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Surgery Clerkship > Endocrine > Flashcards

Endocrine Flashcards

1
Q

What’s in the differential for adrenal nodule?

A 
Hypercortisolism
Hyperaldosteronism
Catecholamine hypersecretion
Androgen hypersecretion
Benign, nonfunctional mass
Adrenocortical carcinoma
Mets
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2
Q

What are the key 2 defining characteristics of an adrenal mass?

A

1 Hormone hypersecretion?

2 malignant?

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3
Q

What are the findings on H&P of a patient that hyper secretes cortisol?

A
  • Truncal obesity
  • Moon facies
  • Buffalo hump
  • Proximal weakness
  • Purple striae
  • to name a few
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4
Q

What’s the differential for hypercortisolism?

A

Exogenous
Adrenal
Pituitary: high ACTH
Lung: NSCLC

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5
Q

What is the clinical presentation of an adrenal nodule that hyper secretes aldosterone?

A

Hypertension (refractory to severe agents) with hypokalemia

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6
Q

What signs/symptoms are suspicious for adrenocortical carcinoma?

A
  • Cushing’s
  • Nonfunctional tumors: abdominal mass, pain, N, anorexia, early satiety, weight loss
  • > 6cm
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7
Q

What is the most common adrenal mass?

A

Nonfunctional benign adrenocortical adenoma (only 15% secrete hormones - cortisol being most common)

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8
Q

Why does hyperaldosteronism cause hypertension and hypokalemia?

A
  • Increase Na reabsorption to increase extra cell vol/BP

- K excreted to balance positively charged Na ions

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9
Q

What is next step after adrenal adenoma is suspected or seen on imaging?

A

H&P with labs: test:

  • cortisol
  • catecholamines
  • aldosterone if HTN
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10
Q

What labs to draw for hypercortisolism?

A
  1. 24-hour urine free cortisol
  2. Low dose dexamethasone suppression test
  3. Serum/salivary cortisol at midnight * Plasma ACTH level if necessary
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11
Q

What labs to draw to evaluate hyperaldosteronism?

A
  1. Serum aldosterone: renin ratio (>30 is diagnostic, 4-10 nl)
  2. Serum K+
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12
Q

What labs to draw to evaluate for catecholamine hyper secretion / pheochromocytoma?

A

24-hour urine metanephrines and catecholamines OR

Plasma metanephrines/ catecholamines

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13
Q

What is the best imaging modality to evaluate an adrenal nodule? Another option?

A

CT with contrast

MRI another option

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14
Q

What imaging characteristics of an adrenal nodule can help differentiate benign from malignant?

A

Benign: < 4cm, homogenous, well-defined borders, low vascularity, rapid contrast washout
Malignant: >6cm, irregular borders with necrosis, calcification and/or hemorrhage in mass

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15
Q

What is the treatment for a nonfunctional adrenal mass?

A

< 4cm: observe with interval CT scans
>6cm or concerning features: Resect
4-6cm: depends on other risks, resect if good surgical risk

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16
Q

What is the surveillance protocol for an adrenal nodule that will not be resected?

A
  • Repeat imaging: 6, 12, 18 months

- Repeat biochemical evaluation for hormone levels every 4 years

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17
Q

What is the treatment for a functional adrenal mass?

A

Surgical resection

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18
Q

What are important perioperative management principles for patients with Cushings?

A

Peri/post op GC replacement

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19
Q

What are important perioperative management principles for patients with hyperaldosteronism?

A

Spironolactone and K pre-op

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20
Q

What are important perioperative management principles for patients with pheo?

A

Alpha blockade 10-14 days prior to surgery: unopposed alpha stimulation can cause severe vasoconstriction and HTN

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21
Q

What is the venous drainage of L vs. R adrenal?

A

L: left adrenal to left renal
R: right adrenal to IVC

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22
Q

What is a critical portion of the right adrenalectomy?

A

Control right adrenal vein because it enters IVC!

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23
Q

Why do we not biopsy adrenal masses?

