VCUVCUDEATH AND DEATH AND COMPLICATIONS COMPLICATIONS CONFERENCECONFERENCE

Brief Overview of CaseBrief Overview of Case

Diagnosis:Diagnosis: Papillary thyroid cancerPapillary thyroid cancer Primary hyperparathyroidismPrimary hyperparathyroidism

Procedure:Procedure: Total thyroidectomy, neck exploration and Total thyroidectomy, neck exploration and

parathyroid biopsy parathyroid biopsy Complication:Complication:

Error in diagnosis and hypocalcemiaError in diagnosis and hypocalcemia

Clinical History

HPI: 11 yo boy

6 months of vomiting Thought to be an infectious etiology Placed on antibiotics.

Workup Extensive GI workup

Was diagnosed with gastritis – placed on Prevacid

Medical History

PMH: Gastritis Recurrent emesis Undescended testis

SurgHx: Bilateral orchipexy @ 4 yo Tympanostomy tubes @ 2 yo

Meds: Prevacid Keflex

Allergies: NKDA

Labs: Calcium: 13.9 PTH: 508 Vit D: 13.3 Calcitonin normal Serum metanephrines normal

SocHx: Nephrolithiasis Parathyroidectomy GM, GGM

Medical History

Physical Exam: Vitals: T 36.2 HR 93 BP 108/65 RR 22 O2 100% RA WT 27.9

kg Gen: NAD HEENT: Trachea midline. No palpable mass

Studies: Thyroid US showed 1.5 cm right inferior thyroid pole Sestamibi scan tracer uptake in inferior right thyroid pole FNA: papillary carcinoma

Hospital Course

Jan 18th: Admitted for vomiting and hypercalcemia

Jan 19th & 20th: Thyroid US/sestamibi scan and FNA showed papillary carcinoma

Jan 25th -27th: To OR for total thyroidectomy, neck exploration and parathyroid biopsy Intraop PTH: 552.4 > thyroidectomy > 21.5 > 9.2 > 5 Calcium: 14.6 > 11.4 > 10.5 > 9.5 > 8.7 > 8.6 > 8.3 Discharged Jan 27th with calcium 1250 mg tid, synthroid, calcitriol

Jan 30th

Admitted to hospital for dizziness, knee pain, increased lower extremity tone

Ca 6.4, Mag 1.8, K 2.4

Analysis of Complication

• Was the complication potentially avoidable?– Error in diagnosis: No– Hypocalcemia: Possibly yes. Calcium level trending

down • Would avoiding the complication

change the outcome for the patient?– Yes. No readmission for hypocalcemia

• What factors contributed the complication?– Error in diagnosis of papillary thyroid cancer

In 2007, National Cancer Institute organized NCI Thyroid Fine Needle aspiration state of science conference.

Goal was to establish a guideline and system of nomenclature for the interpretation of Thyroid FNA.

Became known as Bethesda System for reporting cytopathology

Using Bethesday System Retrospective review 1992 – 2009 of

patients undergoing FNA for suspicious lesion