Endocrine and Breast

Question 1

Causes of hyperthyroidism?

Answer 1

Diffuse toxic goitre (Graves Disease)
Toxic nodular goitre
Toxic nodule
Rare causes

Question 2

What is the most sensitive test for diagnosing hyperthyroidism?

Answer 2

The most sensitive test for diagnosing hyperthyroidism is plasma T3 (which is raised).

Question 3

What is tested for in Graves’ disease ?

Answer 3

Anti-TSHr

Question 4

Treatment for graves?

Answer 4

Block and replace
Carbimazole , thyroxine

Question 5

Types of thyroid cancer?

Answer 5

Papillary carcinoma
Follicular carcinoma
Anaplastic carcinoma
Medullary carcinoma
Lymphoma’s

Question 6

Complications following thyroid surgery?

Answer 6

Anatomical such as recurrent laryngeal nerve damage.
Bleeding. Owing to the confined space haematoma’s may rapidly lead to respiratory compromise owing to laryngeal oedema.
Damage to the parathyroid glands resulting in hypocalcaemia.

Question 7

Which thyroid cancers may cause pathological fractures?

Answer 7

Follicular carcinomas may metastasise haematogenously (often to bone) where they may give rise to pathological fractures as in this case.

Question 8

when are TPO antibodies found?

Answer 8

Found Found in autoimmune disease affecting the thyroid (Hashimotos 100%) and Graves (70%) in autoimmune disease affecting the thyroid (Hashimotos 100%) and Graves (70%)

Question 9

What is thyroglobulin used for?

Answer 9

Not useful for clinically distinguishing between different types of thyroid disease, may be used as part of thyroid cancer follow up

Question 10

when is calcitonin found?

Answer 10

Released from the parafollicular cells
Usually found in patients with medullary carcinoma of the thyroid

Question 11

Management of thyroglossal cyst?

Answer 11

Surgical treatment with resection of cyst, associated track, central portion of the hyoid and wedge of tongue muscle behind the hyoid
[sistrunks procedure]

Question 12

What is a phaeochromocytoma?

Answer 12

Neuroendocrine tumour of the chromaffin cells of the adrenal medulla. Hypertension and hyperglycaemia are often found.

Question 13

Features of phaechromocytoma?

Answer 13

10% of cases are bilateral.
10% occur in children.
11% are malignant (higher when tumour is located outside the adrenal).
10% will not be hypertensive.
Normotension in 10% of cases

Question 14

Diagnosis of phaeochromocytoma?

Answer 14

Urine analysis of vanillymandelic acid (VMA) - false +ves in those eating a lot of vanilla ice cream
Blood testing for plasma metanephrine levels.

CT and MRI scanning are both used to localise the lesion.

Question 15

Factors suggesting benign adrenal disease on CT?

Answer 15

Size less than 3cm
Homogeneous texture
Lipid rich tissue
Thin wall to lesion

Question 16

Treatment of phaeochromocytoma?

Answer 16

1. irreversible alpha adrenoreceptor blocker [Labetolol may be co-administered for cardiac chronotropic control]
2. moderate volumes of intra venous normal saline perioperatively
3. Laparoscopic adrenalectomy

Question 17

How is medullary thyroid cancer inherited?

Answer 17

Autosomal dominant

Question 18

What is a thyroglossal cyst?

Answer 18

Moves on tongue protrusion
Thyroglossal cysts are the commonest midline cysts in the neck found in children

Question 19

What is a mucinous carcinoma?

Answer 19

Mucinous carcinomas comprise 2-3% of all breast cancers.
special type of carcinomas. These have a better prognosis than is associated with tumours of Non Special Type (NST) and axillary nodal disease is rare in this group.

Question 20

Most common type of breast cancer?

Answer 20

nvasive ductal carcinomas are the most common type. Some may arise as a result of ductal carcinoma in situ (DCIS).

Question 21

Calculation of Nottingham prognostic index?

Answer 21

Tumour Size x 0.2 + Lymph node score(From table below)+Grade score(From table below).

Score Lymph nodes involved Grade
1 0 1
2 1-3 2
3 >3 3

Question 22

Features of subacute thyroiditis? (De Quervains thyroiditis)

Answer 22

tender goitre, hyperthyroidism and raised ESR. Globally reduced uptake on technetium thyroid scan is also typical

Question 23

What is Hashimoto’s thyroiditis?

