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20
Q

lymphatic drainage from adrenals?

A

subdiaphragmatic and renal LNs.

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21
Q

rate of adrenal incidentaloma?

A

1-2% of CTs. 5% are mets.

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22
Q

when to check for functionalty of adrenal mass?

A

ASAP, BEFORE IMAGING.

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23
Q

concerning adrenal incidentaloma findings

A

> 4 cm
10 HU
internal calcs/hemorrhage
high vascularity
heterogeneous
interval tumor growth

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24
Q

functional studies for incidentaloma?

A

urine metanephrines/VMA/catecholamines
urinary hydroxycorticosteroids,
serum K, plasma renin/aldosterone
low dose dexamethasone suppression test

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25
Q

indication for adrenalectomy?

A
  1. 4+ cm or ENLARGING 0.5 cm/6 mos
  2. functional
  3. non-homogenous on CT scan >10 HU
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26
Q

how to follow incidentaloma < 4 cm and nonfunctional and homogenous (AKA not going to resect)?

A

CT scan q3mo x 1 year then yearly.

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27
Q

how to access (post or ant) adrenal for resection?

A

anterior approach. reflect right lobe of liver or reflect spleen & pancreas.

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28
Q

common mets to adrenal?

A

LUNG&raquo_space;» breast, melaoma, renal. must biopsy before.

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29
Q

isolated mets to adrenal? chemo or surgery.

A

just resect.

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30
Q

salt sugar sex. GFR
MESODERM CORTICAL CELLS

A

glomerulosa: aldosterone
fasciculata: glucocorticoids
reticularis: androgens/estrogens

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31
Q

where do hormones originate from? base.

A

cholesterol > progesterone > hormones x 3.

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32
Q

common hydroxylases?

A

21 and 11 B-hydroxylase.

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33
Q

posterior pituitary gland secretes what 2 things?

A

ADH and oxytocin alone.

NEUROhypophysis does not contain cell bodies

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34
Q

where ADH and oxytocin stimulated (nuclei) in hypothalamus

A

ADH: supraoptic nuclei
oxytocin: paraventricular nuclei

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35
Q

blood supply to anterior pituitary

A

PORTAL venous system (from neurohypophysis - posterior pitutary)

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36
Q

hypothalamus stuff travels where?

A

TRH, CRH, GnRH, GHRH, DA travel into median eminence and pass through NEUROHHYPOPHYSIS ON WAY TO ADENOHYPOPHYSIS

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37
Q

congenital adrenal hyperplasia? 21

A

21 deficiency: MC. hypotensive man. increased 17-hydrogyproge
early puberty in M, virilization in F. salt wasting (hypoTN).
treat: cortisol + genitoplasty.

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38
Q

congenital adrenal hyperplasia? 11

A

11 deficiency. hypertensive man. increased 11-deoxycortisone, later…
early puberty M, virilization in F. salt saving (causes HTN)
treat: cortisol, genitoplasty.

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39
Q

Conn syndrome sx?

A

hypertension and hypokalemia (weakness, polydipsia, polyuria)

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40
Q

primary Conn (dx: renin)

A

MC from HYPERPLASIA > adenoma, ovarian tumor, carcinoma

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41
Q

secondary hyperaldosteronism/Conn?

A

more common than primary Conn’s
etiology: CHF, RAS, liver failure, diuretics, Bartter’s (renin-secreting tumor)
renin is HIGH

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42
Q

Bartter’s syndrome

A

renin secreting tumor

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43
Q

how to dx primary Conn? 2 modalities

A
  1. salt load suppression test (urine aldosterone stays HIGH)
  2. AND aldosterone:renin > 25 (renin low)

then.. localize.

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44
Q

imaging for adrenal tumor?

A

CT scan
consider: MRI, NP-59 scintigraphy, venous sampling

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45
Q

when to consider adrenal scintigraphy?

A

when cross sectional is nondiagnostic.

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46
Q

NP-59 scintigraphy can show what

A

adenoma from hyperplasia

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47
Q

how to optimize prior to adrenalectomy

A

BP and K control.

