Li, Henry Winston Li, Kingbherly Lichauco, Rafael Lim, Imee Loren Lim, Jason Morven Lim, John...
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Transcript of Li, Henry Winston Li, Kingbherly Lichauco, Rafael Lim, Imee Loren Lim, Jason Morven Lim, John...
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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