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MRSA theory > Endocrine and Breast > Flashcards

Endocrine and Breast Flashcards

1
Q

Causes of hyperthyroidism?

A

Diffuse toxic goitre (Graves Disease)
Toxic nodular goitre
Toxic nodule
Rare causes

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2
Q

What is the most sensitive test for diagnosing hyperthyroidism?

A

The most sensitive test for diagnosing hyperthyroidism is plasma T3 (which is raised).

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3
Q

What is tested for in Graves’ disease ?

A

Anti-TSHr

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4
Q

Treatment for graves?

A

Block and replace
Carbimazole , thyroxine

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5
Q

Types of thyroid cancer?

A

Papillary carcinoma
Follicular carcinoma
Anaplastic carcinoma
Medullary carcinoma
Lymphoma’s

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6
Q

Complications following thyroid surgery?

A

Anatomical such as recurrent laryngeal nerve damage.
Bleeding. Owing to the confined space haematoma’s may rapidly lead to respiratory compromise owing to laryngeal oedema.
Damage to the parathyroid glands resulting in hypocalcaemia.

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7
Q

Which thyroid cancers may cause pathological fractures?

A

Follicular carcinomas may metastasise haematogenously (often to bone) where they may give rise to pathological fractures as in this case.

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8
Q

when are TPO antibodies found?

A

Found Found in autoimmune disease affecting the thyroid (Hashimotos 100%) and Graves (70%) in autoimmune disease affecting the thyroid (Hashimotos 100%) and Graves (70%)

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9
Q

What is thyroglobulin used for?

A

Not useful for clinically distinguishing between different types of thyroid disease, may be used as part of thyroid cancer follow up

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10
Q

when is calcitonin found?

A

Released from the parafollicular cells
Usually found in patients with medullary carcinoma of the thyroid

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11
Q

Management of thyroglossal cyst?

A

Surgical treatment with resection of cyst, associated track, central portion of the hyoid and wedge of tongue muscle behind the hyoid
[sistrunks procedure]

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12
Q

What is a phaeochromocytoma?

A

Neuroendocrine tumour of the chromaffin cells of the adrenal medulla. Hypertension and hyperglycaemia are often found.

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13
Q

Features of phaechromocytoma?

A

10% of cases are bilateral.
10% occur in children.
11% are malignant (higher when tumour is located outside the adrenal).
10% will not be hypertensive.
Normotension in 10% of cases

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14
Q

Diagnosis of phaeochromocytoma?

A

Urine analysis of vanillymandelic acid (VMA) - false +ves in those eating a lot of vanilla ice cream
Blood testing for plasma metanephrine levels.

CT and MRI scanning are both used to localise the lesion.

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15
Q

Factors suggesting benign adrenal disease on CT?

A

Size less than 3cm
Homogeneous texture
Lipid rich tissue
Thin wall to lesion

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16
Q

Treatment of phaeochromocytoma?

A
  1. irreversible alpha adrenoreceptor blocker [Labetolol may be co-administered for cardiac chronotropic control]
  2. moderate volumes of intra venous normal saline perioperatively
  3. Laparoscopic adrenalectomy
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17
Q

How is medullary thyroid cancer inherited?

A

Autosomal dominant

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18
Q

What is a thyroglossal cyst?

A

Moves on tongue protrusion
Thyroglossal cysts are the commonest midline cysts in the neck found in children

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19
Q

What is a mucinous carcinoma?

A

Mucinous carcinomas comprise 2-3% of all breast cancers.
special type of carcinomas. These have a better prognosis than is associated with tumours of Non Special Type (NST) and axillary nodal disease is rare in this group.

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20
Q

Most common type of breast cancer?

A

nvasive ductal carcinomas are the most common type. Some may arise as a result of ductal carcinoma in situ (DCIS).

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21
Q

Calculation of Nottingham prognostic index?

A

Tumour Size x 0.2 + Lymph node score(From table below)+Grade score(From table below).

Score Lymph nodes involved Grade
1 0 1
2 1-3 2
3 >3 3

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22
Q

Features of subacute thyroiditis? (De Quervains thyroiditis)

A

tender goitre, hyperthyroidism and raised ESR. Globally reduced uptake on technetium thyroid scan is also typical

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23
Q

What is Hashimoto’s thyroiditis?

