Endocrine Flashcards
mc pituitary adenoma?
prolacitnoma.
`prolactin dx?
> 150 (symptomatic)
sx of prolactinoma?
galactorrhea, irregular menses, decreased libido, infertility
mgmt prolactinoma?
asx and <1 cm, follow with MRI.
if sx or if >1cm, bromocriptine (if pregnant) or cabergoline»_space;> transsphenoid resection if failed mgmt
what is deadly about acromegaly?
cardiac sx (valve dysfunction, cardiomyopathy).
acromegaly GH dx?
elevated IGF-1 > 10 in 90%; MRI
mgmt acromegaly?
transsphenoid resection, XRT, bromocriptine, octreotide, pegvisomant (GH-R antagonist)
Sheehan’s syndrome?
postpartum lactation issues, amenorrhea, AI, hypothyroid
anterior pit ischemia after peripartum hemorrhage
mgmt sheehan’s?
steroids, hormone replacement
pituitary apoplexy
bleeding into pituitary tumor with gland destruction; acute bleeding sx
treat: steroids emergently; hormone replacement
craniopharyngioma origin?
rathke’s pouch; benign calcified cyst.grows along stalk to suprasellar anterior pituitary
mgmt craniopharyngioma?
resection (endocrine abnormalities, bitemporal hemianopsia, HA, hydrocephalus, etc.)
complication of craniopharyngioma resection
DI
Nelson’s syndrome?
after b/l adrenalectomy; increased CRH (enlarged pituitary).
sx: amenorrhea, bitemporal hemianopia, hyperpigmentation (B-MSH byproduct of ACTH)
mgmt Nelson’s
steroids.
Waterhouse Friderichsen syndrome?
adrenal gland hemorrhage after meningococcal sepsis leading to AI.
arterial supply to adrenals?
superior: inferior phrenic
middle: aorta
inferior: renal.
venous drainage from adrenals?
left: left renal
right: cava.
innervation to the adrenals?
cortex: none
medulla: from sympathetic splanchnics.
lymphatic drainage from adrenals?
subdiaphragmatic and renal LNs.
rate of adrenal incidentaloma?
1-2% of CTs. 5% are mets.
when to check for functionalty of adrenal mass?
ASAP, BEFORE IMAGING.
concerning adrenal incidentaloma findings
> 4 cm
10 HU
internal calcs/hemorrhage
high vascularity
heterogeneous
interval tumor growth
functional studies for incidentaloma?
urine metanephrines/VMA/catecholamines
urinary hydroxycorticosteroids,
serum K, plasma renin/aldosterone
low dose dexamethasone suppression test
indication for adrenalectomy?
- 4+ cm or ENLARGING 0.5 cm/6 mos
- functional
- non-homogenous on CT scan >10 HU
how to follow incidentaloma < 4 cm and nonfunctional and homogenous (AKA not going to resect)?
CT scan q3mo x 1 year then yearly.
how to access (post or ant) adrenal for resection?
anterior approach. reflect right lobe of liver or reflect spleen & pancreas.
common mets to adrenal?
LUNG»_space;» breast, melaoma, renal. must biopsy before.
isolated mets to adrenal? chemo or surgery.
just resect.
salt sugar sex. GFR
MESODERM CORTICAL CELLS
glomerulosa: aldosterone
fasciculata: glucocorticoids
reticularis: androgens/estrogens
where do hormones originate from? base.
cholesterol > progesterone > hormones x 3.
common hydroxylases?
21 and 11 B-hydroxylase.
posterior pituitary gland secretes what 2 things?
ADH and oxytocin alone.
NEUROhypophysis does not contain cell bodies
where ADH and oxytocin stimulated (nuclei) in hypothalamus
ADH: supraoptic nuclei
oxytocin: paraventricular nuclei
blood supply to anterior pituitary
PORTAL venous system (from neurohypophysis - posterior pitutary)
hypothalamus stuff travels where?