A

Could be a pheo which may release massive amounts of catecholamines

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24
Q

What is the prognosis of an adrenal adenoma:

A

Benign: excellent

Functionally secreting aldosterone: resolution of HTN in 70-90%

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25
Q

What is the differential for hypercalcemia?

A 
Chimpanzees:
Calcium supplements
Hyperparathyroidism
Hyperthyroidism
Immobility
Iatrogenic (HCTZ)
Milk alkali syndrome
Paget's dz
Addison's dz
Acromegaly
Neoplasm
Zollinger-Ellison syndrome
Excessiev vitamin D
Excessive vitamin A
Sarcoidosis
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26
Q

What is most common cause of hypercalcemia in hospitalized patients?

A

Malignancy

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27
Q

What is most common cause of hypercalcemia in outpatients?

A

primary hyperparathyroidism

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28
Q

What causes humoral hypercalcemia of malignancy?

A

80% PTHrP

20% cytokines/chemokines

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29
Q

What causes familial hypocalciuric hypercalcemia?

A

CASR mutation: lack of Ca signal increases PTH level with increases renal Ca absorption. Less Ca in urine

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30
Q

How does hypercalcemia present?

A

Stones: kidney stones
Bones: aching bones
Groans: abdominal pain
Moans: neuropsychiatric

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31
Q

What are renal manifestations of hypercalcemia?

A

Nephrolithiasis
Nephrocalcinosis
Polyuria, polydipsia
Hypertension

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32
Q

What are GI manifestations of hypercalcemia?

A

constipation
N/V
Heartburn
Ab pain

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33
Q

What are neuro manifestations of hypercalcemia?

A 
fatigue
depressed mood
difficulty concentrating
impaired memory
anxiety
sleep change
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34
Q

What patient demographic most commonly presents with hyperparathyroidism?

A

postmenopausal women

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35
Q

What are risk factors for primary hyperparathyroidism?

A

Ionizing radiation
Family history
Lithium for bipolar

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36
Q

What are d/o or MEN-1?

A

Hyperparathyroidism
Pituitary adenomas
Pancreatic neuroendocrine tumors

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37
Q

What are d/o or MEN-2A?

A

Hyperparathyroidism
Medullary thyroid cancer
Pheo

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38
Q

What are d/o or MEN-2B?

A

Marfanoid habitus
Oral neuromas
Medullary thyroid cancer
Pheo

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39
Q

What do we see for labs in primary hyperparathyroidism?

A

Elevatd Ca w/ high or inappropriately nl PTH

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40
Q

What do we see for labs in secondary hyperparathyroidism?

A

Decreased Ca
Increased intact PTH
In setting of renal dz

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41
Q

In asymptomatic patients with hypercalcemia, what do we do next?

A

Obtain DEXA for bone density

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42
Q

What are PTH’s actions on bone and kidney?

A

Bone: increase breakdown for calcium absorption into blood
Kidney: Vitamin D activation

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43
Q

What’s vitamin D’s action in gut?

A

Increase Ca absorption

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44
Q

What is the indication for parathyroidectomy in asymptomatic patients with primary HPT?

A 
1 Serum Ca > 1 more than UL nl
2 Cr clearance < 60
3 BMD w/ T score < 2.5 at any site
4 Age < 50
5 Patients that cannot undergo routine surveillance
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45
Q

What is the indication for parathyroidectomy in patients with secondary HPT?

A 
High PTH level despite medical management
Bone pain
Pruritis
Progressive renal dz
Osteopenic fractures
Calciphylaxis
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46
Q

What do we do with a suspected PTH adenoma?

A

Localize it with sestamibi scan and ultrasound

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47
Q

What is the typical cause of primary HPT? What do 10-15% patients have?

A

Single parathyroid adenoma, but multiple gland parathyroid dz is present 10-15% patients

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48
Q

What is T-score? What does it represent?

A

Test of bone density, shows number of std deviations below average for a young adult at peak bone density.

  • Normal > -1
  • Osteopenia: -1 to -2.5
  • Osteoporosis: < 2.5
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49
Q

Where can the inferior parathyroid glands hide?

