A brief explanation of nuclear medicine application in parathyroid disorders including diagnosis and minimally invasive radioguided parathyroid surgery including parathyroid adenoma, carcinoma, hyperplasia, etc.
thyriod gland HYPOTHYRIODISM imaging part 4 (hypothyriodism) Dr Ahmed EsawyAHMED ESAWY
This document discusses various causes of congenital and acquired hypothyroidism and provides an overview of thyroid ultrasound findings. It begins by listing common causes of congenital hypothyroidism such as dysgenesis, ectopic thyroid, and familial enzyme defects. It then discusses acquired hypothyroidism due to conditions like iodine deficiency, Hashimoto's thyroiditis, subacute thyroiditis, and postpartum thyroiditis. The rest of the document provides ultrasound images and descriptions of thyroid findings in these various hypothyroid conditions.
This document discusses the approach for suspected parathyroid adenoma. It begins with a brief historical overview of discoveries related to the parathyroid glands and their relationship to calcium metabolism. It then covers the embryology, anatomy, characteristics and vascular supply of the parathyroid glands. The document discusses various localization techniques used preoperatively including ultrasound, scintigraphy, SPECT, CT and MRI. It also discusses invasive techniques. Surgical indications and various surgical techniques for parathyroidectomy are outlined including open, minimally invasive and endoscopic approaches. The role of intraoperative PTH monitoring is also summarized.
This document provides a pictorial review of ultrasound images to illustrate benign and malignant features of thyroid nodules according to the U1-U5 classification system of the British Thyroid Association. It begins with an overview of normal thyroid ultrasound appearance and anatomy as a baseline for comparison. The majority of the document then features ultrasound images paired with descriptions of thyroid nodules demonstrating benign characteristics, such as a halo sign, microcystic/spongiform appearance, peripheral egg shell calcification, or peripheral vascularity, which correspond to a U2 classification. The aim is to help radiologists and clinicians recognize sonographic patterns to determine whether fine needle aspiration is necessary.
thyroid thyroid nodules benign and malignant thyroid lesions
difference between benign and malignant nodules
TIRADS
imaging criteria
description of tirads
TIRADS scoring system
Thyroid Ultrasound For The Endocrine Surgeonu.surgery
This document discusses the value of ultrasound for endocrine surgeons. It summarizes a study of over 5,700 ultrasounds performed by an endocrine surgeon between 1999-2004. Key findings include that ultrasound enhanced the diagnosis of coexisting thyroid and parathyroid diseases, helped localize abnormal parathyroids, modified treatment in 62% of thyroid cancer cases, and improved resident education. The conclusion is that surgeon-performed neck ultrasound is a specific, accurate tool that enhances patient care and surgical decision making.
thyriod gland HYPOTHYRIODISM imaging part 4 (hypothyriodism) Dr Ahmed EsawyAHMED ESAWY
This document discusses various causes of congenital and acquired hypothyroidism and provides an overview of thyroid ultrasound findings. It begins by listing common causes of congenital hypothyroidism such as dysgenesis, ectopic thyroid, and familial enzyme defects. It then discusses acquired hypothyroidism due to conditions like iodine deficiency, Hashimoto's thyroiditis, subacute thyroiditis, and postpartum thyroiditis. The rest of the document provides ultrasound images and descriptions of thyroid findings in these various hypothyroid conditions.
This document discusses the approach for suspected parathyroid adenoma. It begins with a brief historical overview of discoveries related to the parathyroid glands and their relationship to calcium metabolism. It then covers the embryology, anatomy, characteristics and vascular supply of the parathyroid glands. The document discusses various localization techniques used preoperatively including ultrasound, scintigraphy, SPECT, CT and MRI. It also discusses invasive techniques. Surgical indications and various surgical techniques for parathyroidectomy are outlined including open, minimally invasive and endoscopic approaches. The role of intraoperative PTH monitoring is also summarized.
This document provides a pictorial review of ultrasound images to illustrate benign and malignant features of thyroid nodules according to the U1-U5 classification system of the British Thyroid Association. It begins with an overview of normal thyroid ultrasound appearance and anatomy as a baseline for comparison. The majority of the document then features ultrasound images paired with descriptions of thyroid nodules demonstrating benign characteristics, such as a halo sign, microcystic/spongiform appearance, peripheral egg shell calcification, or peripheral vascularity, which correspond to a U2 classification. The aim is to help radiologists and clinicians recognize sonographic patterns to determine whether fine needle aspiration is necessary.
thyroid thyroid nodules benign and malignant thyroid lesions
difference between benign and malignant nodules
TIRADS
imaging criteria
description of tirads
TIRADS scoring system
Thyroid Ultrasound For The Endocrine Surgeonu.surgery
This document discusses the value of ultrasound for endocrine surgeons. It summarizes a study of over 5,700 ultrasounds performed by an endocrine surgeon between 1999-2004. Key findings include that ultrasound enhanced the diagnosis of coexisting thyroid and parathyroid diseases, helped localize abnormal parathyroids, modified treatment in 62% of thyroid cancer cases, and improved resident education. The conclusion is that surgeon-performed neck ultrasound is a specific, accurate tool that enhances patient care and surgical decision making.