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48
Q

adenoma tx

A

adrenalectomy

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49
Q

hyperplasia tx MC: conn

A

medical therapy first (spironolactone, ACEi, CCBs nifedipine, potassium)
then bilateral resection for refractory hypokalemia

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50
Q

what supplement will be required after bilateral adrenal resection?

A

fludrocortisone.

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51
Q

adrenal insufficiency Addison’s disease = hypocortisolism
#1 cause?

A

withdrawal of exogenous steroids

global: TB
developed: autoimmune

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52
Q

sx adrenal CRISIS

A

all loss…. refractory hypotension, fever, lethargy, pain, n/v

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53
Q

sx addisons disease

A

weakness, nausea, anorexia, weight loss, hyperK

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54
Q

2 cause hypocortisolism

A

autoimmune disease

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55
Q

labs for hypocortisolism?

A
  1. decreased AM cortisol? then proceed.
  2. ACTH stimulation test - cosyntropin – cortisol should stay LOW in primary
  3. get AM ACTH level: if high, primary adrenal insufficiency; if low/nl , secondary adrenal insufficiency
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56
Q

dx hypocortisolism?

A

cosyntropic stimulation test. give ACTH, cortisol will remain LOW

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57
Q

how to tx acute adrenal crisis/insufficiency?

A

dexamethasone, fluids, tx the hyperkalemia & hypoglycemia

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58
Q

how to tx chronic adrenal insufficiency?

A

steroids

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59
Q

hypercortisolism = Cushing’s SYNDROME; #1 cause

A

IATROGENIC > cushing disease > ectopic > adenoma primary

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60
Q

dx hypercortisolism?

A

24 hour urine cortisol and ACTH
ACTH low then primary (adrenal) secreting lesion
ACTH high then secondary (pituitary or ectopic)

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61
Q

if ACTH and cortisol is high on 24 hour urine collection?

A

high dose dexamethasone suppression test
pituitary adenoma will have SUPPRESSED cortisol “Cushing’s disease”
ectopic source (small cell lung ca) will not suppress

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62
Q

Cushing’s *DISEASE

A

= PITUITARY ADNOMA.
#1 non-iatrogenic cause of Cushing’s syndrome 80%

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63
Q

1 cause of noniatrogenic Cushing’s syndrome

A

Cushing’s disease - pituitary adenoma

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64
Q

dx Cushing’s disease

A

brain MRI

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65
Q

treat Cushing’s disease

A

transsphenoidal resection
radiation if too large for resection or if postop high cortisol that responds to HD dexa… there’s still some tissue there

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66
Q

dx ectopic ACTH secretion (failed high dose suppression test)

A

CT CAP to localize primary tumor

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67
Q

treat ectopic

A

resect primary and medically suppress if inoperable

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68
Q

adrenal cause of hypercortisolism? low ACTH. and high cortisol.

A

adenoma > hyperplasia

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69
Q

treat adrenal hypercortisolism adenoma vs hyperplasia

A

adenoma: adrenalectomy (use scintigraphy to figure out adenoma vs hyperplasia)
hyperplasia: metyrapone (block cortisol synthesis), aminoglutethimide (inhibit steroid production), bilateral adrenalectomy if all else fails.

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70
Q

when to consider bilateral adrenalectomy without adrenal lesion

A

when cannot find ectopic tumor source
when ectopic tumor source is unresectable (and it’s slow growing)
when pituitary adenoma cannot be found

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71
Q

what age gets adrenocortical carcinoma?

A

before 5 YO
after 50 YO
bimodal!

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72
Q

F or M get adrenocortical carcinoma?

A

F

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73
Q

are adrenocortical caricinomas functional?

A

50% are.

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74
Q

treat adrenocortical carcinoma?

A

radical (take kidney) adrenalectomy with debulking

+ mitotane/external beam RT (chemoXRT) if high risk local recurrence (positive margin, invasion, intraop spillage, Ki67 > 10%)

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75
Q

role of debulking in adrenocortical carcinoma?

A

helps with sx. and prolongs survival.

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76
Q

how to treat recurrent, residual, or metastatic disease after adrenocortical carcinoma?

