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Flashcards in ENDOCRINE Deck (63):
1

FNA not sensitive to identify

not sensitive to identify lymphoma

not sensitive to follicular thyroid
malignancies

2

If FNA is negative,

must repeat with US or open biopsy

Tru cut biopsy can be performed but FNA is preferred

3

new test to screen individuals suspected of papillary
thyroid cancer.

RET proto-oncogene is a new test to screen individuals suspected of papillary
thyroid cancer. Test is not available in all centers

4

evidence of dysphonia or vocal cord
involvement

Indirect laryngoscopy is done if there is

5

when is External radiation is administered for thyroid cancer

when there is a large malignant thyroid mass


6

When thryoid metastases occur they first go to

neck nodes,
bones,
liver,
brain

7

factors that suggest a malignant thyroid like

age 70,
male sex, associated with dysphagia or dysphonia, prior radiation, firm hard nodule,

8

medullary thyroid cancer what is most important part of evaluation

r/o MEN

9

Most patients who have an incidental adrenal mass have no symptoms when they do have sx what may they be


o Non-functional masses:
fever,
weight loss,
abdominal pain,
back pain,
bdominal fullness

o Functional tumors:
Cushing syndrome
Virilization syndromes
Precocious puberty
Amenorrhea
Facial acne
Hypo or hyper-aldosteronism

Adrenal Carcinoma
Cachexia
Conn syndrome

10

screening for adrenal incidentaloma


o Should screen for excess hormone production:

corticosteroids and appropriate suppression tests

aldosterone
adrtogen
estradiol
catecholamines (metanephrines) plasma / urine

11

Imaging Considerations adrenal incidentaloma

CT and MRI are equally
good to visualize adrenal mass


CT
attuenuation values :
higher than 20 are thought to be related to malignant mass

12

Aldo to renin ratio of what to dx conns

greater than 20

13


biochemical workup for patient who does not have a clear diagnosis of primary hyperparathyroidism (PHPT)

chloride:phosphate (Cl:PO4) ratio greater than 33 lends further support to the diagnosis.

ionized calcium,
creatinine,
albumin,
25-OH Vitamin D levels



Vitamin D deficiency is common in the setting of PHPT and warrants replacement, because increased parathyroid hormone (PTH) results in increased clearance and degradation of Vitamin D.

A 24-hour urine collection for calcium and creatinine may also be indicated to exclude a renal calcium leak causing a secondary rise in PTH.



14

Patients with bilateral idiopathic hyperaldosteronism are treated with

selective
and nonselective mineralocorticoid receptor blockers


15

Indications for performing. Thyroidectomy in asymptomatic patients

Patients Who Meet ONE or More Guidelines Should Be Referred for Surgery.

LESS than age 50

Serum calcium (above upper limit of normal) 1.0 mg/dL

Renal function GFR

16

Ssx to ask about for w/u of thyroid cancer

B symptoms

voice changes
dysphagia

if concerened - laryngoscopy

CT head and neck if concern

17

If nodes positive on papillary

total

central neck

AND

modified radical

18

risk of caner if path comes back follicular neoplasm

20%

(unless patient presents with local invasion symptoms)

19

symptomatic hypocalcium

in hospital with IV calcium

20

tricky lab to get on thyroid cancer in pregnant

DNA mutation analysis

if negtive you can watch thryoid cancer

21

normal PTH

Normal values are 10 to 55 picograms per milliliter (pg/mL).

expect 50% decrease intra op at 10 mins post excision

22

Approach if parathyroid hormone does not drop after you remove abnormal gland

Explorer ALL three other parathyroid's

Then start by taking out the most abnormal looking gland and redraw calcium

23

If all parathyroid glands look normal

Biopsy them to make sure that they are in fact all parathyroid's

Because finding the fourth gland easier then finding a supernumerary fifth gland(Which is most common sinus)

24

What is the dose of calcium gluconate

10% and 10 mL give never 10 minutes

Alternative 30 mg IV

25

Where is the management of a follicular me a pleasant in a pregnant woman

Can watch

(if you want to be fancy you could do a DNA mutation study)

