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Surgery Rotation > EOR endocrine part 1- pheochromocytoma, thyroid nodule, thyroid carcinoma > Flashcards

EOR endocrine part 1- pheochromocytoma, thyroid nodule, thyroid carcinoma Flashcards

1
Q

What is pheochromocytoma?

A

Tumor of the adrenal medulla and sympathetic ganglion (from chromaffin cell lines) that produces catecholamines (NE>epi)

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2
Q

Which age group is most likely to be affected by pheochromocytoma?

A 
Any age (children and adults)
Average age is 40-60 yrs
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3
Q

Associated RFs of pheochromocytoma

A

MEN-II
FHx
von Recklinghausen dz
von Hippel-Lindau dz`

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4
Q

S/sx of pheochromocytoma

A 
Classic triad:
Palpitations
HA
Episodic diaphoresis
Also:
HTN
Pallor, leading to:
Flushing
Anxiety
Wt loss
Tachycardia
Hyperglycemia
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5
Q

What is the most common sign of pheochromocytoma?

A

HTN

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6
Q

What diagnostic tests should be performed in a pheochromocytoma?

A

Urine screen: VMA, metanephrine, and normetanephrine

Urine/serum epi/norepi levels

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7
Q

What are the other common lab findings of pheochromocytoma?

A

Hyperglycemia (epi increases glucose, norepi decreases insulin)
Polycythemia (resulting from intravascular volume depletion)

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8
Q

What is the MC site of a pheochromocytoma?

A

Adrenal >90%

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9
Q

What are the other sites of pheochromocytoma?

A

Organ of Zuckerkandl
Thorax (mediastinum)
Bladder
Scrotum

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10
Q

What are the tumor localization tests for pheochromocytoma?

A 
CT scan
MRI
I-MIBG
PET scan
OctreoScan
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11
Q

How does the I-MIBG scan work?

A

I-MIBG is a norepi analog that colelcts in adrenergic vesicles and, thus, in pheochromocytomas

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12
Q

What is the role of PET scan in pheochromocytoma?

A

Positron Emission Tomography is helpful in localizing pheochromocytomas that do no accumulate MIBG

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13
Q

What is the scan for imaging adrenal cortical pheochromocytoma?

A

NP-59 (cholesterol analog)

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14
Q

What is the localizing option for pheochromocytoma if a tumor is not seen on CT, MRI, or I-MIBG?

A

IVC venous sampling for catecholamines (gradient will help localize the tumor)

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15
Q

What is the tumor site for pheochromocytoma if epinephrine is elevated?

A

Must be adrenal or near the adrenal gland because nonadrenal tumors lack the capability to methylate norepinephrine to epinephrine

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16
Q

Can histology be used to determine malignancy in pheochromocytoma?

A

No

Only distant metastasis or invasion can determine malignancy

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17
Q

What is the classic pheochromocytoma rule of 10s?

A 
10% malignant
10% bilat
10% in children
10% multiple tumors
10% extra-adrenal
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18
Q

What is the preop/medical tx of pheochromocytoma?

A

Increase intravascular volume with alpha blockade (e.g., phenoxybenzamine or prazosin) to allow reduction in catecholamine-induced vasoconstriction and resulting volume depletion
Tx should start as soon as dx is made +/- beta blockers

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19
Q

What is the surgical tx of pheochromocytoma?

A

Tumor resection with early ligation of venous drainage and minimal manipulation

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20
Q

What are the possible periop complications of pheochromocytoma?

A

Anesthetic challenge: hypertensive crisis with manipulation (treat with nitroprusside)
Hypotension with total removal of the tumor
Cardiac dysrhythmias

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21
Q

In the pt with pheochromocytoma, what must be ruled out?

A

MEN type II (almost all cases are bilat)

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22
Q

What is the organ of Zuckerlandl?

A

Body of embryonic chromaffin cells around the abdominal aorta
Normally atrophies during childhood, but is the most common site of extra-adrenal pheochromocytoma

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23
Q

DDx of thyroid nodule

A 
Multinodular goiter
Adenoma
Hyperfunctioning adenoma
Cyst
Thyroiditis
Carcinoma/lymphoma
Parathyroid carcinoma
24
Q

Name three types of nonthryroidal neck masses

A

Inflammatory lesions
Congenital lesions
Malignant lesions: lymphoma, metastases, squamous cell carcinoma

25
Q

What studies can be used to evaluate a thyroid nodule?