A

mitotane (adrenalytic + XRT

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77
Q

5yr survival rate adrenocortical carcinoma?

A

20%.

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78
Q

postop adrenalectomy if negative margins?

A

CT CAP q 3 mos x 2 years

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79
Q

if R1 adrenalectomy,/invasiom/spillage/Ki67 >10%>

A

postop chemoradiation with mitotane

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80
Q

neural crest cell to adrenal medulla catecholamines?

A

tyrosine >tyrosine hydroxylase> dopa > dopamine > NE >PNMT> Epi

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81
Q

epi is made where exclusively

A

in the medulla where PNMT is - so excess epi is for sure a pheo in the ADRENAL GLAND. cannot be extra-adrenal

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82
Q

VMA vanillylmandelic acid

A

byproduct of epinephrine to metanpehrine and norepi to normetapnephrine via MAO.

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83
Q

pheo origin

A

slow growing from sympathetic ganglia or ectopic neural crest cells

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84
Q

10% rule of pheo

A

10% malignant, bilateral, kids, familial, extraadrenal

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85
Q

pheo laterality

A

R>L

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86
Q

dx pheo?

A
  1. plasma non specific
  2. confirm with urine metanephrines (24 hr) and VMA
  3. localize CT vs hyperintense T2 MRI vs mIBG
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87
Q

adjunct pheo diagnostics?

A

131Iodinine-MIBG (norepi analgoue) can ID location if CT/MRI cannot help
clonidine suppression will have no effect on the elevated hormones (used as adjunct if all levels are normal)

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88
Q

venography in pheo dx?

A

DO NOT DO. can cause hypertensive crisis.

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89
Q

preoperative preparation for pheo removal?

A

a-blocker first (phenoxybenzamine, prazosin) and volume replacement then B block if tachycrdic or arrhythmias ssen

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90
Q

mgmt of pheo?

A

adrenalectomy (ligate veins first to avoid spilling catecholamines)

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91
Q

debulking role in pheo?

A

helps with sx

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92
Q

metyrosine role in pheo?

A

can give preop or in unresectable.
inhibits tyrosine hydroxylase to decrease synthesis of catecholamines.

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93
Q

extraadrenal 10% mostly malignant; locations?

A

MC: aortic bifurcation = origin IMA = organ Zuckerkandl

other: vertebral bodies, bladder

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94
Q

extramedullary tissue rests especially on organ of Zuckerkandl; where is that

A

inferior aorta near bifurcation

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95
Q

falsely elevated VMA

A

coffee, tea, fruit, vanilla, iodine contrast, labetalol, a/B-blocker

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96
Q

pharyngeal arches that make up the thyroid?

A

1st and 2nd. (* as opposed to pharyngeal POUCHES)

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97
Q

byproduct of T3 to T4 conversion?

A

cAMP

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98
Q

superior thyroid aa origin?

A

1st branch of ECA.

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99
Q

inferior thyroid aa origin?

A

off thyrocervical trunk; supplies both inferior and superior parathyroids.

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100
Q

Ima aa?

A

1%.
arises from innominate or aorta; traverses towards isthmus.

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101
Q

venous drainage from thyroid?

A

superior/middle thyroid: into IJ
inferior: into innominate.

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102
Q

innervation around thyroid?

A

external branch superior laryngeal nerve, recurrent laryngeal nerve.

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103
Q

external branch superior laryngeal nerve function?

A

motor to cricothyroid muscle
INJURY = loss of PROJECTION and voice FATIGUABILITY.

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104
Q

where dose superior laryngeal nerve run?

A

lateral to thyroid lobes. close to superior thyroid aa.

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105
Q

MC injured nerve in thyroidectomy?

A

superior laryngeal nerve.

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106
Q

MC injury location SLN?

A

near superior pole of thyroid during ligation of superior thyroid aa

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107
Q

recurrent laryngeal nerve function?

A

motor to all of larynx except cricothyroid. control vocal cords.
INJURY = HOARSENESS, b/l injury can obstruct airway (need trach)

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108
Q

where does recurrent laryngeal nerve run?

