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A 27-year-old woman presents to your office with a left-sided neck mass approximately 2.5 cm in size. FNA reveals papillary thyroid neoplasm. She has no palpable lymph nodes. What is the best management for this patient?
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A. Left thyroid lobectomy with left modified radical neck dissection
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B. Total thyroidectomy with bilateral modified radical neck dissection
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C. Left thyroid lobectomy with postoperative I-131 therapy
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D. Total thyroidectomy with postoperative I-131 therapy
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E. Total thyroidectomy alone
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For papillary thyroid cancers larger than 2 cm, total thyroidectomy is indicated. Postoperative I-131 therapy is given for tumors >4 cm or extrathyroidal disease. Neck dissection is unnecessary without evidence of nodal disease.
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A 27-year-old woman presents to your office with a left-sided neck mass approximately 2.5 cm in size. FNA reveals papillary thyroid neoplasm. She has a 1-cm palpable left cervical lymph node. What is the best management for this patient?
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A. Left thyroid lobectomy alone
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B. Left thyroid lobectomy with left modified radical neck dissection
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C. Total thyroidectomy with left modified radical neck dissection
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D. Total thyroidectomy with postoperative I-131 therapy
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E. Total thyroidectomy alone
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The size of the tumor necessitates a total thyroidectomy. This patient has a palpable cervical lymph node, and thus a unilateral modified radical neck dissection or excision of the enlarged lymph node should be done.
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A 17-year-old male has a 2-cm right cervical nodule. An FNA is done and cells stain positive for calcitonin. Labs also reveal elevated calcium. What is the most likely diagnosis?
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B. Follicular thyroid cancer
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Calcitonin-positive cells indicate a diagnosis of MTC. Elevated calcium suggests hyperparathyroidism. Along with pheochromocytoma, these diagnoses make up MEN 2a. MEN 2b would include MTC, pheochromocytoma, and mucosal neuromas.
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A 46-year-old woman presents to the emergency department with fever, tachycardia, diaphoresis, and tremors. She has a history of a goiter. Initial management should include all of the following except:
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This patient has thyroid storm. β-blockers are used to control heart rate with reported inhibition of peripheral conversion of T4 to T3. Steroids and PTU work by decreasing production and release of thyroid hormones. IV fluids and oxygen are part of routine resuscitative care. I-131 has no role in the treatment of thyroid storm.
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Which of the following is NOT commonly seen in patients with MEN 1 syndrome?
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D. Parathyroid hyperplasia
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MTC is seen in patients with MEN 2a and 2b. Parathyroid hyperplasia is the earliest and most common manifestation of MEN 1. It develops in 80% to 100% of patients by age 40. Gastrinomas are the most common pancreatic islet cell tumor in MEN 1, which occurs in about 50% of patients, followed by insulinomas, which develop in 10% to 15% of cases. Prolactinomas are the most common pituitary lesion, which occurs in 10% to 50% of MEN 1 cases.
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What is the most common adrenal incidentaloma found on CT scan?
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A. Adrenocortical carcinoma
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Nonfunctioning cortical adenomas comprise the majority of adrenal incidentalomas in patients without a history of cancer.
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Which of the following is an indication for surgery in a patient with asymptomatic primary hyperparathyroidism?
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A. History of an episode of life-threatening hypercalcemia
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B. Medical surveillance not desirable/possible
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D. Osteoporosis (bone density T-score <–2.5 at any site)
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The 2002 NIH consensus conference guidelines for parathyroidectomy in patients with asymptomatic primary hyperparathyroidism are serum calcium >1 mg/dL above the upper limits of normal, life-threatening hypercalcemia episode, creatine clearance reduced by 30%, kidney stones on abdominal x-ray, markedly elevated 24-hour urinary calcium excretion >400 mg/dL, age <50 years, long-term medical surveillance not desired or possible, and substantially decreased bone mineral density at the lumbar spine, hip, or distal radius (T score <–2.5).
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A 65-year-old male is found to have an incidental right adrenal mass on CT scan during workup for trauma. He does not have a history of hypertension or any malignancies. Physical examination is negative. Blood work demonstrates normal electrolytes and plasma metanephrines. Urinary free cortisol is normal and low-dose overnight dexamethasone suppression test shows a low cortisol level the following morning. The CT scan demonstrates a 6-cm irregularly shaped heterogenous mass. What is the next appropriate step in management?
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A. Perform CT-guided needle biopsy of adrenal mass
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B. Repeat CT scan in 6 months
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C. Perform open adrenalectomy
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The patient is found to have an incidentaloma that is asymptomatic and nonfunctioning. However, given its size of 6 cm and CT findings that suggest malignancy, the patient should undergo adrenalectomy. Other CT scan features that suggest malignancy include evidence of necrosis, hemorrhage, local invasion, lymph node metastasis, and high attenuation. Needle biopsy of an adrenal mass should only be performed in patients with a history of malignancy to rule out an adrenal metastasis after ruling out pheochromocytoma. Mitotane is an adrenal cytotoxic agent that is used as adjuvant therapy for adrenocortical carcinoma.
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A 50-year-old woman presents with truncal obesity and hirsutism. A 24-hour urinary free cortisol is markedly elevated. Low-dose dexamethasone suppression test fails to suppress plasma cortisol levels. Plasma ACTH levels are also elevated. High-dose dexamethasone suppression test yields low plasma cortisol levels. Which imaging study would most likely demonstrate the cause of her symptoms?
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C. MRI of the sella turcica
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D. Metaiodobenzylguanidine (MIBG) scan
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When Cushing syndrome is suspected, the first test should be a 24-hour urinary free cortisol. If it is elevated, a low-dose dexamethasone suppression test is performed. Failure to suppress cortisol levels indicates Cushing syndrome. ACTH levels are then measured. Low ACTH levels indicate a cortisol-secreting tumor such as a primary adrenal source. A CT scan of the abdomen would be helpful in this case. A high ACTH level suggests a pituitary or ectopic source of ACTH. A high-dose dexamethasone suppression test will differentiate this. The pituitary source will be suppressed; thus, pituitary MRI should be performed. Failure to suppress production suggests an ectopic ACTH tumor, which most commonly is small cell lung cancer or bronchial tumors. CT of the chest would be warranted in this case.
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A 55-year-old male with newly diagnosed hypertension complains of muscle weakness. Laboratory data demonstrates hypokalemia and low plasma renin activity. CT scan shows bilaterally enlarged adrenal glands without a definite mass. What is the next best step in management?
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B. Perform selective venous catheterization
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C. Perform unilateral adrenalectomy
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D. Perform bilateral adrenalectomy
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The patient is suspected to have primary hyperaldosteronism, which may be due to bilateral adrenal hyperplasia or an aldosteronoma. Selective venous catheterization for aldosterone sampling in adrenal veins can aid in localizing the aldosteronoma, thus determining if surgical intervention would be beneficial. If the aldosteronoma is localized to 1 adrenal gland, then the patient should undergo unilateral adrenalectomy. If bilateral adrenal glands are hyperfunctioning or if there is failure to localize the aldosteronoma, then medical management with spironolactone would be the mainstay therapy. There is increased morbidity with bilateral resection, which is reserved for refractory hypokalemia for cases of bilateral hyperplasia. NP-59 scintography can also be used to differentiate adenoma from hyperplasia.