Endocrine Flashcards
Suspicious ultrasound Thyroid features
-solid versus cystic nodules
-hypoechogenicity
-microcalcifications
-intranodular vascularity
-irregular or infiltrative margins
-shape taller than wide.
when to consider FNA for small Nodule in Thyroid ?
-family history of thyroid cancer
-history of radiation exposure
-isolated uptake on PET scan
-suspicious cervical lymphadenopathy
-hoarseness
Pathophysio of Gynecomastia
-enhanced peripheral aromatization of androgen to
-estrogen (obesity)
-increases in available estrogen
-alterations in sex hormone-binding-globulin
-decreases in free androgen
Workup for primary hyperparathyroidism
-Part of the history to check for inherited syndrome
-Biochemical evaluation should include
calcium
parathyroid hormone levels
creatinine
25-hydroxyvitamin D levels
24-hour urine for creatinine and calcium
-patients with asymptomatic pHPTH undergo abdominal imaging to detect nephrocalcinosis or nephrolithiasis
Adrenal incidentalomas Workup
-24-hour urine collection for fractionated catecholamines and metanephrines
-or plasma-free metanephrines to rule out
pheochromocytoma.
-An overnight 1-mg dexamethasone suppression test to evaluate for Cushing syndrome.
-aldosterone:plasma renin activity ratio
Algorithm for the evaluation of incidentalomas
in Pic
Papillary Thyroid Ca Lobectomy Vs TT
lobectomy for up to 4-cm unifocal
intrathyroid papillary thyroid cancer tumors
absence of prior head and neck radiation
No familial thyroid cancer or clinically detectable cervical nodal metastasis
diagnosis of primary HPTH
elevated calcium and parathyroid hormone levels
Vitamin D level
familial hypocalciuric hypercalcemia :
low urinary excretion of calcium along with elevated parathyroid hormone and calcium levels.
Hypercalcemia Tx
-IV Saline
-IV bisphosphonates (the initial treatment of choice) > inhibit osteoclastic bone resorption > max effectiveness 2-4 days
-calcitonin > rapidity of its effect > Renal calcium absorption is blocked > effects are seen as soon as 6 hours after administration.
Cinacalcet ?
-corrects hypercalcemia by decreasing the production of PTH > For parathyroid cancer and ectopic production of PTH
renal compromised patients with High Calcium
Saline diuresis may lead to volume overload.
The most appropriate treatment hemodialysis
Bethesda System
- Nondiagnostic or Unsatisfactory
II. Benign
III. Atypia of Undetermined Significance or Follicular Lesion of Undetermined Significance
IV. Follicular Neoplasm or Suspicious for a Follicular Neoplasm
V. Suspicious for Malignancy
VI. Malignant
Adrenocortical carcinomas features
typically large (6-8 cm) and have characteristic features on imaging such as irregular borders and heterogenous attenuation.
what size adrenal tumor suggest resection
Clinical guidelines suggest that any lesion larger than 4 cm undergo resection because of increased cancer risk.
Pheochromocytomas initial screening
initial screening test for a pheochromocytoma is plasma-free metanephrines.
If these are elevated THEN 24-hour urine collection for catecholamines and metanephrines should be performed
Confirmatory testing for Primary HPTH
-elevated levels of urinary calcium excretion
-normal Vitamin D level
-depressed serum phosphate
-Serum chloride-to-phosphate ratio of greater than 33.
for primary HPTH no further imaging is necessary incase of
traditional 4-gland neck exploration is planned
If a patient is a candidate for focused parathyroidectomy, or “minimally invasive”
Most experienced surgeons use a 2-imaging test algorithm, and if concordant and confirmatory of solitary adenoma, focused exploration may be appropriate.
neck ultrasonography
Tc-99 sestamibi scanning
contrast-enhanced CT scan of the neck.
whenever a diagnosis of medullary thyroid cancer is made you should ?
Exclude pheochromocytomas
because pheochromocytomas should be treated first when any intervention is planned
Indications for Parathyroidectomy
-Serum calcium
(>upper limit of normal) 1.0 mg/dL
-Skeletal
BMD T-score < -2.5
Vertebral fracture by x-ray, CT, MRI, or VFA
-Renal
CrCL <60 mL/minute
24-hour urine for calcium >400 mg/day
Presence of nephrolithiasis or nephrocalcinosis
-Age < 50 Years
persistent pHPTH Vs Recurrent pHPTH
persistent > failure of cure before 6 months postoperatively
Recurrent > initial normalization of calcium with recurrence after 6 months
Patient with Recurrent Primary HPTH after focused parathyroidectomy 1 year ago
sestamibi scintigraphy, should be repeated.
If not localize an adenoma > ultrasound aspiration of potential adenomas with PTH measurement Or parathyroid angiography with selective venous sampling
If Still no localization is found > nonoperative management
Initial evaluation of a young patient with apparently localized medullary thyroid cancer
-neck ultrasound examination
-measurement of serum calcium
-calcitonin and carcinoembryonic antigen levels
-urine screening studies for pheochromocytoma
-and genetic counseling for consideration of RET proto-oncogene testing.
persistent elevation of calcitonin after thyroidectomy for medullary Cancer
most commonly due to persistent disease in the neck or distant metastatic disease
imaging is indicated