A

mediastinum (thymus)
within carotid sheath
behind esophagus

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50
Q

How is primary HPT different in sporadic vs. MEN patients?

A

Sporadic: single adenoma
MEN: expressed in all glands = four gland hyperplasia

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51
Q

What is the pathophys of tertiary HPT?

A

Persistent excess PTH following renal transplant: very rare

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52
Q

What labs do we use to diagnose primary HPT?

A

Ca, phosphate, chloride, bicarb, mag, serum Cr, PTH level, 24 hour urine Ca

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53
Q

Does elevated PTH + elevated serum Ca diagnose primary HPT?

A

No: need urine Ca to rule out hypocalciuric hypercalcemia

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54
Q

What is total serum Ca vs. ionized Ca?

A 
Total = protein-bound + free Ca
Ionized = free only
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55
Q

If serum Ca high, but PTH is normal, can we r/o primary HPT?

A

No: PTH should be low! This suggests primary HPT

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56
Q

How can serum Cl to phosphate ratio suggest primary HPT?

A

> 33: PTH acts on kidneys and increased Ca reabsorption and excretion of bicarb and phosphate. Excretion of bicarb = rise in serum Cl to balance ions = hyperchloremic metabolic acidosis

57
Q

What XR findings are associated with bony involvement in HPT?

A
  • Hands: subperiosteal cortical bone resportion in distal phalanges
  • Rarely: osteitis fibrosa cystica
58
Q

What tests help to localize the involved gland in HPT?

A

Sestamibi scanning and ultrasound

59
Q

What tissues take up sestamibi? Why does it matter?

A

Parathyroid and thyroid - thyroid nodule can mimic appearance of parathyroid adenoma.

60
Q

What is the non-op management of patients with HPT?

A
  • monitor Ca and Cr annually
  • Measure bone mineral density every 1-2
  • Bisphosphonates or Cincalcet if needed
61
Q

What is the role of intraoperative PTH monitoring?

A
  • Draw PTH level at time of gland excisio and again 10 min post resection
  • Fall of > 50% of PTH associated with 98% cure rate
62
Q

What is post-op management after parathyroidectomy?

A

Monitor for:

  • Neck hematoma
  • Voice change (recurrent laryngeal nerve)
  • Perioral numbness
  • Tingling in finger
63
Q

What is the treatment for neck hematoma with stridor?

A

Immediate bedside decompression + evacuate hematoma and hemostasis in OR

64
Q

What are benefits of parathyroidectomy?

A
  • Increases in bone mineral density at multiple sites

- Decreased risk of new kidney stones

65
Q

Why does post-op hypocalcemia occur after parathyroidectomy?

A

High levels of PTH lead bone to be chronically starved of Ca - bones will voraciously absorb Ca after surgery

66
Q

If patient with hypocalcemia doesn’t respond to Ca repletion, what to do?

A

Check mg: hypomagnesemia can cause refractory hypocalcemia due to inhibition of PTH bioactivity

67
Q

How to treat hypercalcemic crisis?

A

1 Aggressive infusion of normal saline
2 Loop diuretics once euvolemic
3 Bisphosphonates

68
Q

What are the symptoms of pheochromocytoma?

A 
Episodic hyperadrenergic symptoms (5 P's): 
Pressure (HTN)
Pain (HA)
Perspiration
Palpitation
Pallor
69
Q

What disorders are pheochromocytomas associated with?

A

MEN 2
NF -1
VHL disease

70
Q

What cells are pheos derived from?

A

Chromaffin cells in the adrenal medulla or sympathetic ganglia

71
Q

What are the predominant catecholamines released by pheos?

72
Q

What are the triggers of hypertensive crisis in pheo?

A 
Changes in blood flow
Physical stimulation
Tumor necrosis
Anesthetic agents
Foods containing tyramine
Surgical manipulation
73
Q

How do we determine if a pheo is malignant?

A

Local invasion, NOT cellular features

74
Q

How is pheo diagnosed?

A

24 hour Urine / blood levels of catecholamines and their metabolites: > 2x UL nl is diagnostic
- Plasma-free metanephrine is most sensitive: higher false positives

75
Q

What is first line imaging for pheo?

