Rapid Fire

1. Rapid Fire

2. 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

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

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

5. 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

6. Most common cause of hypothyroidism? Hashimoto’s thyroiditis Path: lymphocytic infiltrate Enlarged, painless, chronic thyroiditis

7. Most common thyroid cancer? Papillary Least aggressive, slow growing, best prognosis Path: psammoma bodies, orphan annie nuclei

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

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

10. 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

11. Thyroid cancer with worst prognosis? Anaplastic If resectable, do total thyroidectomy

12. Treatment for papillary thyroid cancer? <1cm – lobectomy >1cm – 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

13. Treatment for follicular thyroid cancer? <1cm – lobectomy >1cm – total thyroidectomy I-131 for >1cm, extrathyroidal disease

14. Embryologic origin of parathyroids? Superior parathyroids 4th branchial pouch Inferior parathyroids 3rd branchial pouch

15. Blood supply to parathyroids? Inferior thyroid artery

16. Is PTH high or low in…primary hyperparathyroidism?secondary hyperparthyroidism?tertiary hyperparathyroidism? Primary High Secondary Low Tertiary High

17. Treatment of parathyroid cancer? En bloc resection – parathyroidectomy & ipsilateral thyroidectomy

18. Which adrenal vein goes directly into IVC? Right adrenal vein

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

20. What is produced by parafollicular cells? Calcitonin

21. What is the most sensitive indicator of thyroid function? TSH

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

23. What is the most common cause of hypercortisolism? Iatrogenic

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

25. What lab values are seen with primary hyperaldosteronism? Serum K low, urine K high Serum Na high Plasma renin low Aldosterone:renin >20

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

27. What is the rate limiting step in catecholamine production? Tyrosine hydroxylase

29. What is the Rule of 10s? Pheochromocytoma 10% malignant 10% bilateral 10% familial 10% extra-adrenal 10% in children

30. What is MEN-1? Parathyroid hyperplasia Pancreatic islet cell tumor Pituitary adenoma

31. What is the most common pancreatic islet cell tumor in MEN-1? Gastrinoma

32. What is the most common pancreatic islet cell tumor overall? Insulinoma

33. What do you fix first in MEN-1? Parathyroid disease

34. What is MEN-2A? Parathyroid hyperplasia Pheochromocytoma Medullary thyroid cancer

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

36. What do you fix first in MEN-2A and 2B? Pheochromocytoma

37. What gene mutation is associated with MEN-1? MENIN gene

38. What gene mutation is associated with MEN-2? RET proto-oncogene

39. 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

40. When do you do a parathyroidectomy for Familial Hypercalcemia Hypocalciuria? Never

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

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

43. The anatomic relationship of the parathyroid glands to the recurrent laryngeal nerve can be described as • Both the superior & inferior glands are posterolateral to the nerve • The superior glands are anteromedial and inferior glands are posterolateral to it • Both the superior & inferior glands are anteromedial to the nerve • The superior glands are posterolateral and inferior glands are anteromedial to it • The superior glands are posteromedial and inferior glands are anterolateral to it

44. The anatomic relationship of the parathyroid glands to the recurrent laryngeal nerve can be described as • Both the superior & inferior glands are posterolateral to the nerve • The superior glands are anteromedial and inferior glands are posterolateral to it • Both the superior & inferior glands are anteromedial to the nerve • The superior glands are posterolateral and inferior glands are anteromedial to it • The superior glands are posteromedial and inferior glands are anterolateral to it

45. A 63yo man has symptoms of Cushing’s 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 • Adrenal carcinoma • Pituitary adenoma • Ectopic ACTH producing tumor • Bilateral adrenal hyperplasia • Adrenal adenoma

46. A 63yo man has symptoms of Cushing’s 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 • Adrenal carcinoma • Pituitary adenoma • Ectopic ACTH producing tumor • Bilateral adrenal hyperplasia • Adrenal adenoma

47. Hypercortisolism – Causes • Pituitary • Adrenal – cancer, adenoma, hyperplasia • Ecotopic ACTH producing tumor

48. Hypercortisolism Work-up • 24hr urine cortisol • Low-dose dexamethasone suppression test • Suppression is normal • Failure to suppress confirms Cushing’s 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 can’t tell from above tests • ACTH will increase with pituitary tumor, no change in ACTH in ectopic ACTH producing tumor

49. 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

50. 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 isn’t effective. For palpable lymph node in this case, do MRND.