Endocrinologist - Surgeon: Critical Collaboration with Case-Based Conversations

Transcription

1 Endocrinologist - Surgeon: Critical Collaboration with Case-Based Conversations Chairs: Jeffrey Garber MD and Mira Milas MD W32: Pre-Congress Session II

2 Endocrinologists and Surgeons Mira Milas MD Banner-U Arizona Phoenix, AZ Jeffrey Garber MD Harvard/BIDMC-BWH Boston, MA Maria Fleseriu MD OHSU Portland, OR Edward Laws MD Harvard/BWH Boston, MA Daniel Ruan MD Norman Parathyroid Ctr Tampa, FL

3 1:00 pm Welcome and Introduction 1:05 pm Thyroid and Parathyroid Session (Milas & Garber) 2:30 pm Coffee Break 3:00 pm Pituitary and Adrenal Session 3:00 Peri-operative Endo (Fleseriu) 3:30 Pituitary Surgery (Laws) 4:00 Adrenal Surgery (Ruan) 4:30 Case Discussion 5:00 pm Adjourn

4 Philosophy of this AACE Session

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6 Endocrinologist - Surgeon: Thyroid and Parathyroid Surgery and Peri-Operative Care Jeffrey Garber MD and Mira Milas MD

7 OBJECTIVES Communication & Nuances 1. Primary Hyperparathyroidism: diagnosis, surgical indications, and the role of imaging 2. The Extremes of Calcium Imbalance: hypercalcemic crisis and post-operative hypocalcemia 3. The Extremes of Thyroid Surgery: for benign disease/low-risk cancers to the lethal cancers

8 ACKNOWLEDGMENTS William C. Faquin MD, PhD Barry A. Sacks MD, FSIR, FACP

9 Vijaya Chockalingam MD, FACE Eric Miller BS, MS3

10 Primary Hyperparathyroidism

11 Clinical Scenario-1 73 year man with hypercalcemia on routine labs Concerned about insomnia, fatigue, memory loss Denied other symptoms related to hypercalcemia No family history of hypercalcemia/hyperparathyroidism No medications that could cause hypercalcemia No supplements PMHx: Hepatitis B, CAD, HTN, HLD, chronic anemia, Barrett s esophagitis PSHx: Inguinal hernia, cataract, prostatectomy Physical exam normal

12 Clinical Scenario-1

13 Case-based Conversation What is the diagnosis? Primary hyperparathyroidism? Mild, asymptomatic PHP? Symptomatic PHP? Normocalcemic PHP? Do enough indications for surgery already exist?

14 Clinical Scenario-1 Indications for surgery in asymptomatic primary hyperparathyroidism Serum Calcium 1 mg/dl > upper limit of normal T-score less than -2.5 at lumbar spine, total hip, femoral neck or distal 1/3 radius* Vertebral fracture 24 hour urine calcium > 400 mg/day and increased stone risk by biochemical stone risk analysis Presence of nephrolithiasis, nephrocalcinosis Age < 50 years of age *for women John P. Bilezikian, Maria Luisa Brandi, Richard Eastell, Shonni J. Silverberg, Robert Udelsman, Claudio Marcocci, and John T. Potts Jr

15 The AAES Guidelines for Definitive Management of Primary Hyperparathyroidism (PHPT) Wilhelm SM, Wang TS, Ruan DT, Lee JA, Asa SL, Duh QY, Doherty GM, Herrera MF, Pasieka JL, Perrier ND, Silverberg SJ, Solórzano CC, Sturgeon C, Tublin ME, Udelsman R, Carty SE. JAMA Surg. Published online August 10, 2016 doi: /jamasurg

16 Clinical Scenario-1 DXA scan Lumbar 1.26 gm/cm 2 T-score 0.2 Femoral 1.10 gm/cm 2 T-score 0.0

17 Clinical Scenario-1 With negative Sestamibi scan, would you refer patient to surgeon?

18 Clinical Scenario-1 ULTRASOUND Right paratracheal density measuring 13 x 10 mm with teardrop hypoechoic shape and vascular branching pattern compatible with parathyroid adenoma

19 4-Dimensional CT Imaging 3-D CT method with 4 th dimension representing changes in perfusion of contrast over time: hyperfunctioning parathyroid glands have rapid uptake and washout. 3-D reconstruction/ rendering based on 4-D CT imaging 1.25 mm Axial 2.5 mm sagittal coronal oblique Perrier JACS 2012, Rodgers Surgery 2006, Mortenson JACS 2008

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21 Case-based Conversation Parathyroid Imaging Who orders? Who views the studies? What kind of study? Who does the US? Does $/XRT of 4DCT offset costs of OR time? Imaging is a localization NOT diagnostic tool Tells the surgeon where to start. But..can it be a decision-making tool?

