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Title: ABSITE Review Thyroid Parathyroid Adrenal


1
ABSITE ReviewThyroidParathyroidAdrenal
  • January 26, 2012

2
Rapid Fire
3
Blood supply to the thyroid?
  • Superior thyroid artery
  • 1st branch of external carotid
  • Inferior thyroid artery
  • From thyrocervical trunk
  • Ima artery
  • From innominate or aorta

4
The recurrent laryngeal nerve loops around what?
  • Right subclavian (sometimes innominate)
  • Aorta on left

5
If you find a non-recurrent nerve, which side is
it more likely to be on?
  • Right

6
Medications for treating hyperthyroidism? How do
they work?
  • PTU (propylthiouracil)
  • Inhibit peroxidases, preventing DIT MIT
    coupling
  • Inhibits peripheral conversion of T4 to T3
  • Methimazole
  • Inhibit peroxidases, preventing DIT MIT
    coupling
  • Methimazole has longer half life, PTU is less
    likely to cross placenta

7
Most common cause of hypothyroidism?
  • Hashimotos thyroiditis
  • Path lymphocytic infiltrate
  • Enlarged, painless, chronic thyroiditis

8
Most common thyroid cancer?
  • Papillary
  • Least aggressive, slow growing, best prognosis
  • Path psammoma bodies, orphan annie nuclei

9
Thyroid cancer with hematogenous spread?
  • Follicular
  • Spread to bone most common
  • More aggressive than papillary

10
Thyroid cancer associated with MEN?
  • Medullary
  • Arise from parafollicular cells
  • Path amyloid deposition
  • Gastrin causes increased calcitonin in medullary
    thyroid cancer

11
Treatment for medullary thyroid cancer?
  • Total thyroidectomy with central neck dissection
  • Monitor disease recurrence with calcitonin
  • Clinically lymph nodes B/L MRND
  • MEN proph thyroidectomy central neck by age 2

12
Thyroid cancer with worst prognosis?
  • Anaplastic
  • If resectable, do total thyroidectomy

13
Treatment for papillary thyroid cancer?
  • lt1cm lobectomy
  • gt1cm total thyroidectomy
  • Special circumstances
  • Bilateral lesions, multicentricity, history of
    XRT, positive margins
  • Total thyroidectomy
  • I-131 metastatic disease, residual local
    disease, lymph nodes, capsular invasion

14
Treatment for follicular thyroid cancer?
  • lt1cm lobectomy
  • gt1cm total thyroidectomy
  • I-131 for gt1cm, extrathyroidal disease

15
Embryologic origin of parathyroids?
  • Superior parathyroids
  • 4th branchial pouch
  • Inferior parathyroids
  • 3rd branchial pouch

16
Blood supply to parathyroids?
  • Inferior thyroid artery

17
Is PTH high or low inprimary hyperparathyroidism
?secondary hyperparthyroidism?tertiary
hyperparathyroidism?
  • Primary
  • High
  • Secondary
  • Low
  • Tertiary
  • High

18
Treatment of parathyroid cancer?
  • En bloc resection parathyroidectomy
    ipsilateral thyroidectomy

19
Which adrenal vein goes directly into IVC?
  • Right adrenal vein

20
In pheochromocytoma, what drug should be given
preoperatively?
  • Phenoxybenzamine
  • Alpha blocker
  • Do not give beta blocker before alpha blocker ?
    hypertensive crisis

21
What is produced by parafollicular cells?
  • Calcitonin

22
What is the most sensitive indicator of thyroid
function?
  • TSH

23
What is the function of the recurrent laryngeal
nerve?
  • Motor to all muscle of larynx except
    cricopharyngeus

24
What is the most common cause of hypercortisolism?
  • Iatrogenic

25
What is the most common endogenous
(non-iatrogenic) cause of hypercortisolism?
  • Pituitary adenoma

26
What lab values are seen with primary
hyperaldosteronism?
  • Serum K low, urine K high
  • Serum Na high
  • Plasma renin low
  • Aldosteronerenin gt20

27
What is the treatment for adrenocortical
carcinoma?
  • Radical adrenalectomy
  • Residual or recurrent disease
  • Mitotane treats endocrine symptoms, has caused
    tumor regression in some

28
What is the rate limiting step in catecholamine
production?
  • Tyrosine hydroxylase

29
(No Transcript)
30
What is the Rule of 10s?
  • Pheochromocytoma
  • 10 malignant
  • 10 bilateral
  • 10 familial
  • 10 extra-adrenal
  • 10 in children

