Pretest_6_Endocrine Problems and the Breast Flashcards
What are the constellation of findings seen in adrenal insufficiency?
skin pigmentation, weakness, weight loss, hypotension, hyponatremia, hyPERkalemia, hypoglycemia, abdominal pain
How can insidious, post-operative adrenal insuffiency occur?
hemorrhage into the gland (as in patients on anticoagulants)
An isolated focus of increased uptake on a thyroid scan is virtually diagnostic of
hyperfunctioning adenoma
T/F: Previous radiation therapy to the breast is a contraindication to breast conservation therapy.
True
T/F: There are similar outcomes between patients receiving modified radical mastectomy and lumpectomy/axillary node dissection followed by radiation for STAGES 1 AND 2.
True
What is the treatment for inflammatory breast cancer?
chemo, radiation, and surgery! only 50% survival at 5 years
What is the treatment for asymptomatic prolactinoma? Symptomatic?
asymptomatic = observation! symptomatic = dopamine agonist (usually causes tumor shrinkage); surgery for when medical tx doesn't work
Sestanibi scans are used to diagnose
parathyroid adenomas (also taken up by the thyroid apparently)
_______ may be useful in the treatment of patients with unresectable glucagonomas.
Octreotide to control hyperglycemia
All functioning adrenal adenomas should be resected, while nonfunctioning should be if the lesion is greater than __ cm. __% of adenomas are bilateral.
> 6 cm
10-15% of adrenal adenomas are bilateral
Radiation induced thyroid cancer is usually which type?
papillary
FNA of thyroid mass showing calcified lumps of sloughed cells =
papillary cancer
Lobular carcinoma in situ is a risk factor for which invasive breast carcinoma, especially?
ductal carcinoma. The risk is equivalent in BOTH BREASTS and lasts indefinitely!
These breast tumors have a characteristic “fish flesh” texture:
lymphomas
Thiazide diuretcs promote (retention/secretion) of calcium.
Retention!
Phenoxybenzamine (alpha-blockade) should be started in patients with pheochromocytomas ______ weeks before surgery.
1-3 weeks
T/F: Chemotherapy for breast cancer in a pregnant patient does not increase the risk of congenital malformations if given in the second and third trimesters.
True
Paget’s disease of the breast originates in which part of the breast?
retroareolar lactiferous ducts
A paradoxical rise in serum gastrin after IV secretin is diagnostic of
Zollinger-Ellison syndrome (secretin inhibits gastrin release from normal stomach)
In preparation for thyroidectomy, what should be done preoperatively to decrease the likelihood of thyroid storm?
Drops of Lugol iodide solution daily beginning 10 days preoperatively. PTU or methimazole can also be used preoperatively but are contraindicated in pregnant women.
What is the name of the disease characterized by severe demineralization with subperiosteal bone resorption (most prominent in the middle phalanx of the second and third fingers), bone cysts, and tufting of the distal phalanges on hand films?
What conditions is it associated with?
osteitis fibrosis cystica. Associated with hyperparthyroidism and Vit D deficiency (hyper vs hypocalcemia)
What is administered in the treatment of thyroid storm?
Beta blockers, antithyroid meds (PTU), rapid fluid replacement, iodine solutions (Lugol iodine, to decrease iodine uptake), steroids (blocks hepatic thyroid hormone conversion)
What labs do you use to diagnose hyperaldosteronism?
plasma aldosterone concentration and plasma renin activity. PAC:PAR of 25-30:1 is suggestive
What is the treatment of cystosarcoma phyllodes?
simple excision with adequate margins
Most insulinomas are (single/multiple).
Single! But if in the context of MEN-1, more likely to be multiple
Though not a definitive treatment, which antibiotic can control symptoms from unresectable malignant tumors of pancreatic islet cells (insulinoma)?
Streptozocin
Carcinoid tumors are most commonly found where?
appendix and small bowel
What is the generally acceptd treatment for stage 1 breast cancer in PREmenopausal women?
lumpectomy with axillary LN dissection (sentinel LN bix) and radiation therapy
T/F: Lobular carcinoma in situ (LCIS) is a precancerous lesion.
FALSE. However, it does increase the risk of subsequent canceri n BOTH breasts (so no point of excising it). No need for prophylactic mastectomy.
What are the four subtypes of DCIS and which has the greatest tendency to recur after wide excision alone?
papillary, cribriform, solid, comedo
What is an indication for radical mastectomy (seldom done!)?