A

Hashimotos thyroiditis is an immunological disorder in which lymphocytes become sensitised to thyroidal antigens. The three most important antibodies include; thyroglobulin, TPO and TSH-R.

During the early phase of Hashimotos the the thyroglobulin antibody is markedly elevated and then declines.

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24
Q

Features of Hashimoto’s thyroiditis?

A

Goitre and either euthyroid or mild hypothyroidism
Progressive hypothyroidism (and associated symptoms)

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25
Q

Management of Hashimoto’s thyroiditis?

A

During the hyperthyroid phase of illness beta blockers may manage symptoms
As hypothyroidism develops patients may require thyroxine

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26
Q

Management of subacute thyroiditis?

A

Usually self-limiting - most patients do not require treatment
Thyroid pain may respond to aspirin or other NSAIDs
In more severe cases steroids are used, particularly if hypothyroidism develops

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27
Q

Lab results for sick euthyroid?

A

TSH: low
Free t4: low
Common in hospital inpatients
*can be referred to as non thyroid Al illness

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28
Q

Lab results for secondary hypothyroidism?

A

TSH: low
Free t4: low
Replacement steroid therapy is required prior to thyroxine

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29
Q

Lab results for poor compliance with thyroxine?

A

TSH: high
Free T4: high/normal

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30
Q

Hormone profile in primary hyperparathyroidism?

A

PTH (Elevated)
Ca2+ (Elevated)
Phosphate (Low)
Urine calcium : creatinine clearance ratio > 0.01

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31
Q

Hormone profile in secondary hyperparathyroidism?

A

PTH (Elevated)
Ca2+ (Low or normal)
Phosphate (Elevated)
Vitamin D levels (Low)

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32
Q

Hormone profile in tertiary hyperparathyroidism?

A

Ca2+ (Normal or high)
PTH (Elevated)
Phosphate levels (Decreased or Normal)
Vitamin D (Normal or decreased)
Alkaline phosphatase (Elevated)

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33
Q

Clinical features of primary hyperparathyroidism?

A

May be asymptomatic if mild
Recurrent abdominal pain (pancreatitis, renal colic)
Changes to emotional or cognitive state

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34
Q

Cause of primary hyperparathyroidism?

A

Most cases due to solitary adenoma (80%), multifocal disease occurs in 10-15% and parathyroid carcinoma in 1% or less

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35
Q

Clinical features of secondary hyperparathyroidism?

A

May have few symptoms
Eventually may develop bone disease, osteitis fibrosa cystica and soft tissue calcifications

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36
Q

Causes of secondary hyperparathyroidism?

A

Parathyroid gland hyperplasia occurs as a result of low calcium,

almost always in a setting of chronic renal failure

37
Q

Clinical features of tertiary hyperparathyroidism?

A

Metastatic calcification
Bone pain and / or fracture
Nephrolithiasis
Pancreatitis

38
Q

Causes of tertiary hyperparathyroidism?

A

Occurs as a result of ongoing hyperplasia of the parathyroid glands after correction of underlying renal disorder, hyperplasia of all 4 glands is usually the cause

38
Q

Indications for surgery in primary hyperparathyroidism?

A

Elevated serum Calcium > 1mg/dL above normal
Hypercalciuria > 400mg/day
Creatinine clearance < 30% compared with normal
Episode of life threatening hypercalcaemia
Nephrolithiasis
Age < 50 years
Neuromuscular symptoms
Reduction in bone mineral density of the femoral neck, lumbar spine, or distal radius of more than 2.5 standard deviations below peak bone mass (T score lower than -2.5)

39
Q

Management of secondary hyperparathyroidism?

A

Usually managed with medical therapy.

Indications for surgery in secondary (renal) hyperparathyroidism:
Bone pain
Persistent pruritus
Soft tissue calcifications

40
Q

Management of tertiary hyperparathyroidism?

A

Allow 12 months to elapse following transplant as many cases will resolve
The presence of an autonomously functioning parathyroid gland may require surgery. If the culprit gland can be identified then it should be excised. Otherwise total parathyroidectomy and re-implantation of part of the gland may be required.