31
What is MEN-1?
  • Parathyroid hyperplasia
  • Pancreatic islet cell tumor
  • Pituitary adenoma

32
What is the most common pancreatic islet cell
tumor in MEN-1?
  • Gastrinoma

33
What is the most common pancreatic islet cell
tumor overall?
  • Insulinoma

34
What do you fix first in MEN-1?
  • Parathyroid disease

35
What is MEN-2A?
  • Parathyroid hyperplasia
  • Pheochromocytoma
  • Medullary thyroid cancer

36
What is MEN-2B?
  • Pheochromocytoma
  • Medullary thyroid cancer
  • Mucosal neuromas
  • Marfanoid body habitus

37
What do you fix first in MEN-2A and 2B?
  • Pheochromocytoma

38
What gene mutation is associated with MEN-1?
  • MENIN gene

39
What gene mutation is associated with MEN-2?
  • RET proto-oncogene

40
What labs values are seen with Familial
Hypercalcemic Hypocaliuria?
  • High serum Ca, low urine Ca
  • Urine Ca should be high in hyperparathyroidism
  • Normal PTH
  • Caused by defect in PTH receptor in distal
    convoluted tubule causing increased reabsorption
    of calcium

41
When do you do a parathyroidectomy for Familial
Hypercalcemia Hypocalciuria?
  • Never

42
What are the layers of the adrenal cortex what
is produced by each?
  • Zona glomerulosa
  • Mineralcorticoids (aldosterone)
  • Zona fasciculata
  • Glucocorticoids
  • Zona reticularis
  • Androgens/estrogens

43
What ezyme converts norepinephrine to
epinephrine? Where is it found?
  • PMNT
  • Adrenal medulla and Organ of Zuckerkandl

44
The anatomic relationship of the parathyroid
glands to the recurrent laryngeal nerve can be
described as
  1. Both the superior inferior glands are
    posterolateral to the nerve
  2. The superior glands are anteromedial and inferior
    glands are posterolateral to it
  3. Both the superior inferior glands are
    anteromedial to the nerve
  4. The superior glands are posterolateral and
    inferior glands are anteromedial to it
  5. The superior glands are posteromedial and
    inferior glands are anterolateral to it

45
The anatomic relationship of the parathyroid
glands to the recurrent laryngeal nerve can be
described as
  1. Both the superior inferior glands are
    posterolateral to the nerve
  2. The superior glands are anteromedial and inferior
    glands are posterolateral to it
  3. Both the superior inferior glands are
    anteromedial to the nerve
  4. The superior glands are posterolateral and
    inferior glands are anteromedial to it
  5. The superior glands are posteromedial and
    inferior glands are anterolateral to it

46
A 63yo man has symptoms of Cushings syndrome.
Labs show an elevated cortisol level with a
slightly elevated plasma ACTH. A high dose
dexamethasone suppression test shows suppression
of ACTH and decreased cortisol. The condition
most likely responsible is
  1. Adrenal carcinoma
  2. Pituitary adenoma
  3. Ectopic ACTH producing tumor
  4. Bilateral adrenal hyperplasia
  5. Adrenal adenoma

47
A 63yo man has symptoms of Cushings syndrome.
Labs show an elevated cortisol level with a
slightly elevated plasma ACTH. A high dose
dexamethasone suppression test shows suppression
of ACTH and decreased cortisol. The condition
most likely responsible is
  1. Adrenal carcinoma
  2. Pituitary adenoma
  3. Ectopic ACTH producing tumor
  4. Bilateral adrenal hyperplasia
  5. Adrenal adenoma

48
Hypercortisolism Causes
  • Pituitary
  • Adrenal cancer, adenoma, hyperplasia
  • Ecotopic ACTH producing tumor

49
Hypercortisolism Work-up
  • 24hr urine cortisol
  • Low-dose dexamethasone suppression test
  • Suppression is normal
  • Failure to suppress confirms Cushings syndrome
  • ACTH measurement
  • Is it ACTH dependent or independent?
  • Low ACTH suggests adrenal cause
  • High ACTH pituitary or ectopic ACTH producing
    tumor
  • High-dose dexamethasone suppression test
  • Suppression suggests pituitary cause
  • Failure to suppress suggests ectopic ACTH
    producing tumor
  • CRH test
  • Used if still cant tell from above tests
  • ACTH will increase with pituitary tumor, no
    change in ACTH in ectopic ACTH producing tumor

50
A patient with a 1cm medullary carcinoma of the
right thyroid and no clinically significant
adenopathy is best treated with
  1. Total thyroidectomy with central lymph node
    dissection
  2. Right thyroid lobectomy and isthmusectomy
  3. Total thyroidectomy
  4. Right thyroid lobectomy and subtotal left
    thyroidectomy

51
A patient with a 1cm medullary carcinoma of the
right thyroid and no clinically significant
adenopathy is best treated with
  • Total thyroidectomy with central lymph node
    dissection
  • Right thyroid lobectomy and isthmusectomy
  • Total thyroidectomy
  • Right thyroid lobectomy and subtotal left
    thyroidectomy
  • MTC has high incidence of multicentricity, more
    aggressive course, I-131 isnt effective. For
    palpable lymph node in this case, do MRND.

