Thyroid: Facts to remember

Most common thyroid malignancy : Papillary CA
Orphan Annie-eyed Nuclei: Seen in Papillary CA

Hurthle Cell CA:

1. Subtype of Follicular
2. More invasive, frequent bone mets
3. Abundant mitochondria in cytoplasm therefore an eosinophilic appearance

FNAC cannot distinguish between Follicular Adenoma and Carcinoma as this distinction is based on histological changes like capsular and vascular invasion. 

Papillary: mainly lymph nodal metastasis
Follicular: mainly blood vessel metastasis

Medullary: mainly lymph nodal metastasis

Chances for multiple foci and bilateral tumors more in Papillary than Follicular

Tumor Markers: 

Papillary, Follicular: Thryoglobulin

Medullary: Calcitonin

Aberrant Thyroid tissue (lingual/cervical/intra-thoracic) never occurs in lateral position unless it is a malignancy. 

Papillary CA most commonly associated with lateral aberrant thyroid tissue. 

MEN Syndrome:

MEN 1

Pitutary Adenoma/Hyperplasia

Parathyroid Adenoma/Hyperplasia

Pancreatic islet cell hyperplasia/adenoma/carcinoma (Neuroendocrine tumors, viz. gastrinoma, insulinoma, etc.)

Les common: foregut carcinoid, pheochromocytoma, lipomas

MEN 2A

Medullary Carcinoma: Thyroid

Pheochromocytoma

Parathyroid Adenoma/Hyperplpasia

Hirschsprung's Disease

Cutaneous Litchen Amyloidosis

MEN 2B

Medullary Carcinoma: Thyroid

Pheochromocytoma

Marfanoid features

Mucocutaneous and GI neuromas

Pulsatile mets are seen in Follicular Thyroid Carcinoma and Renal Cell Carcinoma

On FNAC, if Hurthle Cells are seen along with lymphocytes, it's characteristic of Hashimotos. 

Blood Supply of thyroid:

1. Superior Thyroid Artery
2. Infereior thyroid Artery
3. Accesory Thyroid Artery
4. Thyroide Ima Artery

STA comes from ECA, Related to External Laryneal Nerve

ITA from Thyrocervical Trunk, from Subclavian Artery. Related to RLN. Supplies parathyroids also. 

ATA from tracheal and esophageal arteries

Ima arises from the brachiocephalic trunk or directly from arch of aorta. 

Veins: 

1. Superior Thyroid Vein
2. Middle thyroid Vein
3. Inferior Thyroid Vein
4. Kocher's Vein

ITV drains nto left brachiocephalic vein. 

The rest drain into IJV, not EJV

STV may also drain into common facial vein. 

What I'm doing currently

Well, this post is about my study plans. I'm going to do a thorough read of Das's Surgical Short Cases (the only copy I could manage to get my hands on was this 1991 First Edition, in surprisingly pristine condition).

At the same time I hope to go through Bailey & Love and Sabiston as well. I hope that by the end of this month I should be finished with one reading of Short Cases. I also plan to do some mcq's side by side and maybe I'll finish Surgery wholly by mid-April.

What I'm really worried about are the other subjects I need to study. Who the fuck will want to read Biochemistry and Physiology at this stage of their lives? I don't know if I'll succeed this time.

Role of Frozen Section in Thyroid Surgery

Chandra is the accomplished surgeon in our motley crew of 3. He is quite knowledgeable and I was fortunate enough to hear these wise words from him today.

"Why would you want to do a Frozen Section on a Thyroid perioperatively? It is futile. What you are trying to distinguish with a frozen section is papillary from follicular. The only way you can say that it is papillary is by looking at Orphan Annie eyed nuclei (OAN). But OAN is a histological artifact which is formed due to paraffin accumulation while fixing the slide. Since there is no paraffin involved in the making of the frozen section, you cannot diagnose papillary carcinoma from follicular.
"What about follicular? Well, whether benign or malignant, the frozen section will show follicular cells only. What you need to identify it as carcinoma is evidence of tissue invasion which, again cannot be judged on frozen section. Hence, that is out too."

Hydrocele

I'll just tell you something one of my favorite consultants told me,during my first few days at CMC.

No examiner will pass you, at any stage of your medical training, if you fail to do a trans-illumination test on a Hydrocele. 

The Varicocele

There are two incidences I can remember about a varicocele.

The first was when my grandfather narrated to me an incident when he was working as a newly graduated medico in a mission hospital in Kerala. A foreign doctor (missionary) was arguing with a woman who insisted that her son had a unilateral testicular swelling; but he could not find it. There was no love lost between this missionary and grandpa, I must add.

My grandfather then went to the kid and told him to stand up. After a few minutes a swelling slowly started forming. That is the sign of a varicocele.

The second was when I myself was examining a patient complaining of a testicular swelling but I could not find anything. I went to my consultant who again made the patient stand and I saw a small increase in the size f the testes. Varicocele.

The obvious question that is asked is, "On which side is a varicocele commoner, and why".

The answer is, left side. There are seven reasons for it, as mentioned in the classic text "A Textbook on Surgical Short cases" by S. Das.