Answer 23

Hashimotos thyroiditis is an immunological disorder in which lymphocytes become sensitised to thyroidal antigens. The three most important antibodies include; thyroglobulin, TPO and TSH-R.

During the early phase of Hashimotos the the thyroglobulin antibody is markedly elevated and then declines.

Question 24

Features of Hashimoto’s thyroiditis?

Answer 24

Goitre and either euthyroid or mild hypothyroidism
Progressive hypothyroidism (and associated symptoms)

Question 25

Management of Hashimoto’s thyroiditis?

Answer 25

During the hyperthyroid phase of illness beta blockers may manage symptoms As hypothyroidism develops patients may require thyroxine

Question 26

Management of subacute thyroiditis?

Answer 26

Usually self-limiting - most patients do not require treatment Thyroid pain may respond to aspirin or other NSAIDs In more severe cases steroids are used, particularly if hypothyroidism develops

Question 27

Lab results for sick euthyroid?

Answer 27

TSH: low Free t4: low Common in hospital inpatients *can be referred to as non thyroid Al illness

Question 28

Lab results for secondary hypothyroidism?

Answer 28

TSH: low Free t4: low Replacement steroid therapy is required prior to thyroxine

Question 29

Lab results for poor compliance with thyroxine?

Answer 29

TSH: high Free T4: high/normal

Question 30

Hormone profile in primary hyperparathyroidism?

Answer 30

PTH (Elevated) Ca2+ (Elevated) Phosphate (Low) Urine calcium : creatinine clearance ratio > 0.01

Question 31

Hormone profile in secondary hyperparathyroidism?

Answer 31

PTH (Elevated) Ca2+ (Low or normal) Phosphate (Elevated) Vitamin D levels (Low)

Question 32

Hormone profile in tertiary hyperparathyroidism?

Answer 32

Ca2+ (Normal or high) PTH (Elevated) Phosphate levels (Decreased or Normal) Vitamin D (Normal or decreased) Alkaline phosphatase (Elevated)

Question 33

Clinical features of primary hyperparathyroidism?

Answer 33

May be asymptomatic if mild Recurrent abdominal pain (pancreatitis, renal colic) Changes to emotional or cognitive state

Question 34

Cause of primary hyperparathyroidism?

Answer 34

Most cases due to solitary adenoma (80%), multifocal disease occurs in 10-15% and parathyroid carcinoma in 1% or less

Question 35

Clinical features of secondary hyperparathyroidism?

Answer 35

May have few symptoms Eventually may develop bone disease, osteitis fibrosa cystica and soft tissue calcifications

Question 36

Causes of secondary hyperparathyroidism?

Answer 36

Parathyroid gland hyperplasia occurs as a result of low calcium, almost always in a setting of chronic renal failure

Question 37

Clinical features of tertiary hyperparathyroidism?

Answer 37

Metastatic calcification Bone pain and / or fracture Nephrolithiasis Pancreatitis

Question 38

Causes of tertiary hyperparathyroidism?

Answer 38

Occurs as a result of ongoing hyperplasia of the parathyroid glands after correction of underlying renal disorder, hyperplasia of all 4 glands is usually the cause

Question 38

Indications for surgery in primary hyperparathyroidism?

Answer 38

Elevated serum Calcium > 1mg/dL above normal Hypercalciuria > 400mg/day Creatinine clearance < 30% compared with normal Episode of life threatening hypercalcaemia Nephrolithiasis Age < 50 years Neuromuscular symptoms Reduction in bone mineral density of the femoral neck, lumbar spine, or distal radius of more than 2.5 standard deviations below peak bone mass (T score lower than -2.5)

Question 39

Management of secondary hyperparathyroidism?

Answer 39

Usually managed with medical therapy. Indications for surgery in secondary (renal) hyperparathyroidism: Bone pain Persistent pruritus Soft tissue calcifications

Question 40

Management of tertiary hyperparathyroidism?

Answer 40

Allow 12 months to elapse following transplant as many cases will resolve The presence of an autonomously functioning parathyroid gland may require surgery. If the culprit gland can be identified then it should be excised. Otherwise total parathyroidectomy and re-implantation of part of the gland may be required.

