Download - Endocrine Surgery MCQ.docx
-
8/16/2019 Endocrine Surgery MCQ.docx
1/71
Endocrine Surgery MCQ1. When progressive enlargement of a multinodular goiter causes
symptomatic tracheal compression, the preferred management in otherwise
good-ris patients is!
". #odine treatment.
$. %hyroid hormone treatment.
C. Surgical resection of the a&normal thyroid.
'. (adioactive iodine treatment.
"nswer! C
'#SC)SS#*+! When a multinodular goiter enlarges enough to cause
symptoms of tracheal compression, surgical treatment is usually reuired if
the patient is considered a reasona&le operative ris. Medical treatment may
&e effective in preventing the initial growth of the goiter &ut is unliely to
cause enough regression to relieve symptoms. (adioactive iodine can
occasionally &e used to cause some regression in patients who are poor
anesthesia riss, &ut this is a temporiing treatment rather than a definitive
one.
. %he most precise diagnostic screening procedure for differentiating &enign
thyroid nodules from malignant ones is!
". %hyroid ultrasonography.
$. %hyroid scintiscan.
C. /ine-needle-aspiration &iopsy 0/+"$.
'. %hyroid hormone suppression.
"nswer! C
'#SC)SS#*+! "nalysis of multiple series in which patients with thyroid
nodules have undergone /+"$ has demonstrated a false-negative rate of
-
8/16/2019 Endocrine Surgery MCQ.docx
2/71
.23 and a false-positive rate of 4.43. Sensitivity for this method is 536
specificity 723. %his surpasses the other methods for accurate selection of
patients who reuire surgical resection.
4. %he preferred operation for initial management of a thyroid nodule that is
considered suspicious for malignancy &y /+"$ is!
". E8cision.
$. 9artial lo&ectomy.
C. %otal lo&ectomy and isthmusectomy.
'. %otal thyroidectomy.
"nswer! C
'#SC)SS#*+! %here is a consensus that the initial minimum operation for a
nodule suspected to &e malignant is total lo&ectomy and isthmusectomy.
9artial lo&ectomy or e8cision of the nodule is associated with a higher ris of
local recurrence if the nodule proves to &e malignant. (eoperation on the side
of a partial lo&ectomy can &e technically difficult and associated with a
higher ris of recurrent nerve in:ury. *rdinarily, total thyroidectomy is not
performed until a conclusive diagnosis of malignancy is esta&lished.
2. "dvantages of total thyroidectomy for management of papillary
carcinomas of the thyroid larger than 1.; cm. include!
". 9ossi&ility of using radioactive iodine postoperatively to identify and treat
metastases.
$. %he a&ility to use thyroglo&ulin levels as a marer for recurrence.
C.
-
8/16/2019 Endocrine Surgery MCQ.docx
3/71
efficiently &ecause of the a&sence of normal thyroid tissue, which has greater
affinity for iodine than papillary carcinoma tissue. When all normal thyroid
tissue is removed, serum thyroglo&ulin, which is produced &y normal and
malignant thyroid tissue, &ecomes a more effective marer for recurrence.
%he overall recurrence rate is lower for patients undergoing total
thyroidectomy, &ut the ris of hypoparathyroidism is higher for patients who
have total thyroidectomy instead of unilateral lo&ectomy.
;. Which of the following statements a&out follicular carcinoma is=are true>
". #t presents at a later age than papillary carcinoma.
$. #t disseminates via hematogenous routes.C. #t is the most common type of well-differentiated thyroid carcinoma.
'. E8tensive angioinvasion portends a poor prognosis.
E. /ollicular carcinomas are freuently multicentric.
"nswer! "$'
'#SC)SS#*+! /ollicular carcinoma is more common in older patients 0pea
incidence in the fifth decade. %he tumor has a mared propensity for
vascular invasion and spreads hematogenously to &one, lung, liver, andcentral nervous system sites.
-
8/16/2019 Endocrine Surgery MCQ.docx
4/71
of C-cell hyperplasia in areas of the gland ad:acent to foci of M%C.
'. "ll of the a&ove.
"nswer! '
'#SC)SS#*+! Sporadic M%C is unilateral in at least @A3 of cases.
Bowever, in patients with M%C occurring as a component of the multiple
endocrine neoplasia 0ME+ type " or type $ syndromes, the tumor is
virtually always multifocal and &ilateral. %ypically, in this setting the M%C
appears as multiple whitish-tan tumor nodules in the middle and upper thirds
of each thyroid lo&e.
" diffuse premalignant proliferation of the C cells of the thyroid is thought to
precede the development of M%C in patients with familial M%C. %his proliferation, nown as C-cell hyperplasia 0CCB, consists of parafollicular
clusters of increased num&ers of C cells. %he finding of CCB in areas of the
thyroid ad:acent to gross foci of M%C is strong evidence for familial M%C.
7. "ll of the following are components of the ME+ type $ syndrome
e8cept!
". Multiple neuromas on the lips, tongue, and oral mucosa.$. Byperparathyroidism.
C. M%C.
'. 9heochromocytoma.
"nswer! $
'#SC)SS#*+! M%C and pheochromocytoma occur in &oth ME+ " and
ME+ $ syndromes. 9atients with ME+ " may also develop hyperplasia of
the parathyroid glands. "lthough some investigators have reported euivocal
histologic a&normalities in the parathyroid glands of patients with ME+ $,
hyperparathyroidism is not a component of this syndrome.
#n contrast to patients with ME+ ", those with ME+ $ have a
characteristic phenotype, including a tall, thin marfanoidD ha&itus. 9atients
-
8/16/2019 Endocrine Surgery MCQ.docx
5/71
with ME+ $ also develop multiple neuromas on the lips, tongue, and oral
mucosa, creating the appearance of thic lips.
@. ME+ " and ME+ $ syndromes are associated with germline mutations
in!
". %he p;4 tumor suppressor gene.
$. %he B-ras gene.
C. %he +-myc gene.
'. %he (E% proto-oncogene.
"nswer! '
'#SC)SS#*+! ermline mutations in the (E% protooncogene, a receptor
tyrosine inase that maps to chromosome 1A, are associated with ME+ "
and ME+ $ syndromes. Bomoygous loss of the tumor suppressor gene p;4
is associated with the
-
8/16/2019 Endocrine Surgery MCQ.docx
6/71
'#SC)SS#*+! %he pathologic change in the pancreas of patients with ME+
1 is typically multicentric. 'iffuse hyperplasia of islet cells and
microadenoma formation are often identified in areas of the gland distant
from grossly evident tumor. %umors are commonly multifocal. #slet cell
neoplasms of the pancreas occur in 4A3 to @A3 of patients with ME+ 1. %he
most common islet cell neoplasm in these patients is gastrinoma.
astrinomas associated with ME+ 1 pro&a&ly account for A3 to ;A3 of all
cases of the Follinger-Ellison syndrome. %he second most common islet cell
tumor is insulinoma. *ther pancreatic islet cell neoplasms, such as
glucagonoma, somatostatinoma, or vasoactive intestinal polypeptide
neoplasm 0G#9oma, are rarely associated with ME+ 1. "ppro8imately 1A3
of insulinomas and appro8imately 1;3 or more of gastrinomas in patientswith ME+ 1 are malignant.
1A. Which of the following statements a&out the differential diagnosis of
hypercalcemia is=are correct.
". Malignant tumors typically cause hypercalcemia &y ectopic production of
parathyroid hormone 09%B.
$. %he diagnosis of primary hyperparathyroidism is supported &y these serumlevels! calcium, 1A.@ mg. per dl.6 chloride, 1A2 mmol. per liter6 &icar&onate
1 mmol. per liter6 phosphorus, .2 mg. per dl.6 elevated parathyroid
hormone.
C. /amilial hypocalciuric hypercalcemia is distinguished from primary
hyperparathyroidism &y parathyroid imaging.
'. "lthough serum al&umin &inds calcium, the measured total calcium value
is usually unaffected in patients with severe hypoproteinemia.
E. %hiaide diuretics are a good treatment for hypercalcemia and can &e
given to patients with apparent hypercalcemia of malignancy.
"nswer! $
'#SC)SS#*+! Malignant tumors rarely secrete 9%B itself6 they can secrete
-
8/16/2019 Endocrine Surgery MCQ.docx
7/71
9%Br9 or cytoine activators of osteoclast activity. %he diagnosis of primary
hyperparathyroidism is supported &y hypercalcemia with mild
hyperchloremic meta&olic acidosis and a chloride-phosphate ratio greater
than 44 or a modified chloride 0mmol. per liter=mg. per dl. phosphate ratio
greater than ;AA. /amilial hypocalciuric hypercalcemia is distinguished from
primary hyperparathyroidism &y a low urine calcium. Serum calcium changes
appro8imately A.@ mg. per dl. for every 1 gm. per dl. change in serum
al&umin. %hiaide diuretics can cause hypercalcemia and should not &e given
to patients who are hypercalcemic.
11. #ndications for operation in a patient with previously asymptomatichyperparathyroidism include!
". "ge older than ?A.
$. +ephrolithiasis.
C. " su&stantial decline in renal function.
'. " su&stantial decline in &one mass.
E. 'epression and fatigue.
"nswer! $C'E
'#SC)SS#*+! "ge younger than ;A is considered an indication for
operation.
1. %he parathyroid glands!
". 'evelop from the second and third pharyngeal pouches, along with the
palatine tonsil and the thymus.
$. Migrate caudally in the nec in normal development &ut can &e found
anywhere from the pharyngeal mucosa to the deep mediastinum.
C. Secrete 9%B and calcitonin to manage calcium homeostasis.
'. )sually num&er four, &ut freuently num&er only two or three.
E. Contain enymes that catalye the conversion of ;0*B vitamin ' 4 to
-
8/16/2019 Endocrine Surgery MCQ.docx
8/71
1,;0*B vitamin ' 4.
