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FRCS A > Endocrine surgery > Flashcards

Endocrine surgery Flashcards

1
Q

Causes of Primary hyperparathyroidism

A

Single or double adenomas (80-85%)
Multi-gland hyperplasia (15%)
Carcinoma (<1%)

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2
Q

Localisation studies for primary hyperparathyoidism

A

Technetium 99 Sestamibi - SPECT or SPECT-CT

85% successful

Co-localising US to increase specificity yada sensitive - 95% if concordant

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3
Q

Medical management of hypercalcaemia

A

Rehydration, furosemide diuresis, steroids.

Cinacalcet- given and continued on discharge til surgery

Bisphosphonates can also be used but take 48-72hrs

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4
Q

Surgical approach

A

Bilateral neck exploration or focused

IF cannot find need to check high in the neck, low in the thymus or thyrothymic ligament, carotid sheath and enclosed within thyroid

Hemithyroidectomy or mediastinal exploration should only be considered at a second operation

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5
Q

Secondary hyperparathyroidism

A

Excessive secretion secondary to low calcium causing hyperplasia of glands and raised PTH

Commonly caused by CKD, low Vitamin D or high dose phosphate

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6
Q

Pathophysiology of secondary hyperparathyroidism

A

initially FGF 23 from bones keeps phosphate levels down by increased excretion and decreasing 1 alpha hydroxylation.

AS disease progresses Kidneys become resistant to FGF-23 and decrease 1-alpha hydroxylation of Vitamin D - decreased phosphate excretion

Deficiency in Vit D cause reduced calcium reabsorption for urine, Gut and failing kidneys result in low calcium and high phosphate which triggers PTH secretion and growth of gland

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7
Q

Management of 2nd Hyperparathyroidism

A

Medical Tx - depends on aetiology

If Vit D deficient - replace - Cholecalciferol for 8 weeks

In CKD - managed bone disease and ectopic calcification
Use dietary phosphate restriction and phosphate binders and Vitamin D supplimentation and calcimimetic (cinacalcet - binds to calcium sensing receptor - decrases PTH)

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8
Q

Indications for surgery in 2nd

A

Prolonged severe hyperparathyroidism
Calciphylaxis
Refractory hyperpohsphataemia
Hypercalcaemia
Evidence of bone disease
Extraskeletal calcification

Surgery improves overall mortality of dialysis patients

Total (4 gland or subtotal (3 and a half glands)

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9
Q

Multinodular Goitre

A

Enlarged thyroid gland consisting of multiple nodules (toxic or non-toxic.

Most develop as a result of TSH stimulation secondary to low thyroid hormone levels

Nodules are extremely common - up to 60% of population have them

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10
Q

Symptoms and signs of goitre

A

Compressive symptoms
Dysphagia
Pembertons sign - distension of veins when arms raised - retrosternal extension

Red Flag - Rapid onset and progression, pain referring to ear, family Hx, Genetic condition (PTEN,MEN2,FAP), severe dysphagia, stridor and previous radiation exposure

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11
Q

Risk of recurrent laryngeal nerve injury and EBSLN

A

RLN -Approx 1% with benign goitre - thought to be relatively low risk

EBSLN - can be as high as 40%

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12
Q

Causes of hyperthyroidism

A

Graves disease
Antibody mediated activation of TRH receports
Toxic nodule with autonomous secretion
Thyroditis
Medications
Pituitary adenoma, struma ovarii
thyroid cancer

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13
Q

Management of hyperthyroidism

A

Betablockers for tachycardia and anxiety
Block and replace using Carbimazole (40-60mg OD) - more likely to induce remission
Remain of media for 12-18months
50% relapse rate

Definitive Tx is surgery or radioidodine

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14
Q

Investigation of adrenal mass

A

Check if functional (<10%)
Serum and urine metanephrines and normetanephrines - pheo
Serum K and renin to aldosterone ration - Conns
Sport cortisol and ACTH - Cushing
Testosterone and oestrogen - possible cancer

CT adrenal protocol - cancer has poor washout, >4cm (25% malignancy), high hounsfield units, poorly defines, irregular heterogenous or areas of necrosis

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15
Q

Well differentiated Thyroid cancer

A

Histological subtype of cancer from thyroid follicular cells
Papillary
Mixed Papillary follicular
follicular and Hurtle cell

Papillary subtype more common than follicular except in iodine deficient areas

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16
Q

Thyroid nodule US

A

BTA 2014 guidelines to allow uninformed reporting - U:
1- Normal
2-Benigh
3 - Indeterminate
4 - suspicious
5 - Malignant

