head and neck, endocrine, breast Flashcards
neck anatomy
1) borders of the anterior neck triangle
2) borders of posterior neck triangle
3) which contains the carotid sheath
4) which contains the accessory nerve and brachial plexus
5) what does the accessory nerve inervate
6) location of false vocal cords in relation to true vocal cords
7) composition of the trachea anterior and posterior
1) sternocleidomastoid muscle (SCM), sternal notch, inferior border of digastric muscle
2) posterior border of the SCM, trapezius muscle and clavicle
3) anterior neck triangle
4) posterior neck triangle
5) SCM, trapezius, platysma
6) false cords are superior to true cords
7) U-shaped cartilage and posterior portion that is membranous
What do they secrete
1) parotid glands
2) sublingual glands
3) submandibular glands
1) mostly serous fluid
2) mostly mucin
3) 50/50 serous/mucin
neck anatomy
1) what does the vagus nerve run between
2) where does the phrenic nerve run
3) where does the long thoracic nerve run
1) bw Internal jugular vein and carotid artery
2) on top of anterior scalene muscle
3) posterior to middle scalene muscle
Head anatomy 1) Trigeminal nerve a-branches b-actions 2) Facial nerve a-branches b-actions 3) Glossopharyngeal nerve a-actions b-what does injury affect 4) hypoglossal nerve a-actions b-findings in hypoglossal nerve injury 5) recurrent laryngeal nerve- innervates all of larynx except what muscle? what nerve innervates that muscle
1) a-ophthalmic, maxillary, and mandibular branches
b- sensation to most of face. mandibular branch supplys taste to anterior 2/3 of tongue, floor of mouth and gingiva
2) a-temporal, zygomatic, buccal, marginal mandibular and cervical branches (to zanzibar by motor car)
b-motor function to face
3) a-taste to posterior 1/3 of tongue, motor to stylopharyngeus
b-swallowing
4) a-motor to all of tongue except palatoglossus
b-tongue deviates to the same side of the injury
5) innervates all of larynx except cricothyroid which is innervated by superior laryngeal nerve
Frey’s syndrome
1) after what surgery does it occur
2) what nerve is injured
3) resulting symptoms
1) after parotidectomy if injury of (2)auriculotemporal nerve-> cross-innervates with sympathetic fibers to sweat glands of skin-> gustatory sweating (sweating on cheek area when eats or smells or thinks of food)
Name the branches of the thyrocervical trunk in the order that they branch off after it leaves the subclavian artery
STAT= 1st- suprascapular artery; 2nd-transverse cervical artery, 3rd- ascending cervical artery, 4th-inferior thyroid artery
what does the superior thyroid artery come from
1st branch of the external carotid artery
what artery is the
1) trapezius flap based on
2) pectoralis major flap based on
1) transverse cervical artery (2nd branch of thyrocervical trunk)
2) either the thoracoacromial artery or the internal mammary artery
Describe what they are and rx
1) Torus palatini
2) Torus mandibular
1) congenital bony mass on the upper palate of mouth. no rx.
2) same as 1 but on lingual surface of mandible. no rx.
What do you take in a:
1) Modified radical neck dissection
2) radical neck dissection
3) what is the mortality difference between the two
1) takes omohyoid, submandibular gland, sensory nerves C2-C5, cervical branch of facial nerve, and ipsilateral thyroid
2) same as above + accessory nerve (CN XII), SCM, and internal jugular resection. (rarely done)
3) no mortality difference, but most morbidity occurs from accessory nerve resection so RND rarely done
Oral cavity CA- mouth floor, anterior 1/3 tongue, gingiva, hard palate, anterior tonsillar pillars and lips
1) MC CA of the oral cavity, pharynx and larynx
2) biggest risk factors
3) difference between erythroplakia and leukoplakia
4) MC site for oral cavity CA
5) what location of tumor is the survival rate lowest
6) rx
1) Squamous cell cancer
2) Tobacco and ETOH
3) erythroplakia (flat red patch/lesion on mouth) considered more premalignant than leukoplakia (white patch)
4) lower lip
5) hard palate tumors-hardest to resect
6) wide resection (1cm margin)
- for tumors >4cm, clinically positive noses or bone invasion do MRND
- Do postop XRT for lesions >4cm, positive margins, or nodal/bone involvement
Oral Cavity CA 1) Lip CA a- which lesions are most aggressive b- when do you need flaps 2) T/F- In tongue CA you can still operate with jaw invasion? If true, name the procedure 3) Verrucous ulcer a-what is it b-where is it found c-risk factor d-rx
1) a-lesions along the commissure are most aggressive
b-need flap if >1/2 of lip is removed
2) True. Commando procedure.
3) a-well-differentiated SCC, not aggressive, rare metastasis
b-cheek
c-oral tobacco
d-full cheek resection +/- flap. no MRND!
Oral Cavity Ca 1) rx of maxillary sinus CA 2) Tonsillar CA a-risk factors b-MCC type c- prognosis d-rx
1) maxillectomy
2) a-ETOH, tobacco, males
b-SCC
c- pts asx until large so 80% have LN met at time of d- rx- tonsillectomy best way to bx, then wide local resection with margins after that
Pharyngeal CA
1) Nasopharyngeal SCC
a- risk factors and presentation
b- where does it spread to
c- rx
2) #1 tumor of nasopharynx in kids and rx
3) MC benign neoplasm of nose/paranasal sinuses
1) a- EBV, Chinese. presents with nose bleed or obstruction
b- posterior cervical neck nodes
c-XRT primary therapy (with chemo for advanced disease). NO SURGERY
2) lymphoma. rx- chemo
3) papilloma
Pharyngeal CA 1)Oropharyngeal SCC a- sx b- where does it spread c-rx 2) Hypopharyngeal SCC a- sx b-where does it spread c-rx
1) a-neck mass, sore throat
b-posterior cervical neck nodes
2) a-hoarseness; EARLY metastases
*c for both: XRT for tumors <4cm and no nodal or bone invasion. Combined surgery MRND, and XRT for more advanced tumors
Pharyngeal CA 1_ Nasopharyngeal angiofibroma a-prognosis b-population and sx c-rx
1) a- benign tumor
b- males <20yo with obstruction or epistaxis
c-angio and embolization (usually internal maxillary artery), followed by resection
Laryngeal CA
1) sx
2) rx
3) MC benign lesion of larynx
1) hoarseness, aspiration, dyspnea, dysphagia
2) XRT (if vocal cord only) or chemo-XRT (if beyond vocal cord). Surgery is not primary treatment bc try to preserve larynx, but MRND (includes ipsilateral thyroid lobe) needed if nodes clinically positive.
3) papilloma
Salivary Gland CA- parotid, submandibular, sublingual and minor salivary glands 1) Benign of Malignant. a- Mass in large salivary gland b- Mass in small salivary gland c- MC site for malignant tumor 2) Malignant tumors a- presentation b- site of lymphatic drainage c- rx 3) Top 2 malignant tumors of the salivary glands and characteristics and which is v sensitive to XRT
1) a- benign
b) malignant
c- Parotid gland (even though it is large)
2) a-painful mass, facial nerve paralysis or lymphadenopathy
b-intra-parotid and anterior cervical chain nodes
c- resection of salivary gland (ie-total parotidectomy), prophylactic MRND and postop XRT if high grade or advanced disease
3) mucoepidermoid CA (#1)- wide range of aggressiveness
Adenoid cystic CA (#2)- long, indolent course, propensity to invade nerve roots, very sensitive to XRT
Salivary Gland TUmors
1) benign tumors
a- presentation
b-MC benign tumor, malignant potential and rx
c-Warthin’s tumor (submandibular duct)- who gets it, % bilateral and rx
d-MC salivary gland tumor in children
1)a- painless mass
b- Pleomorphic adenoma (mixed tumor), malignant degeneration in 5%. rx- superficial parotidectomy. if malignant need total parotidectomy
