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Um Hi guys. Uh So we're having endocrine next. So this, this is Doctor Vila. She's a consultant in endocrinology and she's agreed to do the endocrinology talk for us. Um I'll pass it on to you, doctor. Ok. Hi. Um, good afternoon. I'm doctor. I'm currently working as a consultant uh in Forest NHS Trust and uh II tried to make sure my slides are just right for your stage of learning. Um Just um apologies if it's little at once. But I, we'll, we'll try to discuss if you have any questions. I'm happy to answer. Ok. So it, I would like to initially, I thought about the thyroid nodule, but thyroid nodule is um just being that is extensive topic. And for you, I stage I think we just have to cover uh uh diagnosis of a nodule and evaluation. Although I would like II added some slides regarding um the hyperthyroidism and thyroid storms and my a coma. So, um my objective, so I understand the presentation thyroid emergencies and to understand how to diagnose the management and to improve the referral pattern, thyroid cancer patients and perioperative care during thyroid surgery. I just got that this um question from one of your question banks. But see whether you have the answer 40 year old present with sweating, loose stools, weight loss and heat intolerance. On examination, there are three thyroid nodules with observations as follows temperature. 36.8 heart rate, 92 BP, normal. So just the most likely diagnosis. So actually, I don't know. The question bank gives you certain questions. I think it's not complete without thyroid function test. You cannot say much of information, sir. But however, if you go through the answers, see your thyroidism amiss when you are sick or acutely ill, your thyroid function tests are abnormal. Usually TSH is low t four low t three low. It's because the dias enzymes are deactivated during um sickness. Um So it's all low thyroid hormones are suggestive of secure thyroid. But thyroid Strome is a condition where you diagnose based on a criteria. But patient may have symptoms of hypothyroidism and marked symptoms like loose stools are the gastrointestinal cardiovascular. Uh all the symptoms with increased thyroid function test, um suggestive of hyperthyroidism, uh so difficult to diagnose with at stone. But heart rate being 92 is less likely because it's maybe 100 and 40 120 more than 20 100 and 20 atrial fibrillation associated thyroid stone graves disease is likely diagnosis. However, diagnosis confirmed by presence of antibodies called thyroid receptor antibodies. We can say this is likely to be a hypothyroidism, but we need to confirm with the thyroid function test. So, questions can be incomplete. But if you're given four answers or five answers, you have to collect tt one thyroid cancer. We cannot say with presence of nodules that no, all the nodules are cancerous. It, diagnosis of a biopsy of multi goiter can be a possible diagnosis and they can present with thyrotoxicosis. Um I think either graves would be the diagnosis because they also have nodules, multinodular goiter, not necessarily being hyperthyroid. So if you have any questions or if you want to answer any questions, I can interrupt in the middle and answer. Please let me know. Um So the clinical presentation usually symptoms often asymptomatic. They can be hypothyroid, hypothyroid, they can have nodules, goiters and symptoms of pressure can be difficult in solving breathing problems, voice changes and there can be an any family history of thyroid disease. Physical examination, gland examination is important to palpate the glands and auscultate. You can have thyroid bruit in the presence of grapes, features of thyrotoxicosis and malignancy features heart goiter, lymph nodes, voice changes suggestive of a malignancy. So these are the few symptoms of hyperthyroidism might can affect almost all the head to toe, hair loss, thyroid gland enlargement. Bru there may be lymphadenopathy even with thyroiditis. Not necessarily be a cancer, muscle weakness, proximal muscle weakness, oligomenorrhea, or increased menstrual cycles. They are very much um heat sensitive and they increased appetite weight loss, sweating, diarrhea, unintentional weight loss, especially tremors of the hands and palpitations, insomnia and anxiety. When we come specifically for graves, you get eye signs, some of the eye signs you see in hypothyroidism itself because of sympathetic activation. However, the grave specific signs are mainly um li l and conjunctival chemosis. Um you can see edema over eyelids. It's because we get thyroid receptor, thy IG I especially IGF growth hormone receptors um present and in the, that was stimulated by thyroid uh receptors. Yes, receptor antibodies and thyroid acropa acropa is a co condition affect your nails. It's like just like globbing, but it's not globbing. It's enlargement of the extremities, uh especially the hands. Um So these are specific. Uh the other thing I forgot to mention I th pial myedema, it's also specific for graves. So when you diagnose, um when you have these symptoms in a patient, you do thyroid function test a suggestive of clinic hyperthyroidism confirmed. And um the usual treatment is