"nswer! $
'#SC)SS#*+! %he parathyroid glands develop from the third and fourth
pharyngeal pouches, along with the thymus and the thyroid ultimo&ronchial
&ody6 there are four glands in the vast ma:ority of persons. Calcitonin is
secreted &y the C cells of the thyroid. Gitamin ' 4 hydro8ylation occurs in
the idney.
14. Byperparathyroidism can affect which of the following organs and &ody
systems>". astrointestinal tract.
$. Hidneys.
C. Seleton.
'. +euromuscular system.
E. Cardiovascular system.
"nswer! "$C'E
'#SC)SS#*+! astrointestinal involvement includes pancreatitis and pepticulcer disease. %he idneys can &e affected &y nephrocalcinosis or
nephrolithiasis. %he &ones can &e severely affected &y &one resorption.
+euromuscular complaints can include weaness and fatigue. Bypertension
is present in as many as 7A3 of people with hyperparathyroidism and may &e
related to the renal disease.
12. Secondary hyperparathyroidism!
". #s a meta&olic disease in which the primary a&normality is decreased
glomerular filtration rate.
$. #s &est treated initially &y su&total parathyroidectomy.
C. #s caused &y increased production of 1,;0*B vitamin ' 4, causing
-
8/16/2019 Endocrine Surgery MCQ.docx
9/71
increasing intestinal calcium a&sorption and hypercalcemia.
'. Can have severe effects on &ones e8acer&ated &y aluminum contained in
phosphate &inders and dialysate water.
E. #s &est treated initially &y total parathyroidectomy with
autotransplantation.
"nswer! "'
'#SC)SS#*+! Secondary hyperparathyroidism is caused &y renal disease,
including decreased glomerular filtration rate and decreased 1,;0*B
vitamin ' 4 production. #t is &est treated &y medical management restricting
dietary phosphate, administering vitamin ' and calcium with phosphate-
&inding gels, and limiting aluminum e8posure, which can e8acer&ate &onedisease.
1;. Bypoparathyroidism!
". #s most commonly encountered as a postviral syndrome.
$. Can &e associated with mared hypocalcemia after parathyroidectomy in
patients with &one disease.
C. Can cause an8iety, depression, or confusion.'. Can cause physical signs such as ChvosteIs and %rousseauIs signs.
E. #s treata&le acutely with intravenous calcium salts and chronically with
oral calcium and vitamin '.
"nswer! $C'E
'#SC)SS#*+! Bypoparathyroidism is most commonly encountered after
thyroid surgery. #t can &e temporarily severe after parathyroidectomy in
patients with &one disease 0postoperative &one hungerD. %he signs and
symptoms can include an8iety, depression, confusion, ChvosteIs sign, and
%rousseauIs sign, as well as circumoral or e8tremity tingling, tetany with
carpopedal spasms, or seiures. %reatment is as noted.
-
8/16/2019 Endocrine Surgery MCQ.docx
10/71
1?. %rue statements a&out pituitary anatomy and physiology include!
". %he pituitary has dual em&ryonic origin! the anterior pituitary arises from
em&ryonic ectoderm6 the posterior pituitary, from the diencephalon.
$. %he hypophyseal portal system integrates function of the anterior and
posterior pituitary.
C. "drenocorticotropin 0"C%B, formed &y posttranslational processing of
the precursor 9*MC, is normally controlled &y hypothalamic C(/ &ut may
&e released &y immune-related mechanisms.
'. rowth hormone 0B directly stimulates longitudinal growth of the
seleton and growth of muscles.
E. Cell types of the anterior pituitary are classified &y their position in theanterior pituitary and &y their staining characteristics with histologic dyes.
"nswer! "C
'#SC)SS#*+! %he anterior pituitary arises from (atheIs pouch 0em&ryonic
ectoderm, and it includes the pars distalis, pars intermedia, and pars
tu&eralis. %he posterior pituitary arises from the diencephalon and includes
the neural stal, infundi&ulum, and posterior lo&e. %he hypophyseal portal
system drains from the hypothalamus and integrates function of thehypothalamus and anterior pituitary &y carrying hypothalamus-derived
releasing factors to target cells in the anterior pituitary. "C%B may &e
released during stress in response to interleuin-1, -, and -?. Somatotrophic
actions of B are indirect and are mediated &y the insulinlie growth factors
formerly nown as somatomedins. Current classification of anterior pituitary
cells is &ased on immunochemical identification of their secretory products
0i.e., corticotropes produce "C%B, lactotropes produce prolactin, and
thyrotropes produce thyroid-stimulating hormone J%SBK.
17. "ntidiuretic hormone 0"'B!
". #s related to o8ytocin, and &oth are released from the posterior pituitary in
-
8/16/2019 Endocrine Surgery MCQ.docx
11/71
con:unction with neurophysins.
$. #s released into the circulation &y the posterior pituitary in response to a
rise in plasma osmolality a&ove @; m*sm. or a decrease in circulating &lood
volume.
C. May &e stimulated &y catecholamines and inhi&ited &y phenytoin, alcohol,
and lithium.
'. #n e8cess, may produce a syndrome of euvolemic hyponatremia with
inappropriately concentrated urine that is responsive to free water restriction.
E. 'eficiency causes prolonged polyuria and polydipsia and may &e
diagnosed &y a com&ination of high plasma osmolality and low urine
osmolality following water deprivation.
"nswer! "$C'E
'#SC)SS#*+! "'B and o8ytocin are nineLamino acid peptides derived
from a common ancestral peptide, vasotocin. "'B is released from the
posterior pituitary with neurophysin ## in response to a rise in plasma
osmolality greater than @; m*sm=g. B *. &y a ;3 or greater decrease in
&lood volume, and &y catecholamines. %he syndrome of inappropriate "'B
release 0S#"'B produces euvolemic hyponatremia and is responsive to free
water restriction. 'ia&etes insipidus 0'# reflects a deficiency of "'B andcauses prolonged polyuria and polydipsia. 'ia&etes insipidus is diagnosed &y
a com&ination of high plasma osmolality and low urine osmolality following
water deprivation. E8ogenously administered "'B differentiates central
0"'B-responsive '# from nephrogenic 0"'B-unresponsive '#.
1@. Signs and symptoms of acute pituitary apople8y include!
". Severe headache.
$. Meningismus.
C. Gision loss.
'. Shoc.
E. May &e relieved &y emergent transsphenoidal decompression of the sella
-
8/16/2019 Endocrine Surgery MCQ.docx
12/71
turcica.
"nswer! "$C'
'#SC)SS#*+! "cute pituitary apople8y follows sudden hemorrhage into a
pre-e8isting pituitary tumor or following closed head trauma. Symptoms,
including headache, meningismus, and vision loss, are attri&uta&le to the
intracere&ral &lood. 9ituitary insufficiency, as well as the accompanying
secondary adrenal insufficiency, may cause hypotension and shoc. *ther
manifestations may include '# and my8edema. "cute pituitary apople8y is a
neurosurgical emergency that reuires transsphenoidal decompression of the
sella turcica.
15. 9rolactinomas of the pituitary!
". Most often produce dysfunctional uterine &leeding in women.
$. Most commonly produce infertility in men.
C. When asymptomatic, are &est treated surgically early in the microadenoma
stage.
'. May enlarge during pregnancy, reuiring treatment with &romocriptine or
surgery.E. Commonly occur in patients with ME+ .
"nswer! '
'#SC)SS#*+! 9ituitary prolactinomas are the most common pituitary tumor
and cause amenorrhea, galactorrhea, or &oth in women. Men usually have
macroprolactinomas and e8perience symptoms of a space-occupying lesion
of the sella 0i.e., headache. " minority of men e8perience impotence and
infertility. "symptomatic prolactinomas remain sta&le over time and reuire
o&servation only. Symptomatic prolactinomas reuire treatment, usually with
&romocriptine. 9rolactinomas may enlarge during pregnancy and can produce
symptoms reuiring treatment with either &romocriptine or surgery.
9rolactiomas are seen in as many as 2A3 of patients with ME+ 1.
-
8/16/2019 Endocrine Surgery MCQ.docx
13/71
A. Bypercortisolism!
". #s most often "C%B-dependent, owing to an "C%B-producing pituitary
adenoma.
$. #s &est diagnosed &y measurement of cortisol from a serum sample
collected at @ ".M.
C. #s attri&uta&le to an adrenal source if the &asal serum "C%B level is a&ove
1A pg. per ml., if the hypercortisolism is suppressed &y high-dose
de8amethasone, and if an adrenal tumor is visualied radiographically.
'. May &e caused &y small cell carcinoma of the lung, carcinoid tumors,
tumors of the endocrine pancreas, pheochromocytoma, or medullary thyroidcarcinoma 0M%C.
E. #n children is most often caused &y adrenocortical neoplasia.
"nswer! "'E
'#SC)SS#*+! CushingIs syndrome is most often 0@A3 to 5A3 "C%B-
dependent and is most often due to an "C%B-secreting pituitary adenoma
0CushingIs disease. Some 1A3 to A3 of "C%B-dependent CushingIs
syndrome is caused &y ectopic production of "C%B from small cellcarcinoma of the lung, carcinoid tumors, tumors of the endocrine pancreas,
pheochromocytoma, and M%C. "C%B-independent CushingIs syndrome
secondary to primary adrenal pathology occurs in 1A3 to A3 of cases in
adults and is the most common form in children. Measurement of cortisol in
two to three consecutive 2-hour collections of urine is the &est screening test
for CushingIs syndrome! plasma levels of cortisol show mared varia&ility,
and a single random level is not helpful in esta&lishing the diagnosis. "C%B-
independent CushingIs syndrome suppresses the pituitary and is diagnosed if
the &asal serum "C%B level is suppressed &elow ; pg. per ml., if the
hypercortisolism is not suppressed &y high-dose de8amethasone, or if the
metyrapone stimulation test is negative. %he de8amethasone suppression and
metyrapone tests do not, however, distinguish an adrenal from an ectopic
-
8/16/2019 Endocrine Surgery MCQ.docx
14/71
"C%B cause of CushingIs since &oth suppress the pituitary. (adiographic
evidence of an adrenal tumor must &e supported &y &iochemical testing to
confirm that the adrenal is the primary cause of CushingIs syndrome.
