Endocrine Surgery Flashcards
What are some post operative complications following thyroid surgery?
Neck bleeding
- usually immediately or on ward
- compression of haematoma into the neck
Acute bilateral Recurrent Laryngeal nerve injury
Acute thyrotoxic crisis
- due to handling of the gland
Hypocalcemia
- removal of the parathyroid glands
What are the benign causes of an enlarged thyroid?
Non- toxic goitre/ hyperplasia of the thyroid
Thyroid adenoma
Thyroid cyst - colloid cyst
thyroglossal cyst (although this doesn’t usually sit on the thyroid)
What are the common causes for a non-toxic goitre?
Iodine deficiency
- most common cause
physiological demand for thyroid hormones
- pregnancy
- teenagers
Goitrogens
- substances which promote hormone synthesis
What are the symptoms of a goitre and what investigations are done into goitres?
Usually asymptomatic:
Dyspnea
Dysphagia
Hoarseness of voice
Investigations:
- TFTs
- Ultrasound +/- FNA
- CXR - looking for tracheal deviation
- Radionuclide uptake (malignant tend to be cold)
*if the TFTs were off - then FNA should be carried out to define what it is.
What is the treatment of a non- toxic goitre?
medical:
- levothyroxine - replace deficiency
- Radioactive iodine
Surgical
- thyroid lobectomy
- thyroidectomy
What are the symptoms of a thyroglossal cyst?
Painless midline cyst
if infected:
- pain
- fistula formation
*inflammation often occurs following URTI
What are the investigations into thyroglossal cyst and what is the management?
Ultrasound
FNA - straw colour will come out
Treatment:
Antibiotics - if infected
Drainage - if infected
Elective surgery
What are the types of malignant tumours one can get in their thyroid, and how what is their prevalence?
Papillary carcinoma:
- most common malignant
- females/ young children
- good prognosis
- spreads to lymph nodes first
Follicular Carcinoma:
- elderly females
- solitary nodule
- spreads late
Medullary:
- Associated with MEN -IIa and IIb
- excessive calcitonin release - C cell release
- must carry out CT of abdomen for risk of pheochromocytoma
Anaplastic
- older women
- rare and extremely aggressive
Thyroid lymphoma
- B cell - non hodgkin lymphomas
- rarely associated with long standing hashimotos disease
What are the types of benign tumours of the thyroid?
Colloid Adenoma / Cyst
- most common
Follicular adenoma
- develops in a pseudocapsule
What diagnostic investigations should be carried out on thyroid tumours?
TFTs Thyroid antibodies FNA - ultrasound guided Neck ultrasound ECG
What is the grading system used for thyroid cancers?
following from FNA, they are given a point score:
- thy 1 = non diagnostic
- thy 2 = benign colloid
- thy 3 = follicular or colloidal - further investigation
- thy 4 = suspicion of malignancy
- thy 5 = diagnostic of thyroid cancer
Which type of thyroid cancer can have a neoplastic effect? and what is it?
Medullary:
- cushing’s effect
What are some emergencies following thyroid surgery?
Neck bleeding:
- pressure hematoma on neck
- dyspnea
- pain
- stridor
- cyanosis
- give high flow O2.
- cut Stitches on ward if needs be
- CPR if needed
- fluid resuscitation
Acute bilateral Recurrent laryngeal injury:
- paralysis of both vocal cords causing acute airway obstruction
- noticed when extubation is carried out
- stridor
- O2 stats fall
- re-intubation
- emergency cricothyroidotomy
Acute Thyrotoxic Crisis: caused by handling of thyroid - sweating - fever - tachycardia - AF
- fluid resuscitation
- High flow O2
- may need transferred to ICU to manage effects
Hypoglycaemia
- due to removal of parathyroid glands
*Supplementation of Ca2+ and Vit D
What are the most common causes of hyperparathyroidism?
Parathyroid Adenoma
- most common in postmenopausal women
Hyperplasia of parathyroid glands
- MEN I
Parathyroid cancer
- this is rare
What investigations should be done into hypercalcaemia?
Adjusted Ca2+ levels
PTH levels
Urine Ca2+ levels
Bone scan
Drug history:
- lithium
- vitamin D
Check for malignancy
- this is the 2nd biggest cause
If a patient present with hypercalacaemia and high PTH, what investigations should be done?
High resolution US sound of neck
Sestamibi scan - radioisotope scanning
What is the treatment for adenoma of the parathyroid? and what are the indications for surgery?
minimally invasive parathyroidectomy
- symptomatic
- Ca2+ >3
- <50 years
- End organ damage
What are the symptoms of parathyroid cancer?
Severe hypercalcemia
excessive high PTH
local infiltration
*80% survival rate
What are the most common causes of pancreatic cancer?
Adenocarcinoma
- usually effects the head of the pancreas
Ampullary tumour
Pancreatic islet tumour
What are the risk factors for pancreatic cancer?
Smoking
alcohol
recurrent pancreatitis
large waist circumference
What investigations should be done into pancreatic cancer?