carbimazole or propylthiouracil. We tend to give carbimazole first because it's um uh more potent and less side effects than propylthiouracil. In view of white cell count suppression and liver function elevation. Propylthiouracil is a di uh medication uh for pregnancy until 12 weeks. And carbimazole once daily propythiouracil unit multiple doses, 10 mg, carbimazole equivalent to um 100 mg pro uracil. So that's a conversion and propylthiouracil has added advantage, it inhibit T four T three conversion. So that is T three is the active hormone. I think you're aware about that. Um So that is inhibited by PT. So it's very good in thyroid stroma. And uh carb muscle doesn't have that action, however, they cross react to each other. So, if you have sensitivity to carbimazole, you may have sensitivity to prothil as well. Right. So I told you I will just, just focus on thyroid crisis. So, thyroid crisis, they can't listen to it. This is not uncommon um because they think these symptoms are anxiety, they get diarrhea, agitation, delirium, psychosis, cardiovascular neurological and um gastrointestine. So we have the classification depending on the scoring system, you decide whether you treat as thyroid strong or not. So, treatment to protect your heart, uh beta blockers. And also it has inhibit the conversion of T four to T three, which is um essential in acute stage antithyroid agents. We usually use PT because it also blocks the hormone synthesis and as well as conversion of TT to T four. Um we also tend to give um glucocorticoids because to stabilize the uh vasomotor stability as well as if there's coexisting o and adrenal insufficiency, giving thyroid thyro thyroid crisis, uh precipitate adrenal crisis. And um very infrequently, we use iodine solution which has ablative effect on the thyroid gland and inhibit hormone synthesis and B acid we usually don't use currently, which has reduced um ability to um prevent enterohepatic recycling of the thyroid hormones Um So this patient need I if there's atrial fibrillation, cardiovascular assessment, echocardiogram, he if there's heart failure treatment for heart failure is also indicated and also um thyroid functions can be monitored maybe once in three days. And patient can be stabilized uh by intravenous fluid. This medication and as the last option, it's thyroid surgery or total thyroidectomy if they do not respond. Um And this is the other presentation of this patient, hypothyroidism. Extremely. The other end of what we discussed, uh just a while before thyroid gland can be enlarged because of increased production of thyroid hormones, compensatory, primary hypothyroidism usually have TSH elevation, secondary hypothyroidism is due to pituitary insufficiency. So TSH is not elevated as expected as expected uh in thy low thyroid hormone in the presence of low thyroid hormone. They do have puffy face. They have crossed features. There can be little tinge of jaundice, icteric and uh they can have pleural effusions, pericardial effusions as well. The extreme cases they have nonpitting ankle edema and um they can have memory problems, uh constipation especially um and weight gain. We do s we don't see much of thyroid um myxedema coma currently, but the treatment will be levothyroxine replacement dose 1.6 mcg per kg per day. You need to give me the dosing instructions because thyroid hormones, very unstable in the presence of gastric acid. So first thing in the morning, uh with a glass of water do not take any tablets, especially calcium or iron tablets together with thyroxine. But if you see in the wards, um nobody has given levothyroxine. That's the first thing in the morning. So they all given with the other tablets. So that's a problem. Ongoing problem. Ok. Um, if you see a patient with mixed in a coma, you are lucky because we don't see this at the moment because TSH is commonly done and elevated of TSH found by G GPS and start treatment. But um T three is a low thyronine that's active, active medication, intravenous, low thyronine and thyroxine. We do give with hydrocortisone and hyponatremia can be there which need treatment with uh water restriction because it's managed just like sad. And if they have effusions, uh pulmonary edema, they can have um fursemide and they are hypothermic, they're called intolerance. So we can treat hypothermia revering and also panhypopituitarism need to be um looked into if the TSH is low and concurrent hyper can be there in autoimmune problems underlying of panhypopituitarism. Ok. Just to make it a little interesting, I thought I would add a case. So this is Sarah who presented the primary care physician with complain of a lump in the neck for two months and gradual increase in size. It's a painless one, no difficulty in solving breathing problems or voice changes. Um No hypothyroid hyperthyroid features, family history of not significant, no previous thyroid problems or radiation radiation is important if you think about thyroid cancer. That's a risk factor. And on examination two centimeter, firm nontender nodule palpated in the right lobe of the thyroid, no lymphadenopathy, no signs of overactive underactive thyroid. So, ultrasound of the neck found to have right side thyroid