1. 9rimary aldosteronism!
". 9roduces a syndrome of diastolic hypertension, hypoalemia, and edema.
$. #s suggested &y findings of serum potassium less than 4.; mE. per liter,
urinary potassium e8cretion greater than 4A mE. per day, upright plasma
renin &elow 4 ng. per ml., and a plasma aldosterone concentrationLplasma
renin activity ratio greater than A!1.
C. #s most often due to an aldosterone-producing adrenal adenoma, whichmay &e distinguished from idiopathic adrenal hyperplasia &y its sensitivity to
diurnal changes in "C%B and insensitivity to changes in posture.
'. May &e diagnosed in hypertensive patients &y demonstration of an adrenal
mass larger than 1 cm. on computed tomography alone.
E. #s &est treated surgically if it is due to either aldosteronoma or idiopathic
adrenal hyperplasia.
"nswer! $C
'#SC)SS#*+! 9rimary aldosteronism is a syndrome of diastolic
hypertension and hypoalemia6 edema typically is a&sent. %he diagnosis
relies on demonstration of hypoalemia with inappropriate aliuresis and
inappropriately elevated plasma aldosterone with suppression of plasma renin
following sodium loading. 9rimary aldosteronism most often is due to an
adrenal adenoma, which must &e distinguished from idiopathic adrenal
hyperplasia since resection of the adenoma is nearly always curative, whereas
adrenal resection for idiopathic adrenal hyperplasia is curative less than A3
of the time. C% evidence of adrenal tumor alone is inadeuate to diagnose
aldosteronism, even in a hypertensive patient.
-
8/16/2019 Endocrine Surgery MCQ.docx
15/71
. "drenocortical carcinoma!
". May &e suspected in a patient with rapidly progressive CushingIs
syndrome and viriliing features or in asymptomatic patients with adrenal
tumors larger than ? cm on C%.
$. Most often is diagnosed early in its course when disease is confined to the
adrenal gland.
C. #s differentiated from &enign adrenocortical adenoma &y tumor necrosis,
hemorrhage, and cellular features of large hyperchromatic nuclei and more
than A mitoses per high-power field.
'. Should &e resected only if disease is localied to the adrenal gland6
otherwise treatment with mitotane is indicated.
E. Carries a poor prognosis! overall ;-year survival less than ;3."nswer! "E
'#SC)SS#*+! 9atients with adrenocortical carcinoma often present with
rapidly progressive syndromes of com&ined adrenocortical hormone e8cess.
Bowever, appro8imately half do not have syndromes of hormone e8cess &ut
present with a&dominal pain, increased a&dominal girth, weight loss, and
anore8ia. /urthermore, incidentally discovered adrenal masses larger than ?
cm. har&or carcinoma in as many as 53 of cases. "drenocortical carcinomais differentiated from adenoma &y pathologic demonstration of either local
invasion or distant metastases. Most patients with adrenocortical carcinoma
present with locally advanced 0stage ### or metastatic 0stage #G disease.
9rognosis for these patients is poor! ;-year survival is less than ;3 in most
series. 9atients with adrenocortical carcinoma should undergo primary
surgical resection or palliative surgical de&uling of locally advanced,
metastatic, or even recurrent disease since response of these tumors to
medical therapy, including mitotane, is poor.
4. "ddisonian crisis, or acute adrenocortical insufficiency!
". *ccurs only in patients with nown adrenal insufficiency or in those
-
8/16/2019 Endocrine Surgery MCQ.docx
16/71
receiving long-term supraphysiologic doses of e8ogenous steroids.
$. Can mimic an acute a&domen with fever, nausea and vomiting, a&dominal
pain, and hypotension.
C. May cause electrolyte a&normalities, including hypernatremia,
hypoalemia, hypoglycemia, and hypercalcemia, as well as eosinophilia on
peripheral &lood smear.
'. Should &e diagnosed with the rapid "C%B stimulation test &efore steroid
replacement is instituted.
E. May &e effectively treated with intravenous stress-doseD glucocorticoid
and mineralocorticoid replacement.
"nswer! $
'#SC)SS#*+! "ddisonian crisis, or acute adrenal insufficiency, may &e seen
following even mild illness in patients with suppression of the hypothalamic-
pituitary-adrenal a8is. %his suppression can &e produced &y as little as 1 wee
of supraphysiologic stress dose steroids in the year &efore the stressful event.
"ddisonian crisis is a medical emergency that reuires prompt treatment
&ased on clinical suspicion. Clinical findings include fever, nausea and
vomiting, a&dominal pain, and hypotension.
-
8/16/2019 Endocrine Surgery MCQ.docx
17/71
$. Bydration.
C. "lpha-adrenergic &locade, with or without &eta-adrenergic &locade.
'. 9reoperative Swan-an monitoring in all patients.
E. 9lanning removal through an anterior, posterior, or laparoscopic approach
&ased upon tumor localiation with C%, magnetic resonance imaging 0M(#,
and=or 141#-M#$.
"nswer! $CE
'#SC)SS#*+! 9rinciples of preoperative management for
pheochromocytoma include preoperative alpha-adrenergic &locade using
pheno8y&enamine or phentolamine. $eta-adrenergic &locade with
propranolol is then used selectively in patients who develop tachycardia, havea history of cardiac arrhythmia, or have primarily epinephrine-secreting
tumors. $eta-adrenergic &locade should &e undertaen only after successful
alpha &locade is esta&lished. 9atients with pheochromocytoma freuently
e8hi&it intravascular volume depletion, and careful hydration is mandatory.
Central venous pressure monitoring alone is helpful to guide hydration6 more
intensive monitoring with a Swan-an catheter is indicated for patients with
pre-e8isting heart disease. /ormerly, the anterior approach was preferred for
adrenalectomy as it facilitated complete a&dominal e8ploration and search for e8tra-adrenal pheochromocytoma. "ccurate preoperative localiation with
C%, M(#, and 141#-M#$ has allowed selective use of the posterior, or even
the laparoscopic, approach for adrenalectomy.
;. #ndications for surgical adrenalectomy include!
". "n adrenal mass larger than ? cm.
$. Bypertensive patients with aldosteronism that is "C%B insensitive and
posture sensitive and who also have multiple adrenal nodules on C%.
C. CushingIs syndrome secondary to adrenal neoplasms or to persistent
ectopic "C%B syndrome when the primary tumor is inopera&le.
'. 9heochromocytoma in adults and children.
-
8/16/2019 Endocrine Surgery MCQ.docx
18/71
E. Congenital adrenal hyperplasia secondary to 1-hydro8ylase deficiency.
"nswer! "C'
'#SC)SS#*+! "drenalectomy is indicated for the management of adrenal
masses larger than ? cm. on C% since tumors of this sie har&or carcinoma in
more than 5A3 of cases. Surgical adrenalectomy is also the treatment of
choice for primary adrenal causes of CushingIs syndrome. Surgical
adrenalectomy may &e considered as an alternative to medical adrenalectomy
with metyrapone, aminoglutethimide, or mitotane in patients with ectopic
"C%B syndrome when treatment of the primary tumor is unsuccessful.
9atients with aldosteronism that is "C%B sensitive and posture insensitive
liely have an adrenal adenoma that is cura&le &y adrenalectomy."ldosteronism that is "C%B insensitive and posture sensitive is liely caused
&y idiopathic adrenal hyperplasia, which is &est managed medically with
spironolactone, triamterene, amiloride, or nifedipine. "drenalectomy
following preoperative alpha-adrenergic &locade, with or without &eta-
adrenergic &locade, and hydration is the treatment of choice of all
pheochromocytomas. "drenalectomy is not indicated in the management of
any of the congenital adrenal hyperplasias.
?. #ncidental adrenal masses!
". May &e seen in as many as 1A3 of a&dominal C% studies.
$. Most commonly represent pheochromocytoma6 adrenocortical adenoma,
adrenocortical carcinoma, and metastases from other primary cancers occur
less freuently.
C. May represent adrenocortical carcinoma if greater than ? cm. in diameter.
'. Should &e routinely evaluated &y measurement of 2-hour urine levels of
catecholamines and their meta&olites, cortisol, and aldosterone plus fine-
needle aspiration.
E. Should &e resected if &iochemically active, if greater than ? cm., or if they
grow over si8 monthsI follow-up.
-
8/16/2019 Endocrine Surgery MCQ.docx
19/71
"nswer! CE
'#SC)SS#*+! %he incidental adrenal mass is seen in as many as 1.43 of
a&dominal C% scans performed for other reasons. "drenocortical adenomas
are most common, followed &y adrenocortical carcinoma, metastases from
other primary cancers, and pheochromocytoma. $iochemical evaluation must
weigh the prevalence of adrenal neoplasms against the conseuences of a
missed life-threatening diagnosis, as in pheochromocytoma. "ll adrenal
masses should &e evaluated for pheochromocytoma with measurement of 2-
hour urine catecholamines and their meta&olites. "ldosterone and cortisol
measurement are indicated if clinical features suggest aldosteronism or
CushingIs syndrome. /ine-needle aspiration of adrenal masses is indicated for clearly cystic lesions or if metastasis is suspected &ased on the presence of
another nown primary. /ine-needle aspiration is not routinely indicated in
the evaluation of adrenal lesions and is contraindicated until
pheochromocytoma is definitively e8cluded. "drenal lesions should &e
resected if they are functional, are larger than ? cm., or have enlarged during
follow-up.
7. Which of the following statements is true a&out the synthesis of thyroid
hormone and its physiology>
". %he iodine utilied in hormone synthesis is derived principally from
dietary sources.