41
Q

which thyroid cancer is hashimotos associated with?

A

Hashimoto’s thyroiditis is associated with thyroid lymphoma

42
Q

Main complication of longstanding very large goitre?

A

Tracheomalacia
Airway compromise and strider

43
Q

What is the most important prognostic factor in breast cancer?

A

Nodal status

44
Q

Features of duct ectasia?

A

-Mammary duct ectasia may be seen in up to 25% of normal female breasts
-Patients usually present with nipple discharge, which may be from single or multiple ducts (usually present age >50 years)
-The discharge is often thick and green
-Duct ectasia is a normal variant of breast involution and is not the same condition as periductal mastitis
-Mass develops behind nipple

45
Q

Features of intraductal papilloma?

A

Growth of papilloma in a single duct
Usually presents with clear or blood stained discharge originating from a single duct
No increase in risk of malignancy

46
Q

Features of periductal mastitis?

A

Present at younger age than duct ectasia
May present with features of inflammation, abscess or mammary duct fistula
Strongly associated with smoking
Usually treated with antibiotics, abscess will require drainage
Mass develops around nipple

47
Q

Features of breast abscess?

A

Lactational mastitis is common
Infection is usually with Staphylococcus aureus

On examination there is usually a tender fluctuant mass
Treatment is with antibiotics and ultrasound guided aspiration
Overlying skin necrosis is an indication for surgical debridement, which may be complicated by the development of a subsequent mammary duct fistula.

47
Q

Features of breast abscess?

A

Lactational mastitis is common
Infection is usually with Staphylococcus aureus

On examination there is usually a tender fluctuant mass

Treatment is with antibiotics and ultrasound guided aspiration

Overlying skin necrosis is an indication for surgical debridement, which may be complicated by the development of a subsequent mammary duct fistula.

48
Q

Features of breast TB?

A

Rare in western countries, usually secondary TB
Affects women later in child bearing period
Chronic breast or axillary sinus is present in up to 50% cases
Diagnosis is by biopsy culture and histology

49
Q

Management of large multi modular goitre?

A

Surgery for pressure symptoms. Total thyroidectomy is treatment of choice

50
Q

Management for toxic nodule?

A

Hemithyroidectomy

51
Q

Management of follicular lesion?

A

Hemithyroidectomy to establish diagnosis

52
Q

Management of papillary thyroid cancer?

A

Total thyroidectomy and central compartment nodal dissection (extended lymphadenectomy as required)

53
Q

Management of follicular thyroid cancer?

A

Total thyroidectomy (usually completion as already had hemithyroidectomy)

54
Q

Management of anaplastic thyroid cancer?

A

Palliative radiotherapy

55
Q

Management of medullary thyroid cancer?

A

Total thyroidectomy and central compartment nodal dissection (screen for other MEN tumours)

56
Q

Management of thyroid lymphoma?

A

Consider core biopsy

57
Q

Management of persistent refilling cysts

A

Injection sclerotherapy and surgery if this fails

58
Q

Management of graves with significant eye signs?

A

Total thyroidectomy

59
Q

Management of graves without significant eye signs?

A

Patient choice radioiodine Vs surgery

60
Q

Causes of primary hyperparathyroidism?

A

Causes of primary hyperparathyroidism
80%: solitary adenoma
15%: hyperplasia
4%: multiple adenoma
1%: carcinoma

61
Q

Features of primary hyperparathyroidism ?

A

Features - ‘bones, stones, abdominal groans and psychic moans’
Polydipsia, polyuria
Peptic ulceration/constipation/pancreatitis
Bone pain/fracture
Renal stones
Depression
Hypertension

62
Q

Associations of hyperparathyroidism?

A

Hypertension
Multiple endocrine neoplasia: MEN I and II

63
Q

Investigation of hyperparathyroidism?

A

Raised calcium, low phosphate
PTH may be raised or normal
Technetium-MIBI subtraction scan

64
Q

Complications of breast surgery?

A
  • long thoracic nerve injury
  • intercostobrachial nerve injury
  • injury to the thoracodorsal trunk
  • infection , cellulitis
  • lymphoedema
  • seroma
65
Q

Surveillance strategy for BRCA1?

