Pretest_6_Endocrine Problems and the Breast

Question 1

What are the constellation of findings seen in adrenal insufficiency?

Answer 1

skin pigmentation, weakness, weight loss, hypotension, hyponatremia, hyPERkalemia, hypoglycemia, abdominal pain

Question 2

How can insidious, post-operative adrenal insuffiency occur?

Answer 2

hemorrhage into the gland (as in patients on anticoagulants)

Question 3

An isolated focus of increased uptake on a thyroid scan is virtually diagnostic of

Answer 3

hyperfunctioning adenoma

Question 4

T/F: Previous radiation therapy to the breast is a contraindication to breast conservation therapy.

Answer 4

True

Question 5

T/F: There are similar outcomes between patients receiving modified radical mastectomy and lumpectomy/axillary node dissection followed by radiation for STAGES 1 AND 2.

Answer 5

True

Question 6

What is the treatment for inflammatory breast cancer?

Answer 6

chemo, radiation, and surgery! only 50% survival at 5 years

Question 7

What is the treatment for asymptomatic prolactinoma? Symptomatic?

Answer 7

asymptomatic = observation!
symptomatic = dopamine agonist (usually causes tumor shrinkage); surgery for when medical tx doesn't work

Question 8

Sestanibi scans are used to diagnose

Answer 8

parathyroid adenomas (also taken up by the thyroid apparently)

Question 9

_______ may be useful in the treatment of patients with unresectable glucagonomas.

Answer 9

Octreotide to control hyperglycemia

Question 10

All functioning adrenal adenomas should be resected, while nonfunctioning should be if the lesion is greater than __ cm. __% of adenomas are bilateral.

Answer 10

> 6 cm

10-15% of adrenal adenomas are bilateral

Question 11

Radiation induced thyroid cancer is usually which type?

Answer 11

papillary

Question 12

FNA of thyroid mass showing calcified lumps of sloughed cells =

Answer 12

papillary cancer

Question 13

Lobular carcinoma in situ is a risk factor for which invasive breast carcinoma, especially?

Answer 13

ductal carcinoma. The risk is equivalent in BOTH BREASTS and lasts indefinitely!

Question 14

These breast tumors have a characteristic “fish flesh” texture:

Answer 14

lymphomas

Question 15

Thiazide diuretcs promote (retention/secretion) of calcium.

Answer 15

Retention!

Question 16

Phenoxybenzamine (alpha-blockade) should be started in patients with pheochromocytomas ______ weeks before surgery.

Answer 16

1-3 weeks

Question 17

T/F: Chemotherapy for breast cancer in a pregnant patient does not increase the risk of congenital malformations if given in the second and third trimesters.

Answer 17

True

Question 18

Paget’s disease of the breast originates in which part of the breast?

Answer 18

retroareolar lactiferous ducts

Question 19

A paradoxical rise in serum gastrin after IV secretin is diagnostic of

Answer 19

Zollinger-Ellison syndrome (secretin inhibits gastrin release from normal stomach)

Question 20

In preparation for thyroidectomy, what should be done preoperatively to decrease the likelihood of thyroid storm?

Answer 20

Drops of Lugol iodide solution daily beginning 10 days preoperatively. PTU or methimazole can also be used preoperatively but are contraindicated in pregnant women.

Question 21

What is the name of the disease characterized by severe demineralization with subperiosteal bone resorption (most prominent in the middle phalanx of the second and third fingers), bone cysts, and tufting of the distal phalanges on hand films?

What conditions is it associated with?

Answer 21

osteitis fibrosis cystica. Associated with hyperparthyroidism and Vit D deficiency (hyper vs hypocalcemia)

Question 22

What is administered in the treatment of thyroid storm?

Answer 22

Beta blockers, antithyroid meds (PTU), rapid fluid replacement, iodine solutions (Lugol iodine, to decrease iodine uptake), steroids (blocks hepatic thyroid hormone conversion)

Question 23

What labs do you use to diagnose hyperaldosteronism?