$. %he role of thyroid-stimulating hormone 0%SB in thyroid physiology is
limited to regulation of the release of thyroid hormone in plasma.
C. Enough thyro8ine 0% 2 is stored in the normal thyroid to provide a
euthyroid state for 4 wees despite a&sence of iodine intae.
'. %he regulation of thyroid function involves pituitary, &ut not
hypothalamic, input.
"nswer! "C
-
8/16/2019 Endocrine Surgery MCQ.docx
20/71
'#SC)SS#*+! #odine is necessary for the synthesis of thyroid hormone, and
appro8imately AA to ;AA mg is ingested daily. Most of it is a&sor&ed from
the small intestine and is cleared from the plasma &y secretion of thyroid
hormone. %SB is reuired for the normal production and secretion of thyroid
hormone. #t is generally accepted that %SB also has a ma:or role in thyroid
growth. %he thyroid gland has a storage reserve of appro8imately 4 wees.
%he principal regulatory mechanisms of the thyroid gland are the
hypothalamic-pituitary-thyroid control system and the intrathyroidal
regulatory systems. %(B is produced &y the superoptic and paraventricular
nuclei within the hypothalamus and passes down their a8ones. /ollowing
secretion into the hypophyseal portal &lood systems %(B passes to the
pituitary and induces stimulation of %SB secretion.
@. Correct statements a&out thyroid function tests include which of the
following>
". Contraceptive pills and pregnancy increase the amount of thyro8in-
&inding glo&ulin 0%$, and, conseuently, the total % 2 level.
$. "nticonvulsive medications and chronic de&ilitating illnesses decrease the
amount of %$ and, conseuently, the total % 2 level.C. #ntravenous pyleography can lower the rate of active iodine uptae &y the
thyroid.
'. " triiodothyronine 0% 4 suppression test that demonstrates
nonsuppressi&ility of thyroid function is compati&le with the diagnosis of
ravesI disease, to8ic adenoma, or functioning carcinoma.
E. "n increased serum cholesterol level in a hypothyroid patient indicates a
thyroid cause.
"nswer! "$C'
'#SC)SS#*+! Bormone &inding proteins are the principal intravascular
factors influencing total hormone concentration. Garious factors may cause
changes in the concentration of %$. Contraceptive pills and pregnancy
-
8/16/2019 Endocrine Surgery MCQ.docx
21/71
increase the amount of %$, while anticonvulsive medications and chronic
de&ilitating disease may decrease the amount of %$. "dministration of
e8cess amounts of iodine may lower the rate of active iodine uptae in the
thyroid gland. %he thyroid suppression test is &ased on the principle that
administration of thyroid hormone does not suppress the patientIs thyroid
function when normal homeostatic mechanisms are disrupted. %hyroid
function is nonsuppressi&le in hyperthyroidism or in the presence of thyroid
hormoneLsecreting tumors. Serum cholesterol, deep tendon refle8 time, and
cardiovascular functions can &e measured to reflect hypothyroidism and
hyperthyroidism &ut do not give an indication of the etiology of
hypothyroidism.
5. Byperthyroidism can &e caused &y all of the following e8cept!
". ravesI disease.
$. 9lummerIs disease.
C. Struma ovarii.
'. BashimotoIs disease.
E. Medullary carcinoma of the thyroid.
"nswer! E
'#SC)SS#*+! Common types of hyperthyroidism include diffuse to8ic
goiter 0ravesI disease, named after the 'u&lin physician (o&ert raves who
descri&ed it in 1@4; &ut nown since its original description &y 9arry in 17@?
and descri&ed &y von $asedow in 1@2A and to8ic adenoma or to8ic
multinodular goiter 09lummerIs disease. )ncommon causes include
thyroto8icosis factitia, functioning metastatic thyroid carcinoma,
tropho&lastic tumors that secrete human chorionic gonadotropin 0having
thyroid-stimulating properties, inappropriate secretion of thyrotropin &y
pituitary tumors, struma ovarii, iodide-induced hyperfunction, and thyroiditis.
-
8/16/2019 Endocrine Surgery MCQ.docx
22/71
4A. Which of the following is true a&out the use of radioiodine to treat
hyperthyroidism>
". #f hyperthyroidism is secondary to radioiodine use, it will occur within
years of treatment.
$. %here is a maredly increased ris of future thyroid cancer following
radioiodine therapy.
C. %he ris of leuemia following radioiodine therapy is appro8imately 1A3.
'. Mutation a&normalities occur in 1;3 of fetuses in utero following internal
treatment of the mother with radioiodine during pregnancy.
E. (adioiodine may pass through the placenta and lactating &reast to produce
hypothyroidism in a fetus or infant.
"nswer! E
'#SC)SS#*+! Bypothyroidism secondary to radioiodine therapy increases
in freuency with time to @;3 after ; years. %here has &een no demonstration
of an increase in malignancies following radioiodine therapy. (adioactive
iodine can cross the placenta and lactating &reast to produce hypothyroidism
in a fetus or a nursing infant and is, therefore, contraindicated.
41. "rrange the following complications of thyroid surgery 0&ilateral su&total
thyroidectomy in decreasing order of incidence in patients with ravesI
disease.
".
-
8/16/2019 Endocrine Surgery MCQ.docx
23/71
additional increase in su&seuent years. %he associated mor&idityrelated
primarily to damage to the recurrent laryngeal nerves and parathyroid glands
is estimated to &e A.;3 to 4.A3.
4. %he most common cause of goitrous hypothyroidism in adults is!
". ravesI disease.
$. (iedelIs thyroiditis.
C. BashimotoIs disease.
'. de QuervainIs thyroiditis.
"nswer! C
'#SC)SS#*+! BashimotoIs disease was first descri&ed in Napan &y Baaru
Bashimoto in 151 and is the &est-nown of the immunologic thyroid
diseases. #t is the most common cause of goitrous hypothyroidism in adults
and of sporadic goiter in children. %he incidence is A.4 to 1.; cases per 1AAA
population per year and it is 1A to 1; times more common in women than in
men, with the highest incidence in the group aged 4A to ;A years.
44. %herapy for BashimotoIs disease includes!
". (adioiodine.
$. "ntithyroid medications.
C. Su&total thyroidectomy.
'. +one of the a&ove.
"nswer! '
'#SC)SS#*+! %here is no specific treatment for BashimotoIs disease.
9atients are usually followed medically, and replacement therapy with % 2 is
&egun in patients with hypothyroidism that is symptomatic or associated with
a goiter that is causing pressure symptoms. Early initiation of thyroid
hormone therapy has &een recommended &y many to prevent further thyroid
-
8/16/2019 Endocrine Surgery MCQ.docx
24/71
enlargement and reduce the ris of my8edema, especially in postpartum
patients. Surgical reduction of goiter should &e performed if severe pressure
symptoms that have not responded to corticosteroid therapy are present. %his
usually consists of su&total thyroidectomy. $iopsy to rule out malignancy in
nodules suspicious for thyroid carcinoma 0usually papillary or lymphoma is
indicated. #f carcinoma is suspected, lo&ectomy should &e performed, and if
froen section demonstrates carcinoma, su&total or total thyroidectomy
should &e performed.
42. #ndications for surgical thyroidectomy for ravesO disease include which
of the following>
a. *cular involvement
&. Symptomatic large goiter
c. Women of child&earing age
d. Concomitant thyroid nodule
e. "ll of the a&ove
"nswer! &, c, d
"ntithyroid drugs are the initial therapy in most patients with ravesO
disease, either as a definitive therapy or in preparation for 141# therapy or
surgical a&lation. $ecause of the high failure rate of long-term treatment with
thionamides, the use of these drugs as definitive treatment has decreased.
'raw&acs include the important A.;3 incidence of agranulocytosis and a
recurrence rate as high as 243 during the first year when the drug is stopped.
/ive years after treatment only ;3 of patients remain in remission. )nlie
other definitive treatments, hypothyroidism does not occur as a result of
thionamide treatment if an appropriate dosage is used. 141# has &een used as
definitive treatment for patients with ravesO disease for many years with
predicta&le and long-lasting good results in most patients. #t has few, if any,
serious side effects. #t is a&lative to the thyroid gland and hypothyroidism is a
-
8/16/2019 Endocrine Surgery MCQ.docx
25/71
nearly inevita&le result of effective therapy, although it may tae years to
&ecome clinically apparent. "&out 7A3 of patients treated with 141# are
hypothyroid within 1A years of treatment. %he ris of recurrence of
hyperthyroidism after an initial response is less than ;3. Most adult patients
in the )nited States are treated with 141# as definitive treatment for ravesO
disease. E8ceptions are women in the child&earing years where a su&seuent
fetus would &e affected, patients with concomitant thyroid nodules where
carcinoma is a concern, those with e8tremely large glands and, increasingly,
those who are opposed to 141# therapy. %hyroidectomy is an important
alternative in selected patients with ravesO disease. "lthough controversial
in the past, it now appears that ocular involvement does not respond more
favora&ly to thyroidectomy than to 141# a&lation.
4;. Which of the following statements regarding anatomic relationships of
the thyroid gland are true>
a. %he middle thyroid artery is intimately related to the superior laryngeal
nerve
&. %he superior thyroid artery is usually the first &ranch of the e8ternal carotidartery
c. %hyroidea ima arteries are found in appro8imately A3 of individuals
d. %he parathyroid glands may lie within the pretracheal fascia
"nswer! &, d
%he thyroid gland is a vascular organ supplied &y four main arteries! two
superior and two inferior. %he superior thyroid artery usually arises as the
first &ranch of the e8ternal carotid artery :ust a&ove the &ifurcation of the
common carotid artery. %he superior thyroid artery descends medially on the
surface of the inferior pharyngeal constrictor muscle to divide into an anterior
and posterior &ranch at the ape8 of the thyroid lo&e on its anteromedial
surface. #ts relation to the e8ternal &ranch of the superior laryngeal nerve is
-
8/16/2019 Endocrine Surgery MCQ.docx
26/71
important during thyroid lo&ectomy. %he inferior thyroid arteries usually arise
from the thyrocervical truns and ascend &ehind the carotid sheath &efore
passing downward and medial to enter the thyroid gland at its middle portion.