A

annual breast MRI

66
Q

High risk genes for BC?

A

BRCA1, BRCA2 or TP53

67
Q

Drug treatment for breast cancer?

A

Premenopausal women at high risk can be offered tamoxifen
Post menopausal women at high risk can be offered anastrazole.
Where drug treatment is given, the period of dosage should not exceed 5 years.

68
Q

What is medullary breast cancer characterised by?

A

Medullary breast cancer is a breast cancer of special type. Histologically, it is characterised by a marked lymphocytic infiltrate. Many of the breast cancers of special type (which comprise less than 5% of all breast cancers) have a very good prognosis.

69
Q

Special type breast cancers?

A

medullary, tubular, mucinous, adenoid cystic,

Improve

70
Q

Features of inflammatory carcinoma?

A

Aggressive
Early dissemination
Treatment resistant
Often occurs in regnancy or lactation

71
Q

What are brown tumours of bone associated with?

A

Hyperparathyroidism
Excess osteoclast activity

72
Q

Typical features of insulinoma?

A

Symptomatic hypoglycaemia during fasting
Concomitant blood glucose of less than 3mmol/L
Relief of hypoglycaemia by use of glucose

73
Q

what is insulinoma?

A

Insulin producing tumours of the pancreatic β cells
Incidence of 1 per 1,000,000 per year
90% of lesions are benign
Most tumours less than 2cm in size
Between 5 and 10% have MEN type 1
75% of patients with MEN 1 will develop pancreatic islet cell tumours

74
Q

What level is plasma insulin concentration commonly in insulinoma?

A

The plasma insulin concentration is >10 micro U/ml in patients with the disorder.

75
Q

Tumour localisation of insulinoma?

A

USS (25% accuracy), endoscopic USS better (75% accuracy)
CT scanning (pancreatic protocol=40% accuracy)
Malignant insulinomas are larger and diagnostic accuracy with MRI is nearly 100% in such cases
Somatostatin receptor scintigraphy (50% accuracy)

76
Q

Where do glucagonomas originate?

A

Glucagonomas originate in the alpha 2 cells of the pancreas.

77
Q

Symptoms of glucagonomas?

A

Symptoms are generally related to hormone overproduction and include diabetes, hypoaminoacidemia, normochromic and normocytic anemia, and necrolytic migratory erythema (NME), which is the most characteristic clinical sign (as opposed to symptom)

78
Q

Diagnosis of glucagonomas?

A

Serum measurement of glucagon levels (a level of greater than 1000pg/ml is diagnostic)
Imaging with CT scanning of the chest/ abdomen and pelvis
Endoscopic USS may be used
Combined CT/MRI can accurately localise the lesion in 95% of cases

79
Q

Treatment of glucagonomas?

A

Often metastatic at presentation
Chemotherapy: doxorubicin and 5FU
Biological: Sunitinib

80
Q

What is a somatostatinoma?

A

Somatostatinomas are rare neuroendocrine tumors that arise from the pancreas or the gastrointestinal tract and are characterized by excessive secretion of somatostatin hormone by tumor cells of D-cell origin

81
Q

Symptoms of somatostatinoma?

A

Classic clinical pentad:
1. diabetes mellitus
2. cholelithiasis
3. weight loss
4. steatorrhea and diarrhea
5. hypochlorhydria and achlorhydria.

82
Q

Diagnosis of somatostatinoma?

A

serum measurements of somatostatin
Imaging is with CT and MRI
Endoscopic USS is also useful

Biopsy not routinely performed

83
Q

Treatment of somatostatinoma?

A

Often already metastasised on presentation
Chemotherapy is sometimes used as a treatment and 5FU and doxorubicin are typically the agents of choice.

84
Q

Where are gastinomas typically found?

A

Near the head of the pancreas

85
Q

What are gastronomes typically associated with ?

A

Zolinger Ellison Syndrome

Normally treated with surgical excision

86
Q

What is Waterhouse - Friderichsen syndrome?

A

adrenal gland failure due to bleeding into the adrenal glands. It is caused by severe bacterial infection (most commonly the meningococcus Neisseria meningitidis).

MRSA theory (20 decks)

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