Thyroid, Parathyroid And Adrenal Glands Flashcards
(187 cards)
1
Q
What is Berry’s ligament?
A
Pre-tracheal fascia condensation (Attaches thyroid gland to trachea)
RLN injured at this site during thyroid surgery
2
Q
Methods for Thyroid examination
A
- Pizzillo’s method
- Lahey’s method
- Crile’s method
3
Q
What is Pizzillo’s method?
A
Patient’s hand on the occiput and leans
4
Q
What is Lahey’s method used for?
A
To feel margin of gland
5
Q
What is Crile’s method?
A
To palpate nodules
6
Q
1st investigation in Thyroid Disorders
A
TFT:
T3,T4, TSH
Anti-thyroid antibodies
7
Q
If TSH is normal or increased, then investigation
A
USG Neck -> FNAC (IOC): Cannot differentiate b/w follicular adenoma v/s carcinoma
8
Q
If TSH is decreased, then investigation
A
Thyroid scan
9
Q
Features of Malignant thyroid nodule
A
- Hypoechoic
- Border irregularity
- Microcalcifications
- Inc in intranodular vascularity
- Gross: Abnormal cervical LN (Round shape + Loss of fatty hilum)
10
Q
TIRADS score where FNAC is needed
A
TR3, TR4, TR5 lesions
11
Q
Thyroid FNAC Classification
A
AKA Royal College of Pathologist classification
Similar to Bethesda classification
12
Q
Thy 1 FNAC report
A
Inference: Non diagnostic
Mx: Repeat FNAC under USG guidance
13
Q
Thy 1c FNAC report
A
Inference: Non diagnostic cystic
Mx: Repeat FNAC under USG guidance
14
Q
Thy 2 FNAC report
A
Inference: Non neoplastic (Benign)
Mx: Follow up
15
Q
Thy 3 FNAC report
A
Inference: Follicular
Mx: Hemithyroidectomy
16
Q
Thy 4 FNAC report
A
Inference: Suspicious of malignancy
Mx: Surgery
17
Q
Thy 5 FNAC report
A
Inference: Malignant
Mx: Surgery
18
Q
Criteria for Thyroid specimen
A
At least 6 groups of follicular cells -> Each group composed adequacy of at least 10 cells on a single slide
19
Q
Isotopes used in Thyroid scan
A
Tc99/I123
20
Q
Indications of Thyroid scan
A
- Features of hyperthyroidism and dec in TSH
- Ectopic or aberrant thyroid tissue
21
Q
Thyroid scan in Cold nodule
A
Non-functioning
Inc malignancy risk (20%)
22
Q
Thyroid scan in Hot nodule
A
Hyper functioning
Malignancy risk: 4%
23
Q
Thyroid scan in Toxic multinodular goitre
A
AKA Plummer’s disease
Multiple hot nodules
24
Q
Thyroid scan in Graves’ disease
A
Diffuse inc uptake
25
Thyroid scan in Thyroiditis
Diffuse dec uptake
26
Thyroid scan in Toxic adenoma
Inc uptake at a certain place with differential uptake everywhere
27
What is Thyroglossal cyst?
Persistent thyroglossal tract
M/C location: Subhyoid
28
Long standing thyroglossal cyst can lead to
Papillary Thyroid Carcinoma
29
C/F of Thyroglossal cyst
Midline swelling moves on:
1. Deglutition
2. Tongue protrusion
30
IOC of Thyroglossal cyst
FNAC
31
Management of Thyroglossal cyst
Sistrunk surgery:
Removal of cyst + part of Hyoid bone + tract till base of tongue
32
Types of Thyroidectomy
1. Hemithyroidectomy
2. Subtotal thyroidectomy
3. Near-total thyroidectomy (Hartley-Dunhill procedure)
4. Total thyroidectomy
33
Rose position
Neck extended + 30 deg elevation
34
Approaches to Minimally Invasive Video-Assisted Thyroid Surgery
1. Transaxillary
2. Trans-oral
3. Retroauricular
4. Nipples
35
Indications of Minimally Invasive Video-Assisted Thyroid Surgery
1. <3 cm nodule
2. T1 papillary thyroid cancer
3. Parathyroid adenoma
36
Complications of Thyroid surgery
1. Hemorrhage
2. Nerve injury:
> Ext laryngeal nerve
> Recurrent laryngeal nerve
3. Post-op respiratory distress
37
Ext laryngeal nerve injury d/t Thyroid injury leads to
M/C, goes unnoticed
U/L or B/L: Hoarseness/inability to speak at high pitch (Not life threatening)
38
Recurrent laryngeal nerve injury d/t Thyroid surgery leads to
U/L: Hoarseness of voice
B/L: Stridor, aphonia, breathlessness (Life threatening)
39
M/C cause of Post-op resp distress
Laryngeal edema
40
Other causes of Post-op resp distress
1. Tension Hematoma
2. Reactionary hemorrhage
3. Laryngomalacia
4. B/L RLN injury
5. Hypoparathyroidism: Late cause (>48-72 hours after surgery)
41
How does hypoparathyroidism happen after Thyroid surgery?