%here are no arteries directly entering the lower poles from &elow with the
e8ception of a thryoidea ima artery that may replace an a&sent inferior artery.
%hyroidea ima arteries arise from either the innominate artery or aorta in 13
to 23 of individuals, entering the lower surface of the isthmus after coursing
on the trachea.
%he pretracheal fascia is referred to as the thyroid sheath and it varies in
consistency and completeness among individuals. 9osteromedially, it is
usually condensed and firmly attaches the thyroid gland to the upper two or
three tracheal rings and the cricoid cartilage. %he superior parathyroid glandmay lie &etween the sheath and the thyroid capsule, within the sheath,
posterior to it in a potentially open plane, or occasionally anterior to the
sheath. %he inferior parathyroid gland liewise may &e within the sheath,
particularly when the gland is adherent to the lower pole of the thyroid.
4?. (adioactive iodine is effective treatment for metastatic lung disease for
which of the following thyroid neoplasms>
a. BPrthle cell carcinoma
&. 9apillary carcinoma
c. /ollicular carcinoma
d. Medullary carcinoma
e. "naplastic carcinoma
"nswer! &, c
(adioactive iodine is used only in patients who have differentiated thyroid
carcinomas. #t is of no value in the treatment and follow-up of patients with
BPrthle cell, medullary or anaplastic carcinomas. Most papillary carcinomas
are capa&le of taing up radioactive iodine. Most papillary carcinomas in
-
8/16/2019 Endocrine Surgery MCQ.docx
27/71
patients under ;A-years of age do so, providing that the patient has had a total
thyroidectomy and there is no normal thyroid tissue to compete for the 141#.
"&out A3 of all papillary carcinomas do not trap sufficient iodine for
imaging or therapy. %hese are usually patients with papillary carcinoma
variants! a tall cell variant of papillary carcinoma, insular carcinoma, or clear
cell carcinoma.
+early all metastatic follicular carcinomas retain the a&ility to trap 141#
sufficiently for imaging and for therapy. Even well-differentiated papillary
and follicular carcinoma cannot compete successfully for 141# with normal
thyroid tissue and unless this has &een removed or su&seuently a&lated with
an initial dose of 141#, many metastases cannot &e detected or treated.
47. %he types of thyroiditis that can cause a&normalities of surgical
significance are which of the following>
a. Chronic lymphocytic thyroiditis 0Bashimoto disease
&. (iedel struma
c. "cute 0viral thyroiditis
d. ranulomatous 0su´ thyroiditis"nswer! a, &, d
%here are three types of thyroiditis that can cause thyroid a&normalities of
surgical significance. %he most common is chronic lymphocytic 0Bashimoto
thyroiditis, an autoimmune disease that can occur in any age group.
*ccasionally, Bashimoto disease causes unilateral thyroid enlargement that
simulates malignancy. %he rarest form of thyroiditis is (iedel struma which
can mimic a diffuse thyroid carcinoma &ecause of the fi&rotic infiltrative
process that results. Bashimoto thyroiditis is associated with reduced
functional capacity of the thyroid which increases %SB secretion, and a goiter
develops. $ecause of the associated fi&rosis, a nodular goiter or neoplasm is
suggested. %hyroidectomy may &e indicated for treatment of a solitary
-
8/16/2019 Endocrine Surgery MCQ.docx
28/71
nodule, particularly if it is cold, suspicious, definitely malignant or solid, and
fine needle aspirate is indeterminate.
ranulomatous, 'eQuervain, and su´ thyroiditis are terms that refer to a
disease that usually occurs in young women within wees of an upper
respiratory or other viral infection. %he disease is usually self-limited, &ut
may persist for several months longer. #n unusual patients, the disease may &e
confined to one lo&e and result in a firm, slightly tender mass suggesting
carcinoma.
a. Superior thyroid arteries
&. #nferior thyroid arteries
c. %hyroidea ima arteries
d. 9arathyroid arterial &ranches directly from the e8ternal carotid artery
e. Bighly varia&le
"nswer! &
-
8/16/2019 Endocrine Surgery MCQ.docx
29/71
%he principal &lood supply to &oth parathyroid glands is the inferior thyroid
artery. 9arathyroid glands invaria&ly have a single end artery supplying them,
and if the main trun of the inferior thyroid artery is ligated during
thyroidectomy, there is no collateral &lood supply to maintain their via&ility.
#t is prefera&le to divide only the &ranch of the inferior thyroid artery medial
to those that supply either of the parathyroid glands. %his reuires individual
clamping of smaller vessels under the thyroid sheath as these vessels
penetrate into the thyroid capsule.
a. Seventy to @A3 of new cases of thyroid carcinoma in the )nited States are
of the papillary type
&. %otal ipsilateral lo&ectomy and isthmus resection are adeuate therapy forminimal thyroid carcinoma
c. Microscopic evidence of multicentric disease is present in 7A3 to @A3 of
cases
d. +early all patients less than 1; years of age have metastatic disease in local
lymph nodes
"nswer! a, &, c, d
Seventy to @A3 of the 11,AAA new patients with thyroid carcinoma diagnosed
annually in the )nited States have papillary carcinoma. 9apillary carcinomas
of the thyroid include minimal thyroid carcinoma, intrathyroidal, and
e8trathyroidal 0invasion through the true thyroid capsule disease. Minimal
thyroid carcinoma refers to those papillary carcinomas that are less than 1 cm
-
8/16/2019 Endocrine Surgery MCQ.docx
30/71
in diameter and not associated with any clinically apparent lymph node
metastases. #n contrast to clinically significant papillary carcinomas, these are
common and are found in 3 to 143 of adult thyroid glands serially
sectioned after autopsy studies of individuals who have died from other
causes. /or tumors &etween A.; and 1 cm, a total lo&ectomy and isthmus
resection are satisfactory treatment.
Most clinically significant papillary carcinomas are 1 to 2 cm in diameter and
are contained within the thyroid capsule. Multicentricity is relatively
common and can &e found on gross sectioning of the thyroid gland in A3 to
4A3 of cases. /urthermore, after serial sectioning of the entire thyroid gland
in patients with papillary carcinoma, microscopic foci are found in 7A3 to
@A3.
-
8/16/2019 Endocrine Surgery MCQ.docx
31/71
(adioisotope scanning measures the functional activity of the thyroid gland
and maps its correlation with physical findings. /or routine scanning, 141#
scanning has &een replaced &y either 14# or 55m%c. $ecause of the lower
radiation e8posure, cost and easy use, 55m%c is preferentially used. %he
differential diagnosis of a solitary nonfunctioning nodule includes carcinoma,
colloid nodule, nonfunctioning adenoma, and cyst. %he prevalence of
carcinoma ranges from ;3 to A3 in cold nodules and such lesions reuire
further evaluation. #f the scan detects other nonfunctioning areas in addition
to the palpa&le nodule, the gland is at low ris for carcinoma &ecause most
patients with this finding have a multinodular goiter. " solitary, discrete area
of increased activity is more often found in a young patient with an otherwisenormal thyroid gland. Multiple hot spots are typically found in an older
patient with a multinodular goiter.
" functioning solitary nodule that is independent of %SB is considered an
autonomous nodule and can &e the cause of hyperthyroidism. #t is hot on
scintigraphic scan. %he presence of a cold nodule is insufficient information
to determine a treatment plan. "lthough nearly all carcinomas are cold, most
cold nodules are &enign. /ine needle aspiration cytology is considered the
most relia&le means of evaluation for the diagnosis of thyroid nodules thatare nonfunctional or hypofunctional &y nuclide scan.
21. Which of the following pharmacologic agents can &e used in the
treatment of thyroto8icosis to &loc the production of thyroid hormone>
a. 9ropylthiouracil
&. 9ropranolol
c. Methimaole
d. Car&imaole
e. #odine
"nswer! a, c, d, e
-
8/16/2019 Endocrine Surgery MCQ.docx
32/71
" num&er of su&stances interfere with normal production of thyroid hormone
&y &locing one of the relevant enymatic steps. #odine was the first effective
drug to &e used in the treatment of thyroto8icosis. #t can &loc the
organification and coupling steps in thyroid hormone synthesis as well as
prevent the release of thyroid hormone. /urthermore, iodine in large doses
pro&a&ly inhi&its the a&ility of %SB to stimulate cyclic "M9 release at the
follicular cell mem&rane.
Commonly used antithyroid drugs are propylthiouracil 09%), methimaole
0%apaole and car&imaole. Car&imaole is widely used in reat $ritain,
only 9%) and methimaole are commonly used in the )nited States. 9%)
interferes with the incorporation of iodine into the tyrosine residues ofthyroglo&ulin, thus preventing o8idation of iodide to iodine. #t also inhi&its
the peripheral conversion of %2 to %4. "lthough &oth 9%) and methimaole
are thionamides, methimaole does not have this peripheral effect, maing
9%) the preferred drug for patients with thyroid storm. "&out 43 of patients
taing 9%) demonstrate at least one side effect during the first 4 months of
therapy whereas the prevalence with methimaole is a&out 73. %hese range
from minor sin rashes to agranulocytosis that can &e irreversi&le.
&-adrenergic antagonists have &een used in the treatment of hyperthyrodism.9ropranolol is the most widely used of these drugs. Bowever, &-&locade
does not alter thyroid function per se. (ather, its effect is to provide
symptomatic relief of hyperthyroidism &ecause of interference with the action
of thyroid hormones at the cellular level.