The Epidemic of Thyroid Nodules: Which Should Undergo Fine Needle Aspiration?u.surgery
The document discusses thyroid nodules and guidelines for performing fine needle aspiration (FNA). It notes that while thyroid nodules are common, detected in up to 67% of ultrasound exams, only 5-15% of nodules are malignant. Sonographic features that increase the likelihood of malignancy include microcalcifications, irregular margins, hypoechogenicity, and intranodular flow. The document recommends FNA for nodules over 1 cm in size or if sonographic features suggest cancer risk. Strategic FNA based on risk factors aims to identify the minority of nodules that are cancer while avoiding unnecessary biopsies of predominantly benign nodules.
Presentation1.pptx, radiological imaging of the thyroid gland diseases.Abdellah Nazeer
This document discusses various radiological imaging modalities used to evaluate thyroid diseases including plain x-rays, ultrasound, isotope scans, CT scans, and MRI. It describes different thyroid conditions such as hypothyroidism, hyperthyroidism, goiter, nodules, cancers, and deficiencies. Specific diseases covered include Hashimoto's thyroiditis, Graves' disease, thyroiditis, subacute granulomatous thyroiditis, euthyroid sick syndrome, and lingual thyroid. Imaging findings are presented for many of these diseases along with photos and scans.
This document summarizes guidelines from the 2015 American Thyroid Association for the management of thyroid nodules and differentiated thyroid cancer. It provides recommendations on the appropriate evaluation of thyroid nodules including laboratory tests, imaging, and fine needle aspiration biopsy. For thyroid nodules found on ultrasound, it recommends FNA based on the sonographic pattern and size of the nodule. It also provides guidance on the surgical and molecular testing approaches for indeterminate cytology results. The guidelines aim to inform clinicians on the best practices for diagnosing and treating patients with thyroid nodules.
This document provides guidelines for evaluating and managing thyroid nodules and differentiated thyroid cancer. It recommends that thyroid sonography be performed on all patients with known or suspected thyroid nodules to evaluate the thyroid parenchyma, nodule characteristics, and cervical lymph nodes. Nodules are classified based on sonographic features into categories of high, intermediate, low, or very low suspicion of malignancy. It provides treatment recommendations based on nodule size, characteristics, extrathyroidal extension, and lymph node involvement.
Ultrasonography is the most valuable imaging modality for evaluating the thyroid gland. It is a simple, non-invasive exam that allows visualization of the thyroid anatomy and assessment of focal lesions. Normal thyroid gland appears homogeneous and mildly hypoechoic relative to surrounding tissues, with few small blood vessels visible on Doppler. Common benign thyroid findings include nodules, colloid cysts, and inflammatory nodules from chronic thyroiditis. Malignant nodules tend to have irregular margins, microcalcifications, and increased vascularity but appearance alone is not definitive.
This document provides information on transsphenoidal hypophysectomy for pituitary tumors. It discusses the classification, clinical features, indications for surgery, surgical approaches and techniques for transsphenoidal hypophysectomy. The transnasal, transseptal and transethmoidal routes are described. Preoperative workup and preparation are also outlined.
This document discusses the classification, clinical features, diagnosis and management of thyroid malignancies. It describes the main types as differentiated (papillary and follicular), medullary, and undifferentiated (anaplastic). Papillary carcinoma is the most common and has a good prognosis. Follicular carcinoma has a greater risk of metastases. Medullary carcinoma arises from C-cells and may be part of MEN syndrome. Anaplastic carcinoma has a very poor prognosis. Surgical resection with lymph node dissection is the main treatment, along with radioiodine ablation for differentiated types. Targeted therapies are used for advanced or metastatic disease.
This document provides guidelines for screening, diagnosing, staging, and treating localized and locally advanced prostate cancer. It recommends offering PSA screening to higher risk men and using MRI to help guide biopsies. For diagnosis and staging, it recommends prostate biopsies, imaging like MRI and bone scans, and evaluating life expectancy. For treatment of localized disease, it discusses active surveillance, surgery, radiation therapy, cryotherapy, HIFU and hormonal therapy. It provides guidance on treating low, intermediate and high risk localized disease as well as locally advanced disease. It also addresses adjuvant therapy, biochemical recurrence, and second line therapies.
This document discusses the current management of pituitary adenomas, including the role of radiotherapy. It provides details on the anatomy of the pituitary gland and classifications of pituitary tumors. Radiotherapy is recommended for patients with residual, recurrent, or progressive tumors after surgery or when medical treatment is insufficient. Radiotherapy techniques including stereotactic radiosurgery and fractionated radiotherapy are described. Radiotherapy provides excellent local tumor control of over 90% and biochemical remission rates of 50-80% for functional tumors. However, hypopituitarism is a common side effect occurring in 30-60% of patients within 10 years of treatment.
This document provides an overview of the approach to evaluating and managing solitary thyroid nodules. It discusses the epidemiology, risk stratification, clinical and laboratory evaluation, imaging with ultrasound and scintigraphy, cytology using the Bethesda system, and management approaches for benign, indeterminate, and malignant nodules. A case example is presented of a patient with a benign nodule based on ultrasound characteristics, TIRADS score, and cytology results. Key points are that risk stratification guides evaluation and management, and a multidisciplinary team approach is important for standardized patient care.
