Li, Henry Winston Li, Kingbherly Lichauco, Rafael Lim, Imee Loren Lim, Jason Morven Lim, John Harold

Li, Henry Winston Li, Kingbherly

Lichauco, RafaelLim, Imee Loren

Lim, Jason MorvenLim, John Harold

20 years old, female

Chief Complaint: RECURRENT LUMBAR PAINS

Vital SignsBP:120/70 RR: 20/minPR: 70/min

Neck2 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. Serum tumor markersb. Screen for pheochromocytomac. 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

20 mg/dL 8.5-10.5 mg/dL ↑

Ionized calcium

8 mg/dL 4.4-5.2 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 (15-

20%)-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

PARATHYOIDECTOMYIndications- 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

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