c- males, bilateral in 10%. rx- superficial parotidectomy
d-hemangiomas
1) MC injured nerve with parotid surgery and resulting deficit
2) what nerves do you need to find for submandibular resection
1) greater auricular nerve-> numbness over lower ear
2) find mandibular branch of facial nerve, lingual nerve and hypoglossal nerve
* branches of facial nerve course bw superficial and deep parotid. Main trunk of facial nerve at level of digastric muscle
Ear-
1) how to rx Pinna lacerations
2) what is cauliflower ear and how to rx
3) what is cholesteatoma, presenting sx and rx
4) Chemodectomas- what are they and rx
1) suture through involved cartilage
2_ undrained hematomas that organize and calcify. need to be drained to avoid this
3) epidermal inclusion cyst of ear, slow drowing but erode. sx- progressive hearing loss and clear drainage from ear. rx- surgica excision
4) vascular tumor of middle ear (paraganglionoma). rx- surgery +/- XRT
Ear 1) acoustic neuroma a- nerve effected b- sx c- where can it grow into d- rx 2) Ear SCC a- where do they metastasize b-rx 3)MC childhood aural malignancy of middle or external ear
1) a-CNVIII
b- tinnitus, hearing loss, unsteadiness
c- cerebellar/pontine angle
d-craniotomy and resection. XRT is alternative to surgery
2) a- 20% met to parotid
b- resection and parotidectomy, MRND for positive LN or large tumor
3) Rhabdomyosarcoma
Nose 1) when to set nasal fx 2) rx of septal heamtoma 3) rx of epistaxis 4) CSF rhinorrhea a-MC cuase b-what protein is in CSF c-how to find leak d-rx
1) after swelling decreases
2) drain to avoid infection and necrosis of septum
3) 90% are anterior- pack. for persistent posterior bleeding despite packing/balloon, consider internal maxillary artery or ethmoid artery embolization
4) a-cribiform plate fracture
b- tau protein
c-can use contrast study to help find leak
d-can repair facial fx. may help. Try conservative rx 2-3 weeks, try epidural catheter drainage of CSF. may need transethmoidal repair
Neck and jaw
1) what is a radicular cyst, appearance on x-ray, and how to rx
2) Ameloblastoma- what is it, appearance on x-ray and how to rx
3) osteogenic sarcoma- prognosis and rx
4) rx of maxillary jaw fx
5) rx of TMJ dislocation
1) inflammatory cyst at the root of teeth (can cause bone erosion). lucent on xray, rx-local excision or curratage
2) slow-growing malignancy of odontogenic epithelium (outside portion of teeth), soap-bubble appearance on CXR. rx- wide local excision.
3) poor prog. rx- multimodality including surgery
4) wire fixation
5) closed reduction
Neck and Jaw
1) nerve damaged when lower lip numbness
2) how to repair stensen’s duct laceration, what is prbm with ligation?
1) inferior alveolar nerve damage (branch of mandibular nerve)
2) repair over catheter stent. ligation can cause painful parotid atrophy and facial assymetry.