nodules measuring two centimeter. Ok. So this might be a little advanced for you, but we always have to go by the ultrasound characters of the nodule. Um So irregular margins, microcalcifications, increased vascularity are dangerous. I would say they are not good and these things can lead to FN and cytology, suspicious follicular neoplasm. So we need to try on some laboratory test, especially thyroid function, test, antibodies, ultrasound, thyroid, thyroid uptake scan is a scan which use iodine to see whether this nodule is functioning or not. So, increased uptake, we call it um hot nodule, reduced uptake, we call it cold nodule and suspicious features of ultrasound scan will lead you to do en ac and biopsy but not all the nodules. So, um whichever the specialty you want to practice you, it's very common to find thyroid nodule and you're not sure whether it's a cancer or not. So next thing is you do a scan and scan comes as two centimeter, U one nodule, U two nodule, U three nodule, U five nodule, U is um uh test usually used in British. And uh this is classification used in USA. This is called tires. I think it's better to have an idea because some radiologist may use thyroids, one T one to T five. Some may use U classification. I'll show you in a while. So tr one, tr two are not suspicious. No FN atr three, mildly suspicious. If they are more than 2.5 you do FNA tr four, more than 1.5 and tr five, more than one U two FNA. If you see how these thyroids comes in, you see composition, it's with a cystic solid, mixed cystic solid. So this is a composition echogenicity. So if it's s appear same consistency like um the same appearance as the uh the thyroid, uh the rest of the thyroid gland, we call it isoechoic, same as thyroid. If it's more than the thyroid gland, like slightly blackish, we call hyper, slightly whitish, we call it hyperechoic, slightly blackish than the thyroid gland. We call it hypoechoic. So this is how it comes the shape. So taller, wider than tall is good. Taller nodules are not good. So they get three points and margins, especially the irregular margins uh are not good. So they are suspicious and echogenic f kind. If you have calcifications, peripheral calcifications, uh they are much more suspicious. So putting all together, we get thyroid score and grading system. So you may get some scans with thyroid. So I think the referral would be to send to endocrinologist for further assessment rather than a surgeon who might remove the thyroid altogether. And uh this is the usual um document we use in as a British guideline. So I mentioned of you you want to do five just as tr one to R five, but you can say the same. So U one and U two are benign. U three is intermediate U four, U five, malignant and suspicious. You can see in U five, you get calcifications, irregularity and toll nodules and um sometimes vascularity is comes as well. Yeah, malignancy, hypervascular, right. So for your interest, just uh uh cystic thyroid nodule, bit isoechoic internal vascularity. So it's kind of au three nodule, it's here and just to show your microcalcifications in thyroid nodules, right. So when you go for FNS A, you get a report of histology comes as thigh. We are looking at whether it's a follicule in your person or whether it's malignancy diagnosis. So, depending on the cells, they will give you a report whether it's non diagnosed with non neoplastic or malignant. Ok. Depending on I think this is too much for you. Let it go. Um So benign nodules of follicule, adenomas, malignancy can be primary malignancy or secondary malignancy. I come in a while. So we get um follicule adenomas are benign. However, you can have malignant secondary malignancy. I'm not going to talk about because it's a metastasis. Primary malignant nodules. Are we worried like benign nodules? We don't worry. So if you get the t classification as um follicular neoplasm. If in FNA C, you do a histology, you'd get a sample, usually remove the same lobe and then if it's benign follicular neoplasm, you don't do anything, just leave it like that. That is this one, right? If you get a primary, um, malignancy of the thyroid can be differentiated, undifferentiated cancers. Um I'll show you differentiated thyroid cancers, uh, cancers primarily coming from the thyroid cells. So it's already derived from the follicular cells which also produce thyroid hormones. They are generally slow growing and good prognosis, especially treated early and usually treated with surgery and radioactive iodine therapy. And good thing is differentiated thyroid cancer produce the same thyroid hormones as well as a protein called thyroglobulin, which is found in the thyroid cells or thyroid gland before production of thyroid. So, thyroglobulin is the protein which bind to uh dihydrothymine 223, tt three and T four. So, thyroglobulin can used as a monitor. Differentiate the thyroid cancers for undifferentiated thyroid cancers are undifferentiated cells. So they are not same alike as thyroid tissue. They are rapid, aggressive and progressive and usually include anaphylactic thyroid, ca anaplastic thyroid carcinoma, and generally poor prognosis, difficult to treat need surgery, radiotherapy chemotherapy, they