External beam radiotherapy (EBRT) for differentiated thyroid cancer (DTC) is debated due to lack of prospective studies. Surgery and radioactive iodine usually effective for locoregional control. Recent retrospective studies report benefit in select patients. Goal of EBRT is to improve locoregional control while limiting treatment toxicity
The document provides information on a seminar about cancer of the thyroid gland including:
1. Brief embryology, surgical anatomy, blood supply, lymph drainage and histology of the thyroid gland.
2. Introduction and classification of thyroid cancer focusing on differentiated thyroid cancer including papillary and follicular thyroid carcinoma.
3. Discussion of the epidemiology, risk factors, pathology, molecular genetics, clinical assessment, investigations and staging of differentiated thyroid cancer.
4. Overview of treatment approaches for differentiated thyroid cancer including surgery, radioactive iodine ablation and thyroxine suppressive therapy.
The document outlines the approach to evaluating thyroid nodules. The initial steps include taking a history, physical exam, measuring serum TSH, and performing an ultrasound. If TSH is low, a radioactive iodine scan is also done. Fine-needle aspiration biopsy is recommended if ultrasound shows characteristics associated with malignancy or if the nodule has grown over time. The evaluation is similar for pregnant patients, though radioactive scans are avoided during pregnancy.
This document discusses Hürthle cells and Hürthle cell carcinoma of the thyroid gland. It notes that Hürthle cells can be found in both benign and malignant thyroid conditions. Hürthle cell carcinoma accounts for 3-10% of differentiated thyroid cancers. It has a higher risk of metastasis than other differentiated thyroid cancers, with metastatic disease found in 10-20% of patients at diagnosis and 34% overall. Management of Hürthle cell carcinoma involves surgical excision followed by iodine-131 scanning and potentially radioactive iodine treatment, though the cancer has lower avidity for iodine than other differentiated thyroid cancers.
1. Pituitary adenomas can be classified as benign, invasive, or carcinomas based on their biological behavior and ability to invade local structures. Surgery and radiation are the main treatment options, while medication is used for functioning tumors.
2. Management involves reducing hormone levels, relieving mass effect, and preserving pituitary function through surgery, radiation, or medication depending on the tumor type and individual factors.
3. Treatment goals are tumor control as well as normalization of hormone levels and reversal of symptoms for functioning tumors.
In this presentation we will discuss about the
Anatomy of Prostate
Technique of Transrectal US
Carcinoma Prostate and
Different modes of prostatic biopsy.
Nuclear medicine application in parathyroid diordersRamin Sadeghi
Parathyroid imaging techniques such as Tc-99m sestamibi scintigraphy and ultrasound are useful for localizing abnormal parathyroid glands prior to surgery for primary hyperparathyroidism. While no single technique is perfect, combining modalities improves sensitivity. Intraoperative PTH monitoring helps confirm surgical success. Bilateral neck exploration is recommended for negative or equivocal imaging to avoid missed multiglandular disease. Minimally invasive approaches require clear, unilateral localization to avoid incomplete treatment.
Parathyroid gland anatomy, its disorders and manangementDrAnjaliBansal1
The document discusses the parathyroid glands and hyperparathyroidism. It covers the development, anatomy, physiology, disorders like hyperparathyroidism, clinical presentation, investigations, medical and surgical management of hyperparathyroidism. Hyperparathyroidism can be primary, secondary or tertiary, and is most commonly due to a parathyroid adenoma. Surgical treatment involves identifying and removing the affected gland(s), while medical management focuses on controlling calcium levels.
The Epidemic of Thyroid Nodules: Which Should Undergo Fine Needle Aspiration?u.surgery
The document discusses thyroid nodules and guidelines for performing fine needle aspiration (FNA). It notes that while thyroid nodules are common, detected in up to 67% of ultrasound exams, only 5-15% of nodules are malignant. Sonographic features that increase the likelihood of malignancy include microcalcifications, irregular margins, hypoechogenicity, and intranodular flow. The document recommends FNA for nodules over 1 cm in size or if sonographic features suggest cancer risk. Strategic FNA based on risk factors aims to identify the minority of nodules that are cancer while avoiding unnecessary biopsies of predominantly benign nodules.
Presentation1.pptx, radiological imaging of the thyroid gland diseases.Abdellah Nazeer
This document discusses various radiological imaging modalities used to evaluate thyroid diseases including plain x-rays, ultrasound, isotope scans, CT scans, and MRI. It describes different thyroid conditions such as hypothyroidism, hyperthyroidism, goiter, nodules, cancers, and deficiencies. Specific diseases covered include Hashimoto's thyroiditis, Graves' disease, thyroiditis, subacute granulomatous thyroiditis, euthyroid sick syndrome, and lingual thyroid. Imaging findings are presented for many of these diseases along with photos and scans.
This document summarizes guidelines from the 2015 American Thyroid Association for the management of thyroid nodules and differentiated thyroid cancer. It provides recommendations on the appropriate evaluation of thyroid nodules including laboratory tests, imaging, and fine needle aspiration biopsy. For thyroid nodules found on ultrasound, it recommends FNA based on the sonographic pattern and size of the nodule. It also provides guidance on the surgical and molecular testing approaches for indeterminate cytology results. The guidelines aim to inform clinicians on the best practices for diagnosing and treating patients with thyroid nodules.
