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Oral Boards > Endocrine > Flashcards

Endocrine Flashcards

1
Q

Bethesda classification 1

A

Non diagnostic - Repeat biopsy (4 weeks)

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2
Q

Bethesda classification 2

A

Benign - Repeat U/S in 12-24 months

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3
Q

Bethesda classification 3

A

Follicular cells of undetermined sig - Repeat FNAB

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4
Q

Bethesda classification 4

A

Follicular cells - lobectomy

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5
Q

Bethesda classification 5

A

Suspicious for malignancy - lobectomy or thyroidectomy

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6
Q

Bethesda classification 6

A

Malignant - thyroidectomy

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7
Q

Commonly injured area of RLN

A

At insertion of the cricothyroid membrane

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8
Q

Relationship of superior parathyroid to RLN

A

Posterior and lateral

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9
Q

Relationship of inferior parathyroid to RLN

A

Anterior and medial

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10
Q

common complication of total thyroidectomy

A

hypocalcemia in 10-20% patients, treated with calcium and vitamin D supplements. (dont forget thyroid replacement therapy)

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11
Q

Indications for post op radioiodine ablation

A

high risk (vascular invasion, etc) residual disease. metastatic disease. Positive lymph nodes. Follow thyroglobulin levels post op after total thyroidectomy.

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12
Q

Size of suspicious nodule needing biopsy, non suspicious nodule?

A

1 cm suspicious 1.5-2 cm non suspicious.

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13
Q

Indications for thyroid scitigraphy and information that can be learned

A

Patient with suppresed TSH and a thyroid nodule.

Can determine if patient has Grave’s disease and a potential cold, cancerous nodule, or if due to hot nodule (which is always benign)

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14
Q

Test needed pre op before thyroidectomy for thyroid malignancy

A

Ultrasound of central and lateral neck compartments.

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15
Q

Level 6 nodes for neck

A

hyoid bone superiorly

Brachiocephalic inferiorly

Carotid sheath laterally (peri thyroid nodes)

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16
Q

Level 1 nodes (neck)

A

Submental and submandibular gland. Above the hyoid, medially

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17
Q

Level 3/4 nodes neck

A

Along the jugular to the lateral border of the SCM

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18
Q

Level 5 nodes neck

A

lateral to the SCM

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19
Q

Indications for lobectomy in papillary thyroid cancer

A

< 1 cm mass (1-4 do total thyroidectomy)

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20
Q

If level 3 node is positive, subsequent LN dissection

A

Level 3 and 6 (always level 6 if doing neck dissection)

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21
Q

Percentage of patients with RLN paresis after thyroidectomy

A

10% (< 1% of permanent problems)

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22
Q

Used to support thyroid function after surgery prior to receiving radioiodine therapy

A

recombinant TSH (instead of synthroid)

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23
Q

Patient with new diagnosis of thyroid nodule and RET proto-oncogone gets what workup?

A
  1. Serum calcitonin
  2. Serum CEA
  3. Serum calcium
  4. serum PTH
  5. CT neck, chest, abdomen, and pelvis (triple phase) (calcitonin > 500)
  6. Bone scintigraphy (calcitonin > 500)
  7. serum metanephrines
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24
Q

Percent of medullary thyroid cancer that is familial

A

25% (most sporadic)

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25
Q

Age of prophylactic thyroidectomy for MEN2A? MEN2B

A

5 years old, 6 months

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26
Q

Indication for contralateral neck dissection in MTC

A

Calcitonin > 200

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27
Q

Superior aspect of level 2, 3, 4 anterior triangle dissection

A

Inferior edge of digastric and omohyoid muscles.

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28
Q

Treatment of post operative chyle leak after neck dissection

A

Fat free diet, compression. May need surgical exploration with ligation.

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29
Q

Post op follow up MTC

A

3, 6, 6, 1 year and annually with calcitonin

If elevated, < 150 - neck U/S

If elevated > 150, metastatic work up (neck, chest, triple phase abdomen/pelvis, bone scintigraphy)

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30
Q

Miami criteria for PTH normazliation

A

> 50% drop in PTH, normalization of PTH values.

Good regimen would be pre-anesthesia, pre-excision, 5, 10, 15 min post excision.