A

posterior to thyroid lobes in TE groove
track with inferior thyroid aa sometimes
L down around aorta
R down under SCA

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109
Q

ligament of berry?

A

posterior medial suspensory ligament of the thyroid close to RLNs.
careful on dissection!

MC injury location of RLN

110
Q

delphian nodes

A

level VI; frequent first mets of thyroid ca

located in ANTERIOR SUSPENSORY LIGAMENT

111
Q

thyroglobulin role?

A

stores T3 and T4 in colloid

112
Q

T3 vs T4

A

T3 is active (tyrosine + iodine)
T4:T3 15:1
T4 to T3 via deiodinases

113
Q

most sensitive indicator for thyroid gland function?

114
Q

tubercles of Zuckerkandl?

A

very lateral; posterior extension of thyroid tissue; rotate medially to find RLNs
leave alone in subtotal because of proximity

115
Q

most common cause of death in thyroid storm?

A

high output heart failure.

116
Q

mgmt of thyroid storm?

A

B-blockade, Lugol’s solution (KI, slow), cool, oxygen, glucose

117
Q

Wolff Chaikoff effect

A

high dose iodine via Lugol’s inhibiting TSH action on thyroid and inhibits coupling of iodide resulting in less T3

118
Q

thyroid nodule step to dx?

A
  1. US to see nodule (if > 1cm sus features or >1.5cm) q6mo US if smaller
  2. FNA and TFTs
    3.
119
Q

FNA results for thyroid nodule?

A
  1. follicular cells - lobectomy
  2. thyroid cancer - thryoidectomy or lobectomy
  3. cyst fluid - drain fluid and send for cytology; resect if recurs/bloody
  4. colloid tissue: leave alone = goiter
  5. normal tissue but TFTs high - toxic nodule…. MTM and iodine if sx
120
Q

concerning US findings for thyroid nodule

A

hypoechogenicity
microcalcification
irregular margin
unorganized vascular pattern
lymphatic invasion
TALLER than wider

121
Q

if indeterminant FNA,

A

get radionuclide study

122
Q

hot nodule on radionuclide sestimibi

A

MTM and iodine if symptomatic

123
Q

cold nodule on sestimibi?

A

lobectomy (likely malignant)

124
Q

MC cause of goiter

A

identifiable is iodine deficiency
MCC In US: low grade stimulation of the thyroid gland

125
Q

primary substernal goiter vessels originate from?

A

innominate

126
Q

secondary substernal goiter vessels originate from?

A

superior and inferior thyroid aas.

127
Q

pyramidal lobe thyroid?

A

10%.
extends from isthmus superiorly.

128
Q

lingual thyroid?

A

base of tongue in foramen cecum.
treat because can cause dysphagia…. thyroxine suppression, abolish with iodine.
2% malignancy risk

129
Q

thyroglossal duct cyst

A

MIDLINE between hyoid and thyroid isthmus. develops in pyramidal lobe
moves with swallow.
can be premalignant or infected

130
Q

mgmt thyroglossal duct cyst?

A

resect with midportion or all of hyoid bone (SISTRUNK PROCEDURE, lateral neck incision)

131
Q

MTM vs PTU

A

PTU OK in pregnancy 1st tri; otherwise use MTM
both inhibit peroxidase (link iodine and tyrosine together)

132
Q

MTM adverse effects?

A

cretinism in newborns, aplastic anemia, agranulocytosis.

133
Q

PTU adverse effects?

A

aplastic anemia, agranulocytosis. hepatotoxicity esp in kids (but overall this precludes use a lot these days except in pregnancy)

134
Q

when to operate on thyroid in pregnancy?

A

2nd trimester

135
Q

graves’ disease Abs

A

IgG to TSH-R
(long acting thyroid stimulator, thyroid stimulating immunoglobulin).

136
Q

dx Graves?

A

decreased TSH, inc T3 and T4, TSH-R Ab, diffuse thyroid uptake of 123I

137
Q

mgmt Graves?

A

thioamides (MTM, PTU), 131Iodine > thyroidectomy

RAI can cause worsening opthalmopathy

138
Q

lugol solution indication

A

thyroidectomy for hyperthyroidism

to make thyroid decrease vascularity… firmer, easier to resect

also in thyroid storm

139
Q

toxic multinodular goiter demographic?

