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Case no 1 ,36/F
c/o Anterior neck swelling-1 year
Progressive increase in size
O/E-Lt lobe thyroid 5x6 cm.Multiple left level 2-5 LN
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Investigations
Clinical Diagnosis- Papillarythyroid carcinoma withcervical LN metastases
EuthyroidFT4
TSH
-
FNAC thyroid& cervical
LN: PTC
Plan- CECT neckroadmap for surgery
Imaging- for discussion
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Case-1Diagnosis
Papillary Thyroid Carcinoma with cervical LN metastases
? lung mets
Plan: Total thyroidectomy +
Central compartment LND +Right Selective Lymph Node Dissection+ left ModifiedRadical neck dissection.
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Total Thyroidectomy+ CCLND +Right Selective Lymph Node Dissection+ LeftModified Radical Neck Dissection
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Post-operative Course
Uneventful
HPE tumor mass-PTC leftlobe
Left MRND-20/40 +veProp y actic oracalcium, Vit D2
Follow up- WBRAIfor discussion
Right MRND- 5/6 +ve
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Post op Tg(ng/ml) ATG(IU/ml)
2 months 30.3
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I-131 Whole body scan
Pre therapy scan 2 months post op
Anterior Posterior
Dose 5 mCi
L-Thyroxine withdrawal
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SPECT/CT
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Follicular thyroid carcinoma
I-131 Whole bodyscan
Anterior Posterior
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Papillary carcinoma thyroid with lung metastasis
I-131 Whole bodyscan
Anterior Posterior
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SPECT/CT
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Cecervical
nodes
ssternum
18F-FDG PET/CT (TENIS SYNDROME)
Urinary
bladder
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CERVICA
L NODE
STERNU
URINARY
BLADDER
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CERVICAL NODE
PULMONARY
& PLEURAL
NODULES
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18F-FDG PET/CT
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Role of CT in thyroid malignancies
Not in the characterization of an intrathyroidal lesionno imaging findings that are histologically specific
Role: to assess the findings related to a thyroid mass,including
invasion through the thyroid capsule and infiltration ofadjacent tissues and structures in the neck
identify the presence of cervical lymph node metastases
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Snippet : Tracheal invasion
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Snippet : Retrosternal extension
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Case no 2
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Case no 220/F
Bone pains- 3 months
Proximal muscle weakness- 3 months
h/o # rt shaft femur on trivial trauma- 10 days
No significant family history
O/E
Neck- WNL
Systemic exam rt femur plaster cast
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Investigations
S. Creat- WNL
S. Ca- 13.2 mg/dl(8.5-10.1)
S. iCa 5.4 (4.6-5.3)
BMD T score
Forearm -4.8
LS -4.3
hip -5.0
S.Pi- WNL
25-OH Vit D-28 ng/ml
S. PTH- 580 pg/ml (15-68)
S. ALP 6503 U/L (80-306)
24hr urinary Ca- WNL
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Clinical Diagnosis
Plan- imaging
for localizationPrimaryHyperparathyroidism
Optimization
for surgery
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Imaging
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Early Late10/11/2013 37PGES endo-radio-nuclear
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SPECT/CT
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Case 2
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Case-2Diagnosis
Primary hyperparathyroidism
Right superior parathyroid adenoma
Plan-
Focused Right superiorparathyroidectomy + Intra-operativePTH
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Right superior Focused Parathyroidectomy+
Intra operati e PTH
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Intra-operative PTH
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Pre incision 297(pg/ml)
Pre-excision 249
5 min 56
10 min 47
15 min 45
P t ti C
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Post-operative Course
Biochemical & symptomatichypocalcemia POD1
IV ca cium g uconate, ora ca ciumcarbonate, Vit D3
Eucalcemic at discharge, symptomaticallyimproved
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S i t
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Snippet
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SPECT/CT
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Snippet
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Snippet
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Case no 3
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Family History
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Family History
Goiter
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MEN 2A
MTC
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Investigations
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Investigations
24hr UMN- >2000 mcg/day (3000 mcg/day (
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Post-operative Course
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Post operative Course