D/t vascular insult (ITA) to the gland during surgery
42
C/F of Hypoparathyroidism
Perioral numbness (Initially) -> Tetany (Trousseau sign + and Chvostek sign +) -> Respiratory distress -> Resp muscle paralysis (M/C cause of death)
43
Management of Post op Hypoparathyroidism
1. Monitoring symptoms
2. Serum Ca and PTH levels
3. S.Ca 2+ >8 mg/dl + Minor symptoms: Oral Ca2+ + Oral vit D
4. S.Ca 2+ <8 mg/dl OR Major symptoms: IV Ca gluconate + Oral Ca 2+ + Oral vit D
44
Syndromes associated with Medullary thyroid carcinoma
MEN 2
Gene: RET
45
Syndromes associated with Follicular thyroid carcinoma
1. Cowden syndrome (PTEN)
2. Werner syndrome (WRN)
46
Syndromes associated with Papillary thyroid carcinoma
1. Familial Adenomatous Polyposis (APC)
2. Cowden syndrome (PTEN)
47
Differentiated Thyroid Cancer (DTC) consists of
1. Papillary thyroid carcinoma
2. Follicular thyroid carcinoma
3. Hurthle cell carcinoma
48
M/C Thyroid cancer
Papillary thyroid carcinoma
Best prognosis
49
Spread of PTC
Lymphatic -> Level 6/Delphian LN > Hematogenous -> Lungs (M/C site)
50
Risk factors of PTC
1. Radiation exposure to neck -> More aggressive tumor arises
2. Long standing thyroglossal cyst
3. Genetic: BRAF gene
51
Feature of PTC
Thyroid swelling -> Multifocal (Usually)
52
What is Lindsay tumor?
Follicular variant of PTC
53
What is Lateral aberrant thyroid?
Palpable LN d/t mets from PTC
54
What is Thyroid incidentaloma?
Incidentally detected < 1 cm tumor
55
Histology of PTC
1. Orphan Annie eye/Coffee bean nuclei
2. Intranuclear inclusions
3. Psammoma bodies
56
Psammoma bodies also seen in
1. Serous cystaadenocarcinoma ovary
2. Meningioma
3. Papillary RCC
57
Indications of Hemithyroidectomy
1. Low risk, U/L DTC
2. DTC b/w 1-4 cm
3. No extrathyroidal extension
58
Indications of TT + Central Neck Dissection
Level 6 LN +
59
Indications of Total thyroidectomy
1. Radiation induced DTC
2. Familial non-medullary thyroid Ca
3. Multifocal B/ DTC
4. Extra-thyroidal extension
60
Indication of Prophylactic CND
T3,T4 disease +
61
Indication of TT + CND + Modified radical ND
Other nodes +
62
Post op management
Traditional: Wait 4-6 weeks
New: Recombinant TSH given
When TSH levels inc (>20 IU/L) -> Whole body I2 scan: Residual ds or metastasis
If +: Radioiodine ablation f/b life long follow-up with Thyroxine (TSH suppression) and USG. Neck and S.Tg (6 monthly)
If -: Life long follow-up with Thyroxine (TSH suppression) and USG. Neck and S.Tg (6 monthly)
63
Why is Serum thyroglobulin (S.Tg) important?
