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Endocrine and Breast Flashcards

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1
Q

How do non-functional tumors of the pituitary present?

A

Macroadenomas that present with mass effect and decreased anterior pituitary hormone levels

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2
Q

What are contraindications to the transsphenoidal approach to pituitary tumors?

A

suprasellar extension, massive lateral extension, dumbbell shaped tumor

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3
Q

What drug to most pituitary tumors respond to?

A

Bromocriptine (dopamine agonist)

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4
Q

What are the characteristics of prolactinoma?

A

Most common pituitary adenoma
Microadenoma
Prolactin > 150 for symptoms

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5
Q

What are indications for resection of macro adenomas?

A

Hemorrhage
Visual loss
Desires pregnancy
CSF Leak

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6
Q

What are the characteristics of growth hormone releasing adenomas?

A

Macroadenomas

Elevated IGF-1 and GH >10 in 90%

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7
Q

What is the treatment of acromegaly?

A

Oxtreotide

Transsphenoidal resection

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8
Q

What is a frequent post-op complication following craniopharyngioma resection?

A

Diabetes insipidus

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9
Q

What should you think of with bilateral pituitary masses?

A

Mets if pituitary hormones OK

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10
Q

What is Nelson’s Syndrome?

A

Pituitary enlargement from bilateral adrenalectomy resulting in amenorrhea and visual problems as well as hyperpigmentation

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11
Q

What is the arterial supply of the adrenal gland from superior to inferior?

A

Inferior phrenic artery
Aorta
Renal artery

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12
Q

What is the workup of an adrenal incidentaloma?

A

Check for functioning tumor: Urine metanephrines/VMA/catecholamines, hydroxycorticosteroids, serum K, plasma renin and aldosterone levels
Metastatic workup: CXR< colonoscopy, mammogram

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13
Q

When is surgery indicated for an adrenal mass?

A

Non-homogenious
> 4-6 cm
Functioning
Enlarging

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14
Q

What hormones are present in all zones of the adrenal?

A

21 and 11 beta hydroxylase

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15
Q

What are the symptoms of Conn’s syndrome?

A

HTN without edema
Hypokalemia
Weakness
Polydipsia and polyuria

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16
Q

What is the diagnostic tests for primary hyperaldosteronism?

A

Salt load suppression test (urine aldosterone stays high)

Aldosterone:renin ratio > 20

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17
Q

What is the treatment for adenomas causing Conn’s syndrome?

A

Control HTN and K

Adrenalectomy

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18
Q

What is the treatment for hyperplasia causing Conn’s syndrome?

A

Sprionolactone, CCBs, K replacement

if refractory: bilateral resection with fludrocortisone post-op

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19
Q

What are the most common causes of Addison’s disease?

A

Withdrawal of exogenous steroids

Autoimmune disease

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20
Q

What is the diagnostic test for Addison’s disease?

A

Cosyntropin test (ACTH given, urine cortisol remains low)

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21
Q

What are hte signs of acute adrenal insufficiency?

A

Refractory hypotension, fever, lethargy, n/v, hypoglycemia, hyperkalemia

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22
Q

What is the most common cause of hypercortisolism?

A

Iatrogenic

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23
Q

What is the diagnostic tests for hypercortisolism?

A

24 hour urine cortisol and ACTH
ACTH low -> cortisol secreting lesion
Both High -> pituitary adenoma or ectopic ACTH (e.g. SSLCA)

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24
Q

What is the follow up test if ACTH is high after a 24 hour urine test?

A

High-dose dexamethasone suppression test
If urine cortisol suppressed -> Pituitary adenoma
Not surpressed -> Ectopic ACTH producer