Oral feeds on POD2
HPE- Bilateral pheochromocytoma,
Medullary throid carcinoma
RET mutation- codon 634
y rocor sone n us ongradually tapered, switchedover to oral hydrocortisone
Genetic testing of familymembers
Fo ow up: UMN UNM WNL
S. CEA 5.36mcg/mL (
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Family History
Goiter
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MEN 2A
MTC
Brother of Case no 3MEN 2A-MTC+ rtadrenalpheochromocytoma
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Brother of Case no 3 pheochromocytoma
Rt laparoscopic adrenalectomy after adequate alphablockade
Admitted at present
Plan-Total thyroidectomy+central compartment LND
I-131 MIBG Scan,72 hrs
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Anterior Posterior
68 Ga-DOTA-NOC PET/CT
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31/M
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Investigations
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g
T4
TSH
S. Cortisol
Aldosterone
PRA
Urinary Cortisol -481 mcg/24 hrs
WNLWNL
ONDST-538
LDDST-472
S. ACTH- WNL
UMN
UNM
IGF 1- WNL
DHEA > 27
Growth Hormone Suppression test 0 min < 0.17
60 min < 0.17 (0-2 ng/mL)
WNL
Clinical Diagnosis: ACTH independent Cushings syndrome63
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Clinical Diagnosis
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Left adrenocortical carcinoma
Cushin s s ndrome
Plan:
Optimization
Left open adrenalectomy
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Left Open Adrenalectomy
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Radio-Isotope Imagi
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99mTc MDP Bone scan
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18 F-FDG PET/CT
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18 F-FDG PET/CT
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Adrenal Cortical Carcinoma with local invasion
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Adrenal Cortical Carcinoma with IVC invasion
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ADRENAL INCIDENTALOMA
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The term adrenal incidentaloma is reserved foradrenal lesions that are 4 cm or smaller.
In an adrenal incidentaloma,
First, whether the mass is hormonally active orinactive.
Second, these lesions must be defined as benign ormalignant.
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If HU < 10 in NCCT, it is an adenoma.
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Portal venous phase (70 sec)
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HU = 74
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Delayed ( 10 minutes)
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HU = 35
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NCCT (N)= 21
Portal venous phase (E)= 74
Delayed (D)= 35
Absolute percentage washout = 73%
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Case no 4
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Case no 4, 17/M
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Recurrent episodes ofloss of consciousnessafter strenuous exerciseor prolonged sleep x 2months
No h/o headache,vomiting, seizures
Evaluated in GorakhpurDocumented low Bloodsugars (32mg/dl and42mg/dl) during episodes
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Clinical Diagnosis
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Multiple Endocrine Neoplasia type 1
Insulinoma
Primary Hyperparathyroidism
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Imaging
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Laparotomy
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Bidigital palpation
Intra-op blood sugar monitoring
Intraoperative USG showed twolesions
Intra-op USG
Distal pancreatectomy & Splenectomy
Bilateral neck exploration with subtotalparathyroidectomy with cervicalthymectomy
(1) at the tip of tail of pancreas
(2) proximal to the first lesion ,inthe body.
Spleen enlarged with firm lesionat the superior surface
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Intra-operative Findings
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Specimen photograph
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Rt superior
Rt inferior
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Lt inferior
109
Post operative course
HPE
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Biochemical hypocalcemia onPOD1, no clinical hypocalcaemia-oral Calcium and Vitamin D
Distal pancreatico-splenectomy specimen:multifocal pancreatic neuroendocrinetumor with splenic infarct
No hyperglycaemia
Serial post op USG: No evidenceof peripancreatic collection
hyperplasia.
Immunohistochemistry : tumor cellspositive for synaptophysin andchromogranin.
Ki-67 ( MIB 1 ) proliferation index 3%
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Follow up:
No s/o hypocalcemia,
S. Calcium and RBS- WNL 110
Neuroendocrine tumors in triple phase CT
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In another case where triphasic CT study wasnegative, Arterial Stimulation & VenousSampling (ASVS) was performed
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p g ( ) p
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ASVS
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Thank You
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