Endocrine Imaging 11th PGES Course

8/11/2019 Endocrine Imaging 11th PGES Course

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Endocrine Imaging

11th PGES Course


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Case no 1 ,36/F

c/o Anterior neck swelling-1 year

Progressive increase in size

O/E-Lt lobe thyroid 5x6 cm.Multiple left level 2-5 LN

10/11/2013 2PGES endo-radio-nuclear


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Investigations

Clinical Diagnosis- Papillarythyroid carcinoma withcervical LN metastases

EuthyroidFT4

TSH

-

FNAC thyroid& cervical

LN: PTC

Plan- CECT neckroadmap for surgery

Imaging- for discussion

10/11/2013 PGES endo-radio-nuclear 3


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Case-1Diagnosis

Papillary Thyroid Carcinoma with cervical LN metastases

? lung mets

Plan: Total thyroidectomy +

Central compartment LND +Right Selective Lymph Node Dissection+ left ModifiedRadical neck dissection.

PGES endo-radio-nuclear10/11/2013 11


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Total Thyroidectomy+ CCLND +Right Selective Lymph Node Dissection+ LeftModified Radical Neck Dissection



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Post-operative Course

Uneventful

HPE tumor mass-PTC leftlobe

Left MRND-20/40 +veProp y actic oracalcium, Vit D2

Follow up- WBRAIfor discussion

Right MRND- 5/6 +ve


Post op Tg(ng/ml) ATG(IU/ml)

2 months 30.3


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I-131 Whole body scan

Pre therapy scan 2 months post op

Anterior Posterior

Dose 5 mCi

L-Thyroxine withdrawal


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SPECT/CT


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Follicular thyroid carcinoma

I-131 Whole bodyscan

Anterior Posterior


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Papillary carcinoma thyroid with lung metastasis

I-131 Whole bodyscan

Anterior Posterior


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SPECT/CT


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Cecervical

nodes

ssternum

18F-FDG PET/CT (TENIS SYNDROME)

Urinary

bladder


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CERVICA

L NODE

STERNU

URINARY

BLADDER


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CERVICAL NODE

PULMONARY

& PLEURAL

NODULES


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18F-FDG PET/CT


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Role of CT in thyroid malignancies

Not in the characterization of an intrathyroidal lesionno imaging findings that are histologically specific

Role: to assess the findings related to a thyroid mass,including

invasion through the thyroid capsule and infiltration ofadjacent tissues and structures in the neck

identify the presence of cervical lymph node metastases



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Snippet : Tracheal invasion



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Snippet : Retrosternal extension



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Case no 2



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Case no 220/F

Bone pains- 3 months

Proximal muscle weakness- 3 months

h/o # rt shaft femur on trivial trauma- 10 days

No significant family history

O/E

Neck- WNL

Systemic exam rt femur plaster cast



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Investigations

S. Creat- WNL

S. Ca- 13.2 mg/dl(8.5-10.1)

S. iCa 5.4 (4.6-5.3)

BMD T score

Forearm -4.8

LS -4.3

hip -5.0

S.Pi- WNL

25-OH Vit D-28 ng/ml

S. PTH- 580 pg/ml (15-68)

S. ALP 6503 U/L (80-306)

24hr urinary Ca- WNL



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Clinical Diagnosis

Plan- imaging

for localizationPrimaryHyperparathyroidism

Optimization

for surgery



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Imaging



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Early Late10/11/2013 37PGES endo-radio-nuclear


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SPECT/CT



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Case 2


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Case-2Diagnosis

Primary hyperparathyroidism

Right superior parathyroid adenoma

Plan-

Focused Right superiorparathyroidectomy + Intra-operativePTH


Right superior Focused Parathyroidectomy+

Intra operati e PTH


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Intra-operative PTH


Pre incision 297(pg/ml)

Pre-excision 249

5 min 56

10 min 47

15 min 45

P t ti C


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Biochemical & symptomatichypocalcemia POD1