Neck and Jaw 1) Suppurative parotitis a- MC age group b-causes c- rx d- prognosis
1) a-elderly
b- dehydration, staph is MC organism
c-fluids, salivation, abx, drainage if abscess develops or pt not improving
d- can be life threatening
Neck and Jaw 1) Sialoadenitis a- what is it and cause b- MC glands affected c- cause of recurrent sialoadenitis d- rx
1) a- acute infam of a salivary gland related to a stone in the duct; most calculi near the orifice
2) submandibular or sublingual glands, 80% of the time
3) ascending infection from oral cavity
4) incise duct and remove stone, gland excision may eventually be necessary
head and neck abscesses 1) peritonsillar abscess a- age group b-sx c- rxx 2) retropharyngeal abscess a- age group b-sx c- what other pt population/disease do you see it in d-rx
1) a- older kids >10yo
b- trismus, odynophagia, usually doesn’t obstruct airway
c- needle aspiration 1st, then drainage through tonsilar bed if no relief in 24hr (may need to intubate to drain. Will self-drain with swallowing once opened)
2) a- younger kids s disease
d-intubate. drain through posterior pharyngeal wall, will self-drain with swallowing once opened
head and neck abscesses cont. 1) Parapharyngeal abscess- a- when do you see it b- what causes it's morbidity c- rx 2) ludwig's angina a- what is it and what muscle is involved b-rx
1) a- all age groups, occurs with dental infections, tonsillitis and pharyngitis
b- morbidity from vascular invasion and mediastinal spread via prevertebral and retropharyngeal spaces
c- drain through lateral neck to avoid damaging internal carotid and internal jugular veins. NEED TO LEAVE A DRAIN
2) -acute infection of the floor of the mouth, involves mylohyoid muscle. MC cause is dental infection of the mandibular teeth
b- airway control (may spread rapidly to deeper structures and cause obstruction), surgical drainage, abx
Preauricular tumors
1) what are they
2) how to diagnose
3) rule of 80% for parotid tumors
4) MC distant met site for head and neck tumors
1) parotid tumors until proven otherwise
2) superficial lobectomy
3) 80% of salivary tumors are in the parotid, 80% of parotid tumors are benign, 80% of benign parotid tumors are pleomorphic adenomas
4) lung
Posterior neck masses
1) what is most likely cause
2) how to dx
1) if no obvious malignant epithelial tumor, considered to have hodgkin’s lymphoma until proved otherwise
2) FNA or open biopsy
Neck mass workup
1) 1st step
2) next step if 1st step nondiagnostic
3) 3rd step if above two steps nondiagnostic
4) if dx reveals adenocarcinoma, what is the likely primary
1) H and P, laryngoscopy and FNA (best test for dx), can consider antibiotics for 2 weeks with re-evaluation if thought to be inflammatory
2) panendoscopy with multiple random biopsies and neck and chest CT
3) excisional biopsy (need to be prepared for MRND)
4) breast, GI or lung primary
Epidermoid CA
1) what is it
2) work up if found in cervical node without known primary (3 steps in order)
3) MC location for occult head/neck tumor
1) SCC variant
2) 1st- panendoscopy to look for primary with random bx’s
2nd- CT scan
3rd- if still can’t find primary, do ipsilateral MRND and tonsillectomy and bilateral XRT
3) ipsilateral tonsil
Other head/neck conditions 1) esophageal forein body a-MC location b- dx and rx c-what determines esophageal perforation risk d- dx steps for pt with fever and pain after EGD for foreign body 2) laryngeal foreing body rx 3) sleep apnea a- associated complications b- who has it c- rx 4) complication of prolonged intubation and how to rx
1) a- 95% just below the cricopharyngeus
b- rigid EGD under anesthesia
c-risk increases with length of time in esophagus
d- gastrografin followed by barium swallow to r/o perf
2) cough, may need emergent cricothyroidotomy as a last resort
3) a-MI, arrhythmia, death
b- obese, micrognathia, retrognathia (snoring and excessive daytime somnolence
c- CPAP, uvulopalatopharyngoplasty (best surgical solution), or permanent trach
4) subglottic stenosis. rx- tracheal resection and reconstruction
1) indications for tracheostomy and advantages
2) Median rhomboid glossitis- what is it and rx
3) cleft lip
a- which palate has defect/ structures involved
b- when to repair. what should you repair simultaneously
c- sx
4) cleft palate
a- which palate/structures
b- sx
c-when to repair
1) pts who will require intubation for >7-14 days. Decreases secretions, provides easier ventilation and decreases pneumonia risk.
2) failure of tongue fusion. no rx
3) a-primary palate. lips +/- alveolus
b- repair at 10 wks, 10lbs, Hgb 10. repair nasal deformities as well.