TRH, CRH, GnRH, GHRH, DA travel into median eminence and pass through NEUROHHYPOPHYSIS ON WAY TO ADENOHYPOPHYSIS
congenital adrenal hyperplasia? 21
21 deficiency: MC. hypotensive man. increased 17-hydrogyproge
early puberty in M, virilization in F. salt wasting (hypoTN).
treat: cortisol + genitoplasty.
congenital adrenal hyperplasia? 11
11 deficiency. hypertensive man. increased 11-deoxycortisone, later…
early puberty M, virilization in F. salt saving (causes HTN)
treat: cortisol, genitoplasty.
Conn syndrome sx?
hypertension and hypokalemia (weakness, polydipsia, polyuria)
primary Conn (dx: renin)
MC from HYPERPLASIA > adenoma, ovarian tumor, carcinoma
secondary hyperaldosteronism/Conn?
more common than primary Conn’s
etiology: CHF, RAS, liver failure, diuretics, Bartter’s (renin-secreting tumor)
renin is HIGH
Bartter’s syndrome
renin secreting tumor
how to dx primary Conn? 2 modalities
- salt load suppression test (urine aldosterone stays HIGH)
- AND aldosterone:renin > 25 (renin low)
then.. localize.
imaging for adrenal tumor?
CT scan
consider: MRI, NP-59 scintigraphy, venous sampling
when to consider adrenal scintigraphy?
when cross sectional is nondiagnostic.
NP-59 scintigraphy can show what
adenoma from hyperplasia
how to optimize prior to adrenalectomy
BP and K control.
adenoma tx
adrenalectomy
hyperplasia tx MC: conn
medical therapy first (spironolactone, ACEi, CCBs nifedipine, potassium)
then bilateral resection for refractory hypokalemia
what supplement will be required after bilateral adrenal resection?
fludrocortisone.
adrenal insufficiency Addison’s disease = hypocortisolism
#1 cause?
withdrawal of exogenous steroids
global: TB
developed: autoimmune
sx adrenal CRISIS
all loss…. refractory hypotension, fever, lethargy, pain, n/v
sx addisons disease
weakness, nausea, anorexia, weight loss, hyperK
2 cause hypocortisolism
autoimmune disease
labs for hypocortisolism?
- decreased AM cortisol? then proceed.
- ACTH stimulation test - cosyntropin – cortisol should stay LOW in primary
- get AM ACTH level: if high, primary adrenal insufficiency; if low/nl , secondary adrenal insufficiency
dx hypocortisolism?
cosyntropic stimulation test. give ACTH, cortisol will remain LOW
how to tx acute adrenal crisis/insufficiency?
dexamethasone, fluids, tx the hyperkalemia & hypoglycemia
how to tx chronic adrenal insufficiency?
steroids
hypercortisolism = Cushing’s SYNDROME; #1 cause
IATROGENIC > cushing disease > ectopic > adenoma primary
dx hypercortisolism?
24 hour urine cortisol and ACTH
ACTH low then primary (adrenal) secreting lesion
ACTH high then secondary (pituitary or ectopic)
if ACTH and cortisol is high on 24 hour urine collection?
high dose dexamethasone suppression test
pituitary adenoma will have SUPPRESSED cortisol “Cushing’s disease”
ectopic source (small cell lung ca) will not suppress
Cushing’s *DISEASE
= PITUITARY ADNOMA.
#1 non-iatrogenic cause of Cushing’s syndrome 80%
1 cause of noniatrogenic Cushing’s syndrome
Cushing’s disease - pituitary adenoma
dx Cushing’s disease
brain MRI
treat Cushing’s disease
transsphenoidal resection
radiation if too large for resection or if postop high cortisol that responds to HD dexa… there’s still some tissue there
dx ectopic ACTH secretion (failed high dose suppression test)
CT CAP to localize primary tumor
treat ectopic
resect primary and medically suppress if inoperable
adrenal cause of hypercortisolism? low ACTH. and high cortisol.
adenoma > hyperplasia
treat adrenal hypercortisolism adenoma vs hyperplasia
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.
when to consider bilateral adrenalectomy without adrenal lesion
when cannot find ectopic tumor source
when ectopic tumor source is unresectable (and it’s slow growing)
when pituitary adenoma cannot be found
what age gets adrenocortical carcinoma?
before 5 YO
after 50 YO
bimodal!