22 Courtesy Barry A. Sacks MD, FSIR, FACP New England Chapter of AACE

23 Clinical Scenario-1 Conclusion: On Oct 13 th 2015, patient underwent focused parathyroid exploration with parathyroidectomy of right lower parathyroid adenoma. IOPTH decreased appropriately and histology confirmed hypercellular parathyroid tissue. 6-month labs were normal. HE FELT MORE ENERGETIC.

24 Thyroid Cancer

25 Your Patient A 30 year old woman has had two prior benign FNA s. At recent visit home, her mom advised her to follow-up again because her goiter looks bigger. FamHx: mom & dad treated for PTC, both are now hoarse, brother with thyroid nodules. The left lobe is normal. The right lobe ultrasound shows the 2 cm nodule that had FNA.

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28 Case-based Conversation What is arguably the single most important next step of management?

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31 Case-based Conversation Lymph node mapping of central and lateral neck pre-operatively in all patients with Bethesda 5 and 6 cytology What are challenges of this goal? What is the role of CT scans?

32 500 pages 100 videos 200 images 45 chapters 80 authors 3 continents multidisciplinary Springer, 2017

33 Hypocalcemia Courtesy Kevin Rooker RDMS, RVT

34 Your Patient POD #1 after successful total thyroidectomy for massive goiter with Graves disease, the patient s serum calcium level is 7.2 mg/dl.

35 Giant 500 grams* Large 50 grams Normal 15 grams *defined as >120 gm

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38 Case-based Conversation How do YOU manage severe hypocalcemia? By protocol? Prescriptive and Pre-emptive approach? Relies on team? Despite protocols, anticipate chaos & calls Minimizes errors? Undertreatment vs. overtreatment

39 Elemental Calcium

40 Dietary Reference Intake: (Dosage is in terms of elemental calcium): years: 1000 mg/day (1250 mg CaCO3 bid) or (625 mg qid) >51 years: 1200 mg/day Dosages and yield of Elemental Ca++ Calcium Carbonate 500 mg chewable tabs (Tums ) 200 mg Calcium Carbonate 650 mg tablets 260 mg Calcium Carbonate 1250 mg tablets OsCal mg Calcium Carb 250 mg + Vit D 125 IU/tablet OsCal 250 +D 100 mg Calcium Glubionate syrup 1.8 gm/5ml NeoCalglucon 115 mg/5ml

41 BIOAVAILABILITY VARIES

42 BIOAVAILABILITY VARIES

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45 Therapy: Acute Calcium Chewable, with food 500 mg/hr maximum GI absorption Carbonate (cheap), Citrate (gastric bypass) Vitamin D 50,000 ergocalciferol (vit D25) mcg qd or BID calcitriol ( rocaltrol vit D1,25) Magnesium Oxide 500 mg daily ( 400 mg BID, elemental applies)

46 Therapy: Calcium Single Dose I.V. 1 amp calcium gluconate is 1000 mg (1 gm) calcium 1 gram=4.65 meq (93 mg ELEMENTAL calcium) ie. very little amount thus safe to push in a crisis 1-2 amps in 250 ml D5NS over minutes Peripheral IV, good vein

47 Therapy: Calcium Drip: LARGER AMOUNTS OVER LONGER PERIODS FOR EXTREME SITUATIONS 1 amp calcium gluconate is 1000 mg (1 gm) calcium Ok to get 1 gm/hr.thus 1 amp/hr 5 amps in 500 ml NS cc/hr Peripheral IV, good vein Always check with primary MD Telemetry, periodic labs

48 Therapy: Calcium Caution Never calcium chloride IV: MORE POTENT IN AVAILBILITY OF ELEMENTAL CALCIUM AND SCLEROSING TO VEINS Never except via central line Never except in ICU or with crash cart Telemetry

49 Therapy: Long Term 1) elemental calcium 2000 mg 3x/day? 2) Calcitriol 0.25 mcg twice a day 3) low phos (renal) diet Natpara (Shire): new injectable PTH Jan 2015 Wait for parathyroid autotransplant to work

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51 Symptomatic Asymptomatic Serum Calcium <7.0 mg/dl 7-8 mg/dl >8.0 mg/dl mg/dl 500 mg po q1 hr Calcitriol 0.5 mcg BID Calcium gluconate Monitor labs and ECG Does NOT go home Standard Plus & Thinking required Standard Standard Plus 500 mg Ca TID with meals 1000 IU vitd qd Increase if symptoms Standard Ionized Calcium <1.0 mmol/l mmol/l >1.1 mmol/l mmol/l