A

CT or MRI with contrast

76
Q

When do we use I-MIBG for pheo diagnosis?

A

Cases of suspected multifocal or extra-adrenal disease

77
Q

What is the first step in management of a pheo?

A

Medical conditioning: alpha blockade for > 2 weeks

78
Q

When are beta blockers used for pheo before surgery?

A

For tachycardia and/or arrhythmia

79
Q

What is the definitive treatment for pheo?

A

Surgical resection

- Laparoscopic if <8cm and have no malignant features on imaging

80
Q

Why don’t we biopsy adrenal masses?

A

Can trigger hypertensive crisis due to release of catecholamines

81
Q

Why do we never give a beta blocker first for pheo treatment?

A

Unopposed alpha constriction: can cause hypertensive crisis

82
Q

What is the classic triad of symptoms in pheo?

A

HA
Flushing
Palpitations

83
Q

Besides the classic triad, what are other symptoms of pheo?

A

Sustained or episodic HTN

84
Q

Why can pheo patients present with orthostatic hypotension?

A

Large amounts of catecholamines can desensitize adrenergic receptors

85
Q

Can pheo be asymptomatic?

A

Yes: incidentaloma on CT scan

86
Q

What percent of pheos are a result of underlying familial syndrome?

87
Q

How do dopamine secreting tumors present?

A

Watery diarrhea

88
Q

Where do pheos develop?

A

Majority: adrenal medulla

If extra-adrenal: paragangliomas

89
Q

Why do patients with pheo have elevated hematocrit levels?

A

Chronic alpha constriction: volume depletion and hemoconcentration

90
Q

Why do pheo patients have hyperglycemia?

A

Catecholamines stimulate hepatic glucose production and inhibit insulin secretion and action

91
Q

What is the treatment for pheo?

A
  1. Alpha blockade w/ occasional beta blockade for at least 2 weeks
  2. Surgical resection
92
Q

Who gets beta blockers before surgery for pheo?

A

Those who develop tachycardia after adequate alpha blockade

93
Q

What are the main complications of adrenalectomy for pheo?

A

Hypertension
Hypotension
Hypoglycemia
Arrhythmia (from HTN crisis)

94
Q

How often should plasma and urinary catecholamines be measured postoperatively for pheo?

A
  • 2 weeks after surgery
  • Every 3 months for year
  • Annually afterwards
95
Q

What is the overall prognosis for pheo?

A
  • Surgical resection is usually curative

- Malignant: palliative treatment

96
Q

What are the risk factors for thyroid cancer?

A

Ionizing radiation

Family history

97
Q

What is the most important initial test for suspected thyroid disease?

98
Q

How should thyroid nodules be evaluated with elevated TSH?

A
  • Ultrasound

- radioactive iodine scan

99
Q

What is the prognosis for iodine avid, “hot” thyroid nodules?

A

Good: low risk of malignancy

100
Q

Which thyroid nodules should undergo FNA?

A
  • > 1cm
  • Suspicious US findings
  • Increasing in size
101
Q

How are thyroid nodules evaluated?

102
Q

What cells do papillary and follicular thyroid cancers arise from?

A

Follicular cells

103
Q

What cells do medullary thyroid cancers arise from?

A

Parafollicular “C” cells

104
Q

What is the most important part of the initial workup for a thyroid nodule?

105
Q

If FNA is inadequate, what is the next step for thyroid nodule?

A

Repeat FNA

106
Q

If FNA is benign, what is the next step of a thyroid nodule?

107
Q

If FNA is suspicious for follicular neoplasm, what is the next step?

A

Diagnostic thyroid lobectomy

108
Q

If FNA is suspicious for malignancy, what is the next step?

A

Consider total thyroidectomy

109
Q

If FNA shows malignant cells, what is the next step?

A

Total thyroidectomy and consider neck dissection

110
Q

In patients with medullary thyroid cancer, what is important to investigate?