F or M get adrenocortical carcinoma?
F
are adrenocortical caricinomas functional?
50% are.
treat adrenocortical carcinoma?
radical (take kidney) adrenalectomy with debulking
+ mitotane/external beam RT (chemoXRT) if high risk local recurrence (positive margin, invasion, intraop spillage, Ki67 > 10%)
role of debulking in adrenocortical carcinoma?
helps with sx. and prolongs survival.
how to treat recurrent, residual, or metastatic disease after adrenocortical carcinoma?
mitotane (adrenalytic + XRT
5yr survival rate adrenocortical carcinoma?
20%.
postop adrenalectomy if negative margins?
CT CAP q 3 mos x 2 years
if R1 adrenalectomy,/invasiom/spillage/Ki67 >10%>
postop chemoradiation with mitotane
neural crest cell to adrenal medulla catecholamines?
tyrosine >tyrosine hydroxylase> dopa > dopamine > NE >PNMT> Epi
epi is made where exclusively
in the medulla where PNMT is - so excess epi is for sure a pheo in the ADRENAL GLAND. cannot be extra-adrenal
VMA vanillylmandelic acid
byproduct of epinephrine to metanpehrine and norepi to normetapnephrine via MAO.
pheo origin
slow growing from sympathetic ganglia or ectopic neural crest cells
10% rule of pheo
10% malignant, bilateral, kids, familial, extraadrenal
pheo laterality
R>L
dx pheo?
- plasma non specific
- confirm with urine metanephrines (24 hr) and VMA
- localize CT vs hyperintense T2 MRI vs mIBG
adjunct pheo diagnostics?
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)
venography in pheo dx?
DO NOT DO. can cause hypertensive crisis.
preoperative preparation for pheo removal?
a-blocker first (phenoxybenzamine, prazosin) and volume replacement then B block if tachycrdic or arrhythmias ssen
mgmt of pheo?
adrenalectomy (ligate veins first to avoid spilling catecholamines)
debulking role in pheo?
helps with sx
metyrosine role in pheo?
can give preop or in unresectable.
inhibits tyrosine hydroxylase to decrease synthesis of catecholamines.
extraadrenal 10% mostly malignant; locations?
MC: aortic bifurcation = origin IMA = organ Zuckerkandl
other: vertebral bodies, bladder
extramedullary tissue rests especially on organ of Zuckerkandl; where is that
inferior aorta near bifurcation
falsely elevated VMA
coffee, tea, fruit, vanilla, iodine contrast, labetalol, a/B-blocker
pharyngeal arches that make up the thyroid?
1st and 2nd. (* as opposed to pharyngeal POUCHES)
byproduct of T3 to T4 conversion?
cAMP
superior thyroid aa origin?
1st branch of ECA.
inferior thyroid aa origin?
off thyrocervical trunk; supplies both inferior and superior parathyroids.
Ima aa?
1%.
arises from innominate or aorta; traverses towards isthmus.
venous drainage from thyroid?
superior/middle thyroid: into IJ
inferior: into innominate.
innervation around thyroid?
external branch superior laryngeal nerve, recurrent laryngeal nerve.
external branch superior laryngeal nerve function?
motor to cricothyroid muscle
INJURY = loss of PROJECTION and voice FATIGUABILITY.
where dose superior laryngeal nerve run?
lateral to thyroid lobes. close to superior thyroid aa.
MC injured nerve in thyroidectomy?
superior laryngeal nerve.
MC injury location SLN?
near superior pole of thyroid during ligation of superior thyroid aa
recurrent laryngeal nerve function?
motor to all of larynx except cricothyroid. control vocal cords.
INJURY = HOARSENESS, b/l injury can obstruct airway (need trach)
where does recurrent laryngeal nerve run?
posterior to thyroid lobes in TE groove
track with inferior thyroid aa sometimes
L down around aorta
R down under SCA
ligament of berry?
posterior medial suspensory ligament of the thyroid close to RLNs.
careful on dissection!
