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Surgery > endocrine > Flashcards

endocrine Flashcards

1
Q

what is the embryological origin of the thyroid?

A

originates from the foramen cecum

when the descending tract doesnt close you can get thyroglossal duct cyst/mass

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2
Q

how can you assess the thyroid on physical exam

A

have them swallow (it should move) and stick out their tongue (it should also move)

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3
Q

how do you assess thyroid with imaging

A

U/S

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4
Q

if a person has a thyroid module and that is his only functioning thyroid tissue on U/S, do you still consider resection?

A

yes

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5
Q

what is the operation to remove the thyroid

A

sistrunk operation with removal of center of the hyoid

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6
Q

what % of the population has a palpable thyroid nodule

A

5-8% of women

1-2% men

increases with age

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7
Q

how do you assess thyroid nodule risk (for malignancy) via history

A

age (rates of cancer similar between ages but have better prognosis when younger)

sex

family history

growth symptoms of mass (rapidly growing masses are cancer until proven otherwise)

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8
Q

how do you assess thyroid nodule risk (for malignancy) via physical exam

A
  1. complete physical
  2. mass that grows fast is likely cancer but if it grows fast and is painful then resolves somewhat…unlikely to be cancer
  3. characterize the mass–> does it move when swallowing?
  4. lymphadenopathy
  5. voice
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9
Q

what is the best test for thyroid nodule risk assessment?

A

FNA

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10
Q

how do you assess thyroid nodule risk (for malignancy) via FNA

A

well differentiated thyroid cancer is based on age (staging differs on whether you are under or over 45)

dont investigate nodules that are less than 1 cm unless there is extension or associated LAD

atypia in a sample will likely be removed

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11
Q

what is the bethesda classification for thyroid cancer FNA?

A
  1. non diagnostic
  2. benign
  3. follicular lesion of unknown significance
  4. follicular neoplasm
  5. suspicious for malignancy
  6. malignant
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12
Q

what characteristics of a single thyroid nodule would suggest thyroid cancer

A

single nodule

calcifications

hypoechoic

taller than wide

heterogenous

hypervascular

take these ones out

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13
Q

indications for surgery for a multinodular goiter

A
  1. suspicion of malignancy/inability to rule out malignancy
  2. compressive symptoms (SOB, dysphagia, etc)
  3. hyperthyroidism
  4. cosmesis
  5. retrosternal goiters (hard to follow clinically and investigate, also hard to biopsy and it can only grow backwards into vital structures)
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14
Q

how does hyperthyroidism usually present

A

multinodular goiter, graves, solitary nodule

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15
Q

treatment for hyperthyroidism

A

anti thyroid medications

radioactive iodine

surgical management (not easy surgery)

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16
Q

what are the types of thyroid cancer

A

(most to least common)

  1. papillary
  2. follicular–> you need to see vascular or capsular invasion, which you can’t see on FNA, in order to determine if malignant or not–> usually do partial lobectomy to check
  3. medullary
  4. anaplastic (high mortality)
  5. lymphoma
  6. metastatic (often from breast)
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17
Q

risk factors for thyroid cancer

A
  1. previous radiotherapy/radiation exposure

2. family history

18
Q

treatment of thyroid cancer

A

even for low risk thyroid malignancy you resect–> make sure to take out enough because there may be vascular and capsular invasion
(going back in a second time has high risk of hemorrhage)

lobectomy is thus primary treatment

19
Q

what are the risks associated with thyroid surgery

A
  1. damage to the recurrent laryngeal nerve
    - -> also a non recurrent right laryngeal nerve goes straight across and can be easily injured
  2. parathyroid risks–> hypercalcemia etc
  3. hemorrhage
20
Q

what is the cause of primary hyperparathyroidism 85% of the time

A

adenoma of the parathyroid gland

21
Q

what is the embryological origin of the 4 glands of the parathyroid

A

lower glands come from the branchial pouch and ascend from the thymus (can approach from the neck)

upper glands are posterior to the thyroid and come from the 4th pouch–> tend to be behind the place of the recurrent laryngeal nerve as opposed to the lower glands

