Women s Health in General Practice Symposium 2015 Thyroid & Parathyroid Cases

Transcription

1 Women s Health in General Practice Symposium 2015 Thyroid & Parathyroid Cases Bill Fleming Epworth Freemasons Hospital 1

2 Common Endocrine Presentations anatomical problems thyroid nodule / goitre embryological problems thyroglossal cyst functional problems thyrotoxicosis parathyroid pathology raised serum calcium 2

3 Thyroid case thyroid nodule 49 yr old woman presents with lump in neck slowly enlarging, painless some dysphagia no family history history of radiation exposure in lab examination solitary nodule L side thyroid no RSE no lymphadenopathy what is differential diagnosis? 3

4 Differential diagnosis dominant nodule in MNG (50%) 3-5% of MNG contain Ca. simple adenoma cyst chronic thyroiditis toxic adenoma carcinoma only 2-3% of truly solitary nodules are malignant next steps for our patient?

5 Investigation bloods thyroid function tests calcium, PTH & vitamin D antibody studies (if toxic) imaging high resolution US best first step

6 Ultrasound what can it tell us? how many dominant nodule cystic / solid nodes malignant features microcalcifications, irregular borders, marked hypoechogenicity, extraglandular extension, high blood flow, and taller than wide shape

7 Ultrasound result There is large, 5cm irregular nodule replacing most of the left thyroid lobe, partially cystic, but predominantly solid. There are 2 smaller nodules on the right side. What next?

8 Specialist thyroid referral does the patient need referral for surgical opinion? cancer or suspicious of cancer FNA follicular lesion, suspicious or atypical symptomatic goitre dysphagia (cf. globus) dyspnoea / stridor / retrosternal extension? change in voice thyrotoxic adenoma cosmetic reasons: big mass decision about when & what to FNA?

9 FNA Cytology (Bethesda) results & risk of Ca? inadequate 1-4% benign 0-3% AUS 5-15% follicular neoplasm 15-30% suspicious for ca % malignant 98-99% other eg: lymphoma metastasis : lymphoma metastasis

10 FNA result in our patient irregular sheets of abnormal cells, with crowded overlapping nuclei. nuclear grooves, nuclear pseudoinclusions are seen conclusion: papillary thyroid cancer

11 Solitary thyroid nodules incidence common age years female : male 3 : 1 palpable 5% ultrasound 50% increased risk age iodine deficiency (e.g. Tas.) irradiation past adenoma or MNG cold nodules

12 Place of other imaging nuclear 99m Tc scan toxic patients?low TSH cancer followup

13 Place of other imaging CT scan surgical considerations

14 Which operation or no operation? single nodule hemithyroidectomy carcinoma known before on FNA hemi / total thyroidectomy + nodes atypical FNA hemithyroidectomy / total incidental finding on histology depends dominant nodule in MNG total thyroidectomy

15 Take Home Messages careful history risk groups? investigations bloods and ultrasound best investigations nuclear scan not useful, unless toxic FNA decisions best made by thyroid specialist CT really a surgical decision vast majority of thyroid nodules are benign even large retrosternal goitres can usually be removed via the neck 15

16 Embryological problems case presentation a 17 year old man presents with a 3 month history of midline neck swelling painless moves up with tongue protrusion what next?

17 Ultrasound no need for FNA if typical site do need referral for excision

18 Functional problems case presentation a 30 year old woman presents with palpitations, tremor of hands poor sleeping, irritable lost 10kg weight eye changes examination investigations?

19 Investigation bloods thyroid function antibodies anti TSH receptor peroxidase anti TG differential diagnosis?

20 Differential diagnosis thyrotoxicosis Graves disease (75%) toxic adenoma toxic MNG thyroiditis drugs e.g. Amiodarone symptoms due to hormone excess due to autoantibodies next step?

21 Investigation imaging Tc nuclear scan specialist referral

22 Treatment of Graves disease antithyroid drugs +/- beta blocker carbimazole or propylthiouracil may need to start immediately radioactive iodine best definitive Rx total thyroidectomy esp. with thyroid eye disease

23 Thyroid Function Tests low TSH, high T3 and/or T4 primary hyperthyroidism low TSH, normal T3 and T4 subclinical hyperthyroidism thyroxine therapy everything low nonthyroidal illness recent treatment for thyrotoxicosis (TSH still suppressed) raised TSH, low T3 and T4 primary hypothyroidism (thyroiditis, post treatment) everything raised rare?interfering antibodies 23

24 Parathyroid case 49 year old woman dancing at her daughter s wedding & fell over felt tiredness, aching muscles XRay: Colles fracture investigations? bone density scan bloods

25 Investigations bloods calcium 2.83 PTH 14.8 Vitamin D hr urine calcium bone density scan

26 Parathyroid presentation suspect the diagnosis presentation rarely stones, bones, moans and groans vast majority now apparently asymptomatic vague symptoms: lethargy, muscle pain, tiredness, etc. bone disease: pathological fractures, low BMD, etc. renal disease: 4-15% have history of renal stones up to 29% will also have thyroid pathology

27 Primary Hyperparathyroidism demographics incidence 1 in 1000, 1 in 100 elderly female age 55 years sex F : M = 2.5 : 1 pathology single adenoma 85-90% hyperplasia 5-10% carcinoma <1%

28 What next for this patient? referral to endocrine surgeon localising studies (US & Sestamibi) focussed parathyroidectomy NIH guidelines 2014 all HPTH patients should be referred to a surgeon even?non surgical pts should see surgeon imaging is not a diagnostic procedure surgery of benefit to all: high cure rates low complication rates reverses skeletal manifestations

29 Asymptomatic group (2014) age <50 years serum Ca 2+ >0.25mmol/L above normal BMD T score <2.5 (osteoporosis) vertebral fracture renal disease creat clearance <60 ml/min elevated 24 hr urine Ca 2+ stones or nephrocalcinosis

30 Focussed parathyroidectomy our patient localised on Mibi & US 2g parathyroid adenoma (N = 40-60mg) postop Ca , PTH 2.8 surgery in elderly? reverses metabolic syndrome increased risk of premature death hypertension cardiovascular disease improves bone disease mental changes may markedly improve

31 Take Home Messages elevated serum calcium is NEVER normal the vast majority have a single gland benign tumour surgery has very low morbidity and near zero mortality surgery is the only way to cure the patient up to 95% will notice symptom improvement after surgery 31

32 Conclusion GP / specialist partnership recognition of problem initial workup & diagnosis making the patient safe for surgery minimally invasive endocrine surgery small incision surgery suitable for most endocrine tumours minimal morbidity & virtually zero mortality

33 Website for more information