Answer 23

plasma aldosterone concentration and plasma renin activity. PAC:PAR of 25-30:1 is suggestive

Question 24

What is the treatment of cystosarcoma phyllodes?

Answer 24

simple excision with adequate margins

Question 25

Most insulinomas are (single/multiple).

Answer 25

Single! But if in the context of MEN-1, more likely to be multiple

Question 26

Though not a definitive treatment, which antibiotic can control symptoms from unresectable malignant tumors of pancreatic islet cells (insulinoma)?

Answer 26

Streptozocin

Question 27

Carcinoid tumors are most commonly found where?

Answer 27

appendix and small bowel

Question 28

What is the generally acceptd treatment for stage 1 breast cancer in PREmenopausal women?

Answer 28

lumpectomy with axillary LN dissection (sentinel LN bix) and radiation therapy

Question 29

T/F: Lobular carcinoma in situ (LCIS) is a precancerous lesion.

Answer 29

FALSE. However, it does increase the risk of subsequent canceri n BOTH breasts (so no point of excising it). No need for prophylactic mastectomy.

Question 30

What are the four subtypes of DCIS and which has the greatest tendency to recur after wide excision alone?

Answer 30

papillary, cribriform, solid, comedo

Question 31

What is an indication for radical mastectomy (seldom done!)?

Answer 31

Locally advanced breast cancer with wide invasion of the pectoralis major in a patient who is able to tolerate general anesthesia

Question 32

T/F: In a patient with a history of neck radiation, it is appropriate to proceed directly to thyroidectomy. The most common thyroid cancer following radiation is

Answer 32

True papillary

Question 33

A thyroid cyst should be aspirated unless it recurs several times or is larger than __ cm, in which case it should be removed to eliminate the risk of malignancy.

Answer 33

4 cm

Question 34

If a nodule is (hot/cold) on radioactive iodine scans, it is more likely to be malignant thyroid cancer.

Answer 34

Cold | Hot nodules are benign 97% of the time

Question 35

Psamomma bodies are a marker for what kind of thyroid cancer?

Answer 35

papillary

Question 36

Amyloid deposits area marker for what kind of thyroid cancer? WHat else is seen on histology in these tumors?

Answer 36

medullary | Als see hyperplasia of C cells

Question 37

Undifferentiated cells on FNA suggests what kind of thyroid cancer?

Answer 37

anaplastic --> chemoradiation or salvage operative therapy

Question 38

Treatment of thyroid lymphomas?

Answer 38

radiation

Question 39

Treatment of thyroidits (like thyroid lymphoma, shows lymphocytic infilatrate)?

Answer 39

no surgery; may require TH replacement. Beta blockers, steroids.

Question 40

An injury to which nerve alters a high-pitched singing voice?

Answer 40

external branch of the superior laryngeal nerve

Question 41

Damage to what nerve results in hoarseness? | To which causes cord paralysis, possibly requiring tracheostomy?

Answer 41

hoarseness: unilateral recurrent laryngeal nerve | cord paralysis: bilateral

Question 42

What determines the differential surgical treatment of papillary thryoid cancer?

Answer 42

If history of head and neck radiation = total thyroidectomy If not, limited thyroid lobectomy (assuming lesion is 1 cm or less) with isthmusectomy. If lesion is >1.5 cm, then total thyroidectomy (due to increased incidence of multicentricity in papillary thyroid cancer)

Question 43

What determines the differential surgical treatment of follicular thyroid cancer? WHere is it most prevalent?

Answer 43

More prevalent in iodine-deficient areas | If MICROINVASIVE and 4cm, total thyroidectomy******

Question 44

What is the treatment of medullary thyroid cancer?

Answer 44

total thyroidectomy in all cases! Central neck compartment nodes are frequently involved and warrant removal; lateral neck dissection may be necessary for palpable nodes

Question 45

What factors go into the prognosis of papillary thyroid cancer? Follicular cancer?

