1. ABSITE Review Thyroid Parathyroid Adrenal
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
Methimazole has longer half life, PTU is less likely to cross placenta

7. Most common cause of hypothyroidism?
Hashimoto’s 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?
<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

14. Treatment for follicular thyroid cancer?
<1cm – lobectomy
>1cm – total thyroidectomy
I-131 for >1cm, 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 in… primary hyperparathyroidism
Is PTH high or low in… primary hyperparathyroidism? secondary hyperparthyroidism? tertiary hyperparathyroidism?
Primary
High
Secondary
Low
Tertiary

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
Aldosterone:renin >20

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

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
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. 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

46. A 63yo man has symptoms of Cushing’s syndrome
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. A 63yo man has symptoms of Cushing’s syndrome
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

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 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

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

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

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

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

54. 21-hydroxylase

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

56. All of the following are direct effects of PTH except
Stimulates absorption of calcium by the small intestine
Stimulates resorption of calcium & phosphate from bone
Stimulates reabsorption of calcium by the kidney
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
Sestamibi scan
FNA
Thyroid function tests
CT scan
Ultrasound

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

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

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

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

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

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

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

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

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

68. A 73yo woman with perforated diverticulitis s/p Hartmann’s 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

69. A 73yo woman with perforated diverticulitis s/p Hartmann’s 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?
Plasma catecholamines
Urine catecholamines
Urinary total metanephrines
Urinary VMA
Urinary free metanephrines & normetanephrines
24hr urine cortisol

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