Nms Sugery Endocrine Disorders

Front 1

Radiation of the neck carries what risk of thyroid cancer?

Back 1

40%

Front 2

Most common cancer following radiation to the neck?

Back 2

papillary carcinoma

Front 3

What are the MEN syndromes?

Back 3

MEN1: Parathyroid hyperplasia, Pituitary adenoma, Pancreatic tumors
MEN2a: MTC, pheo, parathyroid hyperplasia
MEN2b: MTC, pheo, GI and mucosal neuromas, marfanoid habitus

Front 4

MEN genes involved?

Back 4

MEN1: MEN1 gene
MEN2a and 2b: RET proto oncogene

Front 5

Sxs of thyroid malig?

Back 5

Hoarseness, hard, fixed nodule, dyspnea, dysphagia, cervical LN enlargement, vocal cord paralysis

Front 6

Risk of malignancy in a solitary nodule?

Back 6

15%

Front 7

Risk of malignancy in dominant nodule in multinodular gland?

Back 7

5% unless there's previous radiation hx

Front 8

What do you always do with a thyroid nodule?

Back 8

FNA

Front 9

What fraction of aspirates end up benign and malignant?

Back 9

2/3 benign, 1/6 malignant, 1/6 indeterminate

Front 10

When does a cyst need to be resected?

Back 10

What it is >4cm or when it recurs

Front 11

What do we want to do after we aspirate a cyst?

Back 11

Follow it with US to follow size/recurrence

Front 12

What do you do after a benign diagnosis?

Back 12

Thyroid suppression with thyroxine and follow TSH levels

Front 13

What's a benign diagnosis on FNA?

Back 13

Colloid nodule: just thyroid suppression

Front 14

Most common type of thyroid cancer?

Back 14

Papillary

Front 15

What are the malignant diagnoses and signs/cells?

Back 15

Papillary carcinoma: Psammoma bodies
Medullary carcinoma: Amyloid deposits and calcitonin staining
Anaplastic carcinoma: undifferentiated cells
Adenoma or low grade cancer: Hurthle cells

Front 16

What is a nondiagnostic finding on FNA?

Back 16

Follicular cells: does not exclude cancer

Front 17

What do lymphocytes on FNA mean?

Back 17

Lymphoma or thyroiditis. Radiation for lymphoma and thyroid hormone replacement for thyroiditis

Front 18

Complications of thyroid surgery?

Back 18

Damage to recurrent laryngeal or external branch of superior laryngeal nerves, damage to parathyroids can cause hypocalcemia and hyperphos

Front 19

what happens with unilateral recurrent laryngeal nerve injury? b/l injury?

Back 19

Hoarseness, cord paralysis and may require tracheostomy

Front 20

what happens with superior laryngeal nerve damage?

Back 20

Loss of high pitch voice

Front 21

What's surgical treatment for papillary cancer?

Back 21

<1cm: with history of radiation total thyroidectomy. with no history of rad lobectomy and isthmusectomy
>1.5 cm total thyroidectomy
Nodal excision "berry picking" with both

Front 22

What's surgical tx for Follicular cancer?

Back 22

Microinvasive follicular carcinomas <4cm: L+I
>4cm: total thyroidectomy
w/ clear follicular cell cancer: total thyroidectomy for any lesion >1cm

Front 23

Via which route are follicular cancers most likely to spread?

Back 23

Hematogenously

Front 24

2 forms of medullary cancer?

Back 24

Sporadic (80%) and familial (20%) MEN2a and 2b

Front 25

What type of cells do Medullary thyroid cancers come from?

Back 25

C (parafollicular) cells that secrete calcitonin

Front 26

Surgical tx for medullary?

Back 26

total thyroidectomy and lateral neck dissection for nodes

Front 27

Surgical tx for anaplastic?

Back 27

Wide excision of total thyroid and surrounding structures

Front 28

Postop and prog for Papillary?

Back 28

Postop: thyroid suppression with thyroxine, maybe radioiodine ablation.
Prognosis: dependent on AGES (Age>40, Grade, Extent, Size)
Low risk: 10 year survival 100%
High risk: 10 year survival 20%

Front 29

Postop and prog for Follicular?

Back 29

Postop: radioiodine ablation
Prog: vascular invasion worsens prognosis. 10 year survival for favorable vs unfavorable lesions is 80% vs 60%

Front 30

Postop and prog for Medullary?