Answer 45

``` Mets Age at presentation Completeness of resection Invasion (extrathyroidal) Size of mass Follicular: same as above, plus extent of vascular invasion ```

Question 46

What can be monitored in the serum of medullary thyroid cancer patients?

Answer 46

CEA, calcitonin

Question 47

What is the most common site of distal metastasis in anaplastic thyroid cancer?

Answer 47

lung

Question 48

Parathyroid lesions leading to hyperparathyroidism are more likely to be (adenomas/carcinomas)

Answer 48

adenomas

Question 49

Where is the most common location for a missing inferior parathyroid gland?

Answer 49

thymus (may also be intrathyroidal, in the TE groove, carotid sheath)

Question 50

What is Chvostek's sign?

Answer 50

spasm of the orbicularis oris muscle when hypocalcemia is present

Question 51

T/F: THe complications of parathyroid exploration are similar to those in thyroid surgery.

Answer 51

True! Include injury to the recurrent laryngeal (hoarseness, cord paralysis if bilateral), external branch of the superior laryngeal nerve (modification of high pitch) and hypocalcemia

Question 52

What is the management for an asymptomatic parathyroid adenoma?

Answer 52

Watchful waiting until serum calcium exceeds 11 mEq/L to avoid complications of hypercalcemia.

Question 53

What is the acute treatment of hypercalcemia?

Answer 53

Rehydration with normal saline and furosemide (leading to a brisk diuresis high in calcium). Initiation of bisphosphonates and then treatment of underlying cause.

Question 54

Explain secondary hyperparathyroidism:

Answer 54

chronic renal failure leads to retained phosphate as GFR decreases. This causes hypocalcemia, which elevates serum PTH. Calcium absorption from the gut and vit D metabolism are also impaired.

Question 55

What is the common operative finding in secondary hyperparathyroidism? What is the treatment?

Answer 55

hyperplasia of all glands | Treatment is excision of all but 50 mg of parathyroid tissue, which is implanted to the forearm (where more accessible)

Question 56

What is tertiary hyperparathyroidism? What is the surgical treatment?

Answer 56

Parathyroid gland becomes autonomous and does not stop secreting PTH even when renal function has returned (as in after transplant) Treatment is 3 1/2 gland resection

Question 57

_________ are the 10% tumor

Answer 57

Pheochromocytomas: 10% are malignant, extradrenal, epinephrine producers, and bilateral

Question 58

For pheochromocytomas that are difficult to locate, a _______ scan can localize the tumor.

Answer 58

octreotide last resort = nuclear I 131 metaiobenzylguanidine (MIBG) scan is used, which accumulates selectively in chromaffin tissue

Question 59

Why should excision of a pheo be transabdominal?

Answer 59

because 10% are bilateral or extraadrenal; need to be able to manipulate the tumor (but MINIMALLY so as not to release tons of catecholamines)

Question 60

Why do you need to ligate all venous drainage from the pheo before manipulating it?

Answer 60

To avoid systemic release of catecholamines!!

Question 61

Painful, swollen thyroid gland: | What is it called in the acute form?

Answer 61

thyroiditis! de Quervain's thyroiditis in acute form

Question 62

What is the general finding associated with thyroiditis?

Answer 62

elevated ESR

Question 63

What is the classic histology for thyroiditis?

Answer 63

giant cell granulomas around degenerating thyroid follicles

Question 64

What is the treatment of thyroiditis?

Answer 64

analgesics and aspirin, possibly steroids if resistant. Surgery is not necessary. TFTs if patient seems hyperthyroid

Question 65

T/F: A higher incidence of malignancy is associated with Hashimoto's thyroiditis.

Answer 65

True. Especially papillary carcinoma and thyroid lymphomas

Question 66

Patietns with compressive symptoms of the trachea due to Hashimoto's thyroiditis should undergo

Answer 66

palliative resection to relieve the obstruction

