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Li, Henry Winston Li, Kingbherly Lichauco, Rafael Lim, Imee Loren Lim, Jason Morven Lim, John Harold 20 years old, female Chief Complaint: RECURRENT LUMBAR PAINS Vital Signs BP:120/70 PR: 70/min RR: 20/min Neck 2 x 2cm firm palpable mass within the right lobe of the thyroid which moves with deglutition; no other palpable masses Chest (normal) Abdomen Flat, normoactive bowel sounds, liver is not enlarged, no splenomegaly, (+) CVA tenderness Urinalysis: (+) red blood cells and crystals IVP: (+) bilateral kidney stone 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 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 CEA ◦ Not specific for MTC ◦ Also seen in colon CA and metastasis to the liver Fragment of granular and amyloid material Procedures detect distant metastases especially if there is a very high level of calcitonin Imaging studies requested only if there is suspected invasion 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 ↑ 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 Salivary glands Thyroid glands Palpable mass 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. After 1-2 hours, radioactivity in suspected parathyroid adenoma should persist. 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 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 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 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%) Manage the symptomatic disease (Medullary thyroid cancer and primary hyperparathyroidism) 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 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 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 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 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 THANK YOU FOR LISTENING!
