5/3/2019 1 WHAT I WANT FROM MY ENDOCRINE SURGEON? DR. VANITHA SINGARAM, MD, FACE ENDOCRINOLOGIST IOWA DIABETES AND ENDOCRINOLOGY CENTER PRE-LECTURE SURVEY • 52 YEAR OLD MAN WITH A 5 CM RIGHT THYROID NODULE, FNA REVEALS PAPILLARY THYROID CARCINOMA. NEXT STEP? A. TOTAL THYROIDECTOMY B. TOTAL THYROIDECTOMY WITH CENTRAL COMPARTMENT DISSECTION C. US OR CT NECK D. PET
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WHAT I WANT FROM MY ENDOCRINE SURGEON? · 2019-05-06 · 5/3/2019 1 what i want from my endocrine surgeon? dr.vanitha singaram, md, face endocrinologist iowa diabetes andendocrinology
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WHAT I WANT FROM MY ENDOCRINE SURGEON?
DR. VANITHA SINGARAM, MD, FACEENDOCRINOLOGIST
IOWA DIABETES AND ENDOCRINOLOGY CENTER
PRE-LECTURE SURVEY
• 52 YEAR OLD MAN WITH A 5 CM RIGHT THYROID NODULE, FNA REVEALS PAPILLARY THYROID CARCINOMA. NEXT STEP?
A. TOTAL THYROIDECTOMY
B. TOTAL THYROIDECTOMY WITH CENTRAL COMPARTMENTDISSECTION
C. US OR CT NECK
D. PET
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PRE-LECTURE SURVEY
35 YR. OLD FEMALE WITH HYPERCALCEMIA, PARATHYROID LABS HIGHNORMAL, RECURRENT RENAL CALCULI ( CALCIUM STONES ), 24. HR. URINE CALCIUM 250 MG, SESTAMIBI SCAN DID NOT LOCALIZE ANADENOMA ? NEXT STEP ?
a. MEDICAL SURVEILLANCE
b. REPEAT SCAN
c. SURGERY PARATHYROID EXPLORATION
d. REPEAT 24 HR. URINE CALCIUM TO EVALUATE FOR FAMILIALHYPOCALCIURIC HYPERCALCEMIA
PRE-LECTURE SURVEY
• 48 YEAR OLD WOMAN WITH 6.3 CM ENHANCINGHETEROGENOUS RIGHT ADRENAL MASS. SHE ISOTHERWISE HEALTHY WITH NO HISTORY OFHYPERTENSION OR SYSTEMIC ILLNESS. NEXT STEP?A. CT-GUIDED BIOPSY OF MASS
B. RIGHT ADRENALECTOMY
C. CHECK SERUM METANEPHRINES
D. URINARY VMAE. NO FURTHER INTERVENTION
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DISCLAIMERS AND DISCLOSURES
• NO FINANCIAL CONFLICTS OF INTEREST
• NO OFF-LABEL DISCUSSION
OBJECTIVES AND SCOPE
• PROVIDE AN APPROACH TO WORKING UPINCIDENTALLY DISCOVERED ENDOCRINE NODULES
• BRIDGE THE SURGICAL AND THE CLINICAL WORLDS
• THYROID NODULES AND DIFFERENTIATED THYROIDCANCER
• PRIMARY HYPERPARATHYROIDISM
• ADRENAL INCIDENTALOMAS INCLUDING PRIMARYHYPERALDOSTERONISM ANDPHEOCHROMOCYTOMA
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THYROID INCIDENTALOMAS• COMMON:
• PREVALENCE ( PALPATION ) : 5 % IN WOMEN, 1 % IN MEN
• SONOGRAPHIC PREVALENCE UP TO 68 %
• INCREASES WITH AGE
• 27% IN < 50 YEAR OLDS
• ~50% OF 50 YEAR OLDS
• MORE COMMON IN WOMEN
• KEY QUESTIONS :
• ARE THEY AFFECTING THYROID FUNCTION? SERUM TSH
• ARE THEY MALIGNANT? NO ROLE FOR SERUM THYROGLOBULIN
Ezzat S. Arch Int Med 1994 Brander A. Radiology 1991
EVALUATION:
• LABS: TSH TO ASSESS FOR HYPERTHYROIDISM
• IF HYPERTHYROID- POSSIBILITY OF A HOT NODULE
• NEXT STEP : I-123 UPTAKE & SCAN +/- REFERRAL TOENDOCRINOLOGIST TO EVALUATE NEED FOR TREATMENT ANDDISCUSS TREATMENT OPTIONS.