2. " 2;-year-old woman has a solitary, nonfunctioning thyroid nodule and
fine needle cytology is nondiagnostic. Which of the following is the initial
surgical procedure of choice>
a. %otal e8tracapsular thyroidectomy
&. Su&total thyroid lo&ectomy and resection of the isthmus
-
8/16/2019 Endocrine Surgery MCQ.docx
33/71
c. %otal e8tracapsular thyroid lo&ectomy, resection of the isthmus, and
modified unilateral nec dissection
d. %otal e8tracapsular thyroid lo&ectomy and resection of the isthmus
"nswer! d
%otal e8tracapsular thyroid lo&ectomy and isthmus resection is the procedure
of choice when a decision has &een made to surgically remove a thyroid
nodule. %he entire lo&e with the isthmus is su&mitted for froen-section
pathologic e8amination if fine needle aspirate has not already resulted in a
definitive diagnosis of carcinoma. #n performing total lo&ectomy, &oth
parathyroid glands are carefully preserved with their &lood supply. %his is
done in the event that total thyroidectomy is necessary if either the froen or permanent histologic sections confirm the presence of thyroid carcinoma.
%otal lo&ectomy offers the &est opportunity for accurate histologic diagnosis
and is associated with the lowest incidence of complications when the need
for reoperation is considered. #n one e8perience, @AA consecutive cases of
total unilateral lo&ectomy were performed for &enign or malignant nodules
suspected of cancer, and no permanent recurrent laryngeal nerve palsies
occurred. 9rimary total lo&ectomy is safer than a partial lo&ectomy followed
&y resection of the residual lo&e after a delayed diagnosis of malignancy.(eoperation to complete a lo&ectomy is associated with a greater ris to &oth
recurrent laryngeal nerve and the parathyroids on the ipsilateral side.
"lthough there is controversy as to whether a total lo&ectomy and isthmus
resection or a total thyroidectomy is the &est definitive operation for
unilateral papillary carcinoma, a su&total lo&ectomy is universally considered
an inadeuate operation. " definitive cancer operation can &e accomplished
with one procedure in @A3 of the cases when a silled thyroid pathologist is
availa&le for froen-section interpretation.
24. Which of the following statements regarding fine needle aspiration
cytology of a thyroid nodule are true>
-
8/16/2019 Endocrine Surgery MCQ.docx
34/71
a. #t differentiates neoplastic and nonneoplastic nodules in most cases
&. #t does not allow differentiation of papillary, medullary and anaplastic
carcinoma
c. #t cannot differentiate malignant and &enign follicular or BPrthle cell
neoplasms
d. #t is not recommended when a patient has a history of head and nec
radiation
"nswer! a, c, d
When interpreted &y a silled cytologist, fine needle aspiration is highly
accurate and is considered the preferred method of selecting patients withthyroid nodules for surgery. +early @A3 of patients with thyroid nodules
were spared surgical e8ploration as a result of such studies in one report.
$ecause of the ris of false-negative diagnoses 01A3, advocates of this
techniue emphasie the importance of clinical :udgment in addition to the
cytologic study in selecting operative candidates.
#n most cases, fine needle aspiration cytology ena&les the pathologist to
distinguish nonneoplastic from neoplastic nodules and to identify the type of
malignant tumor. 9apillary, medullary, and anaplastic carcinoma all have atypical cytologic appearance. Cytologic studies cannot differentiate malignant
from &enign follicular or BPrthle cell neoplasms. #n this case, a definitive
diagnosis depends on histologic e8amination of the entire e8cised tumor.
/ine needle aspiration has dramatically reduced the num&er of diagnostic
surgical operations for &enign lesions in centers where it is used e8tensively.
#n patients with thyroid nodules and a history of previous head and nec
radiation, operation is generally recommended regardless of cytologic
findings. #n these patients, &oth &enign and malignant lesions may develop
and the chances of sampling error are considera&le.
22. Byperthyroidism results from all of the conditions noted &elow. *f the
-
8/16/2019 Endocrine Surgery MCQ.docx
35/71
following which commonly reuire surgical management>
a. ravesO disease
&. Struma ovarii
c. /unctioning metastatic thyroid carcinoma
d. %o8ic diffuse goiter
e. Single to8ic thyroid nodule
"nswer! a, d, e
Byperthyroidism is associated with clinical manifestations related to an
e8cess of thyroid hormone. %here are three causes of primary concern to the
surgeon. ravesO disease, or to8ic diffuse goiter, is most common, accountingfor more than @A3 of all patients with hyperthyroidism. %he other two
relevant causes of hyperthyroidism are to8ic nodular goiter and a single to8ic
nodule. Common causes of hyperthyroidism that rarely reuire surgery are
postpartum thyroiditis, iodine-induced hyperthyroidism, self-administered or
iatrogenic hyperthyroidism, struma ovarii, functioning metastatic carcinoma
and several rare forms of thyroiditis.
2;. Which of the following statements regarding medullary carcinoma of the
thyroid are true>
a. "ppro8imately 7;3 of all cases are hereditary
&. %he overall 1A-year survival rate is less than 1A3
c. Medullary carcinoma of the thyroid is associated with &oth multiple
endocrine neoplasia ##a 0ME+ ##a and multiple endocrine neoplasia ##&
0ME+ ##& syndromes
d. 9rophylactic total thyroidectomy is recommended for ME+ ##a and ME+
##& patients after the age of 1A years
"nswer! c
-
8/16/2019 Endocrine Surgery MCQ.docx
36/71
Medullary carcinoma of the thyroid 0MC% accounts for a&out 73 of all
malignant tumors of the thyroid. #t is familial in A3 to 4A3 of all cases and
its secretion of a &iologic marer 0calcitonin allows detection of its presence
with the tumor is too small to palpate. MC% appears in three clinical settings.
%he first is a sporadic tumor, usually in patients 4A years or older. Second,
MC% occurs as a component of the ME+ ##a syndrome with or without
adrenal medullary disease 0pheochromocytoma or hyperparathyroidism. "
family history of thyroid carcinoma with or without pheochromocytoma is
invaria&ly present. MC% in the ME+ ##a syndrome is always &ilateral and
multicentric and arises from C-cell hyperplasia. MC% usually does not
develop &efore age 1 and is almost always clinically apparent &efore age 4A.
-
8/16/2019 Endocrine Surgery MCQ.docx
37/71
a. +ormally a&out A3 of %4 is secreted directly from the thyroid gland
&. %he thyroid gland is the only endogenous source of %2
c. E8cess thyroid hormone results in an increase in the num&er of "%9-
dependent sodium pumps on the cell mem&rane
d. %he ma:ority of thyroid hormone in circulating plasma is &ound to
al&umin, thus limiting the availa&ility of the meta&olically active form
"nswer! a, &, c
%he thyroid is the only endogenous source of %2, whereas most %4 is
produced &y the peripheral conversion of %2. %his taes place in the liver,
muscle, idney and anterior pituitary. )nder normal circumstances, onlya&out A3 of %4 is secreted directly from the thyroid gland. #n some thyroid
diseases 0e.g., ravesO disease and to8ic nodular goiter, the proportion of %4
secreted directly &y the thyroid may &e maredly increased.
*nce thyroid hormones are released into the circulation, they are &ound to
thyroid-&inding glo&ulin 0@;3, al&umin 01A3 and transthyretin
0preal&umin. %hese &inding proteins allow the thyroid hormones to remain
solu&le in plasma, contri&uting to systemic distri&ution to various target-cell
populations. " limited amount of thyroid hormones circulates freely in the plasma in meta&olically active form 0free %2, free %4.
"t the cell mem&rane, an e8cess of thyroid hormone results in an increased
num&er of "%9-dependent sodium pumps, thus increasing resting energy
e8penditure and o8ygen consumption. %hyroid hormone also facilitates the
transport of glucose and amino acids across the cell mem&rane. #n addition,
%4-induced mitochondrial o8idation of su&strate results in increased "%9
production.
27. %he definitive treatment of choice for to8ic multinodular goiter is>
a. %otal thyroidectomy
-
8/16/2019 Endocrine Surgery MCQ.docx
38/71
&. $ilateral su&total thyroidectomy
c. )nilateral total lo&ectomy on the side of dominant disease
d. 141# treatment
"nswer! &
Byperthyroidism in the patient with a multinodular goiter usually develops in
women after age ;A &ut is seen occasionally in younger patients. Most
patients have had a nonto8ic nodular goiter for many years. 9referred
treatment for most patients with to8ic multinodular goiters is thyroidectomy
after adeuate preparation renders the patient euthyroid. 141# may &e an
alternative in selected poor-ris patients with goiters that are not causing
airway compression. "lthough 141# can &e used to treat the hyperthyroidism,larger and often repeated doses of 141# may &e reuired. 141# does not
significantly reduce the goiter sie and may, &ecause of radiation-induced
thyroiditis, cause acute enlargement. %his may &e haardous in the patient
with some degree of pree8isting airway compression. "ny airway symptoms,
particularly in patients with su&sternal goiters, should &e considered strong
contraindications to the use of 141#.
Standard surgical treatment of to8ic nodular goiter has consisted of &ilateral
su&total thyroidectomy. (emnant sie is not as important as the e8cision ofall autonomous nodules. $ecause thyroid replacement or suppression is used
routinely to prevent recurrence of goiter when a su&total resection is done,
the ris of hypothyroidism is not a consideration in determining remnant sie.
"lternative procedures are total lo&ectomy with isthmus resection and
contralateral su&total lo&ectomy, or total thyroidectomy. %he latter is not
demonstra&ly superior and may have more technical complications.