IV ca cium g uconate, ora ca ciumcarbonate, Vit D3

Eucalcemic at discharge, symptomaticallyimproved


S i t


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Snippet



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SPECT/CT



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Snippet


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Snippet



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Case no 3



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Family History


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Family History

Goiter

9/6/2014 11th PGES course 49

MEN 2A

MTC


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Investigations


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Investigations

24hr UMN- >2000 mcg/day (3000 mcg/day (


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Post operative Course

Oral feeds on POD2

HPE- Bilateral pheochromocytoma,

Medullary throid carcinoma

RET mutation- codon 634

y rocor sone n us ongradually tapered, switchedover to oral hydrocortisone

Genetic testing of familymembers

Fo ow up: UMN UNM WNL

S. CEA 5.36mcg/mL (


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Family History

Goiter

9/6/2014 11th PGES course 58

MEN 2A

MTC

Brother of Case no 3MEN 2A-MTC+ rtadrenalpheochromocytoma


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Brother of Case no 3 pheochromocytoma

Rt laparoscopic adrenalectomy after adequate alphablockade

Admitted at present

Plan-Total thyroidectomy+central compartment LND

I-131 MIBG Scan,72 hrs


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Anterior Posterior

68 Ga-DOTA-NOC PET/CT


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31/M


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Investigations


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g

T4

TSH

S. Cortisol

Aldosterone

PRA

Urinary Cortisol -481 mcg/24 hrs

WNLWNL

ONDST-538

LDDST-472

S. ACTH- WNL

UMN

UNM

IGF 1- WNL

DHEA > 27

Growth Hormone Suppression test 0 min < 0.17

60 min < 0.17 (0-2 ng/mL)

WNL

Clinical Diagnosis: ACTH independent Cushings syndrome63


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Clinical Diagnosis


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Left adrenocortical carcinoma

Cushin s s ndrome

Plan:

Optimization

Left open adrenalectomy


Left Open Adrenalectomy


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Radio-Isotope Imagi


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99mTc MDP Bone scan



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18 F-FDG PET/CT


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18 F-FDG PET/CT


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Adrenal Cortical Carcinoma with local invasion


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Adrenal Cortical Carcinoma with IVC invasion


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ADRENAL INCIDENTALOMA


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The term adrenal incidentaloma is reserved foradrenal lesions that are 4 cm or smaller.

In an adrenal incidentaloma,

First, whether the mass is hormonally active orinactive.

Second, these lesions must be defined as benign ormalignant.


If HU < 10 in NCCT, it is an adenoma.


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Portal venous phase (70 sec)


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HU = 74


Delayed ( 10 minutes)


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HU = 35



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NCCT (N)= 21

Portal venous phase (E)= 74

Delayed (D)= 35

Absolute percentage washout = 73%



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Case no 4


Case no 4, 17/M


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Recurrent episodes ofloss of consciousnessafter strenuous exerciseor prolonged sleep x 2months

No h/o headache,vomiting, seizures

Evaluated in GorakhpurDocumented low Bloodsugars (32mg/dl and42mg/dl) during episodes


Clinical Diagnosis


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Multiple Endocrine Neoplasia type 1

Insulinoma

Primary Hyperparathyroidism



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Imaging



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Laparotomy


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Bidigital palpation

Intra-op blood sugar monitoring

Intraoperative USG showed twolesions

Intra-op USG

Distal pancreatectomy & Splenectomy

Bilateral neck exploration with subtotalparathyroidectomy with cervicalthymectomy

(1) at the tip of tail of pancreas

(2) proximal to the first lesion ,inthe body.

Spleen enlarged with firm lesionat the superior surface


Intra-operative Findings


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Specimen photograph


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Rt superior

Rt inferior

10/11/2013 PGES endo-radio-nuclear

Lt inferior

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Post operative course

HPE


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Biochemical hypocalcemia onPOD1, no clinical hypocalcaemia-oral Calcium and Vitamin D

Distal pancreatico-splenectomy specimen:multifocal pancreatic neuroendocrinetumor with splenic infarct

No hyperglycaemia

Serial post op USG: No evidenceof peripancreatic collection

hyperplasia.

Immunohistochemistry : tumor cellspositive for synaptophysin andchromogranin.

Ki-67 ( MIB 1 ) proliferation index 3%

10/11/2013 PGES endo-radio-nuclear

Follow up:

No s/o hypocalcemia,

S. Calcium and RBS- WNL 110

Neuroendocrine tumors in triple phase CT


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In another case where triphasic CT study wasnegative, Arterial Stimulation & VenousSampling (ASVS) was performed


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p g ( ) p


ASVS


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Thank You


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Endocrine Imaging 11th PGES Course

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