Tumor marker for all DTCs
If >2 ng/ml: Suspect recurrence
64
Indications of Radioactive ablation
1. Residual disease +
2. LN +
3. Metastasis +
65
2nd M/C thyroid cancer
Follicular thyroid carcinoma
66
Risk factors of Follicular thyroid carcinoma
1. Long-standing multinodular goitre (Rapid inc in size)
2. Genetics:
> PTEN and BAX gene mutations
> Up-regulation of miRNA 197, 346
67
Spread of FTC
Hematogenous: Bones (M/C site) -> May be Pulsatile (D/t vascularity)
LN: Level 6
68
Management of FTC
FNAC -> Follicular neoplasm (Thy 3) -> Hemithyroidectomy f/b frozen section (For diagnostic confirmation of carcinoma)
If +: Sx approach for DTC + Post op Mx
If -: Close up
69
HPE of Hurthle cell carcinoma
Oxyphilic Hurthle cell + (Mitochondria rich)
70
Prognostic indicators of DTCs
1. AGES system
2. AMES system
3. MACIS (Post-op score)
71
AGES system
Age
Histologic Grade
Extrathyroidal invasion
Size
72
AMES system
Age
Metastases
Extrathyroidal spread
Size of tumors
73
MACIS score
Metastases
Age
Completeness of original Sx resection
Extrathyroidal Invasion
Size of original lesion
74
L/C thyroid cancer
Anaplastic carcinoma
75
C/F of Anaplastic Carcinoma
1. Rapidly enlarging swelling
2. Hoarseness of voice (RLN involved)
3. Stridor (Tracheal compression)
76
Anaplastic carcinoma metastasises to
Lungs (M/C)
77
Management of Anaplastic carcinoma
Restricted to thyroid: Aggressive Sx
Extrathyroidal spread: Palliative Mx; Tracheal compression: Isthmusectomy
78
Origin of Medullary Thyroid Carcinoma
Parafollicular ‘C’ cells (From ultimobranchial bodies of neural crest)
| Do not take up iodine
V
Calcitonin produced (Tumor marker of MTC)
79
Etiology of MTC
Sporadic > Familial (A/w MEN 2 syndrome)
80
Features of MTC
Thyroid swelling +/- diarrhea
Aggressive tumors
81
Spread of MTC
Lymphatic (Level 6 LN) + Hematogenous (M/C: Liver)
82
HPE of MTC
Amyloid rich stoma
83
IOC for MTC
FNAC
84
Surgical Mx of MTC restricted to thyroid
TT + CND
85
Surgical Mx of Thyroid tumor + level 6 LN
TT + CND + MRND
86
Surgical Mx of Thyroid tumor + level 6 LN + other nodes
TT + CND + B/L MRND
87
Surgical Mx of Metastases
Vandetinib
Carbozantinib
88
What is Multiple Endocrine Neoplasia (MEN) syndromes?
Multiple endocrine have cancerous growth not d/t metastasis
89
MEN I Syndrome
AKA Werner syndrome
1. Pituitary adenomas: Prolactinoma (M/C)
2. Parathyroid adenoma (M/C presentation in MEN-I syndrome)
3. Pancreatic endocrine tumors: Gastrinoma (M/C in MEN-I)
Other tumors:
Thymic tumors, collagenomas, adrenal cortical tumors
90
Types of MEN 2 Syndrome
1. MEN 2A/Sipple syndrome
2. MEN 2B/MEN 3 syndrome
3. MEN 4 syndrome
91
MEN 2A Syndrome
1. MTC (M/C)
2. Parathyroid adenoma
3. Pheochromocytoma
4. Megacolon
92
MEN 2B/MEN 3 Syndrome
1. MTC (M/C)
2. Marfanoid feature
3. Mucosal neuromas
4. Megacolon
5. Medullated corneal nerve fibre
93
Treatment of MEN 2A syndrome
Prophylactic thyroidectomy done by 5-6 years of age
94
Treatment of MEN 2B/MEN 3 syndrome
Prophylactic thyroidectomy should be done by 1 year of age
95
MEN 4 syndrome
1. Pituitary adenomas
2. Parathyroid adenomas
3. Renal tumors
4. Adrenocortical tumors
5. Reproductive organ tumors
96
Causes of Hyperthyroidism
1. Grave’s ds: M/C cause
2. Solitary toxic nodule
3. Toxic nodular goitre
4. Factitious hyperthyroidism: Inc exogenous thyroxine intake
5. Jod-Basedow phenomenon: I2 induce hyperthyroidism
6. TSH secreting pituitary adenoma
7. Struma ovarii: Thyroid tissue in ovary (Usually malignant)
97
C/F of Hyperthyroidism
1. Thin and irritable
2. Weight loss despite good appetite
3. Tachycardia
4. Diarrhea
5. Tremors
6. Heat intolerance
98
Management of Hyperthyroidism
1. Drugs only:
> PTU: Safe in 1st pregnancy
> Carbimazole
2. Drugs f/b radioactive iodine (I 131)
2. Drugs f/b Sx (Inadequate preparation prior Sx -> Thyroid storm)
99
Preparation of a hyperthyroid pt for surgery
1. Start anti-thyroid medications 6-8 weeks before surgery
2. Long acting beta blockers should be given: Nadolol
3. Last dose of anti thyroid medication is to be given evening before surgery
4. Beta blockers continued for 7 days post surgery
100
What is Grave’s disease?