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25
What are medical treatments for adrenal hyperplasia causing hypercortisolism?
Metyrapone (blocks cortisol synthesis) Aminoglutethimide (inhibits steroid production) If fails: bilateral adrenalectomy
26
What are the characteristics of adrenocortical carcinoma?
bimodal age distribution (<5 > 5th decade), females 50% are functioning Children have virilization 90% of the time
27
What are the treatments for adrenocorticol carcinoma?
Radical adrenalectomy Debulking helps sx and prolongs survival Mitotane for chemo
28
What is the rate limiting step in epinephrine production?
Tyrosine hydroxylase
29
What converts norepinephrine to epinephrine?
PNMT (only in adrenal medulla)
30
Where is the organ of Zuckerkandl?
At the adrenal bifurcation
31
What is the 10% rule for pheochromocytoma?
``` Malignant Bilateral In Children Familial Extra-Adrenal ```
32
Which pheochromoctyomas are more likely to be malignant?
Extra-adrenal tumors
33
What is the most sensitive test for dx of pheochromocytoma?
Urinary VMA
34
What are other tests to diagnose and localize pheochromocytoma?
Ct/MRI MIBG Scan Clonidine suppression test (no response from tumor) NO VENOGRAPHY
35
What drugs should be ready for use during adrenalectomy for pheochromocytoma?
Nipride Neo-synephrine Antiarrythmic agents
36
What causes falsely elevated levels of VMA?
Coffee, tea, fruits, vanilla Iodine contrast labetalol alpha and beta blockers
37
What is a ganglioneuroma?
Rare benign asymptomatic neural crest tumor in adrenal medulla or sympathetic chain
38
What is an Ima artery?
1% of population, directly from innominate or aorta and supplies the isthmus of the thyroid
39
Where do veins of the thyroid drain?
Superior and middle - IJ | Inferior - Innominate
40
What is the function of the superior laryngeal nerve?
Motor to cricothyroid | Loss = loss of projection and voice fatigability
41
What percent of population has a non-recurrent largyneal nerve?
2% | More common on the right
42
What runs near the ligament of Berry?
RLNs | It is the posteromedial suspensory ligament
43
What are the tubercles of Zuckerkandl?
Most posterolateral extension of the thyroid | This is left behind during subtotal as it is near RLN
44
What is the most common cause of death in thyroid storm?
High-output cardiac failure
45
What is the treatment of thyroid storm?
``` Beta blocker first! PTU Lugol's solution Cooling blankets Oxygen Glucose ```
46
What effect does Lugol's solution take advantage of?
Wolff-Chaikoff effect
47
If you drain a thyroid cyst and it recurs or fluid is bloody, what is Tx?
Thyroid lobectomy
48
What is the difference between primary and secondary substernal goiter?
Primary -> Blood vessels from thyroidal arteries | Secondary -> from innominate artery
49
What is the mechanism of PTU and MTH?
Inhibits thyroid peroxidases and prevents iodine-tyrosine coupling
50
What is the operative pathway for Grave's disease?
Pre-op: PTU till euthyroid then beta blocker and Lugol's for 14 days Operation: Bilateral subtotal or total
51
What are indications for surgery in Grave's disease?
``` Noncompliant patient Recurrence Children Pregnant not controlled with PTU Concomitant suspicious nodule ```
52
What does pathology of Hashimoto's disease show?
Lymphocytic infiltrate
53
What is treatment of De Quervain's thyroiditis?
Steroids | ASA
54
What is Riedel's fibrous trauma often associated with?
PSC, fibrotic diseases, methysergide Tx, RP fibrosis
55
What are worrisome features for thyroid CA?
Solid, solitory, cold, slow growing, hard Male, age > 50, prior XRT MEN IIa or IIb
56
What could sudden growth of a thyroid nodule represent?
Hemorrhage into previously undetected nodule or malignancy
57
Are follicular adenomas associated with an increased cancer risk?
NO
58
What is the most common tumor following neck XRT?
Papillary thyroid cancer
59
What is prognosis of papillary thyroid cancer based on?
Local invasion
60
What is seen on pathology for PTC?
Psammoma bodies | Orphan annie nuclei
61
What are indications for total thyroidectomy with PTC?
``` Bilateral lesions Multicentricity History of XRT Positive margins Tumors > 1 cm ```
62
What are indications for I131 in PTC?
Metastatic disease Residual local disease Positive LNs Capsular invasion
63
What is an enlarged lateral neck LN with normal appearing thyroid tissue?
This is PTC with lymphatic spread
64
What is the most common metastatic site for follicular thyroid cancer?
Bone
65
What are indications for total thyroidectomy for FTC?
> 1 cm or extra thyroidal disease
66
What is one of the first symptoms of MTC?
Diarrhea, flushing
67
What is seen on pathology for MTC?
Amyloid deposition
68
Where do mets from MTC go?
Early mets to lung, liver, bone
69
What are indications for MRND with MTC?
Clinically positive nodes, bilateral if disease in both lobes, Or if extra thyroidal disease present
70
What is prophylactic thyroidectomy indicated in MEN II syndromes?
IIa - 6 years | IIb - 2 years
71
Which thyroid cancers is I-131 effective for?
Papillary and Follicular
72
What pharyngeal pouches do the parathyroids come from?
Superior 4th | Inferior 3rd
73
Where are the superior parathyroids found?
Lateral to RLN, superior to inferior thyroid artery
74
Where are the inferior parathyroids found?
Medial to RLN, inferior to the inferior thyroid artery
75
How does Vitamin D act?
Increases levels of calcium binding protein
76
What is a normal PTH level?
5-40
77
What are the laboratory abnormalities in primary hyperparathyroidism?
Increased calcium, Decreased phosphate CL to PO4 ratio > 33 Increased renal cAMP Increased bicarb in urine
78
What are the criteria for intra-op PTH monitoring?
Should decrease by 1/2 in 10 minutes
79
Where is the most common location to find a gland at re-operation for missing gland?
Normal anatomic location
80
What are indications for surgery in secondary hyperparathyroidism?
Bone pain, fractures, pruritus
81
What is the surgical treatment for tertiary hyperparathyroidism?
Subtotal parathyroid resection
82
What are the findings in MEN I?
Parathyroid hyperplasia Pancreatic islet cell tumors (Gastrinoma #1) Pituitary adenoma (Prolactinoma #1)
83
What are the findings in MEN IIa?
Parathyroid hyperplasia Medullary thyroid cancer Pheochromocytoma (bilateral, benign)
84
What are the findings in MEN IIb?
Medullary thyroid CA Pheochromocytoma Mucosal neuromas Marfan's habitus
85
What are the genes for MEN I and MEN IIa/IIb?
I - MENIN | IIa/IIb - RET proto-oncogene
86
What is the treatment for hypercalcemic crisis?
Fluids | Lasix
87
How do breast cancer bone mets cause hypercalcemia?
They release PTHrP

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