c-poor feeding
4) a-secondary palate- hard and soft palates
b- speech and swallowing can be affected if not closed soon enough. maxillofacial growth can be affected if closed too early
c- repair at 12 months
1) MC benign head/neck tumor in adults
2) Mastoiditis
a- what is it and why is it bad
b-what is it a complication of
c- signs
d- rx
3) Epiglottitis
a- why is it now rare
b- age affected
c- sx
d- rx
1) hemangioma
2) a-infection of mastoid cells-> can destroy bone
b- untreated acute supportive otitis media
c- ear pushed forward
d- abx, may need emergency mastoidectomy
3) a- caused by H. influenza type B and now there is the vaccine
b- mainly in kids 3-5yo
c- stridor, drooling, leaning forward position, high fever, throat pain, thumbprint sign on lateral neck film. Can cause airway obstruction
d- rx- early control of airway and abx
Endocrinology
1) what does hypothalamus release and where does it go
2) what does dopamine inhibit the secretion of
3) what does the posterior pituitary secrete and where are they produced
4) what does the posterior pituitary release
1) TRH, CRH, GnRH, GHRH and dopamine into median eminence-> passes through neurohypophysis (posterior pituitary) on way to adenohypophysis (anterior pituitary)
2) prolactin
3) Neurohypophysis- ADH (supraoptic nuclei), Oxytocin (paraventricular nuclei in hypothalamus)
4) ACTH, TSH, GH, LH, FSH, prolactin
Pituitary
1) which part does not contain any cell bodies
2) which part does not have its own direct blood supply
3) what regulates ADH release
4) what part of pituitary comprises 80% of the gland
1) posterior pituitary/neuohypophysis
2) anterior pituitary/adenohypophysis (passes thorugh neurohypophysis 1st (portal venous system)
3) osmolar receptors in hypothalamus
4) anterior pituitary
Pituitary Masses 1) Cause of bi-temboral hemianopia 2) Nonfunctional tumors a- what are they usually b- how do they present c- rx 3) C/I to transsphenoidal resection 4) chemical rx of pituitary tumors 5) MC pituitary adenoma
1) pituitary mass compresses optic nerve (CN II) at the chiasm
2) a-macroadenomas
b- mass effect, decreased ACTH, TSH, GH, LH, FSH
c- transsphenoidal resection
3) suprasellar extension, massive lateral extension, dumbbell-shaped tumor
4) bromocriptine
5) prolactinoma
Prolactinoma
1) MC size
2) prolactin levels at which sx occur
3) sx
4) rx
5) what is rx in pregnancy
6) complications of resection of macroadenoma
1) microadenoma
2) >150
3) galactorrhea, irregular menses, decreased libido, infertility
4, 5) bromocriptine (safe in pregnancy) or cabergoline (both are dopamine agonists),
If fail medical rx- transphenoidal resection
6) hemorrhage, visual loss, CSF leak, don’t do if pt wants pregnancy
Acromegaly
1) hormone involved
2) sx
3) MC tumor size
4) how to dx
5) rx
1) Growth hormone
2) HTN, DM, gigantism. can be life-threatening 2/2 cardiac sx (valve dysfnc or cardiomyopathy)
3) macroadenoma
4) elevated IGF-1 (best test), growth hormone >10 in 90%
5) octreotide or transsphenoidal resection, XRT and bromocriptine can be used as secondary therapies
1) Sheehan's syndrom a- 1st sign b- other sx c- cause d-rx 2) Craniopharyngioma a- what is it and what is it a remnant of b- sx c- rx d- frequent post-op complication
1) a- post-partum trouble lactating
b- amenorrhea, adrenal insufficiency and hypothyroidism
c0 2/2 pituitary ischemia following hemorrhage and hypotensive episode during childbirth
d- hormone replacement
2) a- benign calcified cyst, remnants of rathke’s pouch; grows along pituitary stalk to suprasellar location
b- endocrine abnormalities, visual disturbances, HA, hydrocephalus
c- surgery to resect cyst
d- diabetes insipidus
1) bilateral pituitary masses a- what should you check b- what is it most likely 2) Nelsons syndorme a- complication of what surgery b- sx c- cause d-rx 3) Waterhouse-Friderichsen syndrome- what causes it and resulting deficiency