26

Concern of a large lymph node when doing your hammy thyroidectomy for follicular and neoplasm

Frozen will not help

Because follicular neoplasm and you need to see if there is capsular invasion

27

What is the potential utility of having a TSH level when working at suspected thyroid cancer

TSH is trophic for the thyroid

28

What is typical pathology report follicular and neoplasm

Scant follicular
Rare intranuclear inclusions

This is really nondiagnostic

29

Diffuse goiter

(Grave's disease)

"HYPER about going to the grave with bug eyes"

most common in USA,

enlarged gland

exophthalmoses

positive LATS (antibodies) level in the blood.

30

Nodular goiter

"HYPER big nodules"

multi nodular goiter

Plummer Disease

most common cause of hyperthyroidism overseas,

Uni-nodular

nodule> 3 cm

rare cause of HYPERthyroidism)

31

Thyroid Adenoma or- rarely- cancer

Adenoma or- rarely- cancer

32

Thyroiditis

esp. the subacute

or

Riedel sclerosing thyroiditis

33

Strange causes of hyperthyroidism

Ovarian

testicular

pituitary tumors

34

Ssx of hyperthyroidism

hyper reflexia

tremor

heat intol

afib / tachy

thyroid enlarged

35

Tests to order with hyperthyroid


Free T4 (Free T3), TSH

Thyroid-stimulating immunoglobulin (TSI}

and

Anti TPO and Anti TG. (in Grave's).

High resolution ultrasound to the thyroid

Iodine 123 nuclear scintigraphy (this is one of the rare condition that this test is still being used

36

Tx of hyperthyroid

Antithyroid medications (rarely used these days for poor patient compliance and side effects)

PTU

and

Tapazole;

1-2 years until the natural remission of the disease occurs by auto-infarct (This is achieved in 20-30% of cases).

The main problems with this option are the compliance with taking the meds and the side effects (mostly agranulocytosis with PTU}.

Radioactive iodine /-131 (most common treatment in the US} -Good option in most patients. You need mostly 1-2 doses.

Some of the disadvantages are:
Slow,
needs 2-4 months

should keep the patient on antithyroid meds (The dose is 5 - 15 mCi, repeated after 4 months if thyrotoxicosis persists).

High incidence of hypothyroidism

Risk o f CA in children (negligible).

No pregnancy allowed for one year.



37

How do you prepare hyperthyroid patient for surgery?


1. Continue PTU or Tapazole until the day of surgery, then stop it.

2. Start lugol's solution (Iodine) 2cc T.I.D. for 10 days pre-op.

3. Give lnderal for tachycardia and when you need rapid pre-op control (stop it 2 hours before surgery and continue for 8-10 days post-op which is the half life of Thyroxin)

4. Steroid

A Swiss study indicated that a single dose of steroid administered prior to thyroidectomy can reduce nausea, pain, and vomiting associated with the procedure, as well as improve voice function.)

38


Follow-up after surgery for hyperthyroid

All patients are placed on levoThyroxin for life and followed by TSH level.

39

Surgery for hyperthyroid

TOTAL thyroid for:
Graves disease
multinodular goiter
Riedel disease.

LOBECTOMY rather than radioactive iodine for:
Toxic adenoma
or
solitary nodule associated with hyperthyroidism

NO surgery for Medical (NSAIDS, steroids):
subacute thyroiditis



40

indications for Surgery in hyperthyroidism

Kids with Hyperthyroidis

young women (who are or expect to become
pregnant)

Cardiac effects - Thyrocardiac patients (when you need a rapid control of the disease)

Compressive (dysphagia, voice changes, etc.)

Can not r/o cancer in nodule

Failed meds after 1-2 years!

41

Treatment of hyperthyroidism crisis:

can quickly develop into respiratory arrest and coma;

fever and cardiac arrhythmias are common.