typically do not produce thyroglobulin. So there are no marker to um uh monitor and there is another undifferentiated thyroid cancer, which is called medullary thyroid cancer, which is in usually genetic, genetically inherited, right. So, staging disease is important. And I think for your MS, you might get what are the risk factors for thyroid cancer? These are the risk factor if they have hashimoto thyroiditis, the risk of lymphoma, family history of first thyroid adenomas. And there is a syndrome called CIN syndrome. Uh they can have benign malignant breast disease, sometimes mild learning difficulty and people with familar thyroid cancers like medullary thyroid cancer just mentioned. And neck radiation obesity is also risk factors for thyroid cancer. Ok. So as I mentioned, differential to thyroid cancer can be treated surgically with iodine ablation. So when you do a surgery, you remove whole gland. If you, if you don't think it's a benign follicule, you remove the whole gland. And then next is to see whether there is any remnant. So you do iodine ablation to ablate any of the thyroid tissue in the body. Even the micrometastasis can be ablated and then you monitor thyroglobulin and uh thyroglobulin is usually monitored by antithyroglobulin antibodies. And if there's any recurrence, you get thyroglobulin going up and then you do another scan and iodine scan again to see whether there is any metastasis, undifferentiated, difficult to treat. And a plastic treated with aggressive tumor reduction and joint treatment and medullary thyroid cancer usually is treated with surgery and screening even in the new bones of the same generation or subsequent generations. Newborn needs screening. And if they have this A and two B genetic syndrome, they need prophylactic thyroidectomy. It depends on which type two. There are two A and two B. So some, some kids, some infants may undergo less than one year of age, prophylactic thyroid removal. Ok. So you might come across patients preparing for surgery. Patient need to be your thyroid to surgeon to do a clean surgery without much of a bleeding. So, car muscle pyrolase before surgery to render them your thyroid. However, local iodine can be used to reduce vascularity and um postoperatively, we do start levothyroxine replacement. And hypoparathyroidism is common in some um some patients because of uh temporary or permanent because of damage to parathyroid glands. And they need calcium replacement, sometimes intravenous or early postoperative period. Vocal cord, uh paralysis can happen with um recurrent injury, nerve injury. Ok. So back to Sarah, Sarah was surgically treated with total thyroidectomy because that was a suspicious nodule and monitored for complications. Followed up with thyroid hormone replacement and she was regularly followed up with ultrasound and serum thyroglobulin level monitor. And um the it's a papillary thyroid cancer and routine followup indicated and started on levothyroxine. Ok. Right. Uh This is about the thyroid gland and I the take home message I want you at this stage is not all the nodules are for surgery. Sometimes they can be conservatively managed, sometimes they can manage your hemithyroidectomy. Sometimes they need advanced treatment other than thyroidectomy and follow up with the specialized centers. Um, do you have any questions for this teaching? Hello. Hi. Hello. Yeah, I have finished my first part of teaching. Uh Do I have any questions? Oh, I can see in the chart, right? Yeah, you can see it in the chart. OK. Are these sessions being recorded? I don't know. I think you can answer that. Yes. Yes, they are. Uh OK. So it's a little white. Um So somebody is asking um maha if the option was toxic. Marginal delagoa, will that be correct? Yeah, you can say that. I think that would be the answer be because to say Graves disease, you need to confirm presence of thyroid receptor antibodies. And uh actually multi nod can be toxic, multi nod um in the presence of symptoms um and elevated uh thyroid functions. Um Graves to say something. Graves disease, usually they are uh hyperthyroid with the same symptoms and thyroid hormone elevated and thyroid antibody is positive. Usually that's a smooth goiter, no uh visible nodules but ultrasound scan can find nodules even in graves disease. But I think for your learning toxic nodule would be an answer there. So three nodules. Yeah, it's the same. Uh Yeah, I think I answered the question. Shall I start the next part? Yes, I think we can go to the next one. Yeah, I think if there's any other questions, I think they can answer it over the time and if there's anything we can answer later. Ok, bye. Can you see these lights now? Um No, it's, it's not visible on the screen. Yes, I can see it now now. Yes. Ok. Right. So pituitary two months, it's not, uh just to let you know it's not on full screen. So, no, now it's gone offline. Ok. I try this one. Um, if you can just go to slideshow and make it a full screen, I think. Can you see that? No, like I can see it but it's not full screen. Ok. Um If you can otherwise share your screen, go to the press now and press share screen, I think you'll be able to present anti aspirine. Still not. No. Um If you