ENDOCRINE Flashcards
The most important prognostic factors in survival of patients with differentiated thyroid cancer are
AGE, grade, extracapsular extension, distant metastasis, and size of the tumor.
basic criterion to be low risk papillary thryoid cancer and what is treatment
Partial thyroidectomy can be performed for patients with thyroid cancer that is <45 and no extracapsular invasion. However, there is some data to support doing a total thyroidectomy in this patient population, but it is not the standard of care.
Differentiated thyroid cancers The staging is as follows:
Papillary or follicular (differentiated) thyroid cancer in patients younger than 45:
Stage I: ANY T, any N, M0
Stage II: any T, any N, POSITIVE METS!
Papillary or follicular (differentiated) thyroid cancer in patients 45 years and OLDER:
Stage I: T1, N0, M0:
The tumor is 2 cm or less across and has not grown outside the thyroid.
Stage II: T2, N0, M0::
The tumor 2-4 cm across and has not grown outside the thyroid (T2).
Stage III: One of the following applies: T3, N0, M0: T3 LARGER THAN 4 cm across or has grown slightly outside the thyroid (T3),
not spread to nearby lymph nodes (N0) or distant sites (M0).
T1 to T3, N1a, M0: The tumor is any size and may have grown slightly outside the thyroid (T1 to T3). It has spread to lymph nodes around the thyroid in the neck (N1a) but not to other lymph nodes or to distant sites (M0). Stage IVA: One of the following applies:
T4a, any N, M0: The tumor is any size and has grown beyond the thyroid gland and into nearby tissues of the neck (T4a). It might or might not have spread to nearby lymph nodes (any N). It has not spread to distant sites (M0). T1 to T3, N1b, M0: The tumor is any size and might have grown slightly outside
the thyroid gland (T1 to T3). It has spread to certain lymph nodes in the neck (cervical nodes) or to lymph nodes in the upper chest (superior mediastinal nodes) or behind the throat (retropharyngeal nodes) (N1b), but it has not spread to distant sites (M0).
Stage IVB (T4b, any N, M0): The tumor is any size and has grown either back toward the spine or into nearby large blood vessels (T4b). It might or might not have spread to nearby lymph nodes (any N), but it has not spread to distant sites (M0).
Stage IVC (any T, any N, M1): The tumor is any size and might or might not have grown outside the thyroid (any T). It might or might not have spread to nearby lymph nodes (any N). It has spread to distant sites (M1).
Answer A: This is not a recognized stage in the TNM staging system
Primary hyperaldosteronism
is also known as Conn syndrome.
The most common presentation of primary hyperaldosteronism is difficult to control hypertension.
Hypertension results from unopposed aldosterone secretion which acts on the kidneys to absorb sodium and increases intravascular volume.
HYPOK and ALKalosis from:
Sodium is for potassium and hydrogen ions in the kidney which further increases sodium retention in the setting of hyperaldosteronism at the expense of decreased potassium and hydrogen ions in the serum.
Other symptoms of hyperaldosteronism are non-specific including weakness, fatigue and headaches. The net effect is hypertension, hypokalemia and alkalosis. (Sodium is retained at the expense of potassium and hydrogen ions).
Bottom Line: Hyperaldosteronism is associated with hypertension, hypokalemia and alkalosis.
Operative treatment of acute PID
Operations are restricted! to:
life-threatening infections,
ruptured tuboovarian abscesses,
Weak easy fatigue of voice after thyroid injury
what nerve
what does it innervate
where is it - land marks
EXTERNAL branch of the superior laryngeal nerve
innervation to the CRICOTHYROID muscle, which tilts the LARYNX during speaking to affect pitch
crosses the superior thyroid vessels
more than 1 cm above the level of the superior thyroid pole
stimulate the release of gastrin
Amino acids Alkaline environment Gastric distension Calcium vagal input
official rule on intraoperative time frame of PTH levels
(3-5) minute half life of parathyroid hormone (PTH).
Within 10 minutes of gland excision, a drop of at least 50% of the highest pre-EXCISION of GLAND (CAREFUL - NOT pre skin incision) value indicates complete resection of hyperfunctioning glands (choices B and C).
Failure to drop after 10 minutes does not imply the removed gland was normal (choice A). It only confirms there is remaining hyperfunctioning tissue within the body.
Even after a successful parathyroidectomy, if there are remaining glands, the patient is still at risk of developing a recurrence of hyperparathyroidism in the future (choice D).
Bottom Line: A 50% drop in parathyroid hormone (PTH) value after gland excision, as compared to the highest value either before skin incision or just before gland excision, is needed to confirm removal of all hyperfunctioning gland.
Familial Hypercalcemic Hypocalciuria
autosomal dominant disease caused by
increased calcium resorption in the kidney due to a defective PTH receptor.
(kidney is just absorbing extra calcium)
mild hypercalcemia
normal levels of parathyroid hormone.
DO NOT TREAT WITH ANYTHING
Primary hyperparathyroidism what are the lyte findings
hypersecretion of parathyroid hormone,
which acts to
increase the serum level of calcium.
Secondary effects of this hormone are a
decrease in serum phosphate levels due to poor renal reabsorption,
elevated urinary calcium levels.
increased chloride
surgical and Adjuvant for parathyroid cancer
en bloc resection with an ipsilateral thyroidectomy.
radiation post op has been shown to decrease local recurrence.