MC injury location of RLN
delphian nodes
level VI; frequent first mets of thyroid ca
located in ANTERIOR SUSPENSORY LIGAMENT
thyroglobulin role?
stores T3 and T4 in colloid
T3 vs T4
T3 is active (tyrosine + iodine)
T4:T3 15:1
T4 to T3 via deiodinases
most sensitive indicator for thyroid gland function?
TSH.
tubercles of Zuckerkandl?
very lateral; posterior extension of thyroid tissue; rotate medially to find RLNs
leave alone in subtotal because of proximity
most common cause of death in thyroid storm?
high output heart failure.
mgmt of thyroid storm?
B-blockade, Lugol’s solution (KI, slow), cool, oxygen, glucose
Wolff Chaikoff effect
high dose iodine via Lugol’s inhibiting TSH action on thyroid and inhibits coupling of iodide resulting in less T3
thyroid nodule step to dx?
- US to see nodule (if > 1cm sus features or >1.5cm) q6mo US if smaller
- FNA and TFTs
3.
FNA results for thyroid nodule?
- follicular cells - lobectomy
- thyroid cancer - thryoidectomy or lobectomy
- cyst fluid - drain fluid and send for cytology; resect if recurs/bloody
- colloid tissue: leave alone = goiter
- normal tissue but TFTs high - toxic nodule…. MTM and iodine if sx
concerning US findings for thyroid nodule
hypoechogenicity
microcalcification
irregular margin
unorganized vascular pattern
lymphatic invasion
TALLER than wider
if indeterminant FNA,
get radionuclide study
hot nodule on radionuclide sestimibi
MTM and iodine if symptomatic
cold nodule on sestimibi?
lobectomy (likely malignant)
MC cause of goiter
identifiable is iodine deficiency
MCC In US: low grade stimulation of the thyroid gland
primary substernal goiter vessels originate from?
innominate
secondary substernal goiter vessels originate from?
superior and inferior thyroid aas.
pyramidal lobe thyroid?
10%.
extends from isthmus superiorly.
lingual thyroid?
base of tongue in foramen cecum.
treat because can cause dysphagia…. thyroxine suppression, abolish with iodine.
2% malignancy risk
thyroglossal duct cyst
MIDLINE between hyoid and thyroid isthmus. develops in pyramidal lobe
moves with swallow.
can be premalignant or infected
mgmt thyroglossal duct cyst?
resect with midportion or all of hyoid bone (SISTRUNK PROCEDURE, lateral neck incision)
MTM vs PTU
PTU OK in pregnancy 1st tri; otherwise use MTM
both inhibit peroxidase (link iodine and tyrosine together)
MTM adverse effects?
cretinism in newborns, aplastic anemia, agranulocytosis.
PTU adverse effects?
aplastic anemia, agranulocytosis. hepatotoxicity esp in kids (but overall this precludes use a lot these days except in pregnancy)
when to operate on thyroid in pregnancy?
2nd trimester
graves’ disease Abs
IgG to TSH-R
(long acting thyroid stimulator, thyroid stimulating immunoglobulin).
dx Graves?
decreased TSH, inc T3 and T4, TSH-R Ab, diffuse thyroid uptake of 123I
mgmt Graves?
thioamides (MTM, PTU), 131Iodine > thyroidectomy
RAI can cause worsening opthalmopathy
lugol solution indication
thyroidectomy for hyperthyroidism
to make thyroid decrease vascularity… firmer, easier to resect
also in thyroid storm
toxic multinodular goiter demographic?
F, 50+YO
etiology toxic multinodular goiter?
low grade chronic TSH stimulation; hyperplastic response
pathology toxic multinodular goiter?
colloid
mgmt toxic mulitnodular goiter
subtotal or total thyroidectomy»_space;»>
if poor surgical candidate, 131Iodide
single toxic nodule size to be sx
> 3 cm to be sx
single toxic nodule dx
thryoid scan shows hot nodule…. 20% of hot eventually end up causing sx
single toxic nodule tx
thioamides and 131i … lobectomy if ineffective
Hashimoto’s Ab?