go to that arrow and shared entire screen usually works best. Mhm The only thing is you won't be able to see the charts but any questions I think we can answer. Yes, I can see it now and just go to the presentation. No. OK. You think this works? No. Uh Yeah. And then just yes and then yeah, I can see it now. OK. OK. So next topic is pituitary tumors. I think uh this usually you, you found this pituitary tumors whenever you i it's usually incidental finding unless somebody thinks about the pituitary problem with the visual field assessment or presentation with the visual problem. Usually it's incidental finding from the scans CT CT scans. The development is anterior pituitary, we call adenohypophysis arises from latus pouch and its ectodermal origin and posterior pituitary is a neurohypophysis arise from downward growth. The flow of diencephalon. So, anterior pituitary and we have anti, which produce certain hormones and posterior, which produce other hormones. I'll show you in next slides. So it's occupied the cavity of the sphenoidal bone and in the middle cranial fossa and you can sit down and tummy in the above, it's opticus, compression, um and diaphragma dixella and pituitary stalk is attached about to the floor of the third ventricle. It's very small and by the sides, you get uh cavernous sinus and sphenoid sss below cavernous sinus usually have um cranial nerves as well as um internal carotid artery. So has incidental finding in 5 to 20% and it's 15% intracranial tumors. It's broadly divided functional or nonfunctional and it is associated with, as I mentioned, some other endocrine problems like multiple endocrine neoplasia. You get parathyroid, pituitary and pancreatic. You see it's triple P chronic complex is associated with adrenal tumors. Myxomas, pituitary adenomas. If you get isolated pituitary adenoma, you can, it can be prolactinoma growth hormone secreting tumor, which also can go in families. I think you are aware about macular Albright syndrome where you get patients with excessive hormone secretion features. Acromegaly Cushing's, this is orogenic associated condition. So, anti pituitary hormones are growth hormone, prolactin, ACTH, FSH, LH TSH growth hormones stimulate liver to produce growth factors and it's controlled mainly by hypothalamus prolactin act as um mammary gland growth and milk production ACTH stimulate adrenal cortex to produce glucocorticoids. Mainly little action on the minero corticoids, aldosterone. A first challenge, stimulate development of ovaries and follicles and reproductive. They are controlled by GNRH and hypothalamic level as well as feedback inhibition by estrogen and I CS H is usually well less well recognized hormone, but it's involving testosterone production. And TSH stimulate thyroid gland to produce T 43. So it is stimulated by hypothalamus, yt Rh and sorry. I uh the other posterior pituitary produce two hormones. We call it neurohypophysis. It has um the origin is different from anterior posterior pituitary. As you can could see the previous slides. The ADH is stimulate motor retention, increase permeability, um add dis convoluted tuber and collecting talks. So it is important to maintain serum osmolality and sodium level. I think you are aware about si A DH is a condition where inappropriate ADH secretion lead to um retention of water as well as hyponatremia. Oxytocin, mainly important in pregnancy, uterine contractions and uh milk, uh discharge milk ejection in females and it is usually secreted during pregnancy and postpartum period. So um the presentation can be headache and visual field defects, visual defects usually by temporal hemianopia due to compression of the optic Cosma, clinical manifestations can be hormonal deficiencies. So, main hormones we we talk about for hormones, growth hormone deficiency in adults can reduce the quality of life, exercise capacity and obesity cardiovascular diseases. Infant, they can develop hypoglycemia and decrease growth and height, gonadotrophin deficiency lead to testosterone deficiency in men and libido, unimportance and reduced spermatogenesis and infertility. Women diminished libido dys gastro and reduce development of um uterus and um Children, they delay puberty and uh development of reproductive organs. TSH deficiency can cause secondary hypothyroidism, corticotropin ACTH deficiency lead to a severe this adrenal insufficiency cancer as medical emergency and very nonspecific symptoms, they get weight loss, lack of energy, malaise hypoglycemia. They can have associated um uh usually ac deficient, doesn't cause pigmentation, so can present without pigmentation. If it is secondary, then hyperpituitarism can be a combination of any of these hormones and hypersecretion. If there are hyperfunctioning, nodules can be hypersecretion of prolactin, mainly causes hypogonadism because hyper lactin inhibit the GNRH pulse in a hypothalamic level. And the woman with uh can cause amenorrhea, galacturia and infertility in men. It can cause low testosterone features but they don't cause gynecomastia. They don't growth hormone insufficiency can lead to um pituitary growth, hormonal production in kids, an adult, uh it's acromegaly, the changes of the hands and