A

U/s- solid or cystic nodule
FNA- cytology
I scintiscan- hot or cold nodule

26
Q

What is the diagnostic test of choice for thyroid nodule?

A

FNA

27
Q

What is the percentage of false neg results on FNA for thyroid nodule?

A

~5%

28
Q

What is meant by a “hot” vs a “cold” nodule?

A

Nodule uptake of IV I131 or mT99
Hot- increased I123 uptake= functioning/hyperfunctioning nodule
Cold- decreased I123 uptake= nonfunctioning nodule

29
Q

What are the indications for a I123 scintiscan for thyroid nodule?

A

Nodule with multiple nondiagnostic FNAs with low TSH

Nodule with thyrotoxicosis and low TSH

30
Q

What is the role of thyroid suppression of a thyroid nodule?

A

Diagnostic and therapeutic

Administration of thyroid hormone suppresses TSH secretion, and up to half of the benign thyroid nodules will disappear

31
Q

What hx suggests thyroid carcinoma in a thyroid nodule?

A

Neck radiation
FHx (thyroid CA, MEN-II)
Young age
M>F

32
Q

What signs suggest thyroid carcinoma in a thyroid nodule?

A 
Single nodule
Cold nodule
Increased calcitonin levels
LAD
Hard, immobile nodule
33
Q

What sx suggest thyroid carcinoma in a thyroid nodule?

A

Voice change (vocal cord paralysis)
Dysphagia
Discomfort (in neck)
Rapid enlargement

34
Q

What is the MCC of thyroid enlargement?

A

Multinodular goiter

35
Q

What are indications for surgery with multinodular goiter?

A

Cosmetic deformity
Compressive sx
Cannot r/o CA

36
Q

What is Plummer’s dz?

A

Toxic multinodular goiter

37
Q

Name the five main types of thyroid carcinoma and their relative percentages?

A 
Papillary carcinoma: 80%
Follicular carcinoma: 10%
Medullary carcinoma: 5%
Hurthle cell carcinoma: 4%
Anaplastic/undifferentiated carcinoma: 1-2%
38
Q

S/sx of thyroid carcinoma

A

Mass/nodule
LAD
Most are euthyroid

39
Q

What comprises the workup of thyroid carcinoma?

A 
FNA
Thyroid u/s
TSH
Ca level
CXR
\+/- I123 scentiscan
40
Q

What oncogenes are associated with thyroid cancers?

A

Ras gene family and RET proto-oncogene

41
Q

Environmental risk of papillary adenocarcinoma

A

Radiation exposure

42
Q

Average age of papillary adenocarcinoma

A

30-40 yrs

43
Q

Sex distribution of papillary adenocarcinoma

A

F>M, 2:1

44
Q

Associate histologic findings of papillary adenocarcinoma

A

Psammoma bodies

45
Q

Route and rate of spread of papillary adenocarcinoma

A

Most spread via lymphatics (cervical adenopathy)

Spread occurs slowly

46
Q

I131 uptake of papillary adenocarcinoma

A

Good uptake

47
Q

10-yr survival rate of papillary adenocarcinoma

A

~95%

48
Q

Tx for papillary adenocarcinoma with <1.5 cm and no hx of neck radiation exposure

A

Thyroid lobectomy and isthmectomy
Near-total thyroidectomy
Total thyroidectomy

49
Q

Tx for papillary adenocarcinoma with >1.5 cm, bilat, + cervical node metastasis OR a h/o radiation exposure?

A

Total thyroidectomy

50
Q

Tx for papillary adenocarcinoma with lateral palpable cervical LNs

A

Selective neck dissection (ipsilateral)

51
Q

Do pos cervical nodes affect the prognosis of papillary adenocarcinoma?

A

No

52
Q

Tx for papillary adenocarcinoma with central cervical LNs

A

Central neck dissection

53
Q

What postop med should be administered with papillary adenocarcinoma?

A

thyroid hormone replacement, to suppress TSH

54
Q

What is the MC site of distant metastases with papillary adenocarcinoma?

A

Pulm (lungs)

55
Q

What are the Ps of papillary thyroid CA?

A 
Popular (MC)
Psammoma bodies
Palpable LNs
Positive I131 uptake
Positive prognosis
Postop I131 scan to diagnose/treat metastases
Pulmonary mets

Surgery Rotation (19 decks)

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