1. The left testicular vein drains into the left renal vein at a right angle. Therefore there is a chance of blockage, as compared to the right testicular vein, which connects to the Inferior Vena Cava. 
2. The length of the left testicular vein is more than the right; because of the higher position of joining the renal vein and because of the lower position of the left testes. 
3. In 15% of cases the left testicular vein may actually join the IVC but in doing so, it would arch over the left renal vein hence predelicting it to obstruction. 
4. A loaded Sigmoid may press on the left testicular vein. 
5. This is a good one. The left adrenal vein also drains into the renal vein and circulating adrenaline can cause local vasoconstriction at the site of the testicular vein!
6.  If the left renal vein passes in between the Abdominal Aorta (posteriorly) and the Superior Mesentric Artery (anteriorly), then it may get compressed. 
7. Incompetent valves are more common in the left testicular vein. (You may need to cite references for this one)

Key words: examine in standing position, bag of worms, decreases spermatogenesis, cough impulse (palpation)

Hey, an interesting test. next time you see one, occlude the superficial inguinal ring with your thumb (on the side of the varicocele) and then ak him to stand up. You will see the varicocele filling up faster!

Also, while holding the testes with you thumb and fingers, ask the patient to bow down. You may feel reduced tension within the varicocele!

7 causes, 2 tests, and 1 clinching diagnosis. No one should have a problem with varicocele now!

Solitary Rectal Ulcer

One of my friends, Eby, came out of the Proctoscopy Room saying something about a filthy rectal ulcer, apparently what he thought was a Solitary Rectal Ulcer. Another fellow, Chandra, asked him whether it was anterior or posterior. He replied something but I was already wondering what could be the significance of that question.

It turns out that Solitary Rectal Ulcer Syndrome (SRUS) is something unique and you can't just go about labeling a single ulcer as SRU.

It is always located on the anterior aspect of the rectum 4 to 12 cm from the anal verge and is thought to correspond to the location of the puborectalis “sling.” It is frequently, although not exclusively, associated with internal intussusception or full-thickness rectal prolapse. Patients are typically young and female, however, with an average age of 25 years and a history of straining and difficult evacuation.

Sabiston, 18th Edition

A quick review of lengths: 

Anal canal: 2.5-4cm 

Rectum: 12cm

The cause of this SRUS, according to Sabiston is an intussuseption lead point which occurs due to repeated straining and ulceration at this point. 

Some fellows might indulge in digital self-disimpaction (Seriously. Yuck)

You have to differentiate this from malignancy, infection or Chrons. The anterior nature of this ulcer helps to clinch the diagnosis. Defecography is the investigation of choice. 

Treat the cause for intususseption, which inevitably means treat the prolapse through an abdominal procedure.  Ripstein is supposed to be considered but no clear indications for this. 

Rectal Prolapse

I was presenting a case of Prolapse to a consultant when he asked me the difference between a complete and partial prolapse. Frankly, I had no freakin' idea!

I told him something similar to 3rd and 4th degree hemmoroids.. i.e. if you have to manually replace the prolapsed rectum then it is a complete prolapse; otherwise it is a partial one! He was stumped for a second, perhaps wondering whether it was some new definition or something... he then asked me that 'Bailey & Love' definition.

Y'know, the thing is, how you say something makes a big difference. You can stump even a really learned man if you are confident of what you say, even if it is slightly wrong.

The correct answer is, that you have to feel the prolapsed structure between your index fingere and thumb. If you can feel a double layer of mucosa then it is a partial prolapse. If you feel the muscular layer as well then it is a complete prolapse.
My consultant later added that a prolapse of 4cm or more can be considered as a complete prolapse.

OPD

Well hell. Today one 21/Male came with a thyroid swelling and exophthalmos. Initially I thought it was Grave's disease. He did not have palpitations/tachycardia/tremors.He was anxious, but mainly due to the nature of his condition.

On palpating the gland, it was slightly lobular. Smoothly lobular would be more correct, as the curves of the lobules sort of molded into each other. Left side more prominent than right. Trachea slightly deviated to the right. I still thought it was Graves. Mistake number 1.

There was a solitary lymph node palpable in the left supraclavicular fossa. No other relavant findings.

I was about to go to my consultant and think about presenting a case of Grave's, when suddenly this fellow produced an FNAC report done from somewhere in West Bengal. It said "Medullary Carcinoma".

What the fuck man!

On second though Grave's is really diffuse. There shouldn't be any lobules! How will one side be more prominent than the left?

He was also a man with thyroid swelling. That should have set the alarm bells ringing.

Never again will I look at a man with a thyroid swelling and not think of malignancy. Anyway I asked for Routine TFT's, S. Calcitonin, USG Thyroid, Review of his FNAC slide and other routine stuff. I forgot Thyroglobulin. Will do that next time; and won't forget again.

First Post

I guess I'd like to chronicle my experiences as a Surgical House Officer in CMC Vellore.

Surgical House Officer, or Senior HO, which is my official designation; implies someone who has finished his internship, but not gotten into a Post Graduate course yet.

CMC stands for Christian Medical College. There are two of them in India; the original in Vellore, Tamil Nadu and one in Ludhiana, Punjab. Both are prestigious places to learn; but the one in Vellore is considered among the best in the country.

I am not a CMC'ite. Which means that I have not completed my undergraduate training in medicine from CMC. I am therefore, an outsider in this place of learned, highly professional and focussed individuals; now and then I come across situations where I have to prove that I belong here.

Like all medical graduates, I am in the pursuit of a Post Graduate seat. My interest lies in Surgery, the reasons of which I am not quite sure of, actually. Anyway, it is highly competitive and I haven't gotten in yet, because of my laid back and easily distracted nature. Maybe I'll get in this year! Maybe in CMC itself, which would be great.. we'll find out soon enough!

The purpose of this blog then, is to consolidate my knowledge in whatever I learn daily by sharing it with you guys. Maybe I'll meet new and interesting people. Maybe I'll be clear about my opinion and my stand on things by putting it in word. Or maybe its a waste of time.

3 against 1, just cause for blogging! I declare this blog open!