A

Underlying germ line mutation (present in 25% patients)

111
Q

Before surgery for medullary thyroid cancer, what must be ruled out and why?

A

Pheo due to risk of MEN syndromes

112
Q

Where does ectopic thyroid tissue in the lateral neck metastasize?

A

Cervical lymph nodes

113
Q

What does numbness and tingling in the lips and fingers after total thyroidectomy signify? How to treat?

A

Hypoparathyroidism: treat with oral Ca

114
Q

Post-operative neck swelling after thyroidectomy with stridor, what is it? How to treat?

A
  • Hematoma compressing the airway

- Surgical emergency: bedside decompression

115
Q

How common are thyroid nodules, and how often are they cancerous?

A

5% of population

95% of them are benign

116
Q

What is the thyroid status of most thyroid carcinoma patients?

117
Q

What is the most common cause of death in patients with thyroid storm? Who gets this?

A

High output cardiac failure: post-op patients with undiagnosed Graves disease

118
Q

How to treat high output cardiac failure from Graves dz in post-op patients?

A

Beta blockers

PTU

119
Q

What is the significance of the mass moving up and down with swallowing?

A

Thyroid gland moves up when a patient swallows due to attachment to trachea via ligament of Berry: likely to be a thyroid mass

120
Q

How do we determine prognosis of papillary thyroid cancer?

A

Presence of local invasion

121
Q

Why does metastatic medullary carcinoma frequently cause diarrhea and flushing?

A

High calcitonin levels

122
Q

Why can’t FNA be used to diagnose follicular thyroid cancer?

A

Histologic diagnosis: need to see if proliferation of follicles invades capsule

123
Q

What is considered well-differentiated thyroid cancer?

A

Anything from follicular cells: Papillary, follicular and Hurthle cell carcinomas

124
Q

Which cancers can produce psammoma bodies?

A

Papillary thyroid cancer
Serious cystadenocarcinoma of ovary
Meningioma
Mesothelioma

125
Q

What labs are for thyroid mass?

A

TSH, do T4/T3 if abnormal

126
Q

Do we use nuclear imaging for an isolated thyroid nodule?

A

Not usually: FNA standard now

127
Q

What is the next step for a benign FNA result?

A

Annual follow up with US

128
Q

What is the next step for an FNA that reports AUS or FLUS (atypia of undetermined significance or follicular lesion of undetermined significant)?

A

Repeat FNA

129
Q

What is the advantage of total thyroidectomy in thyroid cancer vs. lobectomy?

A
  • Removal any missed contralateral foci of cancer
  • Use radioactive iodine scan to find/treat mets
  • Use serum thyroglobulin as marker for recurrence
130
Q

Which thyroid malignancy can be treated with thyroid lobectomy alone?

A

<1cm univocal papillary thyroid carcinomas

131
Q

Who gets central lymph node dissection?

A

Medullary and papillary cancers

  • Medullary: > 1cm
  • Papillary: controversial
132
Q

What is the role of intraoperative frozen section pathology?

A
  • Diagnose papillary thyroid cancer

- Show cancer in lymph nodes

133
Q

Which thyroid cancer concentrate radioactive iodine?

A

Papillary and follicular

134
Q

What is the follow-up procedure post-op for thyroid cancer?

A
  • Measure thyroglobulin and anti-thyroglobulin Ab 2x a year
  • 1x per year when stable
  • Neck US annually
135
Q

If recurrence of thyroid cancer is suspected, what study to perform?

A

Neck US with full lymph node survey

136
Q

What non-op management is available for thyroid nodules?

A
  • Radioactive ablation with iodine for hyper functioning nodules
137
Q

What major structures can be injured during thyroidectomy?

A
  • Recurrent laryngeal nerve
  • External branch of superior laryngeal nerve
  • Parathyroid glands
138
Q

What prophylactic measure should be taken in patients with MEN-2A, 2B or FMTC?

A

Prophylactic thyroidectomy

139
Q

What does thyroid tissue in the lateral neck represent in setting of thyroid cancer?

A

Metastatic papillary thyroid cancer in a lymph node

Surgery Clerkship (16 decks)

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