52 Symptomatic Asymptomatic Serum Calcium <7.0 mg/dl 7-8 mg/dl >8.0 mg/dl mg/dl Standard Plus & Thinking required 500 mg q 2 hrs while awake, check labs again Single dose IV calcium gluconate? Calcium gluconate drip? Symptomatic/asymptomatic? Labs stable? 500 mg q1 hr at home, with calcitriol Ionized Calcium <1.0 mmol/l mmol/l >1.1 mmol/l mmol/l Standard Plus & Thinking required If patient calling after already discharged Trial of q1 hr calcium, 500 mg magnesium daily, call in vitamin D calcitriol script, take IU vit D over the counter Gage patient comfort with this plan Call back or ask patient to come to ER

53 CALCIUM MANAGEMENT FOR HARVARD VANGUARD PATIENTS ON ENDOCRINE SURGERY SERVICE AT BETH ISRAEL DEACONESS HOSPITAL Applies to Harvard Vanguard Endocrinology patients undergoing total thyroidectomy, completion thyroidectomy or surgery for PRIMARY hyperparathyroidism at Beth Israel Deaconess Hospital IN THE HOSPITAL BIDMC STAFF CALCIUM MANAGEMENT FOR HARVARD VANGUARD PATIENTS ON ENDOCRINE SURGERY SERVICE AT BETH ISRAEL DEACONESS HOSPITAL Applies to Harvard Vanguard Endocrinology patients undergoing total thyroidectomy, completion thyroidectomy or surgery for PRIMARY hyperparathyroidism at Beth Israel Deaconess Hospital All patients start standard oral regimen immediately post-op: a. Calcium carbonate 1250 mg Q 6 hrs (each 1250 mg tablet contains 500 mg elemental calcium) b. Calcitriol (Rocaltrol) 0.25 mcg once a day Check calcium in AM (fasting) on POD 1 a. Calcium < 7.5 Increase calcium carbonate to 2500 mg (two 1250-mg tablets=1000 mg elemental calcium) Q 6 hrs Increase calcitriol (Rocaltrol) to 0.5 mcg once a day Recheck calcium in afternoon Discharge when calcium > 7.8 b. Calcium Increase calcium carbonate to 2500 mg (two 1250-mg tablets=1000 mg elemental calcium) Q 6 hrs Continue calcitriol (Rocaltrol) 0.25 mcg once a day Recheck calcium in afternoon Discharge when calcium > 7.8 c. Calcium Discharge home on calcium carbonate 1250 mg (500 mg elemental calcium) 4 times daily, and calcitriol (Rocaltrol) 0.25 mcg once daily d. Calcium > 9.0 Stop calcitriol (Rocaltrol) Discharge on calcium carbonate 1250 mg (500 mg elemental calcium) 3 times daily 8-PAGE PROTOCOL **PATIENTS WHO ARE DISCHARGED ON DAY OF SURGERY (and therefore do not have a POD 1 calcium level) should be started on the standard oral regimen with calcium and calcitriol (Rocaltrol) outlined above and discharged on this regimen with instructions to have a calcium level drawn at Harvard Vanguard on POD 3. If POD 3 falls on a Saturday, the calcium level should be drawn on Friday before noon (POD 2); if POD 3 falls on a Sunday, the calcium level should be drawn on Monday before noon (POD 4). Other than this, follow same instructions below as for all other patients. ALL PATIENTS UPON DISCHARGE: a. Educate regarding signs and symptoms of hypocalcemia b. Provide prescription for 10-day supply of calcitriol (Rocaltrol) if being discharged on Rocaltrol Provide instructions for purchasing OTC calcium tablets: patients should be specifically instructed to purchase OsCal tablets. Any OsCal brand tablet (including

54 Calcium Distribution in Body Source: Textbook of Endocrine Surgery

55 Relationship between Serum & Ionized Calcium Total and Ionized Calcium can change independently of each other, limiting their correlation Due to changes in proteins (including Albumin), ph, etc. Controlling for these variables has not been useful in finding an algorithm to link serum and ionized calcium Courtesy Eric Miller, BS, MS3 UACOM

56 Serum & Ionized Calcium Total calcium greatly underestimates the diagnosis of hypercalcemia in incident renal transplant recipients. (Evenepoel et al, 2010) In conclusion, albumin-corrected tca does not predict ica better than noncorrected tca. Moreover, both noncorrected and albumin-corrected tca concentrations poorly predict hypo- or hypercalcemia in patients with CKD. (Gauci et al, 2008) measurements of ionized calcium, the physiologically active component of total calcium, will become the routine, preferred method for determining the level of calcium in all patients. (Calvi & Bushinsky, 2008) Courtesy Eric Miller, BS, MS3 UACOM