NO role for chemotherapy for these tumors
high grade versus low grade MALToma
Low grade lymphomas can be precipitated by an H.pylori infection and can be treated with antibiotics alone, which usually include Clarithromycin and Amoxicillin. Even with surrounding nodes are seen to be positive on CT
High grade lymphomas are better treated with a combination of chemotherapy and radiation. CHOP. Radiation is also used to treat high grade lymphoma.
Surgery is rarely indicated with gastric lymphoma and is only reserved for instances of perforation or uncontrolled bleeding.
If the results from the thyroid FNA are inconclusive, then the recommendation is
either repeat the procedure
or
have close follow up within three months
The majority of nodules with indeterminant FNA samples ultimately are found to be benign.
Surgery is not indicated after one failed attempt of FNA for diagnosis
percent of renal artery stenosis required for hypertension to occur
Renovascular hypertension is most commonly due to atherosclerosis of the renal artery, where
approximately 60% of the vessel needs to be occluded before hypertension will occur
where is the mean arterial pressure sensed in what is result when there is renal artery stenosis
A decrease in the mean arterial pressure is sensed by baroreceptors in the afferent arteriole which lead to stimulation of the juxtaglomerular apparatus, and ultimately activation of the renin-angiotensin axis
The overproduction of renin leads to hypertension that is difficult to manage with medications.
Patients may benefit from percutaneous transluminal angioplasty to decrease the renal artery stenosis.
The most common malignant tumor of the parotid gland is
mucoepidermoid carcinoma,
histologically consists of epidermoid and mucous cells.
low-, intermediate-, or high-grade, directly
related to the proportion of epidermoid to mucoid cells found on histologic examination.
tx of
mucoepidermoid carcinoma
treated with total parotidectomy, radical neck dissection and postoperative radiotherapy, regardless of nodal status!
CAREFUL, this is exception - as most neck disections are triggered by nodal status!!
High-grade mucoepidermoid carcinomas are highly aggressive, with a local recurrence rate of 60%, regional metastatic rate of 50%, and distant metastatic rate of 30%. These tumors are
with a 5-year survival of 50%.
Tx of far-advanced parotid gland carcinoma
prepared for an
extended, radical parotidectomy,
which may involve resection of overlying skin, adjacent mandible and soft tissue, temporal bone, and a portion of the adjacent external ear.
With advanced presentations, the facial nerve is invariably sacrificed in these patients; free tissue transfer may be necessary for repair.
The most common malignancy of the submandibular gland
adenoid cystic carcinoma
This is also the second most common of the parotid gland
propensity for perineural invasion and spread, as well as distant metastases
Tx of adenoid cystic carcinoma
Surgical management of these tumors
The most common malignancy of the submandibular gland (and the second most common of the parotid gland)
includes radical resection,
sacrificing nerves only for direct tumor extension
and
postoperative radiation therapy.
Despite this aggressive therapy, these tumors, which follow an indolent course, develop regional and distant metastases 40% of the time over a 10- to 20-year course.
Gross and histo features of pleomorphic adenoma
The most common benign lesion of the major salivary glands
Grossly,
smooth and lobular,
well-defined capsule.
Histologically, however,
epithelial and mesenchymal components
incomplete encapsulation
with pseudopod extension beyond the apparent borders of the mass.
These features account for the high recurrence rate when tumors are removed by enucleation alone.
tx of pleomorphic adenoma
resection of the tumor
WITH a margin of normal gland surrounding it.
The intimate relationship between the parotid gland and the facial nerve necessitates facial nerve identification and dissection to ensure its preservation and complete tumor extirpation.
Warthin’s tumors characteristics and treatment
are typically BENIGN (even though 10% bilateral!!)
cystic lesions
tail of the parotid gland.
often multicentric,
approximately 10% are bilateral
Treatment
superficial parotidectomy, similar to pleomorphic adenoma.
treatment of Squamous cell cancer of the parotid lobe is
another indication for a neck dissection even with clinical neg nodes!
Percent gastrinomas malig
Although slow growing, more than 60% of gastrinomas are malignant
sporatdic vs familial gastrinoma percentages
sporadic (80% of cases)
familial or inherited (20% of cases)
Male to female gastinoma ratio
There is a male preponderance, with a male-to-female ratio of approximately 2:1
Symptoms of adrenal insufficiency
reflect glucocorticoid AND mineralocorticoid deficiencies.
fever,
nausea, vomiting,
refractory hypotension,
lethargy.
Acute adrenal insufficiency is a medical emergency and should be suspected in stressed patients with a history of either adrenal insufficiency or exogenous steroid use.
hypercalcemic crisis ssx
Muscle weakness, fatigue, coma, and hypercalcemia are seen in patients with
thyrotoxicosis crisis (thyroid storm ssx
Fever, tachycardia, irritability, vomiting, and diarrhea (and diarrhea)
Laboratory findings of adrenal insufficiency include
hyponatremia,
hyperkalemia,
azotemia,
fasting or reactive hypoglycemia.
Hypercalcemia may also be present.
best test for both acute and chronic adrenal insufficiency
The rapid ACTH stimulation
(also called the cosyntropin stim test)
Synthetic ACTH (250 !g) is administered intravenously, and plasma cortisol levels are measured 30 and 60 minutes later.
Normal peak cortisol response should exceed 20 !g/dL.