This document provides guidelines for evaluating and managing thyroid nodules and differentiated thyroid cancer. It recommends that thyroid sonography be performed on all patients with known or suspected thyroid nodules to evaluate the thyroid parenchyma, nodule characteristics, and cervical lymph nodes. Nodules are classified based on sonographic features into categories of high, intermediate, low, or very low suspicion of malignancy. It provides treatment recommendations based on nodule size, characteristics, extrathyroidal extension, and lymph node involvement.
Ultrasonography is the most valuable imaging modality for evaluating the thyroid gland. It is a simple, non-invasive exam that allows visualization of the thyroid anatomy and assessment of focal lesions. Normal thyroid gland appears homogeneous and mildly hypoechoic relative to surrounding tissues, with few small blood vessels visible on Doppler. Common benign thyroid findings include nodules, colloid cysts, and inflammatory nodules from chronic thyroiditis. Malignant nodules tend to have irregular margins, microcalcifications, and increased vascularity but appearance alone is not definitive.
This document provides information on transsphenoidal hypophysectomy for pituitary tumors. It discusses the classification, clinical features, indications for surgery, surgical approaches and techniques for transsphenoidal hypophysectomy. The transnasal, transseptal and transethmoidal routes are described. Preoperative workup and preparation are also outlined.
This document discusses the classification, clinical features, diagnosis and management of thyroid malignancies. It describes the main types as differentiated (papillary and follicular), medullary, and undifferentiated (anaplastic). Papillary carcinoma is the most common and has a good prognosis. Follicular carcinoma has a greater risk of metastases. Medullary carcinoma arises from C-cells and may be part of MEN syndrome. Anaplastic carcinoma has a very poor prognosis. Surgical resection with lymph node dissection is the main treatment, along with radioiodine ablation for differentiated types. Targeted therapies are used for advanced or metastatic disease.
This document provides guidelines for screening, diagnosing, staging, and treating localized and locally advanced prostate cancer. It recommends offering PSA screening to higher risk men and using MRI to help guide biopsies. For diagnosis and staging, it recommends prostate biopsies, imaging like MRI and bone scans, and evaluating life expectancy. For treatment of localized disease, it discusses active surveillance, surgery, radiation therapy, cryotherapy, HIFU and hormonal therapy. It provides guidance on treating low, intermediate and high risk localized disease as well as locally advanced disease. It also addresses adjuvant therapy, biochemical recurrence, and second line therapies.
This document discusses the current management of pituitary adenomas, including the role of radiotherapy. It provides details on the anatomy of the pituitary gland and classifications of pituitary tumors. Radiotherapy is recommended for patients with residual, recurrent, or progressive tumors after surgery or when medical treatment is insufficient. Radiotherapy techniques including stereotactic radiosurgery and fractionated radiotherapy are described. Radiotherapy provides excellent local tumor control of over 90% and biochemical remission rates of 50-80% for functional tumors. However, hypopituitarism is a common side effect occurring in 30-60% of patients within 10 years of treatment.
This document provides an overview of the approach to evaluating and managing solitary thyroid nodules. It discusses the epidemiology, risk stratification, clinical and laboratory evaluation, imaging with ultrasound and scintigraphy, cytology using the Bethesda system, and management approaches for benign, indeterminate, and malignant nodules. A case example is presented of a patient with a benign nodule based on ultrasound characteristics, TIRADS score, and cytology results. Key points are that risk stratification guides evaluation and management, and a multidisciplinary team approach is important for standardized patient care.
External beam radiotherapy (EBRT) for differentiated thyroid cancer (DTC) is debated due to lack of prospective studies. Surgery and radioactive iodine usually effective for locoregional control. Recent retrospective studies report benefit in select patients. Goal of EBRT is to improve locoregional control while limiting treatment toxicity
The document provides information on a seminar about cancer of the thyroid gland including:
1. Brief embryology, surgical anatomy, blood supply, lymph drainage and histology of the thyroid gland.
2. Introduction and classification of thyroid cancer focusing on differentiated thyroid cancer including papillary and follicular thyroid carcinoma.
3. Discussion of the epidemiology, risk factors, pathology, molecular genetics, clinical assessment, investigations and staging of differentiated thyroid cancer.
4. Overview of treatment approaches for differentiated thyroid cancer including surgery, radioactive iodine ablation and thyroxine suppressive therapy.
The document outlines the approach to evaluating thyroid nodules. The initial steps include taking a history, physical exam, measuring serum TSH, and performing an ultrasound. If TSH is low, a radioactive iodine scan is also done. Fine-needle aspiration biopsy is recommended if ultrasound shows characteristics associated with malignancy or if the nodule has grown over time. The evaluation is similar for pregnant patients, though radioactive scans are avoided during pregnancy.