140
Q

etiology toxic multinodular goiter?

A

low grade chronic TSH stimulation; hyperplastic response

141
Q

pathology toxic multinodular goiter?

142
Q

mgmt toxic mulitnodular goiter

A

subtotal or total thyroidectomy&raquo_space;»>
if poor surgical candidate, 131Iodide

143
Q

single toxic nodule size to be sx

A

> 3 cm to be sx

144
Q

single toxic nodule dx

A

thryoid scan shows hot nodule…. 20% of hot eventually end up causing sx

145
Q

single toxic nodule tx

A

thioamides and 131i … lobectomy if ineffective

146
Q

Hashimoto’s Ab?

A

IgG and T cells to Tg and TPO

147
Q

Hashimoto goiter etiology

A

lack of organification of trapped iodide inside the gland

148
Q

Hashimoto humeral vs cell mediated autommune dsease?

A

BOTH! Tg Abd and microsomal disease!

149
Q

pathology Hashimoto’s?

A

lymphocyte predominance.

150
Q

mgmt Hashimoto’s

A

levothyroxine > partial thyroidectomy.

151
Q

de Quervain’s thyroiditis sx

A

hyperthyroid then hypothyroid, PAINFUL sore throat after URI.

152
Q

de Quervain’s dx?

A

elevated ESR. “subacute granulomatous thyroiditis”

LOW uptake RAI

153
Q

mgmt de Quervains?

A

steroids, aspirin > lobectomy/thyroidectomy.

154
Q

Riedel’s fibrous struma?

A

wood fibrous components involve strap muscles and carotid sheath
sx: hypothryoid, compressive sx

155
Q

Riedel’s fibrous struma dx?

A

looks like ca, so Bx.

156
Q

mgmt Riedel’s

A

steroids, thyroxine

157
Q

Riedel associations

A

PSCLEROSINGCHOLANGITIS
FIBROTIC disease
METHYSERGIDE therapy
retroperitoneal FIBROSIS

158
Q

if FNA shows follicular cells?

A

5-10% malignancy.

159
Q

mgmt follicular adenoma?

A

lobectomy to provide it is not ca

160
Q

most common thyroid cancer?

A

papillary thyroid carcinoma 85%

161
Q

spread lymph or heme papillary
thyroid?

162
Q

prognosis based on what for papillary thyroid ca?

A

local invasion.

163
Q

where does papillary thyroid ca spread (rarely, as it is mostly local invasion)?

164
Q

pathology papillary thyroid carcinoma?

A

psammoma bodies and orphan annie nuclei.

165
Q

5 yr survival rate papillary thyroid carcinoma?

166
Q

papillary thyroid ca postop HIGH RISK next steps

A

after total thyroidectomy, do 131RAI
can do whole body RAI scan 6 mo after to eval for disease

167
Q

HIGH risk papillary ca that will require RAI

A

tumor 2-4 cm
vascular invasion
anti-Tg Abs
Tg < 5

168
Q

follicular thyroid ca spread heme or lymph?

A

heme only. BONE common mets 50% at presentation.

169
Q

prognosis of follicular thyroid ca based on?

170
Q

5 yr survival rate follicular thyroid ca?

A

70% (95% papillary)

171
Q

mgmt of papillary thyroid ca

A

lobectomy.

thyroidectomy indication: 4+cm [Fiser says 1+cm], beyond thyroid capsule/mets/clinical node, multicentric lesions, previous radiation

172
Q

mgmt of follicular thyroid ca

A

lobectomy to diagnose… then THYROIDECTOMY if confirmed
+ MRM for positive nodes (not all)
+ postop RAI (all)

consider just lobectomy if: <4 cm, <45 YO, no distant, no personal/fam hx thyroid ca

173
Q

indications for modified radical neck dissection in the setting of thyroid ca?

A

extrathyroid disease, medullary, or clinically apparent nodal disease (Hurthle, papillary, follciular)

174
Q

indications for postop 131iodide (after thyroidectomy) - 6 wks postop?

