Endocrinology Flashcards
What is adrenal carcinoma?
adrenal cortical cancer (ACC) is a rare disease that can be functional but should be considered on the differential for any adrenal mass, especially tumors larger than 4 cm
What are the characteristics of adrenal carcinoma?
- less common benign masses include myelolipoma/lipoma, ganglioneuroma, epithelial cyst, and pseudocyst
- nearly 4% of abdominal CT scans obtained for another indication demonstrate an incidental adrenal mass
- adrenal tumors can also be detected clinically due to manifestations of tumor hormone production
- of all adrenal masses, 80% are nonfunctional adenomas, while 15% are functional with laboratory evidence of hormonal overproduction
What are the labs for adrenal carcinoma?
- plasms fractionated metanephrines or 24-hours urine metanephrines - must full out pheochromocytoma for any adrenal mass
- serum potassium and aldosterone and plasma renin activity
- 24-hour urinary-free cortisol or dexamethasone suppression test
- DHEA-S - high levels can be associated with ACC; virilization is the clinical manifestations of androgen overproduction
- CT scan - size > 4 cm
- MRI
What is the tx for adrenal carcinoma?
- adrenal tumors with evidence of hormone production or suspicion of ACC should be considered for adrenalectomy
- prognosis for ACC is dependent on treatment at an early stage and complete surgical excision with negative margins
- laparoscopic adrenalectomy is NOT recommended for ACC given higher local recurrence rates due to positive or close margins
- complete resection often requires en bloc resection of kidney, spleen, pancreas, liver, or IVC for negative margins
- overall prognosis remains poor with overall 5-year survival of 25%
What are the ddx of fatigue?
endocrine/metabolic causes of fatigue
- addison’s disease (adrenocorticol insufficiency) - adrenal gland destruction causing lack of cortisol and aldosterone secretion usually autoimmune (decrease cortisol)
- hypothyroidism: cold and heat intolerance, fatigue, constipation, depression, weight gain, bradycardia
- diabetes mellitus: fatigue, weight loss, polyuria, polydipsia, polyphagis
- pituitary insufficiency
- hypercalcemia
- chronic renal failure
- hepatic failure
What are the laboratory testing for fatigue?
- complete blood count - anemia
- erythrocyte sedimentation rate - inflammatory state
- chemistry panel - liver disease, renal failure, protein malnutrition
- thyroid function tests - hypothyroidism
- human immunodeficiency virus antibodies - if not previously tests
- pregnancy test, if indicated
What is less commonly indicated for fatigue?
- chest radiography - adenopathy
- tuberculin skin test
- electrocardiography - CHF, arrhythmia
- pulmonary function tests - COPD, arrhythmia
- toxicology screen - substance abuse
- lyme titers - chronic Lyme disease
- rapid plasma reagin - syphilis infection
- brain magnetic resonance imaging - multiple sclerosis
- echocardiography - valvular heart disease, CHF
- specialized blood testing (e.g. ferritin, iron, vitamin B12, and folate levels; iron-binding capacity; direct ant globulin test
What is hypothyroidism?
Hashimoto’s (chronic lymphocytic/autoimmune), previous thyroidectomy/iodine ablation, congenital
- cold and heat intolerance, fatigue, constipation, depression, weight gain, bradycardia
- Labs: TSH - elevated in primary disease, low T4 (increase TSH and decrease free T4)
What are the sis of hyperthyroidism?
heat intolerance, palpitations, sweating, weight loss, tremor, anxiety, tachycardia
What is hyperparathyroidism?
PALPABLE neck tumor and hypercalcemia (parathyroid cancer)
What is hyperthyroidism?
female with heat intolerance, palpitation, sweating, weight loss, tremor, anxiety, tachycardia
- graves (autoimmune) - most common cause -diffuse goiter with a bruit, exophthalmos, pretibial myxedema
- thyroid storm - fever, tachycardia, delirium
- toxic adenoma, thyroiditis, pregnancy, amiodarone
How is hyperthyroidism dx?
- TSH (best test): decreased in primary disease ( decrease TSH and increase free T4) elevated in secondary disease (increase TSH and increase free T4)
- thyroid radioactive iodine uptake:
- graves: diffusely high uptake
- toxic multionodular: discrete areas of high uptake
What are the antibodies?
(Graves): anti-thyrotropin antibodies (anti-TSH receptor antibodies)
What is the tx for hyperthyroidism?
- beta-blockers (symptomatic), methimazole/propylthiouracil, radioactive iodine, thyroidectomy
- thyroid storm - prompt beta blockers, hydrocortisone, methimazole/propthiouracil, iodine
- thyroidectomy - most likely complication is recurrent laryngeal nerve (hoarseness)
What is hyperthyroidism?
heat intolerance, palpitations, sweating, weight loss, tremor, anxiety, tachycardia
What is a pheochromocytoma?
recurrent headaches, HTN, sweating, palpitations
- adrenal neoplasm - catecholamine secreting adrenal tumor - secretes norepinephrine and epinephrine autonomously and intermittently
- recurrent headaches, HTN, sweating, palpitations
How is a pheochromocytoma dx?
- 24-hour catecholamines including metabolites (metanephrine and vanillymandelic acid)
- MRI or CT of the abdomen to visualize tumor
What is the tx for a pheochromocytoma?
- resect tumor - complete adrenalectomy
- medical treatment preoperative: alpha blocker (phenoxybenzamine)
What is thyroid carcinoma?
a 35-year old female with a hoarse voice, solitary cold nodule on thyroid uptake scan, lymphadenopathy, radiation exposure
- most often papillary carcinoma (80%) - think papillary is “popular”
- follicular carcinoma: 10%
- medularry carcinoma: 5%
- hurthle cell carcinoma: 4%
- anaplastic/undifferentiated carcinoma: 1 to 2%
What are the diagnostic studies for thyroid carcinoma?
- ultrasound is the best initial screen follow by a thyroid uptake scan - usually normal thyroid function
- microcalcification, hypoechogenicity, a solid cold nodule, irregular nodule margins, chaotic intranodular vasculature, and a nodule that is more tall than wide
- fine needle biopsy for definitive diagnosis (all lesions > 1 cm should be biopsied)
- TSH, calcium level, CXR
What is the tx for thyroid carcinoma?
surgical resection with chemotherapy and external beam radiation reserved for anapestic thyroid cancer
What is a thyroid nodule?
the diagnostic test of choice for thyroid nodule is fine needle aspiration (FNA)
What is the evaluation for a thyroid nodule?
- U/S - solid or cystic nodule
- fine needle aspirate (FNA) - cytology 123 1 scintiscan (hot or cold nodule)
- hot - increased 123 1 uptake = functioning/hyperfuntioning nodule (non-cancerous)
- cold - decreased 123 1 uptake = nonfunctioning nodule (cancerous)
What is the history with a thyroid nodule?
- neck radiation
- family history (thyroid cancer, MEN-II)
- young age (especially children)
- male > female