feet, cross face, frontal bossing prognathism, uh changes in voice diabetes, high BP, um carpal tunnel syndrome. Those are acromegalic features because adults they cannot grow much more because theirs are closed. So they grow in musculoskeletal systems and in metabolic parameters. Cushing's stasis usually with central weight gain, obesity, moon phase, we don't call it moon face. Now we call it cush face while it's dry and bruising. II can show you some pictures Um So examination, you get uh visual activity can be reduced. Color vision can be affected. They can have bitemporal hemianopia and optic atrophy and cranial nerve palsies can lead to ophthalmoplegia because you get um if it's a large lesion which involve cavernous sinus, you may uh have cranial nerve palsies and hypo can, chronic hypericism can have uh hypotension, generalized weakness, um malaise and depression. So, hypopituitary patients uh is difficult, very nonspecific symptoms, but acute sudden onset hyperpituitarism usually present in pituitary, apoplexy. They can have shock, coma, even death. And um prolactinoma, as I mentioned, caloria may present in physical examination and males, they can have testicular atrophy and usually test soft to palpation this patient, otherwise it's firm. This is, these are usually signs of uh Cushing's ma mainly mm the central obesity proximal myopathy, wide purple stripe more than one centimeter and dorsocervical and supraclavicular fat pads are cardinal features. Um They also can have diabetes, cataract fungal infections, uh easy bruises. Um and um they also can have um if they are very high act level, they can have pigmentation as well. Acromegaly usually present with large hands and feet, increasing shoe size, ring size, cross facial face, frontal buring dental problems. And um they can have carpal tunnel syndrome, osteoarthritis because of enlargement of joints. Um diabetes, blood high BP, cardiovascular morbidity because of metabolic parameters. Ok. So how are we going to assess these patients? Uh Usually these patients were referred to endocrine with or without this medic uh with or without test. I think uh as a primary physician or the any specialty, if you see a nodule, uh oh adenoma or any lesion in the pituitary, at least you should do cortisol level, at least random or nine name cortisol level because it can be lifesaving. You can start hydrocortisone then and then if it is low. So biochemical test, prolactin level, we can do serum prolactin level, serum prolactin level can be uh around uh if it's prolactin secreting tumor, it can be more than 5000 microprolactinoma, macroprolactinoma. Macro means if the lesion more than one centimeter, we call it macro, macroprolactinoma can be more than 10,000, more than 20,000 and sometimes your prolactin can be slightly high. We call it a stalk effect because prolactin is inhibited by a hormone called dopamine from the hypothalamus. If any tumor compressing the stalk, pituitary stalk can reduce dopamine action and prolactin is elevated slightly. So, having a high prolactin, it doesn't indicate always macro or microprolactinoma that can be pituitary stalk effect due to any other functioning tumor or nonfunctioning tumor growth hormone. We usually do IGF one level. However, if it's secreted more, if it, the patient has acromegaly, we can do oral glucose tolerance test and cushing's disease. We usually do dexamethasone suppression test. Dexamethasone is a steroid to be taken at night and followed by next day, serum cortisol level. If it is less than 50 we call it normal test if it's more than 50 unit, 24 hour urine collection for free cortisol and serum ac level salivary cortisol also can be included here. Thyroid hormone. We about about ht 43. If S and estradiol estrogen or testosterone can be used to detect any problem in the reproductive axis. Usually dedicated. MRI pituitary scan is the first um imaging modality. And uh so we, we call pituitary microadenoma. Usually it's less than one centimeter, macroadenoma, more than one centimeter. And also there are some categorization depending on the tumor extension. And um so the tumor can confine to sella. That means within the pituitary gland or it can go up, grow up, it's supracil extension which can uh lead to casal compression. It also can go to parasal extension which lead to problems in the cavernous sinus, ophthalmoplegia and um cavernous sinus invasion. So, these characteristics in the pituitary are necessary to decide on further management, right. So, in the me, when, when, when we talk about the management, the deficient hormone need to be replaced then and there because they can be lifethreatening hormone deficiencies, usually, levothyroxine is um followed uh by hydrocortisone replacement. So, hydrocortisone needs replaced early and then levothyroxine. Because if you give levothyroxine to a patient with deficiency of cortisol, you may precipitate adrenal crisis. Therefore, you start on hydrocortisone, usually 10 mg in the morning and 10 mg, midday and 10 mg in the afternoon or 10, 55. And that is lifesaving. And if it's accurate situation, you even can go 100 mg um intravenous hydrocortisone stat, followed by 50 mg, intramuscular 46 hours