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General Surgery Oral Boards Review > Endocrine > Flashcards

Endocrine Flashcards

1
Q

Thyroid nodule: key history points

A 
Radiation exposure
     Breast Cancer
     Hodgkins
Endocrine ROS
     hot/cold intolerance
stones/bones/groans/moans
voice changes.
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2
Q

When to perform thyroid scan?

A

Only after clearly documented mass and TSH axis dysfunction.

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3
Q

What are screening labs for MEN?

A

calcitonin
serum calcium and phosphate
urine calcium
urine metanephrines

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4
Q

Who to test for RET oncolgene?

A

All first degree relatives of known MENII

Ay new diagnosis of MTC

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5
Q

When d you order thyroglobulin levels?

A

After diagnosis of a well differentiated thyroid cancer, but prior to surgery.

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6
Q

What is only sub-type of thyroid cancer that gets a subtotal thyroidcectomy?

A

Papillary thyroid cancer

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7
Q

What is the operation for Medullary thyroid cancer?

What is the most likely additional procedure needed with MTC?

A

Medullary cancer is treated with total thyroidectomy, central node dissection and modified radical neck on the side of the primary mass

Need to screen for parathyroid hyperplasia with MENII before the OR as you may need to do a four gland exploration as well.

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8
Q

What is palliative “bail-out” for anaplastic thyroid cancer?

A

Debulk for symtoms where safe.
Divide the isthmus to prevent encirclement
tracheostomy

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9
Q

What is differential and labs for hyperthyroid patient?

A

Graves (Nontender, exophthalmos)
Thyroiditis
chech TSH T2, T4 antithyroid antibodies

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10
Q

Urgent indications for operating on hyperthyroid patient?

A

children
pregnant patient
non-suppressible nodule

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11
Q

Preop medications for thyroid storm?

A
  1. PTU - stop one week before the OR
  2. switch to lugol iodine solution for one week prior to the OR.
  3. Metoprolol for tachycardia
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12
Q

Definition of secondary hyperparathyroidism?

A

four-gland hyperplasia seen in the setting of renal failure in which there is excessive urinary losses of calcium

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13
Q

Work up of primary hyper PTH?

A

rule out bone disease from cancer.
direct assay of PTH and check it against the serum calcium on the normogram.
Check urinary calcium to rule out familial hypocalciuric hypercalcemia.
Cl/phosphate ratio > 33 consistent with hyper PTH.
In borderline cases for surgery, get bone films to check for evidence of early osteopenia or bone cyst formation.

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14
Q

What are criteria for intraoperative PTH after removal of gland?

A

If abnormal gland is removed, serum PTH should drop 50% or more from preoperative baseline within 10 minutes.

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15
Q

Other locations to look for PTH gland besides regular anatomy?

A

Look in upper mediastinum, tracheoesophageal groove, carotid sheath, thymus, etc

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16
Q

What do you do if you cannot find a parathyroid and have already explored extraanatomic sites?

A

hemi-thyroidectomy on side that is missing a gland.

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17
Q

What do you do after performing a hemithyroidectomy for a missing para and labs are still abnormal?

A

Sestamibi scan

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18
Q

Workup and indications for insulinoma?

A

Fasting insulin/glucose ratio > 0.3 is diagnostic.

- Get CT scan and explore if no stage IV disease.

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19
Q

Operation for pancreatic insulinoma?

A

Need to have ability to rapidly check insulin intraop
Intraop ultrasound
Can enucleate benign insulinomas.

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20
Q

Workup and indications for gastrinoma?

A

Baseline serum gastrin level >500 pg
paradoxic increase to 4-5X with secretin
ratio of basal acid output to maximal stimulated output that is >0.6.
Get CT scan and explore if no Stage IV disease.

21
Q

Posible techniques to localize gastrinoma?

A

“gastrinoma triangle”
ultrasound
palpation
transilumination

22
Q

What operation to do if you cannot find the gastrinoma?

A

Do a vagotomy to reduce ulcer risk.

repeat CT scan in 6-12 months

23
Q

Laboratory diagnosis of aldosteronoma (Conn syndrome)

A

hypokalemia with

Aldosterone:renin ratio >30

24
Q

Work up after diagnosing Conn Syndrome?

A

If you can medically control with captopril/sprinolactome, may do so,
Can localize with CT scan, selective venous sampling or NP-59 scan.

25
Q

Workup for hypercortisolism?

