Endocrine Disorders

Question 0

Hx of neck radiation w/ nodule –> next step?

Answer 0

Appropriate to move straight to thyroidectomy

Question 1

Important factors in H&P of thyroid nodule?

Answer 1

Radiation hx, family hx, voice and airway, sx, thyroid nodule pattern

Question 2

Which type of thyroid cancer is inherited? Dx?

Answer 2

Medullary (MEN syndromes - RET gene - AD trait)

Calcitonin levels

Question 3

Signs/sx concerning for thyroid malignancy?

Answer 3

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

Question 4

Risk of solitary nodule vs dominant nodule in multinodular gland

Answer 4

15% vs 5%

Question 5

T/F: radioactive iodine scanning is appropriate initial eval of solitary thyroid nodule

Answer 5

F

Question 6

Usefulness of US in thyroid eval?

Answer 6

Distinguishing cyst from nodules, following the size or recurrence of cysts following FNA

Question 7

FNA shows psammoma bodies?

Answer 7

Papillary cancer

Question 8

FNA shows amyloid deposits

Answer 8

Medullary cancer

Question 9

FNA shows Hurthle cells? Tx

Answer 9

Adenoma or low-grade cancer –> lobectomy, total thyroidectomy

Question 10

FNA shows lymphocytic infiltrate? Dx, Tx

Answer 10

Lymphoma or chronic lymphocytic thyroiditis

Flow cytometry

Radiosensitive –> radiation appropriate

Question 11

Risks of thyroid surgery?

Answer 11

Recurrent laryngeal nerve injury, ex branch of superior laryngeal nerve injury (alters high-pitch singing), parathyroid

Question 12

MC type of thyroid cancer?

Answer 12

Papillary

Question 13

Papillary cancer w/ prior head/neck radiation

Answer 13

Total thyroidectomy

Question 14

Papillary cancer w/ no hx of radiation

Answer 14

lobectomy and isthmusectomy

Question 15

thyroid cancer more prevalent in iodine-deficient areas?

Answer 15

Follicular

Question 16

Follicular < 4 cm and > 4 cm (microinvasive)

Clear follicular cell carcinoma

Answer 16

Lobectomy/isthmusectomy vs total thyroidectomy

total thyroidectomy > 1 cm

Question 17

Route of spread of follicular cancer?

Answer 17

Vascular

Question 18

Medullary cancer cell type?

Answer 18

C cell hyperplasia (parafollicular cells) w/ amyloid

Question 19

Papillary carcinoma prognosis

Answer 19

High survival in well-differentiated (100% at 10 years) and low in high-risk pts (20%)

Question 20

Post-op management of papillary cancer

Answer 20

thyroid suppression w/ TH and maybe Iodine ablation

Question 21

Follicular cancer prognosis and post-op tx

Answer 21

80% v 60%

Iodine ablation

Question 22

Medullary prognosis and post-op tx

Answer 22

80% vs 45%

NOT iodine/TH (wrong cells) –> CEA and calcitonin

Question 23

Most common met site of anaplastic thyroid cancer?

Answer 23

lung

Question 24

Hyperparathyroid localization?

Answer 24

Sestamibi scan

Question 25

MC location for missing inferior parathyroid gland?

Answer 25

Thymus

Question 26

Chvostek's sign

Answer 26

tapping facial nerve near the ear results in spasm of orbicularis oris (hypocalcemia)

Question 27

Common malignant cause of hypercalcemia?

Answer 27

Metastatic carcinoma (breast), multiple myeloma, sarcoidosis, vitamin A intoxication, thiazides, renal cell carcinoma, SqCC of lung (PTHrP), familial hypocaliuric hypercalcemia

Question 28

Acute tx of hypercalcemia?

Answer 28

Results in an osmotic diuresis --> dehydration 1. rehydrate w/ NS 2. Lasix 3. bisphosphonates 4. mithramycin, calcitonin, glucocorticoids

Question 29

Surgical indications in Secondary Hyperparathyroidism

Answer 29

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

Question 30

Hyperparathyroidism and HTN in same pt? Tx?

Answer 30

Possible pheochromocytoma. Combo alpha/beta blocker (never beta alone as unopposed alpha stimulation can be fatal)

Question 31

Test for Pheochromocytoma?

Answer 31

10% tumor; 10% malignant, extra-adrenal, epinephrine producers, and bilateral --> MRI T2 weighted, octreotide scan, MIBG scan (last resort) selects for chromaffin tissue

Question 32

Pheochromocytoma tx?

Answer 32

Alpha blockade - Phenoxybenzamine (10-14 days) prior to surgery Beta blockade Resection

Question 33

Resection of pheochromocytoma? Important step?

Answer 33

Resect w/ MINIMAL manipulation to avoid catecholamine surge. Ligate all venous drainage before manipulation

Question 34

Acute tender neck mass

Answer 34

Painful thyroiditis --> de Quervain's thyroiditis

Question 35

de Quervain's course?

Answer 35

Early = hyperthyroidism due to acutely injured follicles releasing TH

Question 36

de Quervain's histology?

Answer 36

Giant cell granulomas

Question 37

de Quervain's tx?

Answer 37

Analgesics, aspirin, steroids

Question 38

Is surgery appropriate in some cases of acute thyroid inflammation?

Answer 38

Bacterial infection (acute suppurative thyroiditis); Strep, Staph, Pseudomonas --> drainage

Question 39

PAINLESS thyroid mass w/ hypothyroidism

Answer 39

Hashimoto's (chronic lymphocytic thyroiditis)

Question 40

Management of Hashimoto's: Labs? Tx?

Answer 40

T3/T4, TSH ; Thyroid replacement, bx

Question 41

Higher incidence of malignancy w/ Hashimoto's or de Quervain's

Answer 41

Hashimoto's (papillary, lymphoma)

Question 42

Hx of hyperparathyroidism (3 gland resection) and intractable duodenal ulcers. Next steps?

Answer 42

1. r/o H. pylori | 2. Serum gastrin level (> 600 suspect Zollinger-Ellison, > 1000 dxic)

Question 43

Sx of gastrinoma; Dx? Anatomy?

Answer 43

PUD, Diarrhea, esophagitis ; Serum gastrin, Secretin stimulation test ; Duodenum and head of pancreas (gastrinoma triangle)

Question 44

Two types of ZE?

Answer 44

Sporadic, familial (MEN-1)

Question 45

Pituitary sx from MEN-1?

Answer 45

Vision changes (local compression), hypersecretion (lactation)

Question 46

Surgery for gastrinoma?

Answer 46

Yes. Endoscopy to localize, US to isolate --> surgical enucleation or Whipple depending on location

Question 47

Medical management of gastrinoma?

Answer 47

Streptozocin.

Question 48

What is the Whipple triad?

Answer 48

fasting hypoglycemia (< 60), sx hypoglycemia, relief by admin of glucose --> elevated insulin secretion (C peptide measurement)

Question 49

MEN-2a

Answer 49

Medullary thyroid cancer, parathyroid hyperplasia, pheochromocytoma

Question 50

MEN-2b

Answer 50

Similar to MEN-2a w/ exception of associated MARFANoid habitus and ganglioneuromas

Question 51

Incidental adrenal mass: size suspicious of cancer?

Answer 51

> 5 cm

Question 52

Adrenal carcinoma: where might it be a met from?

Answer 52

Lung cancer, others (adrenals common met location)

Question 53

Incidental adrenal mass workup?

Answer 53

Catecholamines, Cortisol, Potassium --> if functional mass = removal Nonfunctional --> serial CT observation