Endocrine Surgery When to Refer and What We Do

Transcription

1 Endocrine Surgery When to Refer and What We Do None Disclosures W. Heath Giles, M.D., F.A.C.S. Surgery Residency Program Director Assistant Professor of Surgery What is Endocrine Surgery? Who performs Endocrine Surgery? Endocrine Pancreas Endocrine Surgeons General Surgeons ENT Urologists HBP Dilemma Do I send the patient to Endocrinology or Endocrine Surgery? Nodules are very common Palpable 5% women, 1% men US detects in 19-60% (higher in women/elderly) Most nodules benign (~85%) High risk patients h/o external beam radiation as child, family h/o thyroid cancer in one or more first degree relatives, prior hemithyroidectomy with cancer, FDG avid on PET 1

2 Check TSH on patients with nodules >1cm or symptoms of hyper/hypofunction Suppressed TSH check thyroid uptake scan prior to biopsy Elevated TSH higher chance of malignancy in nodule FNA Results Benign (<5% False negative rate) If high risk, repeat US 6 months If standard risk, repeat US 1 year Malignant PTC, FTC, MTC ectomy+/- LND Indeterminate (5-30% risk malignancy) Atypical, FLUS, Follicular/Hurthle cell neoplasm lobectomy or genetic testing (Afirma) Surgery in Graves Disease Noncompliant or intolerant of meds Ophthalmopathy Need rapid control hyperthyroidism Concurrent nodule suspicious for malignancy Large goiter/compressive symptoms Surgery in Hashimoto s thyroiditis Compressive symptoms Nodule suspicious for malignancy Difficulty managing thyroid hormone replacement About the operation General anesthesia Time: 45min 1hr for lobe, hrs for total Must be off all anticoagulants (ASA may be okay) Lobectomy possible same day surgery Total thyroidectomy overnight hospital stay 4-6 cm incision Minimal discomfort, fatigue 2-3 weeks 2

3 Benefits of thyroid surgeon one stop shopping Interpretation of FNA results Continued follow-up of nodules Ease patient anxiety This can be HARD! The diagnosis of Primary Hyperparathyroidism is made BIOCHEMICALLY, not radiographically! Primary Hyperparathyroidism High or high normal serum calcium High or inappropriately normal PTH Low or normal 25-OH vit D Low or low normal phosphorus Cl:Phos ratio > 33 3

4 Ultrasound Surgeon performed Identify thyroid pathology Sestamibi Often negative in multigland disease Identifies ectopic glands CT (parathyroid protocol/4-d) Used for recurrent cases or double negative imaging Negative parathyroid imaging does NOT indicate the absence of parathyroid disease. Patient #1 Calcium 11.5 ( ) PTH 120 (15-65) 25-OH vit D 15 (30-70) Kidney stones, fatigue Patient #2 Calcium 8.7 ( ) PTH 100 (15-65) 25-OH vit D 15 (30-70) osteoporosis, fatigue Primary HPTH Secondary HPTH 4

5 Patient #3 Calcium - 11 ( ) PTH 45 (15-65) 25-OH vit D 15 (30-70) Kidney stones, fatigue Patient #4 Calcium 9.3 ( ) PTH 90 (15-65) 25-OH vit D 50 (30-70) Kidney stones, fatigue Sestamibi increased uptake on right Primary HPTH Secondary HPTH Patient #5 Calcium 14 ( ) PTH 11 (15-65) 25-OH vit D 30 (30-70) Fatigue, abdominal pain Other About the operation General anesthesia Time: 30min 2 hrs (intraoperative PTH) Must be off all anticoagulants (ASA may be okay) Primary almost always same day surgery Secondary admit 2-5 days 3-4 cm incision Minimal discomfort, fatigue 2-3 weeks 5

6 Incidentalomas common as we age 4% all CT scans Need to answer 2 questions Hyperfunction Malignancy Hyperfunction Cushing s Syndrome 1mg Dexamethosone suppression test 24 hour free urine cortisol Hyperaldosteronism Plasma renin Plasma aldosterone Salt load challenge potassium Hyperfunction Pheochromocytoma 24 hour urine metanephrines, normetanephrines, VMA Plasma free catecholamines Size > 4-6 cm Growth on subsequent scans Indeterminate/suspicious CT appearance Just because a radiologist mentions that an adrenal mass would be amenable to biopsy, doesn t mean you should do it. When should a percutaneous biopsy be performed? Known extra-adrenal malignancy to rule out metastasis MUST rule out pheochromocytoma first 6

7 About the operation General anesthesia Time: hrs Must be off all anticoagulants (ASA may be okay) Observation status Two laparoscopic approaches Transabdominal Retroperitoneoscopic Right Higher chance for life threatening bleeding Technically more challenging Our Department Left Must mobilize splenic flexure of colon, spleen, and tail of pancreas Less massive bleeding risk but more opportunity for injury to surrounding organs Heath Giles, M.D., F.A.C.S. Michael Roe, M.D., F.A.C.S. References Revised American Association Management Guidelines for Patients with Nodules and Differentiated Cancer: The American Association Guidelines Taskforce on Nodules and Differentiated Cancer.. Nov 2009: Vol 19 (11) Guidelines for the Management of Asymptomatic Primary Hyperparathyroidism: Summary Statement from the Third International Workshop. J Clin Endocrinol Metab Feb: 94(2):