1. IV. fluid mixed with 1-2 amps of multiple vitamins

2. Sedation

3. Lugols solution (p.o. or by NGT) blocks the release of thyroxin.

4. PTU (up to 1gm a day p.o. or by NGT) blocks the synthesis of thyroxin.

5. Hydrocortisone (100mg IVPG Q6 hours) blocks the conversion of thyroxin to its active form at the tissue level.

6. Propranolol (1-2mg slowly IV with EKG monitoring+ 10-40mg p.o. or by NGT Q8 hours).

Very important for rapid control of cardiac arrhythmias and tachycardia.

7. Antipyretics (Tylenol, ice packs, etc. as needed).

8. 02 (by mask, may need intubation and use of paralyzing agents

42

ratio helpful in dx of hyperPARA

Cl / Phos greater than 33 (with hyperchloremic acidosis)

43

Mondor's disease

thrombophlebitis

(also known as "Mondor's syndrome of superficial thrombophlebitis")

rare condition which involves thrombophlebitis of the

superficial veins of the breast and anterior chest wall.

44

Tests to get in work up of medullary thyroid cancer

serum calcitonin (normal 400 pg/ mL, a metastatic workup including CT scans of the neck, chest, and abdomen should be performed. The majority of MTCs occur sporadically, but up to 20% are due to germ-line mutations in the RET protooncogene. Hereditary MTCs occur in multiple endocrine neoplasia (MEN) syndrome 2A and 2B and in familial MTC. According to the American Thyroid Association guidelines, all patients diagnosed with MTC should undergo RET gene testing. Screening for hyperparathyroidism and pheochromocytoma should also be performed, as a pheochromocytoma needs to be resected prior to thyroid resection.

45

treatment for MTC For patients with no evidence of lymph node and distant metastases,

total thyroidectomy
prophylactic central neck (level VI) dissection

46

treatment for MTC For patients with with lymph node metastases limited to the central neck compartment


total thyroidectomy
central neck dissection are performed.

47

reatment for MTC For patients with suspected metastases to the lateral neck compartments

with suspected metastases to the lateral neck compartments

total thyroidectomy
central neck dissection,
modified lateral neck (levels II, III, IV, V) dissection.

48

Central neck dissection once thryoid has been removed

recurrent laryngeal nerves are dissected out

all the fatty tissue between the carotid sheaths from the
hyoid bone superiorly
to
brachiocephalic vessels inferiorly

including the thymus

49

lateral neck dissection / modified radical

begun by dissecting the anterior triangle, containing:
level II, III, and IV lymph nodes.

The submandibular gland is retracted superiorly,

inferior margins of the digastric and omohyoid muscles are skeletonized defining the superior aspect of dissection. The internal jugular vein is exposed and the lateral branches are ligated or sealed, defining the medial border of dissection. The sternocleidomastoid muscle can then be retracted laterally and the tissue on its posterior surface can be dissected, with care taken to identify and preserve the spinal accessory nerve. Attention can then be turned to dissection of the posterior triangle, containing level V lymph nodes. Once the spinal accessory nerve has been identified, the posterior border of the sternocleidomastoid muscle can then be skeletonized down to the trapezius muscle, defining the lateral border of dissection. The dissection proceeds down to the clavicle, which defines the inferior border of resection. Once the fatty tissue containing the lateral neck lymph nodes has been dissected free from all adjacent structures, it can be removed en bloc. After the lymph node tissue has been removed, if required, a drain can be placed in the lateral neck. The medial aspect of the sternocleidomastoid muscle is then reapproximated to the lateral border of the sternothyroid muscle with interrupted sutures. The platysma is reapproximated in the same manner. Finally, the skin is closed with a running subcuticular stitch. Special Intraoperative Considerations Due to the extent of the lymph node dissection, care should be taken to identify the thoracic duct as it enters the neck on the left. Most commonly, the thoracic duct empties into the left subclavian vein at its junction with the left internal jugular vein. Surgeons should be aware of aberrant ductal anatomy, with patients having a right thoracic duct, draining into the right subclavian vein. If the thoracic duct is inadvertently injured and a chyle leak is identified intraoperatively, it should be ligated with either nonabsorbable sutures and/ or

50

4D-CT

three planes
(axial, coronal, sagittal) from the angle of mandible to the mediastinum

The “fourth” dimension is time:

the perfusion information derived from multiple contrast phases. It is most commonly performed with three phases: non-contrast, arterial, and delayed phase imaging (1, 2).