1) check pituitary hormone axis. if ok probably metastasis
2) a- after bilateral adrenalectomy
b,c-inc CRH-> pituitary enlargement->amenorrhea and visual problems (bitemporal hemianopia)
and hyperpigmentation from beta-MSH (melanocyte-stimulating hormone), a peptide byproduct of ACTH
d- rx- steroids
3) adrenal gland hemorrhage after meningococcal sepsis infection –> adrenal insufficiency
Vascular supply to the adrenal gland
1) superior adrenal
2) middle adrenal
3) Inferior adrenal
4) what does to left adrenal vein drain into
5) what does the right adrenal vein drain into
1) inferior phrenic artery
2) aorta
3) renal artery
4) left renal vein
5) IVC
1) 2 parts of the adrenal gland and innervation for each
2) where does adrenal lymph drain to
1) adrenal cortex (no innervation), adrenal medulla (innervated by sympathetic splanchnic nerves)
2) lymph drainage to subdiaphragmatic and renal LNs
1) diagnostic workup for incidental adrenal mass on CT
2) rx of asymptomatic adrenal mass
3) followup of incidentaloma if not resected
4) MC mets to adrenal
5) rx of isolated met to adrenal
1) often benign, check for functioning tumor- urine metanephrines/VMA/catecholamines, urinary hydroxycorticosteroids, serum K with plasma renin and aldosterone levels
- consider CXR, colonoscopy and mammogram to check for primary tumor (lung, colon, breast)
- if pt has a cancer history with asx adrenal mass, need biopsy
2) surgery if ominous characteristics (non-homogenous), >4-6cm, functioning or enlarging. use anterior approach for adrenal CA resection.
3) repeat imaging q3mo for 1 year. then yearly imaging
4) lung CA (#1), breast, melanoma, renal CA
5) some can be resected with adrenalectomy
adrenal cortex
1) what does it develop from
2) name the 3 layers and what is produced in each
3) adrenal enzymes
4) descibe pathway of cortisol release from hypothalamus to adrenal
1) mesoderm
2) (GFR=salt, sugar, sex steroids)
Glomerulosa-aldosterone
fasciculata-glucocorticoids
reticularis- androgens/estrogens
3) 21- and 11-beta hydroxylase are in all zones
4) hypothalamus releases corticotropin-releasing hormone–> anterior pituitary gland–> ACTH release–> release of cortisol from adrenal gland
adrenal cortex
1) when is cortisol peak
2) actions of cortisol
3) actions of aldosterone
4) what stimulates aldosterone secretion
1) diurnal (daily) peak at 4-6am
2) ionotropic, chronotropic, increases vascular resistance, proteolysis and gluconeogenesis, decreases inflammation
3) stimulates renal sodium resorption and secretion of potassium and hydrogen
4) angiotensin II and hyperkalemia (ACTH also does to a small extent)
What should you think of if the adrenals are producing excess estrogens and androgens
cancer
Congenital adrenal hyperplasia
1) what pathway is the enzyme defect in
2) MC deficit and resulting change in hormones
3) other possible deficit
- which deficit is salt-saving vs salt-wasting and resulting effect on BP
4) treatment
1) cortisol synthesis
2) 21-hydroxylase deficiency-> inc 17-OH progesterone-> inc testosterone
* salt-wasting (hypoTN)
3) 11-hydroxylase deficiency-> inc deoxycortisone (mineralocorticoid)-> salt-saving (HTN)
4) cortisol, genitoplasty
Conn’s syndrome- what is it
1) symptoms
2) what distinguishes between primary and secondary disease
3) Causes of primary disease
4) Causes of secondary disease
5) diagnosis
6) localizing studies
7) what are the pre-op considerations for these patients
Hyperaldosteronism
1) HTN 2/2 Na retention without edema, hypokalemia, weakness, polydypsia, polyuria
2) renin level- low in primary disease, high in secondary disease
3) #1=adenoma (85%), hyperplasia (15%), ovarian tumors and CA (rare)
4) more common than primary dz, 2/2 CHF, renal artery stenosis, liver failure, diuretics, Batter’s syndrome (renin-secreting tumor)