2@. " ;A-year-old male has undergone an ipsilateral thyroid lo&ectomy and
isthmus resection for what appeared on froen section to &e a &enign nodular
lesion .A cm in diameter. Seventy-two hours later the final pathology returns
and the diagnosis is a high-grade angioinvasive follicular carcinoma. What do
-
8/16/2019 Endocrine Surgery MCQ.docx
39/71
you recommend>
a. 55m%c &one scan to rule out occult &one metastases
&. #psilateral radical nec dissection
c. %otal thyroidectomy
d. *&servation with seuential 141# scans every 4 months
"nswer! c
/ollicular carcinoma accounts for a&out 1A3 of all new carcinomas of the
thyroid. Most patients are those with minimal invasion of the capsule or
vessels within the neoplasms. Such tumors are seldom diagnosed definitively
&y either needle aspiration cytology or &y froen-section diagnosis at the timeof lo&ectomy. Most freuently, the diagnosis is made after the study of
permanent sections. Microinvasive encapsulated follicular carcinomas are
rarely associated with metastatic lymph nodes and distant metastases
involving &one are also rare at the time of diagnosis.
"ngioinvasive follicular carcinomas are usually large and freuently show
venous invasion of perithyroidal and lateral nec veins at the time of
diagnosis. %hey may have already metastasied to different sites, most
freuently the &one. %hese tumors are often diagnosed at the time ofoperation &ecause of these characteristics. Most patients younger than 2A do
well, &ut patients older than ;A years have a guarded prognosis. /ollicular
carcinomas of the thyroid are treated &y total thyroidectomy.
-
8/16/2019 Endocrine Surgery MCQ.docx
40/71
rule out occult &one metastases. 9atients with large or high-grade
angioinvasive lesions reuire total thyroidectomy.
49. In 1990 a National Institutes of Health Consensus Dev
pment Conference reviewed the available evidence regarding the management of
asmptomatic primar hperparathroidism. !he panel concluded that surgical
intervention was indicated for which of the following indications"
a. #ge less than $0 ears of age
b. %educed creatinine clearance
c. 9resence of idney stone0s 0as detected &y a&dominal radiograph
d. Su&stantial reduced &one mass as determined &y direct measurement
e. Maredly elevated 2-hour urinary calcium e8cretion
"nswer! a, &, c, d, e
"ll of the indications listed a&ove are considered indications for operative
treatment of asymptomatic patients with primary hyperparathyroidism. %heir
conclusions regarding operative indications are summaried in %a&le ;7-@.
%he +#B Consensus 'evelopment Conference mandated close 0every ?
months follow-up for patients with nown primary hyperparathyroidism not
treated &y operation. #n addition, surgery was agreed upon for those patients
in whom medical surveillance was neither desira&le nor suita&le, such as
when the patient reuests surgery, consistent follow-up is unliely, co-
e8istent illness complicates management, or if the patient is young 0 ;A year
of age. #n one recent study of a group of 12 asymptomatic patients followed
without operation, after 1A years, more than A3 of the patients had reuiredsurgery for an increase in serum calcium to greater than 11 mg=d< or for
specific complications attri&uta&le to the disease. "nother A3 were lost to
or declined follow-up. %he remainder either died of unrelated causes or had
persistent asymptomatic disease. %his remains an area of considera&le
-
8/16/2019 Endocrine Surgery MCQ.docx
41/71
controversy. %he &est availa&le recommendations are derived from this
*cto&er 155A +#B Consensus 'evelopment Conference. ;A. Which of the
following statements regarding medullary carcinoma of the thyroid are true>
a. $ilateral medullary carcinoma of the thyroid occurs in every patient withmultiple endocrine neoplasia 1, a or & &. Medullary carcinoma of the
thyroid accounts for appro8imately one-third of all thyroid malignancies c.
A3 of medullary carcinoma of the thyroid cases are familial d. 9rovocative
testing with pentagastrin and calcium infusion for family mem&ers at ris for
medullary carcinoma of the thyroid is diminished in importance &y the recent
development of specific genetic testing "nswer! a, c, d Medullary thyroid
carcinoma accounts for a&out 1A3 of all thyroid malignancies, and A3 of
cases occur in the familial setting of ME+ a, ME+ $, or familial non-
ME+ medullary thyroid carcinoma. #t is usually the first tumor that develops
in these patients and typically occurs in the second or third decade of life.
%umors are virtually always &ilateral and develop in multiple areas of the
middle and upper portions of the thyroid lo&e. 'etection has historically &een
&ased on ela&oration of calcitonin, particularly in response to provocative
testing &y the potent secretagogues calcium and pentagastrin. 9atients with
medullary carcinoma of the thyroid have striing increases in plasma
calcitonin levels after provocative testing, which allows them to &e readily
identified. $y employing provocative testing in indred mem&ers at ris for
disease, medullary carcinoma of the thyroid was diagnosed at a preclinical
stage, and a greater percentage of these patients were cured &y surgical
therapy. With genetic testing now availa&le, early treatment of medullary
thyroid cancer should &e possi&le for all affected people, to hopefully
enhance the num&er of people cured of this cancer. %he ME+ 1, a and &syndromes are inherited in an autosomal dominant fashion with complete
penetrance &ut varia&le phenotype. $ilateral medullary carcinoma of the
thyroid occurs in every affected patient. ;1. While awaiting surgery on a
BM* waiting list, a ;A-year-old female with primary hyperparathyroidism is
-
8/16/2019 Endocrine Surgery MCQ.docx
42/71
admitted to the hospital with oliguria, confusion, nausea and vomiting,
muscle weaness and a serum calcium of 14.; mg=d a. "dminister 1 gm of
hydrocortisone S%"% &. $egin an #G E'%" 0chelating agent infusion S%"%c. "dminister #G Mithramycin and calcitonin concurrently and proceed to
#C) for cardiac monitoring d. $egin a normal saline infusion at R
maintenance volume followed &y 1mg=g furosemide #G e. +one of the
a&ove "nswer! d 9atients with mared hypercalcemia or severe symptoms
should &e admitted to the hospital for careful o&servation and monitoring.
%he mainstay of therapy is intravenous hydration, prefera&ly with normal
saline in sufficient uantities to maintain the urine output a&ove 1AA m
-
8/16/2019 Endocrine Surgery MCQ.docx
43/71
ileal resection d. $reast cancer e. "ll of the a&ove "nswer! a, &, d Multiple
causes of hypercalcemia include the following! Malignancy Gitamin " or '
into8ication %hiaide diuretics Byperthyroidism Mil-alali syndrome
Sarcoidosis and other granulomatous diseases /amilial hypocalciurichypercalcemia #mmo&iliation 9agetOs disease a. 9roceed to *( for e8ploration of
the operative site &. "dminister ; ml of 1A3 calcium gluconate
intravenously c. *&tain a serum magnesium measurement and administer
intravenous magnesium chloride S%"% d. *&tain a C% scan of the head to
evaluate the possi&ility of &rain metastases "nswer! & 9ostoperativehypoparathyroidism commonly develops after total thyroidectomy for
malignancy. Most patients undergoing operation on the thyroid e8perience
some alteration in serum calcium. %he hypocalcemia is usually transient and
is not treated unless significant symptoms develop. %he plasma calcium
-
8/16/2019 Endocrine Surgery MCQ.docx
44/71
usually reaches its nadir at 2@ to 7 hours after surgery and then slowly
returns to normal over to 4 days. /or these reasons, careful postoperative
monitoring of serum calcium levels is essential. /or acute symptomatic
hypocalcemia, calcium should &e administered intravenously. )sually A to4A m< of 1A3 calcium gluconate is infused over a 1; to A minute period
and then ;A to 1AA m< are administered over the ne8t 1 hours in adults.
Calcium gluconate is less irritating to the veins than calcium chloride, and the
calcium release is slower without the ris of overcorrection. Serum
magnesium should always &e measured and hypomagnesemia should &e
corrected if present. %his is not the first priority for this patient. Symptoms
should never &e allowed to progress to the point demonstrated in this patient.
9ostoperative routines include careful monitoring of the serum calcium until
sta&le. %here is no evidence that this patient has a postoperative surgical
pro&lem such as a cervical hematoma.
-
8/16/2019 Endocrine Surgery MCQ.docx
45/71
associated with some diseases of the gastrointestinal tract, &one or other
endocrine organs. *ccasionally, with prolonged secondary stimulation, the
hyperfunctioning glands are no longer physiologically responsive to an
increased ionied calcium. %his rare, relatively autonomous state is referredto as tertiary hyperparathyroidism and develops most commonly after renal
transplantation when the defect in calcium homeostatis is corrected. %he
numerical values for calcium and 9%B here are consistent with primary
hyperparathyroidism. (elation &etween serum immunoreactive parathyroid
hormone 0i9%B and serum calcium in patients with hypoparathyroidism,
pseudohypoparathyroidism, ectopic hyperparathyroidism, and primary,
secondary, and tertiary hyperparathyroidism. 91M, guinea pig antiserum
1M. 0"fter Clar *B, Way a. (ecurrent postoperative hypercalcemia occurs in appro8imately
A3 of patients with this clinical scenario &.
-
8/16/2019 Endocrine Surgery MCQ.docx
46/71
correct initial diagnosis and review of the original operative and pathology
reports are essential. #t is generally agreed that localiation studies do have a
place in the management of recurrent disease. +oninvasive methods are
employed first, and if these are unsuccessful in identifying the diseasedgland, selective angiography and venous sampling for 9%B are employed.
