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NMS Casebook > Endocrine Disorders > Flashcards

Endocrine Disorders Flashcards

1
Q

mobile 1cm firm thyroid nodule. Risk factors for thyroid CA? Tx.

A
  1. Radiation hx (most commonly papillary CA)
  2. FHx

Tx for pts w/radiation exposure = thyroidectomy

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2
Q

Inheritence pattern of medullary thyroid CA. Workup.

A

Autosomal dominant pattern d/t point mutation in RET gene. Measuring serum calcitonin levels (elevated in medullary CA). Consider MEN syndromes (20% of medullary thyroid CA) and evaluate for pheochromocytoma, adrenal medullary hyperplasia, and hyperparathyroidism. MEN type II is the most common form that includes medullary thyroid CA. NO USE for post-op radioactive iodine b/c the tumor arises from C-cells. Monitor recurrence w/serum calcitonin and CEA levels

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3
Q

Solitary nodule vs. multinodular gland risk for CA. Cold vs. Hot noduel risk for CA

A

10% vs. 5%. Cold nodule > hot nodule risk for CA

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4
Q

If nodule is solitary and not hard or fixed what is the next thing to do?

A

Fine needle aspiration with cytology analysis of aspirate.

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5
Q

Workup for cyst and for recurrent cyst.

A

Cyst requires complete aspiration and follow up. A recurrent OR large cyst requires removal to eliminate risk of malgnancy
TFT’s are NOT necessary for workup of thyroid noduels

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6
Q

Workup for thyroid nodule evaluation

A
  1. Radioactive iodine is NOT appropriate in the initial evaluation.
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7
Q

Colloid nodule

A

Benign condition w/o need for surgery (no malignant risk) - medical mgmt w/thyroid suppresion is sufficient

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8
Q

Thyroid mass w/psammoma bodies. Most common thyroid tumor type. a/w thyroid radiation exposure.

A

Papillary CA of thyroid. Total thyroidectomy OR limited thyroid lobectomy and isthmusectomy in some cases. Prophylactic neck LN dissection may be performed to prevent mets. Prognosis depends on age, pathologic grade, extent of disease, size of tumor. Postoperatively req’s the use of thyroid hormone +/- radioactive iodine for ablation

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9
Q

Thyroid mass w/amyloid deposits

A

Amyloid and calcitonin staining suggest medullary thyroid CA. total thyroidectomy indicated.

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10
Q

Thyroid mass w/Undifferentiated cells. CA is advanced stage at onset.

A

Must perform CTX and radiation or salvage operative therapy. Surgical options are limited…must remove tumor from the trachea to prevent respiratory compromise. Often presents with distant mets and prognosis is POOR!

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11
Q

Thyroid mass w/Hurthle cells

A

Adenoma or low-grade CA requiring lobectomy

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12
Q

Thyroid mass w/follicular cells. More prevelant in iodine deficient areas. Propensity for vascular spread and not lymphatic spread.

A

Lobectomy and isthmusectomy are indicated for well-circumscribed lesions (microinvasive). Total thyroidectomy is req’d for microinvasive lesions >4cm. Post-op radioactive iodine ablation reqd. Worse prognosis b/c of vascular invasion.

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13
Q

Thyroid mass w/ymphocytic infiltrate

A

Lymphoma or chronic lymphocytic thyroiditis (differentiated by flow cytometry)

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14
Q

Risks a/w thyroid surgery

A
  1. Injury to recurrent laryngeal nerve
  2. Injury to external branch of superior laryngeal nerves (responsible for high pitched singing voice)
  3. Injury to the parathyroid gland resulting in hypocalcemia AND hyper phosphatemia
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15
Q

Unilateral vs. bilateral injury to recurrent laryngeal nerves

A
  1. Unilateral = hoarse voice

2. Bilateral = vocal cord paralysis requiring tracheostomy

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16
Q

Hypercalcemia, bone reabsorption, generalzied fatigue, osteitis fibrosa cystica. Workup. Tx.

A

Measure PTH, alk phos, and phosphate levels. Primary PTH will show elevation in BOTH Ca and PTH. Most common cause of primary PTH is a parathyroid adenoma. Parathyroid adenomas are resected and all 3 other glands must be ID’d w/biopsy to r/o malignancy. Sestamibi scan may be done pre-op to localize the enlarged glands and thus allowing for conservative incision size.

17
Q

If only 3/4 of PTH glands are ID’d what is the most likely location of the missing gland?

A

The thymus (may require thymectomy), the tracheoesophageal groove and in the carotid sheath. If the last gland cannot be ID’d then localization studies must be done including sestamibi scans, US, CT, MRI, angiography, or venous sampling

18
Q

Risks of PTH surgery

A
  1. Injury to recurrent laryngeal nerve
  2. Injury to external branch of hte superior laryngeal nerve
  3. HypoPTH (hypocalcemia and hyperphosphatemia). May result in tetany, Chvostek’s sign.
19
Q

Nausea, fatigue, wt loss, drowsiness, abd pain, altered mental status, BP d/o, kidney stones, hypercalcemia

A
  1. Metastatic CA from breast = #1 malignant cause of hypercalcemia
  2. PTH hyperplasia
  3. multiple myeloma
  4. HyperPTH
  5. Sarcoidosis
  6. Milkl alkali syndrome
  7. Vit A tox
  8. Thiazie diuretics
  9. RCC
  10. SCC of lung (PTHrP release)
  11. Familial hypocalciuric hypercalcemia
20
Q

Consequences of hyperCa2+

A

Osmotic diuresis resulting in dehydration and worsening hyperCa2+. Requires rehydration followed by furosemide to cause Ca2+ loss, initiation of bisphosphonates, and treatment of the underlying disorder

21
Q

Tx for primary hyperPTH

A
  1. Neck exploration and removal of abnormal PTH glands
22
Q

Renal failure, hyperphosphatemia, hypoCa2+, elevated PTH

A
  1. secondary hyperPTH d/t increased Ca2+ absortion from the gut and vit D metabolism
23
Q

Medical vs. surgical mgmt of 2ndary hyperCa2+

A
  1. Chronic renal failure requires medical mgmt
  2. Bone pain, fractures, intractable pruritus, ectopic Ca2+ of soft tissue requires surgical mgmt (Removal of all but 50mg of PTH tissue which may be transplanted to more accessible sites such as the forearm in case further surgery is needed)
24
Q

Ca2+ changes in pt w/renal transplant. Tx.