Back 30

Postop: Follow serum calcitonin and CEA levels
Prog: radioiodine and thyroid suppression is not useful b/c it's C cells. 10 year survival is 80%, but <45% with LN involvement

Front 31

Postop and prog with Anaplastic?

Back 31

Pre and postop chemoradiation.
50% present with positive nodes. Poor prognosis.

Front 32

Most common site of anaplastic mets?

Back 32

Lung

Front 33

Sxs of primary hyperparathyroidism?

Back 33

Muscle weakness, myalgia, arthralgia, nephrolithiasis, constipation, polyuria, psych disorder, PUD, osteitis fibrosa cystica on imaging

Front 34

Workup for elevated Ca?

Back 34

PTH levels, Phosphate levels, alk phos, GGT levels (low in bone dz, high in biliary dz)

Front 35

How to diag primary hyper PTH?

Back 35

plot PTH vs Ca on a normogram

Front 36

Most likely cause of primary hyper PTH?

Back 36

Parathyroid adenoma. Parathyroid carcinoma <2% of cases.

Front 37

Surgical tx for parathyroid adnoma?

Back 37

Two approaches
1. Sestamibi scan approach: will tell you which parathyroid is the adenoma, go and resect only that one
2. standard approach: explore all 4 glands for adenomas and resect the adnoma

Front 38

Most common location for a missing parathyroid?

Back 38

Thymus. Can also be intrathyroid, tracheoesophageal groove and carotid sheath

Front 39

Imaging methods to find missing parathyroid?

Back 39

Sestamibi, MRI, angiography

Front 40

Risks of parathyroid surgery?

Back 40

Same as thyroid surgery. Damage to superior and recurrent laryngeal nerves, hypoparathyroidism that could get you hypocal and hyperphos, gives you positive Chvostek's sign postoperatively (tapping on the facial nerve gives you a twitch)

Front 41

What's the min calcium level tolerable before exploration?

Back 41

11 mEq

Front 42

Other medical causes of hypocalcemia?

Back 42

DiGeorge Syndrome
Hypomag from diarrhea, aminoglycosides, diuretics, or etoh, b/c mag is cofactor for AC, cAMP necessary for PTH activation
Hypoalbuminemia
Alkalosis (nl total but lower free)
Acute pancreatitis (Ca bound to FA in fat necrosis)
HypoVitaminD due to lack of sun or malabsorption or cirrhosis of CRF
Rickets

Front 43

Most common benign cause of hypercal?

Back 43

Parathyroid adnoma

Front 44

Common malignant cause of hypercal?

Back 44

metastatic carcinoma, can be from breast carcinoma

Front 45

Other causes of hypercal?

Back 45

Parathyroid hyperplasia, MM, hyperT, sarcoid, milk alkali synd, vitamin A intoxication, Thiazides, RCC, Lung squamous cell cancer (secretes PTHrp), familial hypocalciuric hypercal

Front 46

Mgmt of Acute hypercal?

Back 46

1. NS
2. Furosemide for cal diuresis
3. Bisphosphonates (inihibit osteoclasts)
4. tx of underlying dz
5. Parathyroid level

Front 47

What's the etiology of secondary hyperparathyroidism?

Back 47

Hyperphos from CRF, hyperphos drives cal into tissues and inhibits 1alpha-hydroxylase activity which causes hypocal, elevates PTH

Front 48

When do you surgically treat secondary hyperparathyroidism?

Back 48

Bone pain, fractures, intractable pruritis, ectopic calcifications in soft tissues (calcium tachyphylaxis)

Front 49

Surgical tx for secondary hyperparathyroidism?

Back 49

Resect all but 50mg of parathyroid tissue, subq autograft into forearm

Front 50

What's tertiary hyperPTH?

Back 50

when parathyroids don't respond to restoration of renal function after transplant. continue to overproduce PTH.

Front 51

How to treat tertiary hyperPTH?

Back 51

If persistent for 1 year 3.5 gland resection

Front 52

What to do if someone becomes extremely hypertensive during an operation?

Back 52

Maybe pheo, use alpha and beta blockers, stop surgery, and admit to ICU

Front 53

Why are pheos the 10% tumor?