Primary thyrotoxicosis
Autoimmune condition
101
AutoAb in Grave’s disease
Long acting thyroid stimulating antibodies
102
Grave’s ds is associated with
1. Pernicious anemia
2. Myasthenia gravis
103
C/F of Grave’s disease
1. Diffuse enlargement of gland
2. Hyperthyroidism, pretibial myxedema
3. Eye signs:
> Stellwag sign
> Von Graefe sign
> Dalrympie sign
> Joffroy sign
> Moebius sign
104
What is Stellwag sign?
Infrequent blinking
Earliest and M/C sign
105
What is Von Graefe sign?
Lid lag d/t spasm of Muller’s muscle
106
What is Dalrymple’s sign?
Lid retraction d/t spasm of Muller’s muscle
107
What is Joffroy’s sign?
No forehead wrinkling on looking up
108
What is Moebius sign?
Loss of accommodation reflex (Severe toxicity)
109
HPE of Grave’s disease
1. Scalloping of colloid
2. Tall columnar cells
110
Management of Grave’s disease in children
Drugs only
111
Management of Grave’s disease in Pregnant women
Anti-thyroid drugs (1st trimester: Only PTU)
112
Management of Grave’s disease in adults
Without goitre: Drugs f/b radio iodine ablation
With goitre: Drugs f/b Sx (Near total/total thyroid Sx)
113
Management of Grave’s disease in Elderly with co morbidities
Drugs f/b radio iodine ablation (RIA)
114
Management of Grave’s disease in Patients with eye signs
Drugs f/b Sx (RIA worsens eye signs)
115
Causes of Hypothyroidism
1. Iodine deficiency: M/C cause overall
2. Hashimoto’s thyroiditis: M/C in western world
3. Wolf-Chaikoff effect: I2 induced hypothyroidism
4. Non-functioning pituitary adenoma
116
C/F of Hypothyroidism
1. Dull
2. Slow,lethargic
3. Cold intolerant
4. Bradycardia
5. Constipation
6. Weight gain
117
Etiology of Hashimoto’s thyroiditis
AKA Lymphocytic thyroiditis
Autoimmune
A/w:
1. Down’s syndrome
2. Turner syndrome
118
C/F of Hashimoto’s thyroiditis
Painless neck swelling
Course: Hashitoxicosis (Inc T3, Inc T4 briefly) -> Prolonged hypothyroidism
119
Investigations of Hashimoto’s thyroiditis
1. AutoAb (Diagnostic) against:
> Thyroid receptor (Blocking)
> Thyroglobulin
> Thyroid peroxidase
2. HPE: Lymphocytic infiltration
120
Treatment of Hashimoto’s thyroiditis
1. Thyroxine replacement
2. Surgery (Diffuse goitre +)
121
Etiology of De Quervain’s thyroiditis
AKA Viral Granulomatous thyroiditis
1. H/o URTI +
2. A/w HLA B35
3. Subacute
122
C/F of De Quervain’s thyroiditis
Painful neck swelling
Course: Hyperthyroidism -> Hypothyroidism -> Euthyroid
123
Investigations of De Quervain’s thyroiditis
Inc in ESR
124
Treatment of De Quervain’s thyroiditis
Supportive care
125
Etiology of Riedel’s thyroiditis
1. IgG4 mediated
2. Fibrous deposition in and around the gland
126
C/F of Riedel’s thyroiditis
Painless neck swelling
1. Woody hard gland
2. Hoarseness of voice (RLN involved)
3. Stridor (Tracheal compression )
127
Investigation of Riedel’s thyroiditis
Trucut biopsy: To rule out Anaplastic thyroid carcinoma
128
Treatment of Riedel’s thyroiditis
Steroids
Tamoxifen
129
What is Goitre?