A

Return to normal PTH function usually occurs but high serum Ca2+ may occur post-op (aka tertiary hyperPTH). In this case the PTH dont respond to return of normal renal fxn and continue to overproduce PTH. 3.5 gland resection is indicated.

25
Q

Pt undergoing neck exploration for HyperPTH becomes uncontrollably HTN

A

May be d/t catecholamine release from undiagnosed Pheochromocytoma. Must STOP SURGERY and admit to ICU. Give both alpha AND beta blockers to control HTN (NEVER USE BETA BLOCK ALONE d/t uncontrolled alpha that results)

26
Q

markers for pheochromocytoma

A
  1. Elevated urinary catecholamines (metanephrine, vanillylmandelic acid)
  2. MRI demonstrating tumor of adrenals
  3. Octreotide scan used for hard-to-locate tumors
  4. nuclear iodine metaiodobenzylguianidine scan (MIBG accumulates in chromaffin tissue with HIGH specificity for pheochromocytoma)
27
Q

Approach to tx of pheochromocytoma

A
  1. Phenoxybenazmine (alpha block) must be taken for 10-14d pre-op to prevent HTN crisis
  2. Surgical resection of adrenals
28
Q

Tender swollen neck mass with elevated ESR. Granulomatous histology with degenerating thyroid follicles. Tx.

A

Painful thyroiditis from de Quervain’s thyroiditis. Sudden release of thyroid hormone from acutely injured thyroid follicles. Tx = analgesics and aspirin. Steroids may be used in resistant cases. Surgery NOT indicated unless there is a bacterial infxn by strep, staph, pseudomonas, TB, aspergillosis, actinomycoses, and syphilis (acute suppurative thyroiditis)

29
Q

PainLESS thyroid mass with hypertrophy. Replacement of damaged thyroid tissue with lymphocytes and plasma cells. HYPOthyroid state with low T3 and T4. NORMAL TSH. Tx.

A

Hashimoto’s thyroiditis (chronic lymphocytic thyroiditis). Tx = thyroid resection w/biopsy of suspicious lesions. If compression of trachea occurs then palliative resection is indicated.

30
Q

What is Hashimosto’s thyroiditis?

A

Replacing immune damaged thyroid tissue with lymphocytes and plasma cells resulting in an enlarged painless mass a/w low T3/T4 and normal TSH. Hashimoto’s is a/w higher risk of Papillary CA and thyroid lymphoma

31
Q

Pt w/hx of HyperPTH and intractable duodenal ulcers s/p parathyroidectomy for HyperCa2+

A

Zollinger Ellison syndrome (2 forms sporadic vs. familial a/w MEN syndromes)
MEN1 (pituitary adenoma causing vision symptoms or lactation, PTH hyperplasia, pancreatic tumor causing gastrinoma, insulinoma, VIPoma)

32
Q

Workup for Zollinger elison tumor

A
  1. Localize gastrin secreting tumor by CT and MRI (usually at the head of the pancreas or within the duodenal wall)
  2. Endoscopic US
  3. Angiogram
  4. Venous sampling for gastrin
33
Q

Tx for gastrinomas

A
  1. Malignant tumors spread to the LN’s AND especially the liver. Therefore surgery may only be useful if performed early before metastasis occurs.
  2. As much tumor as possible should be removed while preserving the pancreatic mass. However if the mass involves the large pancreatic duct a Whipple procedure (distal pancreatectomy) should be performed.
  3. However, if the tumors are not resectable should undergo gastric resection or selective vagotomy.
  4. CTX include Streptozocin for tumor control.
34
Q

Fasting hypoglycemia <60mg/dL, symptomatic hypoglycemia, relief by glucose administration, elevated C-peptide

A

Insulinoma (usually a/w MEN syndromes)

35
Q

Tx of insulinoma

A
  1. Unresectable insulinomas should be tx w/diazoxide to inhibit insulin release
36
Q

Thyroid mass with amyloid like material and C-cell proliferation on FNA.

A

Medullary CA of the thyroid. Often a/w MEN-2a or MEN-2b syndrome (AD inheritence)

  1. MEN-2a = medullary thyroid CA, parathyroid hyperplasia, pheochromocytoma
  2. MEN-2b = MEN-2a + marfanoid body habitus AND ganglioneuromas
37
Q

Frontal pounding HA, episodic diaphoresis, palpitations, anxiety, episodic/sustained HTN

A

Pheochromocytoma (BL>sporadic)

38
Q

Tx for medullary thyroid CA

A

total thyroidecomy + LN’s in central neck compartment

39
Q

Tx of incidental adrenal mass

A

Depends on size of mass and symptoms.

  1. Adrenal cortical CA = surgical resection of adrenal gland
  2. Small adrenal mass that is functional must be removed
  3. Small adrenal mass that is NONfuncitonal must simply be followed w/close observation.

NMS Casebook (8 decks)

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