thyroxine replace in the means of levothyroxine and the rest of the other hormones doesn't need replaced urgently. However, testosterone can be replaced in the forms of gels or injection and in women, it can replace hormone replacement therapy. Growth hormone can also be given if it's indicated even in Children or adult. And there are certain criteria to start on growth hormone replacement and it's a daily subcutaneous injection. And uh this is an important hormone desmopressin because I mentioned a DH deficiency can lead to diabetes, insipidus. Um desmopressin is usually given as oral tablet or nasal spray to mimic the action of ADH and to conserve uh re water induce water retention. So they don't get uh symptoms of di di I usually present diabetes insipidus usually present as polyuria. Ok. So specific management prolactinoma as a well-known dopamine, agonist, bromocriptin or caragin. Uh usually it's 80 to 90% respond to dopamine agonist without any surgery. And even the shrinkage of the tumor can be observed. Growth hormone releasing tumors are best treated with surgery. Recurrence can be treated with repeat surgery or radiotherapy if it's failed, only we provide medical treatment. Medical treatment can be octreotide, lanreotide. So, somatostatin inhibitors, somatostatin analogs to inhibit hormone production and also growth hormone receptor anti analogs are there. Um And ACTH secreting tumor is best treated with surgery and very rarely if they are refractory, we can use ketoconazole mitotan. Those act on the level of adrenal gland and uh last few slides. Uh I would like to talk about pituitary apoplexy. If a patient, you can give a scenario in AMC patient comes with sudden onset headache and hypoglycemia is there and uh patient has low BP um and level of consciousness was reduced and they can have visual field defects, may or may not. And you may ask, TSH is low cortisol is low. What could be the possibility? So, it's pituitary apoplexy. So, pituitary apoplexy usually happens in the context of pregnancy or postpartum. However, it can happen in previous undiagnosed, pituitary tumor and bleeding into the tumor is indicated by apoplexy which led to sudden enlargement of the pituitary and compressing the pituitary normal tissue make you hypopituitary suddenly and as well as visual field defects due to enlargement. Um so they can be hyponatremic. They can have low sugars because of low cortisol, they can have a low BP again because of low cortisol and um electrolyte imbalance. Usually hyponatremia and low TSH T four but sometimes TSH only low bit T four takes a little while to drop. And uh if there's adverse effects, adverse features like visual field impairment, urgent consult, a neurosurgeon need to discuss and surgical decompression within seven days. But if patient is stable, we can monitor and eventually the bloods can absorb into the pituitary tissue and eventually that can improve. So conservatively can be managed replacing hormones and uh OK. What is this? This is a large pituitary tumor, but the characteristic features are white calcifications. So, calcifications usually seen in craniopharyngioma and I make a separate slide because craniopharyngioma is might recognize as a macroadenoma nonfunctioning. But there are certain characteristics like calcification and cystic areas which are congenital tumors but can appear in later stage because Children can have that, they have two peaks in Children and late fifties and 80% in Children and 20% in adult. And if you see the, if a radiologist see this one, it's craniopharyngioma, it's non functioning tumor. However, that can grow and therefore we need to check uh visual symptoms. And in kids, short stature, delayed puberty and other hypo features, diabetes insipidus can be the presentation and it can be very large and can extend into frontal and temporal areas of the brain. Treatment. Is surgery followed by um hormone replacement and radiotherapy might be indicated in certain uh subjects. So, w what about pituitary surgery? And it's usually transsphenoidal pituitary resection, it's through the nose um through the nose. Uh and it's usually um patient recover within 2 to 3 days. However, if patient has all the patients were started on hydrocortisone replacement on day one and they reassessed in six weeks by short synac test sh sy actin test is a test. We do to see whether actually there is more cortisol deficiency. And if it's normal, we can tell off hydrocortisone replacement. Day 2 to 5, we assess within a week, we assess for thyroxine replacement and we start on thyroxine and depend on the symptomatology. We can start testosterone, hormone replacement therapy and desmopressine. And if you are working in a surgical ward, a neurosurgical ward, you might ask to look after the postoperative patients. So, postoperative diabetes, insipidus is very important, especially di it's not di initially, it's early polyuric phase because um all uh it's mainly uh initial 2024 to 48 hours. Um polyuria and polydipsia, it, it's because of um released posterior pit due to the ADH hormone. And second page, you get um antidiuretic phase usually up to seven days. And later when we see the patient in the clinic, after