Thyroid gland enlargement
130
Types of Goitre
1. Diffuse
2. Multinodular
131
Diffuse goitre seen in
1. Puberty, Pregnancy
2. Hashimoto’s thyroiditis
3. Graves’ disease
4. Iodine deficiency (Initial phase)
132
Multinodular goitre seen in
Long standing I2 deficiency (Variable gland stimulation by TSH)
133
Types of Retrosternal goitre
1. Primary mediastinal
2. Secondary retrosternal
134
Feature of Primary mediastinal Retrosternal goitre
Ectopic thyroid tissue in Mediastinum
135
Feature of Secondary Retrosternal goitre
M/C
Starts in neck -> Goes behind sternum (Plunging goitres)
136
Blood supply of Primary mediastinal Retrosternal goitre
Mediastinal goitre
137
Blood supply of Secondary Retrosternal goitre
Neck vessels
Neck incision made -> Ligate neck vessels, gland removed easily
138
C/F of Retrosternal goitre
1. Dyspnea
2. Stridor
3. Pemberton sign
139
Investigation of Retrosternal goitre
CECT Neck/Thorax
140
What is Pemberton sign?
Facial congestion on raising hands above head
141
Management of Retrosternal goitre
Fails
Surgery -> Neck only (Cervical only) —————> Median sternotomy
142
Other indications of Median Sternotomy
1. Primary mediastinal goitre
2. Large malignant retrosternal goitre
3. Recurrence in mediatinum
143
Bones features of Hyperparathyroidism
1. Pathological #
2. Brown tumors (Von Recklinghausen ds of bone)
144
M/C feature seen in Hyperparathyroidism
Multiple + Recurrent renal stones
145
Causes of Primary hyperparathyroidism
Adenoma > Hyperplasia
146
Other C/F of Hyperparathyroidism
1. Abdominal groans: Colicky abdominal pain, pancreatitis
2. Psychiatric overtones
147
Investigations of Primary hyperparathyroidism
1. Biochemical: S.PTH, S.Ca, urinary Ca, urinary PO4 Inc; S.PO4 Dec
2. Imaging: Sestamibi scan (Best type: SPECT -> Localises parathyroid gland)
148
Management of Primary hyperparathyroidism
Sestamibi scan:
Adenoma: Remove affected gland (Miami criteria done)
Hyperplasia:
1. 3 1/2 gland removed
2. 1/2 gland autotransplanted in brachioradialis (M/C) of forearm of non-dominant hand (If recurrence + : Easy removal)
149
What is Miami criteria?
Intra op PTH assay
10-15 mins after Sx
Pre op PTH level ——————————-> PTH level dec by >50% -> Correct gland removed
150
What is Secondary hyperparathyroidism?
Inc in PTH -> Parathyroid hyperplasia, reversible condition
151
Causes of Secondary Hyperparathyroidism
1. Chronic renal failure
2. Defective intestinal absorption
3. Lithium intake
4. Vit D3 deficiency
152
Management of Secondary hyperparathyroidism
1. Correction of CRF
2. Vit D3 supplement
3. Low phosphate diet
4. Cinacalcet
153
What is Pseudohyperparathyroidism?
AKA Hypercalcemia of Malignancy
A/w
M/C paraneoplastic syndrome -> PTH related peptide mediated ———-> SCC lung; Metastatic: Prostate Ca, Breast Ca
154
C/F of Psudohyperparathyroidism
Altered sensorium and dehydration
155
Management of Pseudohyperparathyroidism
F/b
1. IV fluids (1st line) ————> Diuretics (Lasix)
2. DOC: Bisphosphonates (When RFT normal and urine output adequate)
156
What is Adrenal Incidentaloma?
Incidentally detected adrenal tumor
157
Work up of Adrenal Incidentaloma?