This document discusses Hürthle cells and Hürthle cell carcinoma of the thyroid gland. It notes that Hürthle cells can be found in both benign and malignant thyroid conditions. Hürthle cell carcinoma accounts for 3-10% of differentiated thyroid cancers. It has a higher risk of metastasis than other differentiated thyroid cancers, with metastatic disease found in 10-20% of patients at diagnosis and 34% overall. Management of Hürthle cell carcinoma involves surgical excision followed by iodine-131 scanning and potentially radioactive iodine treatment, though the cancer has lower avidity for iodine than other differentiated thyroid cancers.
1. Pituitary adenomas can be classified as benign, invasive, or carcinomas based on their biological behavior and ability to invade local structures. Surgery and radiation are the main treatment options, while medication is used for functioning tumors.
2. Management involves reducing hormone levels, relieving mass effect, and preserving pituitary function through surgery, radiation, or medication depending on the tumor type and individual factors.
3. Treatment goals are tumor control as well as normalization of hormone levels and reversal of symptoms for functioning tumors.
In this presentation we will discuss about the
Anatomy of Prostate
Technique of Transrectal US
Carcinoma Prostate and
Different modes of prostatic biopsy.
Nuclear medicine application in parathyroid diordersRamin Sadeghi
Parathyroid imaging techniques such as Tc-99m sestamibi scintigraphy and ultrasound are useful for localizing abnormal parathyroid glands prior to surgery for primary hyperparathyroidism. While no single technique is perfect, combining modalities improves sensitivity. Intraoperative PTH monitoring helps confirm surgical success. Bilateral neck exploration is recommended for negative or equivocal imaging to avoid missed multiglandular disease. Minimally invasive approaches require clear, unilateral localization to avoid incomplete treatment.
Parathyroid gland anatomy, its disorders and manangementDrAnjaliBansal1
The document discusses the parathyroid glands and hyperparathyroidism. It covers the development, anatomy, physiology, disorders like hyperparathyroidism, clinical presentation, investigations, medical and surgical management of hyperparathyroidism. Hyperparathyroidism can be primary, secondary or tertiary, and is most commonly due to a parathyroid adenoma. Surgical treatment involves identifying and removing the affected gland(s), while medical management focuses on controlling calcium levels.
Differentiated Thyroid cancer American cancer guidelines. Risk grouping and radioactive Iodine Ablation Low dose vs High dose RAI Ablation. Initial assessment of a thyroid nodule
This document discusses adrenal adenomas. It begins by defining adrenal adenomas and their epidemiology. It then discusses the radiological appearance of normal adrenal glands and adrenal adenomas on ultrasound, CT, and MRI. Specific imaging features that suggest adrenal adenomas include low density on non-contrast CT (<10 HU) and rapid contrast washout on CT or signal drop-out on opposed-phase MRI. The document also discusses differential diagnoses, clinical presentations of functioning adenomas, and management guidelines.
This document summarizes the management of pancreatic carcinoma. It discusses the anatomy, epidemiology, risk factors, hereditary syndromes, pathophysiology including pre-cancerous lesions, types of pancreatic cancer, staging, prognostic factors, diagnostic techniques, treatment including surgery, chemotherapy, targeted therapy, radiotherapy and historical prospective studies. It provides a comprehensive overview of pancreatic carcinoma covering all relevant aspects of the disease.
The document discusses the embryology, anatomy, physiology and pathology of the parathyroid glands. It covers topics such as primary, secondary and tertiary hyperparathyroidism. Surgical options for treating hyperparathyroidism including traditional parathyroidectomy, minimally invasive techniques and medical management are summarized. Special conditions including parathyroid carcinoma, familial hyperparathyroidism and persistent/recurrent hyperparathyroidism are also outlined.
1. Adrenal incidentalomas are adrenal lesions discovered incidentally during imaging for unrelated reasons, and their incidence has increased with more widespread use of CT and MRI imaging.
2. Evaluation of an adrenal incidentaloma involves determining if it is functioning, malignant, and if surgical intervention is needed. Malignancy is uncommon, around 2-5%, but size over 4cm increases risk.
3. Functional evaluation identifies subclinical Cushing's syndrome in around 6-10% of cases. Surgical removal is considered if the mass is over 4cm and non-functioning, or shows signs of malignancy on imaging characteristics.
Thyroid nodules are common and their clinical importance relates to excluding malignancy. The document reviews advances in thyroid nodule evaluation and management according to current guidelines. Key points include: thyroid ultrasound and fine needle aspiration biopsy are recommended for initial evaluation, with FNA indicated for nodules ≥1 cm or those with suspicious ultrasound features; cytology results are categorized as diagnostic (satisfactory) or nondiagnostic (unsatisfactory); and molecular testing of thyroid nodules is mentioned but not described in detail.
Testicular tumors-Cassification, Biomarkers and Staging by Dr RajeshRajesh Sinwer
This document discusses testicular tumors, including:
- Germ cell tumors are the most common type, comprising 95% of cases. Seminomas and non-seminomatous germ cell tumors are the main subtypes.
- Important biomarkers for testicular cancer include AFP, HCG, LDH, and PLAP. Elevated levels can indicate the presence of a non-seminoma.
- Staging is important and is based on whether the cancer is confined to the testis or has spread to lymph nodes or other organs. Spread beyond the retroperitoneum is considered stage III.