FBC
LFTs
Glucose
Ca-19
Pancreatic protocol CT scan
- thoracoabdominal pelvic CT for metastasis
Endoscopic Ultrasound guided biopsy
and/ or
ERCP
- with biopsy
What are the symptoms of pancreatic cancer?
Painless jaundice Anorexia Acute pancreatitis Thrombophlebitis migrans - presents in the portal vein Steatorrhea Diabetes
What is the treatment of pancreatic cancer?
Whipple’s procedure
- Head of pancreas
- duodenum
- gallbladder
- patient needs good baseline of health
Pancreatectomy
Adjuvant therapy
- 5 fluorouracil
- folfirinox
Symptomatic relief
- Endoscopic biliary stenting - ERCP
- Pain relief
What is the prognosis of pancreatic cancer?
~12% for 5 year survival
What does MEN-1 consist of?
3 P’s
- parathyroid tumours
- pituitary tumours
- pancreatic tumours
What does MEN-2a consist of?
- Medullary thyroid tumours
- Pheochromocytomas
- Primary hyperparathyroidism
What is the aetiology of Pheochromocytomas?
MEN - 2
Von Hippel Lindau Disease
Neurofibromatosis - 1
What are the diagnostic procedures for pheochromocytomas?
Urinary Catecholamine testing
- over 24 hours
- metadrenaline
- normetadrenaline
CT of thoraco-abdomen
What is treatment of Pheochromocytomas?
Phenoxybenzamine - alpha blocker
+
Beta blocker
adrenalectomy
*note it is important to give alpha blocker before surgery to prevent catecholamine release
Where are pancreatic cancers most likely to metastasis to first?
Liver early
Peritoneum - usually 2nd place
Lungs
Bones
What is the treatment given for Her2 positive breast cancers and what is the follow up and potential complications?
Trastuzumab
- every 3 weeks for 1 year
Can effect heart - must be monitored and contraindicated in women with heart failure.
Side effects:
- tumour pain
- headaches
What is the treatment given to ER positive women? and who is given what?
Premenopausal women = tamoxifen
Post-menopausal = Aromatase inhibitors (Letrozole)
When is chemotherapy used in breast cancer?
Neoadjuvant - shrink tumour
adjuvant therapy - after surgery to reduce recurrence
For treatment control of metastatic disease
What are some pro’s and con’s of implants?
Pro’s:
- minimal scars
- reasonable appearance
Con’s:
- cold
- don’t feel natural
- Long term effects - hardening, leakage, shape change
What is a con of Transverse rectus abdomens myocutaneous / TRAM flap:
Increased risk of abdominal hernia
What are the complications of non-toxic goitres?
Bleeding
Compression of jugular veins
- Pemberton’s sign
Dysphagia
Recurrent laryngeal damage
Dyspnea due to tracheal compression
In the setting of medullary thyroid cancer there are a few additional tests that should be done, what are these and why?
Urinary catecholamines
CT abdomen
Screening of families
It is associated with MEN-II which also causes Pheochromocytomas.
Family should be tested as well.
What important symptoms help to distinguish a medullary tumour from other types?
Diarrhea
Flushing of the skin
- *measure serum calcitonin
- *scan for pheochromocytoma
What are the defining features of anaplastic thyroid cancer?
Swelling of the neck as opposed to a goitre.
Rapidly enlarging
Dyspnea
Hoarseness of voice
Ear pain
What disease is lymphoma of the thyroid associated with?
Hashimotos
List some causes of hyperthyroidism:
Grave’s disease
Toxic multinodular goitres
Toxic Adenomas
Drugs
- amiodarone
- levothyroxine
Infection
- De- Quervain’s syndrome
Iatrogenic
What is the blood supply to the thyroid?
Superior thyroid A - external jugular
Inferior Thyroid A - Thyrocervical trunk of the subclavian A
Venous:
- Internal jugular
- Brachiocephalic
What are some causes to adrenal masses:
Adenoma Hyperplasia Secondary metastasis Pheochromocytoma Neuroblastoma
What is the blood supply to the adrenals:
Superior artery - inferior phrenic A
Middle Artery - Aorta
Inferior Artery - Renal Artery
Name some causes of Diffuse goitre:
Physiological
Thyroiditis
- De Quervain’s
Grave’s
Hashimoto’s
What are the indications for surgery of the thyroid?
Carcinoma
Pressure from Thyroid
Relapse of symptoms from Hyperthyroidism following medical treatment
- usually the carbimazole fails
Symptomatic patients planning pregnancy
Cosmetic factors
What things must be done prior and post thyroid surgery?
Prior:
- make patient euthyroid
- Laryngoscope of vocal cords
- Check calcium level
Post:
- check vocal cords
- check calcium level
Outline some key findings of thyroid cancer:
Papillary
- young females
- spreads lymph nodes creating a laterally aberrant thyroid *i.e. lymph nodes enlarge before thyroid
Follicular:
- middle aged
- blood spread
Medullary:
- Calcitonin
- MEN syndrome
Lymphoma:
- MALT
Anaplastic
- elderly
- poor response
What test can be done to distinguish whether a node is a toxic nodule or cold:
Radioactive iodine uptake scan