Question 41

which thyroid cancer is hashimotos associated with?

Answer 41

Hashimoto's thyroiditis is associated with thyroid lymphoma

Question 42

Main complication of longstanding very large goitre?

Answer 42

Tracheomalacia Airway compromise and strider

Question 43

What is the most important prognostic factor in breast cancer?

Answer 43

Nodal status

Question 44

Features of duct ectasia?

Answer 44

-Mammary duct ectasia may be seen in up to 25% of normal female breasts -Patients usually present with nipple discharge, which may be from single or multiple ducts (usually present age >50 years) -The discharge is often thick and green -Duct ectasia is a normal variant of breast involution and is not the same condition as periductal mastitis -Mass develops behind nipple

Question 45

Features of intraductal papilloma?

Answer 45

Growth of papilloma in a single duct Usually presents with clear or blood stained discharge originating from a single duct No increase in risk of malignancy

Question 46

Features of periductal mastitis?

Answer 46

Present at younger age than duct ectasia May present with features of inflammation, abscess or mammary duct fistula Strongly associated with smoking Usually treated with antibiotics, abscess will require drainage Mass develops around nipple

Question 47

Features of breast abscess?

Answer 47

Lactational mastitis is common Infection is usually with Staphylococcus aureus On examination there is usually a tender fluctuant mass Treatment is with antibiotics and ultrasound guided aspiration Overlying skin necrosis is an indication for surgical debridement, which may be complicated by the development of a subsequent mammary duct fistula.

Question 47

Features of breast abscess?

Answer 47

Lactational mastitis is common Infection is usually with Staphylococcus aureus On examination there is usually a tender fluctuant mass Treatment is with antibiotics and ultrasound guided aspiration Overlying skin necrosis is an indication for surgical debridement, which may be complicated by the development of a subsequent mammary duct fistula.

Question 48

Features of breast TB?

Answer 48

Rare in western countries, usually secondary TB Affects women later in child bearing period Chronic breast or axillary sinus is present in up to 50% cases Diagnosis is by biopsy culture and histology

Question 49

Management of large multi modular goitre?

Answer 49

Surgery for pressure symptoms. Total thyroidectomy is treatment of choice

Question 50

Management for toxic nodule?

Answer 50

Hemithyroidectomy

Question 51

Management of follicular lesion?

Answer 51

Hemithyroidectomy to establish diagnosis

Question 52

Management of papillary thyroid cancer?

Answer 52

Total thyroidectomy and central compartment nodal dissection (extended lymphadenectomy as required)

Question 53

Management of follicular thyroid cancer?

Answer 53

Total thyroidectomy (usually completion as already had hemithyroidectomy)

Question 54

Management of anaplastic thyroid cancer?

Answer 54

Palliative radiotherapy

Question 55

Management of medullary thyroid cancer?

Answer 55

Total thyroidectomy and central compartment nodal dissection (screen for other MEN tumours)

Question 56

Management of thyroid lymphoma?

Answer 56

Consider core biopsy

Question 57

Management of persistent refilling cysts

Answer 57

Injection sclerotherapy and surgery if this fails

Question 58

Management of graves with significant eye signs?

Answer 58

Total thyroidectomy

Question 59

Management of graves without significant eye signs?

Answer 59

Patient choice radioiodine Vs surgery

Question 60

Causes of primary hyperparathyroidism?

Answer 60

Causes of primary hyperparathyroidism 80%: solitary adenoma 15%: hyperplasia 4%: multiple adenoma 1%: carcinoma

Question 61

Features of primary hyperparathyroidism ?

Answer 61

Features - 'bones, stones, abdominal groans and psychic moans' Polydipsia, polyuria Peptic ulceration/constipation/pancreatitis Bone pain/fracture Renal stones Depression Hypertension

Question 62

Associations of hyperparathyroidism?

Answer 62

Hypertension Multiple endocrine neoplasia: MEN I and II

Question 63

Investigation of hyperparathyroidism?

Answer 63

Raised calcium, low phosphate PTH may be raised or normal Technetium-MIBI subtraction scan

Question 64

Complications of breast surgery?

Answer 64

- long thoracic nerve injury - intercostobrachial nerve injury - injury to the thoracodorsal trunk - infection , cellulitis - lymphoedema - seroma

Question 65

Surveillance strategy for BRCA1?