Locally advanced breast cancer with wide invasion of the pectoralis major in a patient who is able to tolerate general anesthesia
T/F: In a patient with a history of neck radiation, it is appropriate to proceed directly to thyroidectomy.
The most common thyroid cancer following radiation is
True
papillary
A thyroid cyst should be aspirated unless it recurs several times or is larger than __ cm, in which case it should be removed to eliminate the risk of malignancy.
4 cm
If a nodule is (hot/cold) on radioactive iodine scans, it is more likely to be malignant thyroid cancer.
Cold
Hot nodules are benign 97% of the time
Psamomma bodies are a marker for what kind of thyroid cancer?
papillary
Amyloid deposits area marker for what kind of thyroid cancer? WHat else is seen on histology in these tumors?
medullary
Als see hyperplasia of C cells
Undifferentiated cells on FNA suggests what kind of thyroid cancer?
anaplastic –> chemoradiation or salvage operative therapy
Treatment of thyroid lymphomas?
radiation
Treatment of thyroidits (like thyroid lymphoma, shows lymphocytic infilatrate)?
no surgery; may require TH replacement. Beta blockers, steroids.
An injury to which nerve alters a high-pitched singing voice?
external branch of the superior laryngeal nerve
Damage to what nerve results in hoarseness?
To which causes cord paralysis, possibly requiring tracheostomy?
hoarseness: unilateral recurrent laryngeal nerve
cord paralysis: bilateral
What determines the differential surgical treatment of papillary thryoid cancer?
If history of head and neck radiation = total thyroidectomy
If not, limited thyroid lobectomy (assuming lesion is 1 cm or less) with isthmusectomy. If lesion is >1.5 cm, then total thyroidectomy (due to increased incidence of multicentricity in papillary thyroid cancer)
What determines the differential surgical treatment of follicular thyroid cancer? WHere is it most prevalent?
More prevalent in iodine-deficient areas
If MICROINVASIVE and 4cm, total thyroidectomy****
What is the treatment of medullary thyroid cancer?
total thyroidectomy in all cases! Central neck compartment nodes are frequently involved and warrant removal; lateral neck dissection may be necessary for palpable nodes
What factors go into the prognosis of papillary thyroid cancer? Follicular cancer?
Mets Age at presentation Completeness of resection Invasion (extrathyroidal) Size of mass Follicular: same as above, plus extent of vascular invasion
What can be monitored in the serum of medullary thyroid cancer patients?
CEA, calcitonin
What is the most common site of distal metastasis in anaplastic thyroid cancer?
lung
Parathyroid lesions leading to hyperparathyroidism are more likely to be (adenomas/carcinomas)
adenomas
Where is the most common location for a missing inferior parathyroid gland?
thymus (may also be intrathyroidal, in the TE groove, carotid sheath)
What is Chvostek’s sign?
spasm of the orbicularis oris muscle when hypocalcemia is present
T/F: THe complications of parathyroid exploration are similar to those in thyroid surgery.
True! Include injury to the recurrent laryngeal (hoarseness, cord paralysis if bilateral), external branch of the superior laryngeal nerve (modification of high pitch) and hypocalcemia
What is the management for an asymptomatic parathyroid adenoma?
Watchful waiting until serum calcium exceeds 11 mEq/L to avoid complications of hypercalcemia.
What is the acute treatment of hypercalcemia?
Rehydration with normal saline and furosemide (leading to a brisk diuresis high in calcium). Initiation of bisphosphonates and then treatment of underlying cause.
Explain secondary hyperparathyroidism:
chronic renal failure leads to retained phosphate as GFR decreases. This causes hypocalcemia, which elevates serum PTH. Calcium absorption from the gut and vit D metabolism are also impaired.
What is the common operative finding in secondary hyperparathyroidism? What is the treatment?
hyperplasia of all glands
Treatment is excision of all but 50 mg of parathyroid tissue, which is implanted to the forearm (where more accessible)
What is tertiary hyperparathyroidism? What is the surgical treatment?
Parathyroid gland becomes autonomous and does not stop secreting PTH even when renal function has returned (as in after transplant)
Treatment is 3 1/2 gland resection
_________ are the 10% tumor
Pheochromocytomas: 10% are malignant, extradrenal, epinephrine producers, and bilateral
For pheochromocytomas that are difficult to locate, a _______ scan can localize the tumor.
octreotide
last resort = nuclear I 131 metaiobenzylguanidine (MIBG) scan is used, which accumulates selectively in chromaffin tissue
Why should excision of a pheo be transabdominal?
because 10% are bilateral or extraadrenal; need to be able to manipulate the tumor (but MINIMALLY so as not to release tons of catecholamines)
Why do you need to ligate all venous drainage from the pheo before manipulating it?