• IMAGING: HIGH-SENSITIVITY ULTRASONOGRAPHY
• SONOGRAPHIC RISK FACTORS
• HYPOECHOIC NODULES
• IRREGULAR MARGINS
• INCREASED VASCULARITY
• MICROCALCIFICATIONS
Gharib H. Endocrinol Metab Clin N Am 2007
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OTHER MODALITIES :
• FDG-PET – FOCAL UPTAKE WITH US CONFIRMED NODULES > 1 CMWARRANT FNA
• FDG-PET – DIFFUSE UPTAKE WITH US AND BIOCHEMICAL EVIDENCEOF CHRONIC LYMPHOCYTIC THYROIDITIS DOES NOT WARRANT FNA
• CT/MRI:• ONLY IF SUBSTERNAL, NODE MAPPING
• RADIONUCLIDE UPTAKE & SCAN
• ONLY IF HYPERTHYROID- TO CONFIRM HOT NODULE
• COLD NODULE = MALIGNANCY?• BUT MOST COLD NODULES ARE BENIGN
• AND MANY CANCERS DON’T APPEAR COLD ON IMAGING
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ULTRASOUND-GUIDED THYROID BIOPSY
• US-GUIDED FNA• GOLD STANDARD
• OFFICE BASED
• MULTIPLE NODULES: • SONOGRAPHIC SUSPICION
Khoo TK. Endocr Prac 2008 AACE/AME Task Force on Thyroid nodules. Endocr Prac 2006
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RESULTS AND IMPLICATIONS
• DIAGNOSTIC
• BENIGN
• ATYPIA OR FOLLICULAR LESION OF UNDETERMINED SIGNIFICANCE
• SUSPICIOUS FOR FOLLICULAR NEOPLASM OR MALIGNANCY
• ALPHA BLOCKADE- PHENOXYBENZAMINE 10 MGBID, INCREASING TO GOAL
• PRAZOSIN, DOXAZOSIN FOR LONGTERM
• OTHERS: LABETOLOL, NICARDIPINE, • REPEAT BIOCHEMISTRY POST-OP AND ANNUALLY
Amar L. J Clin Endocrinol Metab 2005
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OTHER TESTS
• CORTISOL: 1 MG OVERNIGHT DEXAMETHASONESUPPRESSION TEST
• ANDROGEN: DHEA
IF NONFUNCTIONING:
• IF NO WORRISOME PHENOTYPE, REPEAT IMAGING IN 6 AND 12 MONTHS.
• REPEAT BIOCHEMISTRY FOR ALDOSTERONE AND CATECHOLAMINEANNUALLY?
Terzolo M. Eur J Endocrinol 2011
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SUMMARY• BIOCHEMICAL TESTING IS MANDATORY FOR ALL ADRENAL
INCIDENTALOMAS
• LACK OF SYMPTOMS DOES NOT NEGATE TESTING
• HYPERALDOSTERONISM IS NOT ALWAYS SURGICAL
• MEDICAL PREPARATION IS CRITICAL FOR PHEOCHROMOCYTOMA
POST-LECTURE SURVEY
• 52 YEAR OLD MAN WITH A 5 CM THYROID NODULE, FNA REVEALSPAPILLARY THYROID CARCINOMA. NEXT STEP?
A. THYROIDECTOMY
B. THYROIDECTOMY WITH CENTRAL COMPARTMENT DISSECTION
C. US OR CT NECK
D. PET
5/3/2019
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POST-LECTURE SURVEY
35 YR. OLD FEMALE WITH HYPERCALCEMIA, PARATHYROID LABS HIGH NORMAL, RECURRENT RENAL CALCULI ( CALCIUM STONES ), 24. HR. URINE CALCIUM 250 MG, SESTAMIBI SCAN DID NOT LOCALIZE AN ADENOMA ? NEXT STEP ?
a. MEDICAL SURVEILLANCE
b. REPEAT SCAN
c. SURGERY PARATHYROID EXPLORATION
d. REPEAT 24 HR. URINE CALCIUM TO EVALUATE FOR FAMILIAL HYPOCALCIURICHYPERCALCEMIA
POST-LECTURE SURVEY
• 48 YEAR OLD WOMAN WITH 6.3 CM ENHANCINGHETEROGENOUS RIGHT ADRENAL MASS. SHE ISOTHERWISE HEALTHY WITH NO HISTORY OFHYPERTENSION OR SYSTEMIC ILLNESS. NEXT STEP?A. CT-GUIDED BIOPSY OF MASS