IgG and T cells to Tg and TPO
Hashimoto goiter etiology
lack of organification of trapped iodide inside the gland
Hashimoto humeral vs cell mediated autommune dsease?
BOTH! Tg Abd and microsomal disease!
pathology Hashimoto’s?
lymphocyte predominance.
mgmt Hashimoto’s
levothyroxine > partial thyroidectomy.
de Quervain’s thyroiditis sx
hyperthyroid then hypothyroid, PAINFUL sore throat after URI.
de Quervain’s dx?
elevated ESR. “subacute granulomatous thyroiditis”
LOW uptake RAI
mgmt de Quervains?
steroids, aspirin > lobectomy/thyroidectomy.
Riedel’s fibrous struma?
wood fibrous components involve strap muscles and carotid sheath
sx: hypothryoid, compressive sx
Riedel’s fibrous struma dx?
looks like ca, so Bx.
mgmt Riedel’s
steroids, thyroxine
Riedel associations
PSCLEROSINGCHOLANGITIS
FIBROTIC disease
METHYSERGIDE therapy
retroperitoneal FIBROSIS
if FNA shows follicular cells?
5-10% malignancy.
mgmt follicular adenoma?
lobectomy to provide it is not ca
most common thyroid cancer?
papillary thyroid carcinoma 85%
spread lymph or heme papillary
thyroid?
lymphatic
prognosis based on what for papillary thyroid ca?
local invasion.
where does papillary thyroid ca spread (rarely, as it is mostly local invasion)?
LUNG.
pathology papillary thyroid carcinoma?
psammoma bodies and orphan annie nuclei.
5 yr survival rate papillary thyroid carcinoma?
95%.
papillary thyroid ca postop HIGH RISK next steps
after total thyroidectomy, do 131RAI
can do whole body RAI scan 6 mo after to eval for disease
HIGH risk papillary ca that will require RAI
tumor 2-4 cm
vascular invasion
anti-Tg Abs
Tg < 5
follicular thyroid ca spread heme or lymph?
heme only. BONE common mets 50% at presentation.
prognosis of follicular thyroid ca based on?
staging.
5 yr survival rate follicular thyroid ca?
70% (95% papillary)
mgmt of papillary thyroid ca
lobectomy.
thyroidectomy indication: 4+cm [Fiser says 1+cm], beyond thyroid capsule/mets/clinical node, multicentric lesions, previous radiation
mgmt of follicular thyroid ca
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
indications for modified radical neck dissection in the setting of thyroid ca?
extrathyroid disease, medullary, or clinically apparent nodal disease (Hurthle, papillary, follciular)
indications for postop 131iodide (after thyroidectomy) - 6 wks postop?
1+cm, extra thyroidal disease. (cannot be after lobectomy)
medullary thyroid ca associated syndromes?
MENIIa or IIb (RET protooncogene)
pathology of medullary thyroid cancer
amyloid deposition
manifestation of medullary thyroid ca?
diarrhea
usually early in MEN2 syndromes
etiology of medullary thyroid ca?
parafollicular C cell hyperplasia (calcitonin)
calcitonin fx
release by C parafollicular cells
inhibit osteoclast and decreases Ca
increase renal phosphate excretion
calcitonin sx?
flushing, diarrhea
lymph or heme spread of medullary thyroid ca?
lymphatic - likely to have nodal disease at dx
mets from medullary thyroid ca?
lung, liver, bone.
when to do prophylactic thyroidectomy in MEN2s?
MEN2a: 6 YO
MEN2b: 2 YO
bad prognosis for medullary thryoid ca?
MEN 2b or sporadic type.
mgmt medullary thyroid ca?
total thyroidectomy with central neck dissection
+MRND with palpable mass
+ b/l MRND if extrahyroidal disease or both lobes affected.
5 yr survival medullary thyroid ca?
50% (vs 70% foll, 95% pap)
surveillance of medullary thyroid (high risk recurrence)
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
hurthle cell carcinoma benign or malignant?
mostly benign (adenoma) in older pts
mets from hurthle cell?
bone and lung if malignant.
pathology for hurthle cell ca?