A

Get basal cortisol levels, serum and 24-hour urine, to confirm hypercortisolism. Next determine ACTH – if decreased, autonomous production by adrenal adenoma; if it is increased, need dexamethasone suppression test – Cushing’s disease will suppress, ectopic sites will not.

26
Q

What is medical treatment for bilateral adrenal hyperplasia?

A

mitotane

27
Q

Pheo workup?

A

First obtain urinary measurements of VMA and metanephrine. Get calcium and calcitonin levels if family history suggestive of MEN IIA. If urinary values suggest pheo, get CT scan of abdomen and pelvis. MRI being used increasingly as study of first choice. I-131 MIBG may be helpful in delineating extra-abdominal sites of disease

28
Q

Pheo preop?

A

Prep patient with two week of alpha blockade and aggressive fluid resuscitation. If tachycardia results, treat with beta-blocker.

29
Q

How do you manage BP intraoperatively for a pheo?

A

Be prepared for wide swings in blood pressure – have nitroprusside, NeoSynephrine and phentolamine readily available,

30
Q

Adrenal Incidentaloma?

A

get urinary catecholamines, cortisol and 17 ketosteroids, and serum electrolytes, to rule out function of the mass.
Still remove if suspicious or >5cm.

31
Q

What are options for pituitary ACTH secreting tumor?

A

transphenoidal resection
Cyber Knife radiation therapy
Mitotane
Pasireotide - somatostatin analog that decreases ACTH (FDA approved 2014)

32
Q

What are indications for subtotal thyroidectomy for graves disease?

A

cosmesis/compression symptoms
failure of PTU in pregnancy
failure of 1-2 years of PTU

33
Q

What is treatment for thyroid storm?

A

Supportive care (ICU), may need intubation
beta-blockers for tachycardia
PTU 250 mg q4
hydrocortisone 100mg q6

34
Q

How much thyroid do you leave in a subtotal thyroidectomy?

A

3-5 grams

35
Q

What is main ICU B-blocker gtt?

A

propranolol

36
Q

What is the preop medication for an insulinoma?

mechanism?

A

diazoxide

Potassium channel blocker that prevents release of insulin

37
Q

Follow-up of a pheochromocytoma?

A

Urinary VMA every 3 months, then yearly

Screen all family members yearly for pheo, medullary thyroid cancer, hyperparathyroidism

38
Q

What is work-up for surgical hypertension?

A 
urinary VMA (pheo)
renin/aldosterone level 
         R>>A - renal artery stenosis
         A>>R - aldosteronoma
consider CTA
39
Q

Key venous anatomy for right adrenalectomy?

A

the adrenal vein enters posteriorly into the IVC and mobilization of the right lobe of the liver is necessary if going transabdominal

40
Q

Key venous anatomy for left adrenalectomy?

A

the adrenal vein enters posteriorly into the IVC and mobilization of the right lobe of the liver is necessary if going transabdominal.

41
Q

How can you tell bilateral adrenal hyperplasia from aldosteronoma?

A

Captopril test (1) Give dose of captopril and measure aldosterone level before and after, if decreases, then bilateral hyperplasia

42
Q

What is operation for a parathyroid carcinoma?

A

Enblock resection of the glad with ipsilateral thyroid lobe and MRM on that side.

43
Q

Bethesda criteria for Thyroid FNA: acellular fluid/blood

A

Non-diagnostic - repeat FNA

44
Q

Bethesda critera: Abundant hemosiderin-laden macrophages, scant benign follicular cells, some colloid, and rare Hürthle cells consistent with hemorrhagic colloid nodule.

A

Benign - continue ultrasound surveillance.

45
Q

Bethesda Criteria: Scattered clusters of atypical follicular cells and scant colloid

A

AFLUS - undetermined significance. repeat FNA

46
Q

Bethesda criteria: moderate to high cellularity, scant or absent colloid, and predominantly microfollicular or trabecular configuration of follicular cells.

A

Suspicious for malignancy - thyroid lobectomy

47
Q

Follow-up for papillary thyroid cancer?

A

All pts get placed on Synthroid (enough to make TSH barely measurable) Follow thyroglobulin levels (marker for recurrence) Stop thyroxin for 2 weeks six weeks post-op and do total body radioactive I131 scan to detect any residual tumor for ablation Repeat radioiodine scan q 6 months for next few years

48
Q

Follow-up for Medullary Thyroid Cancer

A

followed by calcitonin levels and DMSA scan (nuclear medicine

General Surgery Oral Boards Review (14 decks)

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