Back 53

10% malig, 10% extra adrenal, 10% familial, 10% bilateral, 10% not assoc w HTN

Front 54

How to detect pheos?

Back 54

Elevated urinary catechols, Metanephrine, and VMA, T2 weighted MRI demonstrates brightness 3x that of liver, octreotide scan, last resort is MIBG scan

Front 55

What drug should be given continuously for 10-14 days prior to adrenalectomy?

Back 55

Alpha blocker phenoxybenzamine

Front 56

Steps in surgery?

Back 56

Ligate venous drainage before any other manipulations of gland

Front 57

Where do extraadrenal pheos occur?

Back 57

along abdominal aorta in a distribution similar to smpathetic chain

Front 58

What could a painful swollen thyroid gland be?

Back 58

DeQuervain's thryoiditis

Front 59

How does DeQuervain's present? Labs? Histology?

Back 59

Initial hyperT because of injured follicles, elevated ESR. Histo classic for giant cell granulomas around degenerating follicles

Front 60

Tx of DeQuervain's thyroiditis?

Back 60

Analgesics and ASA. Steroids if resistant

Front 61

When would surgery for thyroiditis be warranted?

Back 61

Bacterial infection with Step, Staph, Pseudomonas. Acute suppurative thyroiditis. Surgical drainage required. Could also be Aspergillus, Actinomyces, Syphilis. Abx and antifungals.

Front 62

What can a painless thyroid mass with hypothyroid?

Back 62

Hashimoto's thyroiditis

Front 63

Etiology of Hashimotos?

Back 63

Blocking IgG vs TSH receptor and TPO, low T3 and T4 but normal TSH

Front 64

What malignancy assoc w Hashimoto's?

Back 64

Papillary carcinoma and lymphoma

Front 65

Tx for Hashimoto's?

Back 65

T replacement, any compression of trachea warrants total resection

Front 66

What to suspect with persistent duodenal ulcers?

Back 66

ZE syndrome (gastrinoma)

Front 67

Which MEN has gastrinoma?

Back 67

MEN1

Front 68

How might a pituitary adenoma present?

Back 68

vision sxs, hyperlactation

Front 69

Surgical tx for pituitary adnoma?

Back 69

Partial hypophysectomy

Front 70

How to diagnose hypergastrinemia?

Back 70

Elevated unstimulated gastrin level or positive secretin stimulation test: Secretin inhibits gastin secretion from normal stomach but stimulates gastrinomas to secrete gastrin

Front 71

What type of cells secrete gastrin?

Back 71

G cells

Front 72

How to localize gastrinoma?

Back 72

MRI/CT

Front 73

Where are gastrinomas usually found?

Back 73

Head of pancreas or duodenum

Front 74

Tx for gastrinoma?

Back 74

surgical resection: Whipple procedure: pancreatico/hepato/duodenao-jejunostomy.
Non resectable? Highly selective vagotomy

Front 75

Chemotherapeutic agent for gastrinoma control?

Back 75

Streptozocin

Front 76

What is the Whipple triad?

Back 76

For hypoglycemia sugg of insulinoma
1. fasting hypogly <60
2. Symptomatic hypogly: anxiety, nervousness, tachy, sweating, pallor, dilated pupiils
3. relief by glucose

Front 77

How do you differentiate between true hypogly and too much insulin given?

Back 77

Measure C peptide, which is only formed with endogenous insulin secretion

Front 78

Percent of insulinomas that are malignant?

Back 78

10%

Front 79

How to manage insulinoma?

Back 79

If you can resect it, do so. If not, use Diazoxide an inhibitor of insulin release

Front 80

Sxs of pheochromocytomas?

Back 80

HTN, frontal pounding HA, diaphoresis, palps, anxiety

Front 81

When are pheos more likely to be bilateral?

Back 81

When it's MEN2 associated (60-80%). When sporadic only (10%)

Front 82

Surgical tx for MTC?

Back 82

Total thyroidectomy with removal of LN in central compartment of neck

Front 83

What do you do with an incidental adrenal mass?

Back 83

>5cm: surgical resection b/c it could be adrenal cortical carcinoma or met from the lung from LC
<5cm: measure levels of catecholamines, metanephrine, VMA, cortisol, K. If test indicate that it's a functional mass, resect. If nonfunctional follow with serial CTs and remove if it grows