pituitary surgery, they are late polyuric phase. They are usually um hypernatremic and polyuric. So, hypernatremia is initial indication. Initial 48 hours, high sodium is is a clue that this patient has early polyuric phase and need to start on treatment with desmopressin. As you can see this arrow, you need to treat with desmopressin here and then in the m uh within seven days, you may stop it and then may restart in the clinic. So we call it triple phase. After f duty surgery. Initial phase, you get hyponatremia, high sodium, second phase, you get low sodium and third phase, you get um high sodium again. And um it's, it's difficult to identify initial polyuric phase. That's why you do maybe twice a day electrolytes and monitor urine output every four hours. OK? I think that's the end of the presentation and we have about 10 minutes to discuss any questions. And in summary, usually pituitary tumors are benign and 15% intracranial tumors. And you may uh remember some of them are related to genetics and clinical manifestation, depend on hormonal imbalance as well as pressure effects. Radiographic imaging is important to categorize. The which type of tumor is that and treat it with, depend on functional status and usually surgery, radiotherapy or medical treatment and complications are pituitary insufficiency and can be treated with hormone replacement. Ok? I think you got a fairly um adequate exposure to these two subjects. I am happy if you can just uh this scan the QR code and give me a feedback. Um Doctor, we if there's a link for the QR code, we can send it on the message so that people can just scan the feedback or. Ok. OK. Um That would be a um I think no, I won't be able to do it. So if you have just the link, you can paste it on the message. If you can display the QR code again, I should, I think I can make that link. If you can just go up again, I'll make it. I'll try. Yeah, I'll try that. Yeah. Yeah, I've got the link. Just send me. Ok. Um, I'm just going to the chat. Yeah. Um, someone's just written easiest ways to remember. T sht four T, three levels and interpret them. Ok. Uh. Right. Uh, ok. TSH is, Ahamed. TSH is the hormone which produced from the pituitary and, uh, which stimulate T four t three, um, from the thyroid gland. Ok. And, uh I'm trying to get you a slide to show that how it's interpreted in a while. Ok. Uh I don't know whether it's possible. Ok. That's fine. I'll just tell. Um, so TSH is trying to give use signal to produce T four, T, three hormones and T three T four produced from the gland. If you go down on T three, T four, you give a feedback signal to pituitary to produce more and more TSH. So, ideally primary problem in the gland where you have problems in um producing uh T three T four that gives the TSH a feedback signal to produce more. So your TSH will be high more than five and try to stimulate more and more thyroid hormone synthesis. And your T four T three is still low because your gland cannot produce more so high TSH and T three T four, low. It's primary hypothyroidism, right? And if you have low T three T four and low TSH, you think, ok, this patient might have problem in the pituitary because your TSH cannot go up as expected in primary hypothyroidism. So, in the presence of low TSH, you tend to do um pituitary functions and uh especially prolactin FSH, LH and cortisol level to see whether there is a problem in the pituitary. So, ideal situation, primary hypothyroidism, you have high TSH, low T three T four, secondary hypothyroidism, you have all low. Um and hypothyroidism, as I mentioned, T four T three is increased production from the gland. So, hyperactive thyroid gland produce high T three T four, which um gives the signals to your pituitary. Now stop producing TSH. So your TSH goes down that happens in graves disease, toxic M and um that is primary hyperthyroidism. Secondary hypothyroidism is very rare. It's all hormones are high. It's due to TSH producing pituitary tumor, which is very, very rare. We call it TSH oma, but it's very rare. And um I think Mohammed, I answered your question. Um Thank you. So, oh, just have another question. Uh Ahmed. Thank you. What about cancers? OK. So it's a good question, cancers. Um Usually if you have a nodule and if you have hyperthyroidism, it very less likely to be a cancer hyperactivity is not necessarily a feature of cancer. But if you have a nodule, you think it's a cancer and there are usually hypothyroid, as um I mentioned, sometimes you can have hashimoto thyroiditis. So, thyroiditis is where you produce more and more thyroid home because of the inflammation of the gland, which hashimoto can lead to lymphomas. By the time they become lymphomas, they're hypothyroid, they're in hypothyroid phase. Usually TSH T 43, not differently. Ex interpreting the presence of cancer interpretation would be the same. But the presentation of cancer is usually nodule, not the hyper or hypothyroidism. But in fact, if that doesn, it can be uh hypothyroidism usually 90%. Ok. Any other questions? I think the questions have stopped for now, so we can probably end the session. Um Thank you very much for giving this talk. Um Next talk will be beginning at 515. So we'll go offline.