17
Q

Thy classification

A

BTA 2014
Smears must contain 6 or more groups of at least 10cells

Thy1 - Non diagnostic
thy2 - Non neoplastic (need 2 -3to6months apart)
Thy3c Atypical cells 9-20% risk of cancer - may need diagnostic lobectomy
Thy3 F - follicular lesions - requires diagnostic thyroidectomy due to 25-30% chance of malignancy
Thy4 - Abnormal and suspicious but not diagnostic (70% risk of cancer - requires diagnostic lobectomy)
Thy5 - malignant

18
Q

Surgical management of well differential thyroid cancer

A

Tumours<4cm with no high risk features can be considered for hemithyroidectomy alone

High risk : over 45, widely invasive, LN or distant mets, angioinvasion, areas of poor differentiation, multifocal, extra capsular extension, Familial disease, PET positive

19
Q

Prognosis of thyroid cancers

A

10yr survival after diagnosis with Papillary cancer is >90% for stage 1 dropping to 59% with mets

Follicular cancer is worse with 10yr survival approx 85%

20
Q

Neck Limp with diarrhoea

A

Highly suggestive of medullary cancer - high serum calcitonin causing osmotic diarrhoea

21
Q

Work up for medullary thyroid cancer

A

US and FNA
CT of the neck
Direct endoscopy if suspicion of invasion of airway or oesophagus
Serum calcitonin andCEA

Need to ask about MEN 2 syndrome - hypercalcaemia and pheochromocytoma and also family history (cancer, primary hyperparathyroidism, pho)

Need Serum PTH and calcium as well as work up for pheochromocytoma

22
Q

Surgery for medullary

A

Guided by calcitonin
>50 - central node and ipsilateral node direction
>200 contralateral node dissection
>500 consider mediastinal node

Total thyroidectomy

23
Q

If Medullary thyroid and mets

A

Little options - palliative
Can consider external bean radiation, TKI and if severe side effects - cytotoxic chemo - 20% response

24
Q

Medullary cancer genetics

A

Codon 634 mutation
means has MEN2A
50% risk of pheochromocytoma

If family found to have mutation
Need examination and US of thyroid, serum calcitonin and Serum CEA. Prophylactic thyroidectomy before 5 screening for pheochromocytoma starting at 11

25
Q

Difference between pheochromocytoma and parganglioma

A

Both are pargangliomas - tumours of the neural crest

But pheos must originate from the adrenal gland

Both can secrete noradrenaline but only phews can secrete adrenaline

26
Q

Symptoms of pheochromocystoma

A

HTN - usually on multiple agents
Anxiety
Tremors
sweating

27
Q

Genetics of Pheochromocystoma

A

30% are genetic
Associated with MEN2, NF1, VHL and familial paraganglioma syndrome (PGL-4, SDHB)

28
Q

Imaging for Pheochromocystomas

A

US can be useful
MIBG is most widely available
SPECT-CT or PET CT give useful info on lesions and possible Mets

GALLIUM DOTANOC - somatoastatin receptor specific

F-DOPA now functional scan of choice

29
Q

Pre-medication prior to surgery

A

Usually Alpha blockade - Doxazosin or phenoxybenzamine til symtpomatic of postural drop

If not controlled then Beta blockade

30
Q

Vasculature of adrenal gland

A

Multiple feeding arteries - Infraphrenic, arota and renal

Right side - Vein drains into IVC - short and thick - difficult to control if torn

Left - Drains into renal vein - more oblique

31
Q

Follow Up

A

Histology - cellular, nests, humour cell spindles, necrosis, cellularity, mitotic figure, vascular invasion and extra-adrenal extension - Gives PASS score (out of 20)

Tumours classified as lower or higher risk of malignancy

Need follow up for signs of Mets and review of Metanephrines

32
Q

Metastatic disease

A

Difficult to manage
Surgical excision
Chemo limited and may not offer benefit - vincristine and dacarbazine

33
Q

Levels of the Neck

A

1-5 Lateral and 6-7 central

L1 Body of mandible, anterior belly of digastric and vertical plane of the submandilar glad posteriorly (a/b - anterior bell of digastric and hyoid)

L2 - Skull base and hyoid bone, sternocleidomastoid posterior (a/b - accessory nerve)

L3 - Hyoid superior and cricoid inferior. Sternocleidomastoid posteriorly and sternohyoid anterior

L4- Cricod superior, clavicle inferior, sternocleidomastoid posterior and sternohyoid anterior

L5- Sternocleidomastoid anterior, Traapezius posterior, mastoid superior, claavical posterior(a/b- line from inferior boarder of cricoid)

L6 Hyoid superior, sternal notch inferior, medial edge of carotid

L7 (controversial) nodal tissue behind sternum

34
Q

Radical vs selective neck dissections

A

Radical - Levels 1-5 and IJV, SCM and spinal accessory nerve - extensive neck mets - high morbidity

Modified Radical - does not remove IJV, SCM or SAN unless involved - less morbidity by maintains oncological control

Selective - only takes levels related to the cancers

FRCS A (9 decks)

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