Ashkenazi cells
mgmt hurthle?
cannot distinguish adenoma vs ca so need LOBECTOMY vs total thyroidectomy
+MRND if clinical nodes.
anaplastic thyroid ca demographic?
old long standing goiters.
pathology anaplastic thyroid ca?
vesicular appearance of nuclei.
5yr survival anaplastic thyroid ca?
0%.
mgmt anaplastic thyroid ca?
total thyrdoiectomy (rarely resectable)
+/- palliative chemotx
131I not effective for what ca
MTC
anaplastic
Hurthle
131I effect on mets?
good for lung and bone mets
131I side effects?
sialoadenitis, nv, infertility, BM suppression, PTH dysfxn, leukemia
superior vs inferior parathyroid origin?
superior: 4th pharyngeal POUCH ass’d thyroid complex
inferior: 3rd pharyngeal POUCH ass’d thymus
superior parathyroid location
lateral to RLNs, posterior/superior to thyroid, above inferior thyroid aa.
ectopic: check in the (retro esoph) TE groove or carotid sheath
inferior parathyroid location
more likely ectopic
found in tail of thymus > anterior mediastinum, intrathyroid, near TE groove
blood supply to parathyroids
inferior thyroid artery from thyrocervical trunk
4 PTH resected but still high PTH … where to look for supernumerary?
just do thymus
dx primary hyperparatyroidism?
high PTH
high Ca
low urinary Ca <100
low phos
CL:phos ratio > 33
increase renal cAMP
loss bicarb in urine
dx next step to localize PTH adenoma?
SESTAMIBI + US / CTA venous if reoperative/complex case
acid base disturbance in primary hyperPTH
hyperchloremic metabolic acidosis.
indication for parathyroidectomy
symptomatic
asx with Ca>13, decrease Cr clearance, kidney stones, UCa > 600, osteoporosis, <50YO, poor access
how to confirm you got the PTH adenoma out?
50% drop in PTH from pre-incision value to 10 min after resection
mgmt pth adenoma
resect.
mgmt pth hyperplasia
resect 3.5 glands or total and autoimplant.
mgmt pth carcinoma
radical parathyroidectomy (with ipsilateral thyroid lobe)
Ca level in parathyroid carcinoma?
very very high > 14
PTH ca mgmt
en bloc resection + ipsilateral thyroid possibly + neck dissection if LN involvement suspected
PTH ca mgmt if recurrent/metastatic
chemoXRT NOT effective.. so palliative or Ca bisphos/calcimims
pregnancy PTH hyperparathryoidism
resect in 2nd timester
lesion in primary hyperparathyroidism (adenoma vs?)
single adenoma 80%
multiple adenoma 4%
diffuse hyperplasia 15%
carcinoma 1-2% – usually VERY high
MEN association with primary hyperparathryoidism?
MEN I»> and IIa; diffuse 4 gland hyperplasia. treatment is 3.5 or 4 gland
what presents first in MEN I
hyperPTH - Hyper Ca
so, resect 4 and autoimplant first before anything else
utility of sestamibi scan?
best for ectopic glands. use if cannot find gland (close and scan)
bone hunger vs aparathyroidism causing hypocalcemia postop parathyroidecotmy
bone hunger: normal PTH, decrease bicarb, increase UcAMP
aparathyroi: decreased PTH, normal bicarb and UcAMP
mgmt normocalcemic primary hyperparathyroidism nPHPT
surgery if symptomatic
secondary hyperparathyroidism cause
ESRD; chronically lost Ca (lost with HD); cause increase PTH; low Ca***
mgmt secondary hyperPTH?
Ca supplement, Vit D, low phos diet, phos binders (sevelamer), cinacalcet (mimic Ca, inhibits PTH), surgery…
surgical indication (total with auto; or subtotal) in secondary hyperPTH
if bone pain, fx, pruritus
tertiary hyperparathyroidism cause
ESRD s/p txp. autoPTH high
mgmt tertiary hyperPTH?
subtotal 3.5 or total with auto
familial hypercalcemic hypocalciuria lab abnormalities?
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
mgmt FHH
nothing; no surgery.
pseudohypoparathyroisim issue?
