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

3/7/2015 1 CASE DISCUSSION

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

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

• r 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.

Left lateral neck (longitudinal) Left thyroid nodule (transverse) A 33 year old Japanese woman who previously

underwent 2 operations for a right-sided pheochromocytoma and a subsequent resection

• f 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 intraabdominal disease she had not addressed the thyroid lesion for 1 year and there was no growth during that time.

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PET/CT Pelvis showing Paraganglioma Transverse view Longitudinal view

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

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3/7/2015 4

A previously healthy 21 year old woman presented to

the ER with a 6 month history of polyuria, polydipsia, muscle aches and fatigue. She was also found to have a renal stone 3 months previously.

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

surgical management with multiple reoperations

• First cousin with primary hyperparathyroidism

Biochemical cure after parathyroidectomy Single adenoma

• Preoperative localization
• U/S: 1.9 x 1.3 x 1.1cm parathyroid

adenoma inferior to the left thyroid gland without a discrete echogenic plane

TRANSVERSE LONGITUDINAL w/ DOPPLER

Preoperative localization SPECT-CT suspicious for hyperfunctioning left inferior parathyroid gland

• Overnight, the patient developed tingling in

her hands and around her mouth. A serum calcium on POD 1 was 7.5 mg/dL.

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A 65 yo woman presented to ER with a long-

standing history of hypertension, 8 months of intermittent RLQ pain and diaphoresis.

Clinical evaluation at the referring hospital

consisted of a CT scan of the abdomen and pelvis, which revealed a 2.4 x 1.9 cm left adrenal mass.

CT-guided biopsy of the mass revealed adrenal

medullary epithelium consistent with pheochromocytoma. The patient’s biochemical workup revealed:

• Plasma:
• Metanephrine 755 ug/dl (high)
• Normetanephrine 84 ug/dl (high)
• 24-hr urine (total volume: 1482ml):
• Metanephrine 348ug/dl (high normal)
• Normetanephrine 1317 ug/dl (high)

CT abdomen and pelvis: