Transcript ENDOCRINE SURGERY

Li, Henry Winston
Li, Kingbherly
Lichauco, Rafael
Lim, Imee Loren
Lim, Jason Morven
Lim, John Harold
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20 years old, female
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Chief Complaint: RECURRENT LUMBAR PAINS
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Vital Signs
BP:120/70
PR: 70/min
RR: 20/min
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Neck
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2 x 2cm firm palpable mass within the right
lobe of the thyroid which moves with deglutition;
no other palpable masses
Chest (normal)
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Abdomen
Flat, normoactive bowel sounds, liver is not
enlarged, no splenomegaly, (+) CVA tenderness
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Urinalysis: (+) red blood cells and crystals
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IVP: (+) bilateral kidney stone
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20 year old female
Recurrent lumbar pains
Bilateral kidneys stones
RBC and crystals in urine
2 x2 cm palpable mass within the right lobe
of the thyroid with no other palpable mass
Costovertebral angle tenderness
No hepatomegaly, no splenomegaly
a.
b.
c.
Serum tumor markers
Screen for pheochromocytoma
Screen for hyperparathyroidism
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Calcitonin:
◦ produced by C-cells, an antihypercalcemic hormone
which inhibits osteoclast-mediated bone
resorption;
◦ minimal role in calcium regulation
◦ >10 pg/mL = diagnostic of MTC
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CEA
◦ Not specific for MTC
◦ Also seen in colon CA and metastasis to the liver
Fragment of
granular and
amyloid material
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Procedures detect distant metastases
especially if there is a very high level of
calcitonin
Imaging studies requested only if there is
suspected invasion
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24h urine cathecholamines and
metanephrines
Treated preoperatively
Actual
Results
Normal
values
Serum
calcium
Ionized
calcium
20 mg/dL
8.510.5 mg/dL
↑
8 mg/dL
4.45.2 mg/dL
↑
PTH levels
70 mg/dL
50 mg/dL
↑
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Determination of serum calcium levels, ionize
calcium and parathyroid hormone level
24 hour urinary calcium to differnetiate
from BFHH
X-ray of spine and abdomen
Fine needle biopsy of the mass in the right
lobe of the thyroid
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Salivary glands
Thyroid glands
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Palpable mass
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Sestamibi: small protein which is labeled with
the radio-pharmaceutical technetium-99
Radioactive agent is injected into the veins of
a patient with parathyroid disease
Radionuclide is concentrated in thyroid and
parathyroid tissue but usually washes out of
normal thyroid tissue in under an hour. It
persists in abnormal parathyroid tissue.
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After 1-2 hours,
radioactivity in
suspected
parathyroid
adenoma should
persist.
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Not used to confirm diagnosis of PHPT
Used to identify the location of the offending
gland
> 80% sensitivity for parathyroid adenoma
Generally complemented with neck
ultrasound which has 77% sensitivity
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Medullary thyroid carcinoma with concurrent
primary hyperparathyroidism
BASIS:
MTC- 2 x2 cm palpable mass within the
right lobe , FNAC examination revealed
granular amyloid material;
PHPT- bilateral urolithiasis, elevated PTH
and calcium assay
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5% of thyroid malignancies and arise from the
parafollicular or C cells of the thyroid
Forms: Sporadic (80%)
hereditary (20%)- autosomal dominant
inheritance, mutation of RET proto-oncogene
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Increased parathyroid proliferation and PTH
secretion independent of calcium levels
Affects females more than male
Sporadic type more common
Etiology
-Parathyroid adenoma (80%)
-Multiple adenoma or hyperplasia (1520%)
-Parathyroid CA (1%)
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Manage the symptomatic disease (Medullary
thyroid cancer and primary
hyperparathyroidism)
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Total thyroidectomy
-treatment of choice due to high incidence of multicentricity
-bilateral central neck node dissection should be routinely
performed due to frequent involvement of the central
compartment nodes
-patients with tumors larger than 1.5 cm should undergo
ipsilateral prophylactic modified radical neck dissection,
because greater than 60% of these patients have nodal
metastases
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Calcitonin and CEA 2-3 months post-op
If calcitonin >100, evaluate for residual neck
disease or +/- distant metastasis
MEN IIA and MEN IIB: annual screen for
pheochromocytoma
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10-year survival rate is approximately 80%
decreases to 45% in patients with lymph
node involvement.
worst (35% at 10 years) in patients with
MEN2B
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PARATHYOIDECTOMY
Indications
- Markedly increased serum calcium
- Episode of life threatening hypercalcemia
episode
- Reduced creatinine clearance
- Kidney stones
- Markedly elevated 24 hr urinary Ca excretion
- Substantially decreased bone mass
- Age: < 50 years old
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In patients who have hypercalcemia at the
time of thyroidectomy, only obviously
enlarged parathyroid glands should be
removed.
The other parathyroid glands should be
preserved
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