- Diagnostic workup involves imaging like ultrasound, CT, MRI and PET scans
The document discusses prostate cancer and benign prostatic hyperplasia (BPH). It covers the incidence, risk factors, pathology, clinical findings, diagnosis and evaluations, as well as treatments for both conditions. For prostate cancer, it addresses staging and grading. It describes treatments for localized disease and recurrent disease after treatment. For BPH, it discusses symptoms, signs, tests, differential diagnosis, and medical and surgical treatment options.
This document discusses the evaluation and management of adrenal incidentaloma. Some key points:
- Adrenal incidentaloma refers to an adrenal mass found incidentally on imaging not conducted for suspected adrenal abnormality.
- Biochemical, hormonal, and radiological evaluation is needed to determine if the mass is functioning or malignant. Functional masses or those over 4cm may require surgical removal.
- Surgical approaches include laparoscopic or open adrenalectomy depending on factors like mass size and invasiveness. Complete resection of malignant adrenocortical carcinoma provides the best survival outcomes.
This document discusses carcinoma of unknown primary (CUP). It notes that CUP has a poor prognosis, with a median survival of 8-12 months. The most common histological types are adenocarcinoma and poorly differentiated carcinoma. Immunohistochemistry can help determine the primary site through markers for epithelial, melanoma, germ cell, neuroendocrine, lymphoma, thyroid, prostate, and sarcoma origins. Certain subsets have a more favorable prognosis, such as women with isolated axillary adenopathy or peritoneal papillary serous carcinoma, and should receive site-directed therapy. Treatment options are discussed for various clinical presentations like axillary lymph nodes, cervical lymph nodes, bone or prostate involvement, or single resectable metastases
1. Hematuria, both gross and microscopic, is the most common presenting symptom of bladder cancer. Cystoscopy and biopsy are the gold standard for diagnosis.
2. Other diagnostic tests include urine cytology and imaging like CT, MRI, and ultrasound to evaluate the bladder, upper urinary tract, and check for metastases.
3. Several urinary biomarkers are available but none are sensitive or specific enough to replace cystoscopy for diagnosis or surveillance of bladder cancer. Biomarker tests may be used as an adjunct in some cases.
The parathyroid glands are small endocrine glands located near the thyroid gland that regulate calcium homeostasis. They secrete parathyroid hormone (PTH) which increases blood calcium levels. There are usually four parathyroid glands receiving blood supply from the inferior thyroid arteries. Primary hyperparathyroidism is most commonly caused by a single adenoma. Investigations for hypercalcemia include PTH and calcium levels. Treatment involves surgical removal of the affected gland(s), with preoperative localization using ultrasound or sestamibi scans to allow for minimally invasive surgery.
Although the great majority of incidentalomas are adrenocortical adenomas, a number of them, depending on the size and radiological characteristics of the lesions, will turn out to be carci- nomas. These tumors may present as suspicious on initial evaluation and potentially malignant or malignant on histology. Adrenocortical carcinoma is a rare and aggressive malignancy with evolving diagnostic and therapeutic approaches. Laparoscopic surgery has become the gold standard for surgery of benign adrenal tumors. Despite the extensive experience gained in laparoscopic adrenalectomy, controversy still remains in the management of adrenal tumors with high suspicion or evidence of malignancy. The aim of this review is to update the existing information regarding the diagnostic approach and surgical management of suspicious and potentially malignant primary adrenal tumors. The interpretation of radiologic characteris- tics is a cornerstone in pre-operative assessment of large adrenal masses, since open surgery remains the preferred procedure when malignancy is suspected in large tumors with possible local invasion. Despite the improvement of imaging techniques, they lack sufficient accuracy to exclude primary malignancy in tumors from 4 cm to 10 cm in size. An initial laparoscopic approach can be used in this group of patients, but early conversion to open technique is mandatory if curative resection cannot be performed. Adrenal tumors >10 cm of malignant potential should be treated by the open approach from the start. Solitary adrenal metastasis from another primary malignancy is usually amenable to laparoscopic surgery. Patients with suspected adrenal cancer should be referred to tertiary centers that perform laparoscopic and open adrenal surgery with minimal morbidity and mortality.
The document provides information on evaluating and managing solitary thyroid nodules. It discusses obtaining a detailed history, performing a physical exam focusing on the thyroid and lymph nodes, and using diagnostic tests like ultrasound, biopsy, and bloodwork. Fine-needle aspiration biopsy is the most important test, and can determine if a nodule is benign, suspicious, malignant, or nondiagnostic. Treatment depends on biopsy results and risk factors, and may include observation, surgery, radiation, or medication. The document outlines common thyroid cancers like papillary and follicular carcinoma.
A 48-year-old woman underwent a thyroidectomy for papillary thyroid cancer. A PET scan found uptake in her thyroid, and an ultrasound confirmed a nodule. A post-operative iodine scan found uptake in thyroid tissue, but no metastases. She was diagnosed with the tall cell variant of papillary thyroid cancer based on pathology. Papillary thyroid cancer is characterized by mutations affecting the MAPK pathway and is usually differentiated and radioiodine avid. Imaging with iodine scans, PET, and ultrasound can help identify the primary tumor and check for metastases following treatment.
The document discusses the anatomy, blood supply, lymph drainage, etiology, pathological classification, clinical presentation, investigative workup, staging systems, and management of thyroid cancer. It provides details on the location and structure of the thyroid gland. It describes the different types of thyroid cancers including papillary, follicular, hurthle cell, and anaplastic carcinoma. It discusses the role of surgery, radioactive iodine therapy, and neck dissection in the treatment of thyroid cancer.
This document summarizes key information about giant pheochromocytomas. It discusses the anatomy, presentation, diagnosis and management of these rare tumors. Giant pheochromocytomas are defined as greater than 7 cm in size. While most are benign, malignancy cannot be ruled out without evidence of metastasis. The document compares laparoscopic and open surgical approaches for removing giant pheochromocytomas, finding laparoscopic surgery to be feasible and superior with fewer complications. Long term postoperative surveillance with biochemical testing and imaging is important due to the risk of recurrence or metastasis.
Similar to Nuclear medicine application in parathyroid diorders (20)
Sentinel node biopsy in oncology a breif overviewRamin Sadeghi
In this overview, I have discussed the application and indications of sentinel lymph node biopsy in surgical oncology including gynecological cancers, Urological cancers, breast cancer, melanoma, and gastrointestinal cancers.
Several cases of our department were also included in the presentation to augment the message of the presentation.
It is an evidence based overview.
Precision and follow up scans in bone densitometryRamin Sadeghi
The current presentation is a brief overview of precision and follow up scans in BMD with especial attention to least significant change and Z-score changes in children
In this presentation imaging properties of primary bone tumors of the spinal column and sacrum are discussed in detail: Including ABC, plasmacytoma, giant cell tumor, etc.
Powerpoint presentation on techniques and artifacts of bone mineral densitometry.
Especial attention to hip, lumbar spine and forearm artifacts separately. Lots of real patient examples and the solutions to the technical errors.
Different vendors such as Norland, Hologic, and Lunar have been discussed.
Bone mineral densitometry in pediatricsRamin Sadeghi
Update of the previous presentation of the topic of bone mineral densitometry in children.
HAZ method (height for age Z-score) for height adjustment was introduced in this version.
Sentinel node in breast cancer: update of the previous presentationRamin Sadeghi
This is an update of the presentation:
Sentinel node in breast cancer: controversies
In this presentation the most important controversies in breast cancer lymphatic mapping and sentinel node biopsy have been discussed based on NCCN guideline.
Sentinel node mapping in breast cancer controversiesRamin Sadeghi
In this presentation the most important controversies in breast cancer lymphatic mapping and sentinel node biopsy have been discussed based on NCCN guideline.
Bone mineral density (BMD) measurements in children require adjustments for factors like body and bone size due to ongoing growth. Dual energy x-ray absorptiometry (DXA) is commonly used but provides areal BMD which is dependent on bone size. Several methods can adjust for size including calculating bone mineral apparent density (BMAD) and using the Molgaard method. Interpretation requires comparing to age-matched reference data, and the limited Iranian database may not match equipment brands. Serial scans assess changes rather than absolute BMD values due to childhood growth.
Nuclear medicine application in colorectal cancersRamin Sadeghi
In this presentation a brief evidence based application of nuclear medicine in colorectal cancer is given.
All recommendations are based on NCCN guideline.
Nuclear medicine application in neuroendocrine tumors (net)Ramin Sadeghi
This document discusses the use of nuclear medicine techniques for staging and treatment monitoring of neuroendocrine tumors. Positron emission tomography using radiolabeled somatostatin analogues like Ga-68 DOTATATE is recommended for staging most well-differentiated neuroendocrine tumors. In-111 or Tc-99m octreotide scintigraphy is also used but has lower sensitivity than PET. F-18 FDG PET is used for poorly differentiated and extrapulmonary neuroendocrine tumors. I-123 MIBG, somatostatin receptor imaging, or FDG PET are used for pheochromocytoma/paraganglioma staging if metastasis is suspected. Lu-177 DOTATATE
In this presentation nuclear medicine application in nephrology is explained in detail based on UPTODATE evidence based recommendations.
Different examples were given.
The document discusses liver segmentation from medical images. Liver segmentation is an important task for surgical planning and diagnosis but is challenging due to the liver's anatomical complexity and variations across patients. Automatic and accurate segmentation methods using techniques like atlas-based segmentation and deep learning can help physicians by providing segmented liver masks from CT and MRI volumes.
Clinic ^%[+27633867063*Abortion Pills For Sale In Tembisa Central19various
Clinic ^%[+27633867063*Abortion Pills For Sale In Tembisa Central Clinic ^%[+27633867063*Abortion Pills For Sale In Tembisa CentralClinic ^%[+27633867063*Abortion Pills For Sale In Tembisa CentralClinic ^%[+27633867063*Abortion Pills For Sale In Tembisa CentralClinic ^%[+27633867063*Abortion Pills For Sale In Tembisa Central
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Kat...rightmanforbloodline
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
2. HYPERCALCEMIA
Hypercalcemia is a relatively common clinical problem.
Among all causes of hypercalcemia, primary hyperparathyroidism and
malignancy are the most common, accounting for greater than 90
percent of cases
3.