A

1+cm, extra thyroidal disease. (cannot be after lobectomy)

175
Q

medullary thyroid ca associated syndromes?

A

MENIIa or IIb (RET protooncogene)

176
Q

pathology of medullary thyroid cancer

A

amyloid deposition

177
Q

manifestation of medullary thyroid ca?

A

diarrhea
usually early in MEN2 syndromes

178
Q

etiology of medullary thyroid ca?

A

parafollicular C cell hyperplasia (calcitonin)

179
Q

calcitonin fx

A

release by C parafollicular cells
inhibit osteoclast and decreases Ca
increase renal phosphate excretion

180
Q

calcitonin sx?

A

flushing, diarrhea

181
Q

lymph or heme spread of medullary thyroid ca?

A

lymphatic - likely to have nodal disease at dx

182
Q

mets from medullary thyroid ca?

A

lung, liver, bone.

183
Q

when to do prophylactic thyroidectomy in MEN2s?

A

MEN2a: 6 YO
MEN2b: 2 YO

184
Q

bad prognosis for medullary thryoid ca?

A

MEN 2b or sporadic type.

185
Q

mgmt medullary thyroid ca?

A

total thyroidectomy with central neck dissection
+MRND with palpable mass
+ b/l MRND if extrahyroidal disease or both lobes affected.

186
Q

5 yr survival medullary thyroid ca?

A

50% (vs 70% foll, 95% pap)

187
Q

surveillance of medullary thyroid (high risk recurrence)

A

serum calcitonin, CEA repeat every** 2-3 mos** until clear
routine US
thyroid replacement (but to maintain EUTHYROID)
RAI is not necessary.

takes mos to hit nadir after initial ectomy

188
Q

hurthle cell carcinoma benign or malignant?

A

mostly benign (adenoma) in older pts

189
Q

mets from hurthle cell?

A

bone and lung if malignant.

190
Q

pathology for hurthle cell ca?

A

Ashkenazi cells

191
Q

mgmt hurthle?

A

cannot distinguish adenoma vs ca so need LOBECTOMY vs total thyroidectomy
+MRND if clinical nodes.

192
Q

anaplastic thyroid ca demographic?

A

old long standing goiters.

193
Q

pathology anaplastic thyroid ca?

A

vesicular appearance of nuclei.

194
Q

5yr survival anaplastic thyroid ca?

195
Q

mgmt anaplastic thyroid ca?

A

total thyrdoiectomy (rarely resectable)
+/- palliative chemotx

196
Q

131I not effective for what ca

A

MTC
anaplastic
Hurthle

197
Q

131I effect on mets?

A

good for lung and bone mets

198
Q

131I side effects?

A

sialoadenitis, nv, infertility, BM suppression, PTH dysfxn, leukemia

199
Q

superior vs inferior parathyroid origin?

A

superior: 4th pharyngeal POUCH ass’d thyroid complex
inferior: 3rd pharyngeal POUCH ass’d thymus

200
Q

superior parathyroid location

A

lateral to RLNs, posterior/superior to thyroid, above inferior thyroid aa.

ectopic: check in the (retro esoph) TE groove or carotid sheath

201
Q

inferior parathyroid location

A

more likely ectopic
found in tail of thymus > anterior mediastinum, intrathyroid, near TE groove

202
Q

blood supply to parathyroids

A

inferior thyroid artery from thyrocervical trunk

203
Q

4 PTH resected but still high PTH … where to look for supernumerary?

A

just do thymus

204
Q

dx primary hyperparatyroidism?

A

high PTH
high Ca
low urinary Ca <100
low phos
CL:phos ratio > 33
increase renal cAMP
loss bicarb in urine

205
Q

dx next step to localize PTH adenoma?

A

SESTAMIBI + US / CTA venous if reoperative/complex case

206
Q

acid base disturbance in primary hyperPTH

A

hyperchloremic metabolic acidosis.

207
Q

indication for parathyroidectomy

A

symptomatic
asx with Ca>13, decrease Cr clearance, kidney stones, UCa > 600, osteoporosis, <50YO, poor access

208
Q

how to confirm you got the PTH adenoma out?