51

fancy tests if work-up re-do hyperpara

selective venous sampling!

4D CT

PET considered

52

The diagnosis of thyroid storm is based upon

severe and life-threatening symptoms
(hyperpyrexia,
cardiovascular dysfunction,
altered mentation) in a patient with

(elevation of free thyroxine [T4] and/or triiodothyronine [T3] and suppression of thyroid-stimulating hormone [TSH]).

53

tx of thyroid storm

propranolol
(pos dig)

PTU

Lugols

Hyrdrocortisone

Cholestyromine

A beta blocker to control the symptoms and signs induced by increased adrenergic tone

(propranolol in a dose to achieve adequate control of heart rate, typically 60 to 80 mg orally every four to six hour

●A thionamide to block new hormone synthesis

propylthiouracil (PTU) 200 mg every four hours
or
methimazole (20 mg orally every four to six hours).

PTU is favored over methimazole because of PTU’s effect to decrease T4 to T3 conversion. One hour after the first dose of thionamide is taken, we administer iodine (saturated solution of potassium iodide [SSKI], five drops orally every six hours, or Lugol's solution, 10 drops every eight hours).

●An iodine solution to block the release of thyroid hormone - Lugol

●An iodinated radiocontrast agent (if available) to inhibit the peripheral conversion of thyroxine (T4) to triiodothyronine (T3)


●Glucocorticoids to reduce T4-to-T3 conversion, promote vasomotor stability, and possibly treat an associated relative adrenal insufficiency

(hydrocortisone, 100 mg intravenously every eight hours) and

●Bile acid sequestrants to decrease enterohepatic recycling of thyroid hormones

cholestyramine (4 g orally four times daily) to reduce enterohepatic circulation of thyroid hormone.

. Digoxin and beta blocker requirements may be quite high because of increased drug metabolism as a result of hyperthyroidism. Infection needs to be identified and treated, and hyperpyrexia should be aggressively corrected.

Acetaminophen should be used instead of aspirin, since the latter can increase serum free T4 and T3 concentrations by interfering with their protein binding.

Propranolol is frequently selected for initial therapy because it can be given intravenously, but this should only be done in a setting where hemodynamics can be monitored. The intravenous dose is 0.5 to 1 mg over 10 minutes followed by 1 to 2 mg over 10 minutes every few hours

54

Treatment of two year old with positive ret oncogene

Do not even talk about medullary without doing if your screen (this is like proximal and distal control)

MEN IIa - thyroidectomy before the age of two

MEN IIb thyroidectomy when diagnosed - nine months or younger!

55

Which replaced in hepatic artery can be found at the right gastrohepatic

the left!

56

What cancer is associated with positive amyloid

Medullary (pheo screne)

Also has calcitonin stain

57

Rules of 10 for pheochromocytoma

10% family
10% bilateral
10% malignant
10% ectopic / extra adrenal

58

Boundaries of the central compartment next

Level VI

"Coast to Coast"

Carotid to carotid
If your boundaries

59

Growth of adrenal mass that indicates resection should be done

One cm per year(Same as AAA)

60

Lab values to assess if an adrenal mass is functional

Aldosterone
Sodium
Potassium

Cortisol
Salivary/24 hour urine
ACTH

Metanephrines/ catecholamines/VMA
Plasma/24 hour urine

Possible vein sampling

61

Moves if you cannot find gastrinoma

Transillumination
Intraoperative ultrasound
Lateral duodenotomy

62

Most common organ for gastronomer to metastasize to

Liver
"Everything metastasis is to the liver"

Second most common his pancreas

63

Medical management for insulinoma

streptozotocin