Answer 65

annual breast MRI

Question 66

High risk genes for BC?

Answer 66

BRCA1, BRCA2 or TP53

Question 67

Drug treatment for breast cancer?

Answer 67

Premenopausal women at high risk can be offered tamoxifen Post menopausal women at high risk can be offered anastrazole. Where drug treatment is given, the period of dosage should not exceed 5 years.

Question 68

What is medullary breast cancer characterised by?

Answer 68

Medullary breast cancer is a breast cancer of special type. Histologically, it is characterised by a marked lymphocytic infiltrate. Many of the breast cancers of special type (which comprise less than 5% of all breast cancers) have a very good prognosis.

Question 69

Special type breast cancers?

Answer 69

medullary, tubular, mucinous, adenoid cystic, Improve

Question 70

Features of inflammatory carcinoma?

Answer 70

Aggressive Early dissemination Treatment resistant Often occurs in regnancy or lactation

Question 71

What are brown tumours of bone associated with?

Answer 71

Hyperparathyroidism Excess osteoclast activity

Question 72

Typical features of insulinoma?

Answer 72

Symptomatic hypoglycaemia during fasting Concomitant blood glucose of less than 3mmol/L Relief of hypoglycaemia by use of glucose

Question 73

what is insulinoma?

Answer 73

Insulin producing tumours of the pancreatic β cells Incidence of 1 per 1,000,000 per year 90% of lesions are benign Most tumours less than 2cm in size Between 5 and 10% have MEN type 1 75% of patients with MEN 1 will develop pancreatic islet cell tumours

Question 74

What level is plasma insulin concentration commonly in insulinoma?

Answer 74

The plasma insulin concentration is >10 micro U/ml in patients with the disorder.

Question 75

Tumour localisation of insulinoma?

Answer 75

USS (25% accuracy), endoscopic USS better (75% accuracy) CT scanning (pancreatic protocol=40% accuracy) Malignant insulinomas are larger and diagnostic accuracy with MRI is nearly 100% in such cases Somatostatin receptor scintigraphy (50% accuracy)

Question 76

Where do glucagonomas originate?

Answer 76

Glucagonomas originate in the alpha 2 cells of the pancreas.

Question 77

Symptoms of glucagonomas?

Answer 77

Symptoms are generally related to hormone overproduction and include diabetes, hypoaminoacidemia, normochromic and normocytic anemia, and necrolytic migratory erythema (NME), which is the most characteristic clinical sign (as opposed to symptom)

Question 78

Diagnosis of glucagonomas?

Answer 78

Serum measurement of glucagon levels (a level of greater than 1000pg/ml is diagnostic) Imaging with CT scanning of the chest/ abdomen and pelvis Endoscopic USS may be used Combined CT/MRI can accurately localise the lesion in 95% of cases

Question 79

Treatment of glucagonomas?

Answer 79

Often metastatic at presentation Chemotherapy: doxorubicin and 5FU Biological: Sunitinib

Question 80

What is a somatostatinoma?

Answer 80

Somatostatinomas are rare neuroendocrine tumors that arise from the pancreas or the gastrointestinal tract and are characterized by excessive secretion of somatostatin hormone by tumor cells of D-cell origin

Question 81

Symptoms of somatostatinoma?

Answer 81

Classic clinical pentad: 1. diabetes mellitus 2. cholelithiasis 3. weight loss 4. steatorrhea and diarrhea 5. hypochlorhydria and achlorhydria.

Question 82

Diagnosis of somatostatinoma?

Answer 82

serum measurements of somatostatin Imaging is with CT and MRI Endoscopic USS is also useful Biopsy not routinely performed

Question 83

Treatment of somatostatinoma?

Answer 83

Often already metastasised on presentation Chemotherapy is sometimes used as a treatment and 5FU and doxorubicin are typically the agents of choice.

Question 84

Where are gastinomas typically found?

Answer 84

Near the head of the pancreas

Question 85

What are gastronomes typically associated with ?

Answer 85

Zolinger Ellison Syndrome Normally treated with surgical excision

Question 86

What is Waterhouse - Friderichsen syndrome?

Answer 86

adrenal gland failure due to bleeding into the adrenal glands. It is caused by severe bacterial infection (most commonly the meningococcus Neisseria meningitidis).