5) salt-load suppresion test (best, urine aldosterone stays high
- aldosterone:renin ratio > 20 (labs: dec serum and urine K, inc serum Na, metabolic alkalosis
- plasma renin activity low
6) MRI, NP-59 scintigraphy (shows hyperfnc adrenal tissue) , adrenal venous sampling last resort
7) control HTN and K replacement
Hyperaldosteronism (Conn’s syndrome)
1) rx of adenoma
2) rx of hyperplasia
3) what to give post op for BL adrenalectomy
1) adrenalectomy
2) seldom cured (inc morbidity with bilateral resection)
- medical rx 1st (spironolactone-inhibits aldosterone, Ca-channel blocker, potassium
- BL resection only done if refractory to med rx. must give fludrocortisone postoperatively
Addison disease-what is it
1) #1 cause
2) #1 primary cause of disease
3) other causes
4) diagnosis
hypocortisolism, adrenal insufficiency
1) withdrawal of steroids
2) autoimmune disease
3) pituitary disease, adrenal infection/hemorrhage/metastasis/resection
4) cosyntropin test-ACTH given, measure urine cortisol and remains low
- on labs will have low cortisol, high ACTH and low aldosterone
Addison disease/adrenal insuff/hypocortisolism
1) acute adrenal insuff sx
2) rx
3) chronic adrenal insuff sx
4) rx
1) hypotension, fever, lethargy, abdominal pain, N/V, dec glucose, inc K
2) dexamethasone, fluids, and give cosyntropin test (Dexamethasone dose doesn’t interfere)
3) hyperpigmentation, weakness, weight loss, GI sx, inc K, dec Na
4) corticosteroids
Cushing’s Syndrome- what is it
1) MC cuase
2) diagnostic flow chart
3) how to localize tumors and diff adrenal adenomas from hyperplasia
4) top-3 non-iatrogenic causes of cushing’s
hypercortisolism
1) iatrogenic
2) 1st- measure 24-hr urine cortisol (most sensitive) and ACTH
–> if ACTH low (and cortisol high)= cortisol-secreting lesion (adrenal adenoma)
–> if ACTH high (and cortisol is hihg)= pituitary adenoma or ectopic source of ACTH (small cell lung CA)
2nd- if ACTH high, give high-dose dexamethasone suppresion test.
–> if urine cortisol suppressed= pituitary adenoma
–> if urine cortisol not suppressed–> ectopic producer of ACTH (ie-small cell lung CA)
3) NP-59 scintography
4) #1 Pituitary adenoma (80%), #2 Ectopic ACTH (ie-small cell lung CA), #3 adrenal adenoma
Discuss the differences in hormone/signaling mlq levels, diagnosis and the treatment for the following causes of hypercortisolism (Cushings)
1) Pituitary adenoma
2) Ectopic ACTH
3) Adrenal adenoma
4) Adrenal hyperplasia
1) mostly microadenomas, cortisol suppressed with dexameth-supp-test. dx- MRI vs petrosal sampling
rx- transphenoidal removal of tumor. if not possible- do XRT
2) cortisol not suppressed with dex-supp-test. dx- Chest and abdominal CT. rx- resection of primary if possible, if not medical suppression
3) dec ACTH, unregulated steroid production. rx- adrenalectomy
4) micro or macro. rx- metyrapone (blocks cortisol synthesis) and aminoglutethimide (inhibits steroid production). B/L adrenalectomy if medical management fails
When is b/l adrenalectomy indicated and what do you need to give postop if operating for cushings
pts with ectopic ACTH from tumor that is unresectable or ACTH from pituitary adenoma that can’t be found.
for cushings- give steroids postop
Adrenocortical carcinoma
1) MC age and sex
2) what % are functioning tumors
3) signs/sx
4) what % have adv disease at time of dx
5) rx
6) 5-year survival
1) females, bimoral (<5yo and 5th decade)
2) 50% (cortisol, aldosterone, sex steroids)
3) children have virilization 90% of the time (precocious puberty in boys, virilization in females); feminization in men, masculinization in women, abdominal pain, weight loss, weakness
4) radical adrenalectomy, debulking helps symptoms and prolongs survival
* Mitotane (adrenal-lytic) for recurrent, residual or metastatic disease
5) 20%
