D/D of gynecomastia:(Braunstein, G.D., 2007) - Idiopathic : 25% - Post pubertal: 25% - Medications: 10-20% - Primary hypogonadism: 8% - Cirrhosis or malnutrition: 8% -Testicular tumors: 2-4% - Secondary hypogonadism:2% - Hyperthyroidism:1.5% - Chronic renal disease

The criteria of a malignant lymph node in ultrasound ,Towards the metastasis to a local LN in case of thyroid carcinoma. Lymph node enlargement Loss of the fatty hilum A rounded rather than oval shape Hyperechogenicity Cystic change Microcalcifications Peripheral vascularity

The different types of thyroid cancers Papillary thyroid cancer:70% of total thyroid cancers Follicular thyroid cancer:10% of total cases Anaplastic thyroid cancer-Around 2% cases Medullary thyroid cancer: 5-8% of total cases Other rare types Thyroid lymphoma Thyroid sarcoma

A pheochromocytoma is a catecholamine-secreting tumor of chromaffin cells typically located in the adrenals. It causes persistent or paroxysmal HTN . Diagnosis is by measuring catecholamine products in blood or urine. Imaging tests especially CT or MRI, help localize tumors.

The PHEO may also be located in other tissues derived from neural crest cells. Possible sites include the following: Paraganglia of the sympathetic chain Retroperitoneally along the course of the aortaCarotid body Organ of Zuckerkandl Genitourinary system Brain Pericardial sac

Key points PHEO Hypertension may be constant or episodic. Diagnosis involves demonstrating high levels of catecholamine products.Tumors should be localized with imaging tests sometimes using radiolabeled compounds. Trteat combination of alpha and beta-blockers and tumor removal.

The pheochromocytoma is associated with genetic conditions include: Multiple endocrine neoplasia- 2 Von Hippel-Lindau disease Neurofibromatosis 1 Hereditary paraganglioma syndromes .

Signs and symptoms for neurofibromatosis include: Flat, light brown spots on the skin (cafe au lait spots). Freckling in the armpits or groin area Lisch nodules. Neurofibromas. Bone deformities. Scoliosis or bowed lower leg. Optic glioma.

Von Hippel-Lindau disease : It is associated with following type of tumors pheochromocytoma, hemangioblastomas , retinal angiomas, may cause vision loss. Renal cell carcinoma and neuroendocrine tumor

The objectives of preoperative pheochromocytoma care include: -arterial pressure control, -reversal of chronic circulating volume depletion -heart rate and arrhythmia control, -assessment and optimization of myocardial function, -reversal of glucose and electrolyte disturbances.

Phenoxybenzamine is a non-selective, non-competitive, long-acting α-blocker. Its non-competitive antagonism may reduce the effects of catecholamine surges but may be implicated in postop refractory hypotension. It should be stopped 24–48 h before surgery due to its long 1/2life

Before labeling NET It is important to exclude other causes of flushing such as -Hyperthyroidism thus a full thyroid profile should be done -Cushing's syndrome thus a morning cortisol and ACTH can be done -Phaeochromcytoma thus one can do a 24 hour urinary catecholamine screen .

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