3/7/2015 A 65 y/o Chinese woman had a longstanding history of a - PowerPoint PPT Presentation

3/7/2015 � A 65 y/o Chinese woman had a longstanding history of a large multinodular thyroid gland. She had a fine needle aspiration biopsy of the largest nodules about 7 years ago and at that time FNA cytology results were benign. � During the past 2 years she had an enlarging goiter and a CASE DISCUSSION feeling of food being stuck in the back of her throat. A dominant right sided thyroid nodule had grown but rebiopsied to be benign. A coexistent 1.2cm left thyroid nodule which was also observed and previously biopsied with benign cytology was rebiopsied and thought to be indeterminate. � She had been previously treated with 5 mg of methimazole daily for hyperthyroidism. No family history of thyroid cancer or radiation to her head/neck. � Of note, a 7mm left level III neck lymph node was biopsied and read “possible metastatic deposit” from unknown primary. � A 33 year old Japanese woman who previously underwent 2 operations for a right-sided pheochromocytoma and a subsequent resection of a paraganglioma (next slide). � No family history of neuroendocrine disorders or cancer. No radiation to her head/neck. � Screening ultrasound (in Japan) revealed a right 0.6cm micropapillary thyroid cancer on subsequent FNA biopsy. Because of her Left thyroid nodule (transverse) Left lateral neck (longitudinal) intraabdominal disease she had not addressed the thyroid lesion for 1 year and there was no growth during that time. 1

3/7/2015 Transverse view Longitudinal view PET/CT Pelvis showing Paraganglioma � A 58 year old man with a toxic multinodular goiter on methimazole (5mg daily) presented to a tertiary care endocrine surgery unit with dyspnea. � A surveillance PET/CT for a previous subungual melanoma identified a massively enlarged substernal thyroid gland causing substantial constriction of the trachea and extending from the neck to below the aortic arch. � Four years previously, he had an amputation of his right great toe for a 1.6mm deep melanoma and one right groin lymph node was found to be positive for metastatic disease. � Recently the patient had developed progressive dyspnea and was unable to lie flat for 3 months. Pemberton’s sign was positive 2

3/7/2015 3

3/7/2015 • Preoperative localization � A previously healthy 21 year old woman presented to • U/S: 1.9 x 1.3 x 1.1cm parathyroid the ER with a 6 month history of polyuria, polydipsia, adenoma inferior to the left thyroid gland muscle aches and fatigue. She was also found to have without a discrete echogenic plane a renal stone 3 months previously. TRANSVERSE � Upon presentation to the ER her laboratory tests were significant for Ca 13.6, PTH 616, Vitamin D normal. � Positive Family History for parathyroid disease • Father had died of parathyroid cancer despite aggressive LONGITUDINAL w/ DOPPLER surgical management with multiple reoperations • First cousin with primary hyperparathyroidism � Biochemical cure after parathyroidectomy � Single adenoma Preoperative localization • Overnight, the patient developed tingling in SPECT-CT suspicious for hyperfunctioning left her hands and around her mouth. A serum inferior parathyroid gland calcium on POD 1 was 7.5 mg/dL. 4

3/7/2015 � A 65 yo woman presented to ER with a long- The patient’s biochemical workup standing history of hypertension, 8 months of revealed: intermittent RLQ pain and diaphoresis. • Plasma: • Metanephrine 755 ug/dl (high) � Clinical evaluation at the referring hospital • Normetanephrine 84 ug/dl (high) consisted of a CT scan of the abdomen and pelvis, which revealed a 2.4 x 1.9 cm left • 24-hr urine (total volume: 1482ml): adrenal mass. • Metanephrine 348ug/dl (high normal) • Normetanephrine 1317 ug/dl (high) � CT-guided biopsy of the mass revealed adrenal medullary epithelium consistent with pheochromocytoma. CT abdomen and pelvis: 5