1. Serum cortisol
2. Plasma free metanephrines (To rule out pheochromocytoma)
3. Serum DHEA
4. Dexamethasone suppression test (Cushing’s syndrome)
5. Urinary cortisol
If all +: Functional tumor
If all -: Non- functional tumor -> MRI
158
Radiological features suspicious of malignancy
1. Diameter >4 cm and density >10 HU
2. CECT: Wash out
3. MRI chemical shift: No change in signal intensity on out of phase imaging
4. FDG PET: Positive uptake
159
Management of Local invasion of Adrenal Incidentaloma
Yes: Open adrenalectomy
No
No -> Diameter <=6 cm ———-> Individualised Sx approach
| Yes
V
Laparoscopic adrenalectomy
160
Management of Functional tumor
Laparoscopic adrenalectomy
If not: No Sx; Monitor
If imaging shows >25% inc in size: Laparoscopic adrenalectomy
161
What is Pheochromocytoma?
Tumor of adrenal medulla
162
What is Paraganglioma?
Extra adrenal Pheochromocytoma
M/C site: Organ of Zuckerkandl (Sympathetic chain)
163
Rule of 10 in Pheochromocytoma
10% familial
10% bilateral
10% malignant
10% extra adrenal
10% in children
164
Associated syndromes of Pheochromocytoma
1. MEN 2 (M/C)
2. Neurofibromatosis-1
3. Von-Hippel-Lindau syndrome
4. Familial paraganglioma syndrome
165
C/F of Pheochromocytoma
1. Headache (M/C symptom)
2. Sweating
3. Episodic HTN (M/C sign) in young patients
166
Gross appearance of Pheochromocytoma
1. Tan brown colour
2. Areas of necrosis and hemorrhage
167
Young onset HTN D/D
Just study
1. Hyperthyroidism
2. Renal artery stenosis
3. Polycystic kidney disease
4. Pheochromocytoma
168
Investigations of Pheochromocytoma
Screening test: 24 hour urine VMA
IOC: Serum plasma free metanephrines
Imaging IOC: MRI (Light bulb sign)
IOC for Extra adrenal Pheochromocytoma: Gallium dotatate scan
169
Management of Pheochromocytoma
1. Alpha blockade f/b Beta blockade
Phenoxybenzamine (Alpha blocker) -> Inc dose gradually till postural hypotension +
2. Sx: Laparoscopic/Open adrenalectomy (Open Sx if malignancy +)
170
M/C abdominal malignancy in children
Neuroblastoma > Wilm’s tumor
171
Site of Neuroblastoma
Adrenal medulla > Sympathetic chain
172
Genetics involved with Neuroblastoma
N-myc amplication
173
C/F of Neuroblastoma
1. Abdominal lump crossing midline (Wilm’s tumor: Does not cross)
2. >50% present with metastasis
174
Metastatic features of Neuroblastoma
1. Blueberry muffin lesions on skin
2. Raccoon eyes
175
Investigations of Neuroblastoma
IOC: MRI (Tumor site, intratumoral calcifications +)
176
Management of Neuroblastoma
Chemotherapy and Sx
177
Carcinoids are AKA
Neuroendocrine tumors
178
Site of Carcinoids
Appendix > Small bowel
179
Types of Carcinoids
1. Foregut/Bronchial carcinoids
2. Midgut carcinoids
3. Hindgut carcinoids
180
Site of Carcinoids
Foregut/Bronchial carcinoids: Stomach, duodenal
Midgut carcinoids: Appendix, ileum
Hindgut carcinoids: Colon, rectum
181
Metastasis of Carcinoids
Foregut/Bronchial carcinoids: Lungs (M/C)
Midgut carcinoids: Liver
Hindgut carcinoids: Liver
182
Carcinoid syndrome is
Foregut carcinoids: Uncommon
Midgut & Hindgut carcinoids: If liver metastasis +
183
Features of Carcinoids
1. Cutaneous flushing (M/C)
2. Abdominal pain, sweating
184
What is Carcinoid syndrome?
Serotonin enters in circulation:
1. Bronchospasm
2. Right heart valve involved: Tricuspid valve (M/C)
185
Investigations of Carcinoids
Urine: 5-Hydroxy indole acetic acid
Blood: Serum chromogranin
Imaging:
1. CECT
2. Serotonin receptor Scintigraphy (Localise tumor)
186
Management of Carcinoids
F/b. If inc levels
Sx ——>Ki67—————> Malignant NET -> Require ChemoRx
187
Appendicular carcinoid Mx
Just study
<2 cm, away from base: Simple appendicectomy
>2 cm, close to base: Right hemicolectomy