PTH-R in DCT defect (like FHH); does not respond to PTH (normal PTHN levels)
5 yr survival parathyroid ca?
50%.
mets commonly from PTH to what?
lung.
multiple endocrine neoplasia syndromes AD vs AR?
AD.
MEN from what* cells
APUD = GI endocrine cells
MENI menin
PPP parathyroid hyperplasia (urinary first), PNET (gastrinoma >), pituitary adenoma (prolactinoma)
MENIIa ret
PMP parathyroid hyperplasia, medullary thyroid (first, main cause of death), pheo
MENIIb ret
MMP medullary, mucosal, marfan’s habitus, pheo
mgmt hypercalcemic crisis?
fluids=NS and lasix.
mgmt PTHrP medical mgmt (poor surigcal candidate for SCC lung)?
judicious fluids and IV pamidronate (ca binder bisphos)
TIRADS
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+
Bethesda guidelines thyroid FNA
- nondx; repeat FNA
- benign; clinical/US f/u until 2x negative
- atypia of undetermined signif; repeat FNA, molecular testing, lobectomy
- follicular neoplasm or suspicious for; molecular testing, lobectomy
- suspicous for malignancy; lboectomy or near total thryoidectomy
- malignancy diagnosed; lobectomy or near total thyroidectomy.
myxedema coma
intubate, NS (hypoNa), glucose (hypogly), iv thyroxine
intraop BP control in pheo resection
nitroprusside»_space;> phentolamine, nicardipine, labetalol, esmolol
what does a recurrent laryngeal nerve injury look like on DL
adducted cord.
mgmt for thyroid lymphoma (rapidly growing)
B cell lymphoma
R-CHOP
rituximab, cyclophosphamide, doxorubicin, oncovin (vincristine), prednisone
radiation if compressive sx
papillary ca staging
I and II < 55
III and IV > 55
II has mets
recurrent parathyroid ca mgmt
radioresistant;
no role for chemo
so, reexplore/resect.
postop diet after aldosterinoma resection?
HIGH salt to prevent rebound hyperK
timing of thyroidectomy preg graves
4-8 wks after ptu or mtm
stress dose steroids if taking< 5 mg pred a day
jsut take PO dose on AM
stress dose if 5-20 mg/day for > 3 weeks
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
stress dose if >20 mg regardless fo type of surgery
neesd stress dosing steroids
insulin periop
continue reduced dose SC inulin if short proceudre
IV insulin gtt for long omplex
hold oral antihyperglycemics
arterial supply thyroid
superior (ECA) thyroid
inferior (thyrocervical STAT) thyroid
IMA (innominate)
venous drainage thyroid
superior (IJ)
inferior (innominate)
embryology thyroid
pharyngeal pouches (ENDODERM)
C cells (4th and 5th branchial pouches)
RAI doesn’t work for what thyroid ca
MTC
myelolipoma adrenal
benign… CT adrenal to show fat… adrenalectomy if >7cm or symptomatic
arteria lusoria
aberrant R SCA off the descending aorta distal to L SCA; MC congenital arch anomaly… ass’d with R non-recurrent laryngeal nerve
potency of steroids
hydrocortisone < prednisone < methylpred < dexamethasone
incretin signaling pathway
GLP 1
survival prognosis for adrenal carcinoma
adequacy of resection - get it all!!!
not just LNs
adrenal insufficiency - what to avoid for RSI
etomidate (inhibitors steroid synthesis)
contraindications for RAI
current preg, and avoid for 6-12 mos
current breastfeed
severe thyrotoxicosis
severe Graves
paraneoplastic syndromes
PTHrP - squamous cell cancers
ADH and ACTH - small cell lung cancer
postoperative (after lobectomy even) subclinical hypothyroidism
asx
TSH elevated
fT4 normal
start on levothyroxine instead of observing
syndromes associated with pheo
MEN2’s, NF1, Sturge Weber, TS
paraganglioma?
extra-adrenal pheo
ganglioneuroma?
benign.
asx.
neural crest tumor in medulla or sympathetic chain
tx: just resect
thyroxine side effect; long term
osteoporosis