Question 67

T/F: IF you suspect a patient has a gastrinoma, still r/o H pylori.

Answer 67

True

Question 68

A serum gastrin over ___ is diagnostic of Zollinger-Ellison.

Answer 68

>1000 pg/mL

Question 69

Hypergastrinemia may result from a gastrinoma, an incomplete previous gastric resection, or ____ cell hyperplasia

Answer 69

G cell hyperplasia G cells are found deep within the pyloric glands of the stomach antrum, and occasionally in the pancreas[1] and duodenum. The vagus nerve innervates the G cells.

Question 70

If a gastrinoma involves or abuts a large pancreatic duct, what should be performed?

Answer 70

a Whipple or distal pancreatectomy (depending)

Question 71

Treatment of malignant or metastatic gastrinomas that are not resectable involves:

Answer 71

gastric resection or highly selective vagotomy. Streptozocin can be used for tumor control

Question 72

If you suspect a patient has an insulinoma, what do you measure?

Answer 72

C peptide to r/o exogenous administration of insulin

Question 73

If an insulinoma is unresectable, what do you use to treat?

Answer 73

diazoxide, an inhibitor of insulin release.

Question 74

An incidental adrenal mass should be removed with wide resection of the adrenal gland if it is symptomatic (check catecholamines, cortisol, and serum potassium) OR if it is >__ cm

Answer 74

5 (In lesions larger than 5 cm in size, incidence of adrenal cortical carcinoma is high)

Question 75

In the discovery of an incidental adrenal mass, consider that it might be a metastatic lesion from the ____

Answer 75

lung

Question 76

What would Graves disease show on thyroid scan?

Answer 76

diffuse uptake of radioactive iodine by the thyroid gland

Question 77

Hurthle cell cancer is a type of ________ thyroid cancer.

Answer 77

follicular However, it is more often multifocal and bilateral, more likely to spread to local nodes and distant sites, and has a higher mortality rate

Question 78

For thyroid nodules <__cm, thyroid lobectomy is adequate.

Answer 78

4 or confirmed carcioma, total thyroidectomy should be performed

Question 79

Fixed ipsilateral axillary nodes = N2, but ipsilateral internal mammary nodes =

Answer 79

N3

Question 80

Manipulation of the recurrent laryngeal nerve can lead to nerve ________, which is temporary dysfunction. The function will return within a few weeks.

Answer 80

neuropraxia

Question 81

Thyroid nodule showing pathologic characteristics of "atypical cells with capsular invasion and vascular invasion"

Answer 81

follicular

Question 82

The superior thyroid artery is (what branch of what artery) and courses with the superior laryngeal nerve.

Answer 82

first branch of the external carotid

Question 83

The inferior thyroid artery is a branch of ____________ and courses with the recurrent laryngeal nerve.

Answer 83

thyrocervical trunk (branch of subclavian)

Question 84

Dramatically elevated calcium levels (>14) are more likely to be associated with parathyroid carcinoma/adenomas?

Answer 84

carcinoma

Question 85

What is the embryological origin of the inferior parathyroid glands and the thymus? What nerve is it associated with?

Answer 85

third pharyngeal pouch; glossopharyngeal

Question 86

What is the embryological origin of the superior parathyroid glands and parafollicular cells of the thyroid?

Answer 86

fourth pharyngeal pouch

Question 87

What does the fourth pharyngeal arch turn into?

Answer 87

contributes to the superior parathyroids (like the fourth pharyngeal arch) and also the cricopharyngeus muscle

Question 88

What is the treatment for acute adrenal crisis? What is fludrocortisone used for?

Answer 88

Dexamethasone!! Fludrocortisone is for hypoaldosteronism.

Question 89

What are the next steps after finding an adrenal incidentaloma?

Answer 89

serum potassium, aldosterone to renin ratio, cortisol, 24 hour urine for VMA,metanephrines, and normetanephrines to see if mass is functional.