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31
Q

Non PTH mediated reasons for hypercalcemia

A
  1. PTHrP (malignancy)
  2. Granulomatous disease (sarcoid, TB)
  3. Adrenal insuff
  4. Vitamin toxicity
  5. Milk alkali
  6. Prolonged immobilization
  7. Lithium (actually PTH mediated)
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32
Q

Operation for parathyroid carcinoma

A

Parathyroidectomy and thyroid lobectomy

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33
Q

Familial hypercalcemic hypocalciuria

A

SHOULD NOT HAVE SURGERY

Get 24 hour urine calcium - if low, then have diagnosis. High in primary HPT.

34
Q

Work up for patients with hypercalcemia

A
  1. Serum calcium, ionized calcium, PTH, BMP (for chloride and phosphate)
  2. 24 urine calcium
  3. DEXA scan for asymptomatic patients, looking for bone loss.
  4. Renal U/S looking for nephrolithiasis (or CT)
  5. Neck U/S
  6. Technetium Sestimibi with SPECT
35
Q

Missing superior gland

A
  1. Retroesophageal space explored
  2. Carotid sheath opened and explored from bifurcation to base of neck
36
Q

Missing Inferior gland

A
  1. Thymus
  2. Intrathyroidal parathyroid adenoma
37
Q

All 4 glands discovered, but persistent PTH elevation.

A

Supernumary parathyroid glands (usually in the thymus) must do bilateral thymectomy.

38
Q

Percentage of adrenal incedentalomas that are functional

A

20%

39
Q

Adrenal protocol CT

A
  1. Non contrast CT
  2. Rapid injection of contrast with arterial phase 60s later
  3. 15 min delayed washout phase

Benign mass is < 10 HU on noncontrast scan and > 60% washout (lipid rich)

40
Q

Biochemical evaluation of adrenal mass

A
  1. Serum potassium
  2. Serum aldosterone (possible need for venous sampling)
  3. Plasma renin activity
  4. Plasma and urine metanephrines/normetanephrines
  5. Fasting AM cortisol (potentially followed by 24 hour cortisol and suppression tests)
  6. ACTH
  7. DHEAS
41
Q

Findings with functional aldosteronoma

A
  1. Hypokalemia
  2. Elevated plasma aldosterone
  3. Low renin activity
42
Q

Preop treatment of pheochromocytoma

A
  1. Alpha blockade first (phenoxybenzamine - nonselective; doxazosin - selective) for 10-14 days pre procedure
  2. Beta blockade after a week of alpha blockade
43
Q

Pre op treatment for patients with Cushing syndrome

A

Stress dose steroids secondary to suppression of other adrenal gland.

May need adrenolytic (ketoconazole or mitotane)

44
Q

Pre op treatment for Conn’s syndrome

A

Spironolactone

45
Q

Additional work up if concerned about ACC

A
  1. Chest CT
  2. ? bone scintigraphy (if symptoms)
  3. ? head CT (if symptoms)
46
Q

MRI characteristic of pheo

A

Bright T2 (water H2O)

47
Q

Adjuvant therapy for high risk, locally advanced ACC

A

Mitotane (2 years, many drug interactions, GI and neuro side effects) Usually with radiation.

Ki 67 index > 10%

48
Q

Therapy for advanced ACC

A

EDP-M

  1. Etoposide
  2. Doxirubicin
  3. Cisplatin
  4. Mitotane

(Debulking is option if > 90% can be removed and good response to chemoradiation)

49
Q

Most common causea of hypercortisolisms

A
  1. Exogenous steroids
  2. hypersecretion of ACTH from pituitary (Cushing’s disease)
  3. Adrenal hypercortisolisms from tumor or bilateral hyperplasia
  4. Ectopic ACTH producing tumors
50
Q

Patient with elevated 24 hour urine cortisol and low ACTH

A

Adrenal source of cortisol

51
Q

Patient with elevated 24 hour urine cortisol and elevated ACTH

A

Need to do DST (pituitary ACTH will be suppresed and AM cortisol will be lower. SCLC ACTH is not suppressed and cortisol will be high in AM).

52
Q

Cl to PHos ratio suggestive of HPT

A

>33

53
Q

Keys to right adrenalectomy

A

left lateral decubitus

mobilize the right lobe of liver by incising triangular ligament to level of hepatic vein.

? hepatic flexure

dissect vein draining into IVC

Harmonic dissection of vessels near capsule.

54
Q

Keys to a left adrenalectomy

A

right lateral decubitus

mobilize the splenic flexure

Mobilze the spleen and distal pancreas

Divide inferior phrenic vein and vein draining into left renal vein

Harmonic dissection of adrenal close to capsule.