Selective angiography appears to &e the most accurate techniue,
successfully localiing ;A3 to @A3 of parathyroid glands that cannot &e
detected &y any other modality. Surgical ree8ploration can &e difficult.
enerally the nec is e8plored first after which the mediastinum is e8amined
if this is unproductive. Surgical ree8ploration is successful in e8perienced
hands in ?A3 to @A3 of cases. %here is, however, an increased incidence of
complications. )nilateral recurrent nerve in:ury occurs in ;3 to 1A3 of
patients and permanent hypoparathyroidism occurs in 1A3 to A3 of patients
postoperatively. ;?. Which of the following statements regarding calcium and
phosphate meta&olism are true> a. 9arathyroid hormone e8cess produces a
net increase in daily urinary calcium e8cretion &. Calcitonin is essential for
the normal control of calcium meta&olism in adult humans c. 9arathyroid
hormone is the single most important regulator of calcium and phosphate
meta&olism in humans d. 1,; dihydro8yvitamin '4 0calcitriol is the active
form of vitamin ' in humans "nswer! a, c, d %he primary hormonal
regulators of calcium and phosphate meta&olism are parathyroid hormone
09%B, vitamin ' and calcitonin. 9arathyroid hormone appears to &e the
single most important hormonal regulator of calcium and phosphate
meta&olism in humans. #t has direct effects on the seleton and idney and
indirect effects on the intestine, mediated through vitamin '. Sustained
elevations of 9%B stimulate osteoclasts and inhi&it osteo&lasts leading toa&sorption of calcium from &one. #n the idney, 9%B produces an increase in
rea&sorption at any given concentration of e8tracellular fluid calcium,
although e8cess secretion, &ecause of the hypercalcemia, results in a net
increase in daily urinary calcium e8cretion. Gitamin '4, or cholecalciferol, is
-
8/16/2019 Endocrine Surgery MCQ.docx
47/71
produced normally &y the action of sunlight on 7-dehydrocholesterol in the
sin. #t is then hydro8ylated in the liver 0; position and idney 01 position
to form the active 1,; dihydro8yvitamin '4 0calcitriol. %his is the active
form of Gitamin ' in humans. Calcitonin is a 4-amino acid protein produced &y the parafollicular C cells of the thyroid. %otal thyroidectomy, with removal
of all the C cells, is well tolerated, and it has &een concluded that calcitonin is
not essential for the normal control of calcium meta&olism in adult humans.
Calcitonin does inhi&it &one resorption and can produce hypocalcemia in
e8perimental animals. #t also increases urinary calcium and phosphate
e8cretion. ;7. Multiple Endocrine +eoplasia 0ME+ & is characteried &y
which of the following findings> a. Medullary carcinoma of the thyroid,
pheochromocytoma, mucosal neuromas, and a distinctive marfanoid ha&itus
&. 9arathyroid hyperplasia, pancreatic islet cell tumors, and pituitary
adenomas c. Medullary carcinoma of the thyroid, pheochromocytoma, and
parathyroid hyperplasia d. 9arathyroid carcinoma, pheochromocytoma and
chronic pancreatitis "nswer! a %he multiple endocrine neoplasias are familial
disorders typically characteried &y predisposition to the development of
tumors of multiple endocrine organs. %hese disorders are all inherited in an
autosomal dominant fashion, and the tumors tend to &e multicentric. %he
tumors may &e &enign or malignant and may occur metachronously or
synchronously. ME+ 1 is characteried &y the concurrence of parathyroid
hyperplasia, pancreatic islet cell tumors, and pituitary adenomas. ME+ a
consists of medullary carcinoma of the thyroid, pheochromocytoma, and
parathyroid hyperplasia. ME+ & includes medullary carcinoma of the
thyroid, pheochromocytoma, mucosal neuromas, and a distinctive marfanoid
ha&itus. %ogether, these syndromes encompass much of the spectrum ofendocrine neoplasia. ;@. Which of the following signs=symptoms are
pathognomonic of hyperparathyroidism> a. 9athologic fractures of the
metacarpals &. Calcium o8alate nephrolithiasis c. Bypercalcemia causing
mental status changes d. "trophy of %ype ## muscle fi&ers e. *steitis fi&rosa
-
8/16/2019 Endocrine Surgery MCQ.docx
48/71
cystica "nswer! e Manifestations of hyperparathyroidism are protean, &ut
generally nonspecific and may &e difficult to elicit in the history. %he earliest
complaints are often vague and include muscle weaness, anore8ia, nausea,
constipation, polyuria, and polydipsia. %hese nonspecific symptoms may ormay not cause the patient to see medical attention. Symptomatic patients
generally have evidence of chronic disease involving the idney or the
seleton. (enal complications develop &ecause the hypercalcemia leads to
increased urinary calcium e8cretion and 9%B increases the e8cretion of
phosphate. %hese events predispose to stone formation. +ephrolithiasis
develops in a&out 4A3 of patients. +ephrocalcinosis occurs in ;3 to 1A3 of
patients. %hese are &oth nonspecific for hyperparathyroidism. 9arathyroid
&one disease in its most classic and severe form, osteitis fi&rosa cystica, is
seldom seen. Bowever, ;3 to 1;3 of patients present with significant
symptoms of seletal disease. *nly the seletal disease is pathognomonic.
$one changes include su&periosteal resorption of &one on the radial aspect of
the middle phalan8 of the second or third finger. %ufting of the distal
phalanges, &one cysts of the sull and long &ones, &rownD tumors 0i.e.,
localied proliferations of osteoclasts, and diffuse demineraliation or
granularity are seen as well. "trophy of %ype ## muscle fi&ers, consistent with
a neuropathic and not a myopathic cause, has &een demonstrated in patients
with hyperthyroidism, &ut this too is nonspecific. ;5. %he causes of Cushing
syndrome may include which of the following> a. 9osterior pituitary
adenoma &. "drenal hyperplasia c. Small cell lung carcinoma d.
9heochromocytoma e. "drenal carcinoma "nswer! &, c, e %he varied causes
of cortisol e8cess produce clinical features that are collectively called
Cushing syndrome. %hese include e8ogenous steroid administration, Cushingdisease 0e8cessive "C%B production &y the anterior pituitary gland, usually
from an adenoma, ectopic "C%B production 0small cell lung carcinoma,
adrenal adenoma or carcinoma, micronodular pigmented hyperplasia,
macronodular hyperplasia, and steroid-dependent adrenal hyperplasia.
-
8/16/2019 Endocrine Surgery MCQ.docx
49/71
9heochromocytoma is characteried &y catecholamine rather than cortisol
e8cess as it arises from the adrenal medulla rather than the adrenal corte8. ?A.
Which of the following are normal systemic effects of glucocorticoids> a.
Enhanced proteolysis &. #ncreased gluconeogenesis c. 'iminished lipolysis d.'ecreased rate of intestinal epithelial replication "nswer! a, &, d %he many
systemic effects of glucocorticoids are related to regulation of intermediary
meta&olism. #n this regard, perhaps the most important action is the effect of
steroids on protein &readown. " direct proteolytic effect of steroids is
suggested &y several lines of evidence. lucocorticoids enhance
gluconeogenesis &y &oth a direct effect on gluconeogenic hepatic enymes
and also &y provision of su&strate for gluconeogenesis &y proteolysis.
lucocorticoid influence leads to the accentuation of lipolysis. %he truncal
o&esity seen in steroid e8cess is related to the predominance of the lipogenic
effect of insulin on truncal adipocytes over the lipolytic effect of
glucocorticoids. %he opposite relation may hold for the receptors in fat of the
e8tremities and would e8plain the comparatively scant fat in these areas with
steroid e8cess. %he most nota&le effect of glucocorticoids in the intestinal
tract is a decrease in the rate of mucosal cell replication. #n addition,
decreased mucosal and pancreatic prostaglandin synthesis occur. %his may
have important implications for the cytoprotective mechanisms in the
stomach. ?1. " 1A-year-old child presents with hypertension, tachycardia,
nervousness and sweating. %he &est initial diagnostic evaluation is which of
the following> a. (adioimmunoassays for norepinephrine and epinephrine in
serum &. Magnetic resonance imaging of the adrenal gland c. M#$ 0141#-
Methaiodo&enylguanidine scintigraphy d. Measurement of catecholamines
and their degradation products in a 2-hour urine specimen "nswer! d %hefirst diagnostic step in determining the functional state of an adrenal gland or
lesion is to screen the urine or plasma for secretory products. *nce
hypersecretion is demonstrated, the specific type of pathology producing a
syndrome must &e determined with the aid of functional tests and relevant
-
8/16/2019 Endocrine Surgery MCQ.docx
50/71
scanning and imaging. %he most efficient and sensitive means of screening in
a patient suspected of having a pheochromocytoma, 0as indicated here is
measurement of the catecholamines or meta&olic products thereof in the
urine. "lthough 2-hour samples can smooth out the possi&le episodicvariations in catecholamine secretion, shorter sampling periods can &e useful,
especially if corrected for creatinine e8cretion. %iming of the collection is
critical in patients who have only episodic hypertension. )rine collection
should &e started immediately after a suspected attac of hypertension.
/luctuations in plasma catecholamine concentrations are much greater than
those in urinary e8cretion, even in normal su&:ects. 9lasma determinations
are uite sensitive and specific with radioimmunoassays and B9
-
8/16/2019 Endocrine Surgery MCQ.docx
51/71
administering 1AA mg of hydrocortisone intravenously every ? hours during
the first 2@ hours. Some prefer alternating doses of #M cortisone acetate in
the event that intravenous access is lost. 9rovided that no intervening
complications arise, the doses can &e halved every 2@ to 7 hours. #n patientswho have &een e8posed preoperatively to glucocorticoid e8cess, the
maintenance dose may &e as high as 1AA mg=d for several months. $oth high
doses and normal maintenance of 4; to ;; mg=d can &e given in the form of
oral cortisone acetate as long as relia&le alimentation and a&sorption have
&een achieved. %he pituitary-adrenal a8is remains suppressed for ? to 1
months after operation. Complications in the postoperative period include
wound infection, pancreatitis, and throm&oem&olism. %here is no data to
suggest that the ris of postoperative pancreatitis can &e diminished with
somatostatin analogue therapy. ?4. #maging of the adrenal gland is &est
achieved with which of the following techniues> a. )ltrasound &. Computed
tomography 0C% c. "rteriography d. Scintigraphy with 141#-? &-iodomethyl-
15-norcholesterol 0+9-;5 e. Scintigraphy with 141#-
methaiodo&enylguanidine 0M#$ "nswer! & "lthough ultrasonography is
the least e8pensive