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58 Hypercalcemic Crisis

59 Clinical Scenario 65 year old woman was found to have serum calcium level of 16 mg/dl in routine evaluation and referred to an endocrinologist for evaluation She was recently diagnosed with stage 1 invasive ductal breast cancer Features of hypercalcemia: GERD, osteoporosis, patient denied other characteristics No family history of hypercalcemia/hyperparathyroidism Patient was taking hydrochlorothiazide Not taking vitamin D or calcium supplements

60 Clinical Scenario PMHx: Anxiety, HTN, obesity PSHx: Cholecystectomy, TAH with BSO, resection of colon polyp Social Hx: Single, no hx of tobacco, recreational drug use. Drinks wine 5 times/week. One child. Physical exam: no discrete abnormalities Endocrinologist referred patient to my ER and then called my cell phone

61 Clinical Scenario-3

62 Clinical scenario DXA done in 2015 Lumbar 0.84 gm/cm 2 T-score -2.9 Femoral gm/cm 2 T-score -2.0

63 Sestamibi scan Clinical scenario

64 Clinical scenario

65 Clinical scenario ULTRASOUND of thyroid/parathyroid glands

66 Clinical scenario In July 2016, patient underwent focused parathyroidectomy with excision of right inferior parathyroid adenoma that was located in retroesophageal area. Date Baseline PTH (12-88 pg/ml) PTH in 10 minutes Calcium ( mg/dl)

67 Clinical scenario 14,700 mg adenoma (normal parathyroid weight 30 mg)

68 Case-based Conversation Nuances of management What defines hypercalcemic crisis? Is this breast cancer metastasis? Who receives initial consult? At what point order imaging? How much? At what point consult surgeon? Aim for surgery prior to discharge? Use of bisphosphonates? What about vitamin D? Postpone surgery? When suspect parathyroid cancer..... and does it matter?

69 Benign Thyroid Disease

70 Your Patient A 68 year old woman is referred to you for an incidental FDG-avid left thyroid nodule on PET scan. Prior history of breast cancer. No thyroid or neck symptoms. TSH is normal.

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76 Pause/May%202014/Photo%207.jpg

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79 Case-based Conversation Molecular markers in your clinical practice? Veracyte (Afirma) Thyroseq (v2) Rosetta (Reveal) Interpace (ThyGenX, ThyraMIR) Coming to a theater near you in 2017? Afirma v2 Bethesda v2

80 Courtesy Bill Faquin MD, PhD

81 Courtesy Bill Faquin MD, PhD

82 Courtesy Bill Faquin MD, PhD

83 Dr. Milas can you please see Ms. Smith for a total thyroidectomy.

84 Dr. Milas you can only have half of my thyroid, no more.

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88 Anaplastic Thyroid Cancer

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91 Source Google images

92 The Operative Note for a patient with anaplastic thyroid cancer

93 Airway Control What is anaplastic thyroid cancer?

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95 From: Parangi, Sareh,M.D. Sent: Wednesday, March 22, :43 AM To: Wirth, Lori J.,M.D.; Bible, Keith C., M.D., Ph.D. Cc: Subject: anaplastic thyroid cancer Lori and Keith, Mira has a bad ATC invading into the trachea, patient is not low risk is on Coumadin and in a wheelchair Are there trials open for the patient that you might suggest to my friend Mira Sareh ************************************************** Sareh Parangi, MD Associate Professor of Surgery Harvard Medical School General and Endocrine Surgery Administrative assistant: Paula Bono: pbono@partners.org Treasurer for The American Association of Endocrine Surgeons Vice President for the Association of Women Surgeons Association of Women Surgeons Website Parangi Research Lab Parangi Thyroid Cancer Research Lab website Parangi MGH Website Office locations: Wang ACC 460 MGH 15 Parkman st. Boston, MA Phone: Fax: ******************************************************** ** STOP. THINK. External ** Hi Sareh Sorry to learn of this. We have two studies-lenvatinib and an immunotherapy antibody Both have some early promise I m happy to help any way I can. Lori

96 Case-based Conversation Early recognition of the possibility of anaplastic thyroid cancer Protection of Airway Communication among multiple specialists Communication with patient and family Communication with national colleagues for updates on available therapies Quality of Life versus Conventional Therapy

97 Endocrinologist - Surgeon: Critical Collaboration with Case-Based Conversations

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