22
Q

how does a parathyroid nodule present

A

hypercalcemia

23
Q

how do you assess the parathyroid gland

A

labs

imaging

physical exam

24
Q

what are the characteristics of hypercalcemia you might expect to see in a patient with parathyroid nodule

A 
moans
bones
psychic overtimes
kidney stones
fatigue

boney pain, abdo pain, depression, anxiety, anorexia, constipation, irritability, worsening or new depression, fractures, osteopenia or osteoporosis, polyuria, polydipsia, nocturia, pancreatitis

25
Q

treatment for parathyroid disease

A

surgery (need experienced parathyroid surgeon)

26
Q

ddx of hypercalcemia

A
  1. exogenous–> meds (i.e thiazide diuretics at initiation, lithium, tamoxifen, vitamin A and D)
  2. endogenous
    - -cancer is most common cause in hospitals (direct invovement of bone from bony mets or multiple myeloma, or production of parathyroid like substance from a renal carcinoma etc… )
    - -primary hyperparathyroidism
    - -ganulomatous disease
    - -paraneoplastic diseases
    - -familial hypercalciuric hypercalcemia (inherited syndrome that mimics primary hyperparathyroidism)
27
Q

what meds can be associated with hypercalcemia

A

thiazide diuretics at initiation, lithium, tamoxifen, vitamin A and D

28
Q

how do you investigate parathyroid disease

A

PTH level (diagnosis primary hyperparathyroidism)

24 hour urine calcium

29
Q

what are the two questions to ask yourself about adrenal masses

A

is it functioning?

is it malignant?

30
Q

how do you investigate whether an adrenal mass is functioning?

A

hx and px aimed at signs of pheos, HTN, hypercortisolism

dexamethasone test for hypercortisolism

CONS syndrome–> investigate especially if hypertensive (renin-aldosterone ratios)

imaging

31
Q

how do you investigate whether an adrenal mass is malignant?

A

2/3 adrenal masses are usually malignant

on imaging, a mass greater than 6cm has a 25% chance of being a primary adrenal

needle biopsy can be useful (mets disease to the adrenal is pretty poor prognosis but if theyre otherwise healthy you can try and take it out)–> most of the time youre gonna take it out anyway tho

HAVE TO MAKE SURE ISNT A PHEO FIRST

32
Q

what cause of hypercalcemia is most common in the inpatient population? outpatient?

A

inpatient–> malignancy

outpatient–> primary hyperparathyroidism

33
Q

what tests should you order when investigating primary hyperparathyroidism

A

serum calcium, ionized calcium, PTH

24 hour urine calcium, vitamin D

bone densitometry

CBC, lytes, BUN/Cr, alk phos

34
Q

what is the etiology of primary hyperparathyroidism

A
  1. 85% single adenoma
  2. 8-10% 4 gland hyperplasia
  3. 3% double adenoma
  4. less than 1% carcinoma
35
Q

indications for primary hyperparathyroidism surgery

A

either symptomatic or…

  • calcium above 2.8
  • bone density above -2.5 SD
  • age less than 50
  • renal dysfunction/urinary calcium levels/nephrocalcinosis
  • functional symptoms
36
Q

how do you image the parathyroid

A

U/S

sestamibi scan

37
Q

define MEN I

A

primary hyperparathyroid

pituitary adenoma and neuroendocrine tumours of the pancreas and duodenum

38
Q

define MEN IIa

A

pheochromocytoma

medullary thyroid cancer

primary hyperparathyroidism

39
Q

define MEN IIb

A

pheochromocytoma

medullary thyroid cancer

marfanoid features

mucosal neuromas

40
Q

how do you work up an adrenal incidentaloma

A
  1. aldosterone/renin ratio
  2. urine catecholamines and metanephrines
  3. urine free cortisol or low dose dexamethasone test
  4. dedicated adrenal imaging

Surgery (20 decks)

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