NMS Endocrine

Question 1

What is a dangerous cause of hypercalcemia

Answer 1

metastatic carcinoma to bone (esp breast, prostate)

Question 2

what is vicious cycle of hypercalcemia? how do you break it

Answer 2

hypercalcemia –> osmotic diuresis –> dehydration –> hypercalcemia; break it by first rehydrating aggressively, followed by loop diuretic (calcium wasting), and bisphosphonates

Question 3

rule of 10s with pheochromocytomas

Answer 3

10% malignant, 10% bilateral, 10% extraadrenal, 10% epinephrine producing

Question 4

tx of pheo

Answer 4

immediate tx of crisis is alpha + beta blockade (MUST HAVE BOTH) –> octreotide scan to localize tumor –> adrenalectomy

Question 5

what is de quervain’s thyroiditis? how to dx and tx

Answer 5

acutely enlarged/inflamed thyroid with initial hyperthyroidism; DIAGNOSE by elevated ESR, histology showing granulomas and degenerating follicles; TREAT with aspirin and analgesics, NOT SURGERY

Question 6

when to operate in acute thyroiditis

Answer 6

if suppurative/bacterial, need surgical drainage

Question 7

3 big risk factors for thyroid cancer

Answer 7

1) hx of radiation 2) fam hx thyroid cancer 3) voice/airway symptoms

Question 8

how to work up patient with neck mass+ history of radiation

Answer 8

SURGERY –> further eval unnecessary

Question 9

what syndrome is a/w medullary thyroid cancer

Answer 9

MEN 2 (RET gene mutation): pheochromocytoma, parathyroid cancer, thyroid cancer

Question 10

w/u of thyroid nodule

Answer 10

FNA, U/S (NOT radioactive iodine study; FNA is quite accurate)

Question 11

how to tx thyroid cyst

Answer 11

aspiration: if >4 cm or recurrent, increased risk of malignancy –> excision

Question 12

which type of thyroid cancer is BAD

Answer 12

anaplastic/undifferentiated –> needs chemo, rads, NOT surgery (usually already too advanced)

Question 13

4 types of potential surgical complications a/w thyroidectomy

Answer 13

1) unilateral recurrent laryngeal nerve injury (hoarseness) 2) bilateral recurrent laryngeal nerve injury (vocal cord paralysis) 3) external laryngeal nerve injury (distorted high pitched singing voice) 4) parathyroid injury (hypoparathyroidism)

Question 14

most common cause of primary hyperparathyroidism

Answer 14

pituitary adenoma (carcinoma in need to explore neck +/- preop sestamibi imaging Sestamibi: parathyroid scintography; technetium 99

Question 15

procedure for exploring primary hyperparathyroidism

Answer 15

if preop sestamibi, can just take out adenomatous parathyroid glands (“minimally invasive”); if no preop sestamibi, need to explore all 4 parathyroid glands

Question 16

for which thyroid cancers do you use I131 or thyroid hormone suppression postop?

Answer 16

follicular and papillary; doesnt help for medullary since thats parafollicular (C-cell) hyperplasia

Question 17

What if only find 3 parathyroid glands under exploration

Answer 17

have to find the 4th; often intrathyroid

Question 18

what does elevated Ca and PTH suggest? how to tx

Answer 18

primary hyperparathyroidism; if adenoma explore/resect; if carcinoma radical resection

Question 19

what does decreased Ca and elevated PTH suggest? how to tx

Answer 19

secondary hyperparathyroidism (eg, CKD) ; tx medically unless symptomatic (pain, fractures, ectopic calcifications, intractible pruritus) –> surgical mgmt (remove 3.5 PTH glands +/- relocation of remaining 0.5 to arm for easy accessibility)

Question 20

tx of hashimotos

Answer 20

thyroid hormone replacement, bx surveillance to ensure no cancer (hashimotos a/w increased risk)

Question 21

how to tx gastrinoma (Zollinger Ellison syndrome)

Answer 21

can be sporadic or metastatic; if SPORADIC, RESECT; if METASTATIC to liver and LN, consider GASTRIC RESECTION vs. HSV to prevent ulcerative complications

(highly selective vagotomy??)

Question 22

with which syndrome is gastrinoma associated

Answer 22

MEN-1 (MENIN gene mutation); pancreatic, parathyroid, pituitary cancers

Question 23

what classic triad a/w insulinoma

Answer 23

Whipple triad: 1) fasting hypoglycemia; 2) symptomatic hypoglycemia; 3) relief with glucose administration

Question 24

tx of insulinoma

Answer 24

if sporadic, RESECT; if not, can use diazoxide (inhibitor of insulin release)

Question 25

mgmt of incidentally disocered adrenal mass

Answer 25

depends on size; if <5 cm, check labs for indication of malignancy (Vanillylmandelic acid, potassium, cortisol), then remove vs. observe depending on outcome; if >5 cm , high risk of cancer –> wide resection + look for mets