55
Q

differential for hard to control HTN

A
  1. Conn’s syndrome
  2. Pheo
  3. Hypercortisolism
  4. Renal artery stenosis
  5. ESRD
  6. Hyperthyroidism
56
Q

Essential part of work up for Conn’s syndrome, even in presence of imaging findings of nodule

A

Selective venous sampling due to possible presence of smaller functioning nodule.

(access adrenal vein, cosyntropin, then aldosterone/cortisol ratio - higher is more confirmatory)

57
Q

Pheo 10% rule

A
  1. 10% malignant
  2. 10% extra-adrenal
  3. 10% bilateral
  4. 10% part of familial syndromes
58
Q

Pheo familial syndromes (6)

A
  1. MEN2 (A, B)
  2. VHL
  3. NF1
  4. tuberous sclerosis
  5. Sturge-weber
  6. familial paraganglioma syndrome
59
Q

Extraadreanal location of pheo

A

Along sympathetic chain, most common organ of ZUckercandl

60
Q

High dose dexamethasone suppression test will suppress ACTH in…

A

Cushing disease (ACTH secreting pituitary tumor)

Does not suppress ectopic ACTH secreting tumor

61
Q

somatostatinoma syndrome (and confirmatory somatostatin levels)

A

diabetes, hypochlorydia, gallstones (somatostatin > 100 pg/mL)

62
Q

Calcium level diagnostic of parathyroid carcinoma

A

13

treatement is radical parathyroidectomy with ipsalateral thyroidectomy

63
Q

Name of rash and associated condition

A

necrolytic migratory erythema

glucagonoma (also dermatitis, stomatitis, hyperglycemia). Located in distal pancreas

64
Q

Marker of better prognosis when resecting isolated adrenal mets

A

length of time between primary cancer removal and adrenal met

65
Q

Patients with von hippel lindau should be screend for…

A

renal cell cancer

CNS and retinal hemangioblastoma

pheochromocytoma

66
Q

Histology key works for various thyroid cancers

papillary

follicular

anaplastic

medullary

A

papillary: large crowded nucleai, abundant cytoplasm, calcified laminated densities
follicular: solid sheets of cells without colloid
anaplastic: giant multinucleated
medullary: infiltrating neoplastic cells

67
Q

Diagnostic criteria for insulinoma

A

neuroglycopenic symptoms resolved with glucose

fasting glucose < 45

serum insulin > 5 µU/L

elevated C peptide and proinsulin to r/o factitious insulin

68
Q

Relative potencies of

Hydrocortisone

Prednisone

methylprednisolone

dexamethasone

A

Hydrocortison 1

Prednisone 4

solumedrol 5

dexamethasone 30

69
Q

Normal levels of 24 hour cortosol

Diagnostic levels of Cushing Syndrome

A

< 90 mcg/24 hour

> 300 mcg/24 hours

70
Q

Most common cause of Conn’s syndrome unilateral adenoma or bilateral adrenal hyperplasia

A

Bilateral adrenal hyperplasia

71
Q

work up for adrenal insufficiency

A
72
Q

Main concern with Reidel thyroiditis

A

Compressive symptoms; may need isthmusectomy since total thyroidectomy may not be possible. Chronic treatment with steroids, methotrexate, or tamoxifen

73
Q

Most common cancer to metastasize to adrenals

A

lung cancer

74
Q

The least important prognostic indicator for thyroid cancer (papillary and follicular) among

Age, size of tumor, lymph node involvement

A

lymph node involvement; minimal effect on survival

75
Q

PTH effects on calcium and phos in the kidney

A

Prevents secretion of calcium in Distal convoluted tubules

Promotes secretion of phos in proximal convoluted tubules.

76
Q

most common cause of endogenous cushing syndrome

A

ACTH secreting pituitary tumor

77
Q

Treatment for unlocalized gastrinoma

A

vagotomy to decrease PPI requirement

78
Q

Most common cause of hypercalcemia > 13

A

cancer, but most commonly breast or Multiple myeloma. Parathyroid cancer can also cause, but less likely.

79
Q

Indications for unilateral thyroidectomy in patients with thyroid cancer

A

low risk features, size < 4 cm

80
Q

Bilateral adrenal venous sampling should be considered for pateints older than…

A

35 year old.

81
Q

location of functional PNETs in pancreas

Gastrinoma

insulinopma

Glucagonoma

VIPoma

Somatostatinoma

A

Gastrinoma: Gastrinoma triangle

Insulinoma: evenly throughout pancreas

Glucagonoma: Body and tail

VIPoma: Body and tail

Somatostatinoma: head of pancreas

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