A

50% drop in PTH from pre-incision value to 10 min after resection

209
Q

mgmt pth adenoma

210
Q

mgmt pth hyperplasia

A

resect 3.5 glands or total and autoimplant.

211
Q

mgmt pth carcinoma

A

radical parathyroidectomy (with ipsilateral thyroid lobe)

212
Q

Ca level in parathyroid carcinoma?

A

very very high > 14

213
Q

PTH ca mgmt

A

en bloc resection + ipsilateral thyroid possibly + neck dissection if LN involvement suspected

214
Q

PTH ca mgmt if recurrent/metastatic

A

chemoXRT NOT effective.. so palliative or Ca bisphos/calcimims

215
Q

pregnancy PTH hyperparathryoidism

A

resect in 2nd timester

216
Q

lesion in primary hyperparathyroidism (adenoma vs?)

A

single adenoma 80%
multiple adenoma 4%
diffuse hyperplasia 15%
carcinoma 1-2% – usually VERY high

217
Q

MEN association with primary hyperparathryoidism?

A

MEN I»> and IIa; diffuse 4 gland hyperplasia. treatment is 3.5 or 4 gland

218
Q

what presents first in MEN I

A

hyperPTH - Hyper Ca

so, resect 4 and autoimplant first before anything else

219
Q

utility of sestamibi scan?

A

best for ectopic glands. use if cannot find gland (close and scan)

220
Q

bone hunger vs aparathyroidism causing hypocalcemia postop parathyroidecotmy

A

bone hunger: normal PTH, decrease bicarb, increase UcAMP
aparathyroi: decreased PTH, normal bicarb and UcAMP

221
Q

mgmt normocalcemic primary hyperparathyroidism nPHPT

A

surgery if symptomatic

222
Q

secondary hyperparathyroidism cause

A

ESRD; chronically lost Ca (lost with HD); cause increase PTH; low Ca***

223
Q

mgmt secondary hyperPTH?

A

Ca supplement, Vit D, low phos diet, phos binders (sevelamer), cinacalcet (mimic Ca, inhibits PTH), surgery…

224
Q

surgical indication (total with auto; or subtotal) in secondary hyperPTH

A

if bone pain, fx, pruritus

225
Q

tertiary hyperparathyroidism cause

A

ESRD s/p txp. autoPTH high

226
Q

mgmt tertiary hyperPTH?

A

subtotal 3.5 or total with auto

227
Q

familial hypercalcemic hypocalciuria lab abnormalities?

A

increased serum Ca, low urine Ca, normal PTH
due to defect in PTH-R in DCT (can’t resorb Ca)

Diagnosis <100 mg/24 hr urine calcium with high serum Ca

228
Q

mgmt FHH

A

nothing; no surgery.

229
Q

pseudohypoparathyroisim issue?

A

PTH-R in DCT defect (like FHH); does not respond to PTH (normal PTHN levels)

230
Q

5 yr survival parathyroid ca?

231
Q

mets commonly from PTH to what?

232
Q

multiple endocrine neoplasia syndromes AD vs AR?

233
Q

MEN from what* cells

A

APUD = GI endocrine cells

234
Q

MENI menin

A

PPP parathyroid hyperplasia (urinary first), PNET (gastrinoma >), pituitary adenoma (prolactinoma)

235
Q

MENIIa ret

A

PMP parathyroid hyperplasia, medullary thyroid (first, main cause of death), pheo

236
Q

MENIIb ret

A

MMP medullary, mucosal, marfan’s habitus, pheo

237
Q

mgmt hypercalcemic crisis?

A

fluids=NS and lasix.

238
Q

mgmt PTHrP medical mgmt (poor surigcal candidate for SCC lung)?

