Endocrine Flashcards
patient presents wit ha thyroid nodule and decreased TSH, what is the next step?
Technecium uptake scan and start a beta-blocker (propranolol)
What disorders can a technicium thyroid scan differentiate between?
Functional adenoma and graves disease
What is the chance of malignancy from Hurthle cell cytology from a thyroid nodule?
20-30% cancer;
can be either hurthle cell carcinoma or oncocytic variant of PTC
What endocrine tumors can be treated with enucleation?
Only do for functional tumors (insulinoma, gastrinoma etc) or low malignancy hereditary disorders MEN?)
What is best palliation for hepatic metastasis from PNET?
TACE - Palliates pain in 75-100% of liver PNETs
Thyroid nodule with low TSH; what is next step?
thyroid uptake scan and start propranolol.
thyroglobulin positive cells in a lymph node?
is metastatic thyroid cancer. Need a total thyroidectomy and ipsilateral neck dissection.
MEN I
pituitary
hyper parathyroid
pancreas masses
gene for MEN I
mennin
function of menin
transcription regulator.
MEN II
medullary thyroid cancer
Pheochromocytoma
Hyperparathyroid
gene for MEN II
ret-proto oncogene
Von Hippel-Lindau
RCC
pheochromocytoma
pNETs
CNS hemangioblastoma
Key differentiation between MEN and VHL?
VHL does not get hyperparathyroid
gene for Von Hippel-Lindau
vHL; regulates VEGF and HIF1alpha
Best control of symptoms from bulky metastatic carcinoids?
TACE
Medullary Thyroid Cancer prompt
always think about the pheo
Treatment for metastatic MTC
TKIs
vandetanib and cabozatinib
Both have PFS advantage in RCTs.
SCC that is P16 positive is caused by:
HPV
SCC in a neck node on FNA with no primary, next step:
Go to OR for laryngoscopy, esophagoscopy and bronchoscopy.
Random biopsy if necessary
Most common location of occult primary H&N SCC
90% are in the tonsilar pillar or base of tongue.
treatment for adenoid cystic carcinoma?
Parotidectomy and adjuvant RT
Recurrence pattern of adenoid cystic carcinoma
Late, and also “skip lesions” along the nerve.
Very rare to have lymph nodes
FNA proves thyroid mass is PTC; what is next step?
neck ultrasound for lymphadenopathy.
ATA guidelines for central and lateral neck dissection
Do ultrasound
FNA all suspicious nodes
neck dissection only if FNA is positive
most common side effect of central LN dissection
transient hypocalcemia
Second line therapy for hypocalcemia after oral calcium carbonate
calcitriol
ATA indications for total thyroidectomy and indeterminate nodules
tumors > 4cm marked atypia "suspicious for PTC" family history of thyroid cancer radiation exposure
Most common location for a missing parathyroid
open the deep tracheoesophageal groove
Management of secondary hyperparathyroidism
subtotal parathyroidectomy (leave 1/2 a gland behind) with cervical thymectomy.
How long until PTH gland starts to work after forearm autotransplantation?
6-8 weeks
Firm parathyroid gland with severe hypercalcemia
Be prepared to do cancer operation without definitive diagnosis
What do you do for a patient less than 30 years old with a new diagnosis of hyperparathyroidism?
Genetic testing for MEN I (mennin)
PET avid adrenal in setting of lung cancer? What next
Still do endocrine work-up
Two different optimization drugs for pheos
phenoxybenzamine is classic
diltiazem also works
Hyperaldosteronemia and an adrenal mass?
Still do selective adrenal vein sampling; most adrenal masses arebenign and non-functional.
When do you do a nephrectomy for adrenocortical carcinoma
Only with direct invasion.
adjuvant therapy for adrenocortical carcinoma?
Mitotane
When do you give mitotane for adrenocortical cancer?
high grade
tumor rupture
vascular or capsular invasion
toxicities of mitotane
adrenal insufficiency
ataxia
confusion
rash
When do you give cytotoxic chemo for adrenocortical carcinoma?
Stage IV or unresectable;
Role of radiation for adrenocortical carcinoma?
Possibly for R1 resection; poor evidence
Most common location for an extra-adrenal pheo?
organ of Zuckerkandl at the aortic bifurcation.
What do you do before the OR on all re-operative necks?
laryngoscopy to confirm vocal cord function
25 year old with previous thyroidectomy presents with hypercalcemia, what next?
24-hr urine metanephrines to rule out pheo!
Which MTC patients do you send for genetic testing?
All of them (for RET proto-oncogene)
Which pheos do you send for genetic counseling?
Can get away with saying all of them (aggressive)
definitely all bilateral and <45yr olds
difference between vHL and MEN pheos?
vHL - norepinephrine
MEN - epinephrine
size indication for adrenalectomy:
nodule >4cm
surveillance for adrenal nodules
CT every 3-6 months for first year; then anually for 1-2 years. Hormonal evaluation yearly for 5 years.
what is the most effective medication at preventing duodenal ulceration for a gastrinoma?
PPI
Reversal of RLN injury
can be spontaneous in 3-6 months
Nephrectomy for ACC?
No, unless direct invasion
Treatment for incidentally discovered PTC on total thyroidectomy? (ATA 2009)
Nothing if < 1cm
most common side for non-recurrent LN?
right 3%, associated with aberrant subclavian
anatomy associated with a non-recurrent left LN?
Situs inversus
risk of cancer in a Bethesda 4 follicular neoplasm
20-30%
ATA recommended operation for a Bethesda 4 lesion
diagnostic lobectomy
Surgery for Follicular Thyroid cancer?
Total thyroidectomy without lymph node dissection
Adjuvant treatment for Follicular Thyroid Cancer
radioactive iodine and Thyroid suppression for all.
Choices for ACC with vena cava invasion?
Adrenalectomy with venotomy and thrombectomy if R0 resection can be performed.
Imaging for cystic parathyroid glands?
4DCT; Sestamibi doesn’t work.