52
What is the most common cause of congenital
adrenal hyperplasia?
  1. 17-hydroxylase deficiency
  2. 21-hydroxylase deficiency
  3. 11-hydroxylase deficiency
  4. 18-hydroxylase deficiency

53
What is the most common cause of congenital
adrenal hyperplasia?
  1. 17-hydroxylase deficiency
  2. 21-hydroxylase deficiency
  3. 11-hydroxylase deficiency
  4. 18-hydroxylase deficiency

54
21-hydroxylase
55
All of the following are direct effects of PTH
except
  1. Stimulates absorption of calcium by the small
    intestine
  2. Stimulates resorption of calcium phosphate from
    bone
  3. Stimulates reabsorption of calcium by the kidney
  4. Stimulates hydroxylation of 25-hydroxyvitamin D
    in the kidney

56
All of the following are direct effects of PTH
except
  1. Stimulates absorption of calcium by the small
    intestine
  2. Stimulates resorption of calcium phosphate from
    bone
  3. Stimulates reabsorption of calcium by the kidney
  4. Stimulates hydroxylation of 25-hydroxyvitamin D
    in the kidney

57
Effects of PTH
  • Stimulates calcium reabsorption in the kidney
    (distal convoluted tubule)
  • Activates osteoclasts ? bone resorption ?
    elevation of serum calcium
  • Inhibits reabsorption of phosphate by the kidney
  • Stimulates renal production of active vitamin D
    via 1-alpha-hydroxylase
  • Indirect stimulation of calcium reabsorption from
    gut via actions of vitamin D

58
The most important test in the work-up of a
solitary thyroid nodule is
  1. Sestamibi scan
  2. FNA
  3. Thyroid function tests
  4. CT scan
  5. Ultrasound

59
The most important test in the work-up of a
solitary thyroid nodule is
  1. Sestamibi scan
  2. FNA
  3. Thyroid function tests
  4. CT scan
  5. Ultrasound

60
A 60yo woman presents with a history of kidney
stones and serum calcium is 11. The most likely
diagnosis is
  1. Parathyroid adenoma
  2. Parathyroid hyperplasia
  3. Parathyroid cancer
  4. Breast cancer with bone metastasis
  5. Secondary hyperparathyroidism

61
A 60yo woman presents with a history of kidney
stones and serum calcium is 11. The most likely
diagnosis is
  1. Parathyroid adenoma
  2. Parathyroid hyperplasia
  3. Parathyroid cancer
  4. Breast cancer with bone metastasis
  5. Secondary hyperparathyroidism

62
A 60yo woman presents with a history of kidney
stones and a palpable neck mass. Her serum
calcium is 14.1. The most likely diagnosis is
  1. Parathyroid adenoma
  2. Parathyroid hyperplasia
  3. Parathyroid cancer
  4. Breast cancer with bone metastasis
  5. Secondary hyperparathyroidism

63
A 60yo woman presents with a history of kidney
stones and a palpable neck mass. Her serum
calcium is 14.1. The most likely diagnosis is
  1. Parathyroid adenoma
  2. Parathyroid hyperplasia
  3. Parathyroid cancer
  4. Breast cancer with bone metastasis
  5. Secondary hyperparathyroidism

64
Dissection of the superior thyroid arteries
during total thyroidectomy is most likely to
result in which of the following complications?
  1. Aspiration
  2. Voice fatigue
  3. Hoarseness
  4. Stridor
  5. Loss of airway

65
Dissection of the superior thyroid arteries
during total thyroidectomy is most likely to
result in which of the following complications?
  1. Aspiration
  2. Voice fatigue
  3. Hoarseness
  4. Stridor
  5. Loss of airway

66
After total thyroidectomy for follicular thyroid
cancer, the best test to monitor for recurrent
disease is
  1. Serum calcitonin
  2. Ultrasound of the neck
  3. Serum thyroglobulin
  4. Serum TSH
  5. I-131 scan

67
After total thyroidectomy for follicular thyroid
cancer, the best test to monitor for recurrent
disease is
  1. Serum calcitonin
  2. Ultrasound of the neck
  3. Serum thyroglobulin
  4. Serum TSH
  5. I-131 scan

68
A 73yo woman with perforated diverticulitis s/p
Hartmanns procedure with sepsis develops
increasing pressor requirements you suspect
adrenal insufficiency. What initial test can
help you make the diagnosis?
  1. Cosyntropin stimulation test
  2. Serum cortisol
  3. 24hr urine cortisol
  4. Basic metabolic panel
  5. 24hr urine metanephrines

69
A 73yo woman with perforated diverticulitis s/p
Hartmanns procedure with sepsis develops
increasing pressor requirements you suspect
adrenal insufficiency. What initial test can
help you make the diagnosis?
  • Cosyntropin stimulation test
  • Serum cortisol
  • 24hr urine cortisol
  • Basic metabolic panel
  • 24hr urine metanephrines
  • BMP should reveal hyperkalemia, hyponatremia,
    hyperglycemia

70
Which of the following tests to evaluate for
pheochromocytoma has the highest sensitivity?
  1. Plasma catecholamines
  2. Urine catecholamines
  3. Urinary total metanephrines
  4. Urinary VMA
  5. Urinary free metanephrines normetanephrines
  6. 24hr urine cortisol

71
Which of the following tests to evaluate for
pheochromocytoma has the highest sensitivity?
  1. Plasma catecholamines
  2. Urine catecholamines
  3. Urinary total metanephrines
  4. Urinary VMA
  5. Urinary free metanephrines normetanephrines
  6. 24hr urine cortisol
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