A

judicious fluids and IV pamidronate (ca binder bisphos)

239
Q

TIRADS

A

TIRADS 1. benign NTD
2. not suspicious NTD
3. mildly suspicious FNA if 2.5cm+, follow if 1.5cm+
4. moderately FNA if 1.5cm +, follow if 1cm+
5. highly FNA if 1cm, follow if 0.5cm+

240
Q

Bethesda guidelines thyroid FNA

A
  1. nondx; repeat FNA
  2. benign; clinical/US f/u until 2x negative
  3. atypia of undetermined signif; repeat FNA, molecular testing, lobectomy
  4. follicular neoplasm or suspicious for; molecular testing, lobectomy
  5. suspicous for malignancy; lboectomy or near total thryoidectomy
  6. malignancy diagnosed; lobectomy or near total thyroidectomy.
241
Q

myxedema coma

A

intubate, NS (hypoNa), glucose (hypogly), iv thyroxine

242
Q

intraop BP control in pheo resection

A

nitroprusside&raquo_space;> phentolamine, nicardipine, labetalol, esmolol

243
Q

what does a recurrent laryngeal nerve injury look like on DL

A

adducted cord.

244
Q

mgmt for thyroid lymphoma (rapidly growing)

A

B cell lymphoma
R-CHOP
rituximab, cyclophosphamide, doxorubicin, oncovin (vincristine), prednisone

radiation if compressive sx

245
Q

papillary ca staging

A

I and II < 55
III and IV > 55
II has mets

246
Q

recurrent parathyroid ca mgmt

A

radioresistant;
no role for chemo
so, reexplore/resect.

247
Q

postop diet after aldosterinoma resection?

A

HIGH salt to prevent rebound hyperK

248
Q

timing of thyroidectomy preg graves

A

4-8 wks after ptu or mtm

249
Q

stress dose steroids if taking< 5 mg pred a day

A

jsut take PO dose on AM

250
Q

stress dose if 5-20 mg/day for > 3 weeks

A

take AM PO dose if minor surgery (inginalhernia)
take AM + 50 hydrocort wit 25 q8 if moderate (revascul)
take AM + 100 hydrocort with 25q8 if major cardiac/thor/abd

BTK sasy: minor IV hydo 25-50 day of then normal dosing
major IV hydro 50-75 for 1-2 days then normal

251
Q

stress dose if >20 mg regardless fo type of surgery

A

neesd stress dosing steroids

252
Q

insulin periop

A

continue reduced dose SC inulin if short proceudre
IV insulin gtt for long omplex
hold oral antihyperglycemics

253
Q

arterial supply thyroid

A

superior (ECA) thyroid
inferior (thyrocervical STAT) thyroid
IMA (innominate)

254
Q

venous drainage thyroid

A

superior (IJ)
inferior (innominate)

255
Q

embryology thyroid

A

pharyngeal pouches (ENDODERM)

C cells (4th and 5th branchial pouches)

256
Q

RAI doesn’t work for what thyroid ca

257
Q

myelolipoma adrenal

A

benign… CT adrenal to show fat… adrenalectomy if >7cm or symptomatic

258
Q

arteria lusoria

A

aberrant R SCA off the descending aorta distal to L SCA; MC congenital arch anomaly… ass’d with R non-recurrent laryngeal nerve

259
Q

potency of steroids

A

hydrocortisone < prednisone < methylpred < dexamethasone

260
Q

incretin signaling pathway

261
Q

survival prognosis for adrenal carcinoma

A

adequacy of resection - get it all!!!

not just LNs

262
Q

adrenal insufficiency - what to avoid for RSI

A

etomidate (inhibitors steroid synthesis)

263
Q

contraindications for RAI

A

current preg, and avoid for 6-12 mos

current breastfeed

severe thyrotoxicosis

severe Graves

264
Q

paraneoplastic syndromes

A

PTHrP - squamous cell cancers
ADH and ACTH - small cell lung cancer

265
Q

postoperative (after lobectomy even) subclinical hypothyroidism

A

asx
TSH elevated
fT4 normal

start on levothyroxine instead of observing

266
Q

syndromes associated with pheo

A

MEN2’s, NF1, Sturge Weber, TS

267
Q

paraganglioma?

A

extra-adrenal pheo

268
Q

ganglioneuroma?

A

benign.
asx.
neural crest tumor in medulla or sympathetic chain

tx: just resect

269
Q

thyroxine side effect; long term

A

osteoporosis

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