To avoid systemic release of catecholamines!!
Painful, swollen thyroid gland:
What is it called in the acute form?
thyroiditis! de Quervain’s thyroiditis in acute form
What is the general finding associated with thyroiditis?
elevated ESR
What is the classic histology for thyroiditis?
giant cell granulomas around degenerating thyroid follicles
What is the treatment of thyroiditis?
analgesics and aspirin, possibly steroids if resistant. Surgery is not necessary. TFTs if patient seems hyperthyroid
T/F: A higher incidence of malignancy is associated with Hashimoto’s thyroiditis.
True. Especially papillary carcinoma and thyroid lymphomas
Patietns with compressive symptoms of the trachea due to Hashimoto’s thyroiditis should undergo
palliative resection to relieve the obstruction
T/F: IF you suspect a patient has a gastrinoma, still r/o H pylori.
True
A serum gastrin over ___ is diagnostic of Zollinger-Ellison.
> 1000 pg/mL
Hypergastrinemia may result from a gastrinoma, an incomplete previous gastric resection, or ____ cell hyperplasia
G cell hyperplasia
G cells are found deep within the pyloric glands of the stomach antrum, and occasionally in the pancreas[1] and duodenum.
The vagus nerve innervates the G cells.
If a gastrinoma involves or abuts a large pancreatic duct, what should be performed?
a Whipple or distal pancreatectomy (depending)
Treatment of malignant or metastatic gastrinomas that are not resectable involves:
gastric resection or highly selective vagotomy. Streptozocin can be used for tumor control
If you suspect a patient has an insulinoma, what do you measure?
C peptide to r/o exogenous administration of insulin
If an insulinoma is unresectable, what do you use to treat?
diazoxide, an inhibitor of insulin release.
An incidental adrenal mass should be removed with wide resection of the adrenal gland if it is symptomatic (check catecholamines, cortisol, and serum potassium) OR if it is >__ cm
5 (In lesions larger than 5 cm in size, incidence of adrenal cortical carcinoma is high)
In the discovery of an incidental adrenal mass, consider that it might be a metastatic lesion from the ____
lung
What would Graves disease show on thyroid scan?
diffuse uptake of radioactive iodine by the thyroid gland
Hurthle cell cancer is a type of ________ thyroid cancer.
follicular
However, it is more often multifocal and bilateral, more likely to spread to local nodes and distant sites, and has a higher mortality rate
For thyroid nodules <__cm, thyroid lobectomy is adequate.
4 or confirmed carcioma, total thyroidectomy should be performed
Fixed ipsilateral axillary nodes = N2, but ipsilateral internal mammary nodes =
N3
Manipulation of the recurrent laryngeal nerve can lead to nerve ________, which is temporary dysfunction. The function will return within a few weeks.
neuropraxia
Thyroid nodule showing pathologic characteristics of “atypical cells with capsular invasion and vascular invasion”
follicular
The superior thyroid artery is (what branch of what artery) and courses with the superior laryngeal nerve.
first branch of the external carotid
The inferior thyroid artery is a branch of ____________ and courses with the recurrent laryngeal nerve.
thyrocervical trunk (branch of subclavian)
Dramatically elevated calcium levels (>14) are more likely to be associated with parathyroid carcinoma/adenomas?
carcinoma
What is the embryological origin of the inferior parathyroid glands and the thymus? What nerve is it associated with?
third pharyngeal pouch; glossopharyngeal
What is the embryological origin of the superior parathyroid glands and parafollicular cells of the thyroid?
fourth pharyngeal pouch
What does the fourth pharyngeal arch turn into?
contributes to the superior parathyroids (like the fourth pharyngeal arch) and also the cricopharyngeus muscle
What is the treatment for acute adrenal crisis? What is fludrocortisone used for?
Dexamethasone!!
Fludrocortisone is for hypoaldosteronism.
What are the next steps after finding an adrenal incidentaloma?
serum potassium, aldosterone to renin ratio, cortisol, 24 hour urine for VMA,metanephrines, and normetanephrines to see if mass is functional.