4. INTERPRETATION OF SERUM
CALCIUM
In almost all patients, hypercalcemia is due to an elevation in the
physiologically important ionized (or free) calcium concentration.
However, 40 to 45 percent of the calcium in serum is bound to
protein, principally albumin; as a result, increased protein binding
can cause an elevation in the serum total calcium concentration
without any rise in the serum ionized calcium concentration.
In addition, a single elevated serum calcium concentration should be
repeated to confirm the diagnosis. If available, previous values for
serum calcium should also be reviewed.
5.
6. LABORATORY EXAMS
The initial goal of the laboratory evaluation is to differentiate
parathyroid hormone (PTH)-mediated hypercalcemia (primary
hyperparathyroidism and familial hyperparathyroid syndromes) from
non-PTH mediated hypercalcemia (primarily malignancy, vitamin D
intoxication, granulomatous disease)
It is reasonable to order an intact PTH assay as part of the routine evaluation for
hypercalcemia even in a patient with known malignant disease.
In the presence of low serum PTH concentrations (<20 pg/mL), PTH-related peptide
(PTHrp) and vitamin D metabolites should be measured to assess for hypercalcemia
of malignancy and vitamin D intoxication.
7. LABORATORY EXAMS
Ten to 20 percent of patients with primary hyperparathyroidism have
a serum PTH concentration in the upper end of the normal range
Such a "normal" level (ie, not suppressed but not frankly elevated) is also virtually
diagnostic of primary hyperparathyroidism, since it is still inappropriately high
considering the presence of hypercalcemia.
However, in this circumstance, the diagnosis of familial hypocalciuric hypercalcemia
also should be considered, and urinary calcium excretion (24 hour urinary calcium
or calcium to creatinine ratio) should be measured.
8.
9. HYPERPARATHYROIDISM
The most common clinical presentation of primary
hyperparathyroidism (PHPT) is asymptomatic hypercalcemia.
The diagnosis is usually first suspected because of the incidental finding of an
elevated serum calcium concentration on biochemical screening tests.
In addition, PHPT may be suspected in a patient with nephrolithiasis.
PHPT is diagnosed by finding a frankly elevated parathyroid hormone
(PTH) concentration in a patient with hypercalcemia.
When the PTH is only minimally elevated, or within the normal range (but
inappropriately normal given the patient's hypercalcemia), PHPT remains the most
likely diagnosis, although familial hypocalciuric hypercalcemia (FHH), a rare
disorder, is possible.
10. HYPERPARATHYROIDISM
Localization studies with ultrasonography, technetium-99m
sestamibi, computed tomography (CT), or magnetic resonance
imaging (MRI) scanning should not be used to establish the diagnosis
of PHPT or to determine management. If localization studies are
performed, they should be done after a decision for surgery has been
made.
11.
12.
13.
14.
15. ETIOLOGY
Single adenomas
80 to 85 percent of cases
Multiple gland hyperplasia
10 to 15 percent
Double adenomas
2 to 5 percent
Parathyroid carcinoma
1 percent
There is a relationship between iodine treatment as well as irradiation
and primary hyperparathyroidism
16. MANAGEMENT
Patients with symptomatic primary hyperparathyroidism (PHPT)
(nephrolithiasis, symptomatic hypercalcemia) should have parathyroid
surgery, which is the only definitive therapy.
For asymptomatic individuals who meet the Fourth International
Workshop on Asymptomatic Primary Hyperparathyroidism guidelines,
surgery is indicated.
For asymptomatic individuals who do not meet surgical criteria,
monitoring serum calcium and creatinine annually and bone density (hip, spine, and
forearm) every one to two years
17.
18. PRE-OPERATIVE LOCALIZATION
Preoperative parathyroid localization studies are useful for identifying
patients who are candidates for a minimally invasive surgical
approach.
Localization studies should not be used to diagnose or confirm the
diagnosis of primary hyperparathyroidism when positive, or to rule
out the diagnosis when negative.
The diagnosis of primary hyperparathyroidism should be based upon biochemical
evaluation.
Localization studies do not reliably exclude multiglandular parathyroid disease
19. PRE-OPERATIVE LOCALIZATION
Can guide incision placement
Minimize the extent of surgical dissection
Identify concurrent thyroid pathology
Locate ectopic parathyroid tissue in patients with recurrent or
persistent hyperparathyroidism after unsuccessful parathyroid
exploration.
20. TC-99M MIBI SCINTIGRAPHY
A negative 99mTc sestamibi scan does not preclude the diagnosis of
primary hyperparathyroidism, since it occurs in 12 to 25 percent of
patients with disease
is often unrevealing in patients with parathyroid hyperplasia, multiple
parathyroid adenomas, and in those with coexisting thyroid disease
Falsely negative scans can also be caused by calcium channel
blockers that interfere with the take up of the isotope by parathyroid
cells
Other gland characteristics that can increase the likelihood of a
negative scan include small size, superior position, and a paucity of
oxyphil cells
21. SPECT
The multidimensional images illustrate the depth of the parathyroid
gland or glands in relation to the thyroid and improve detection of
ectopic glands which facilitates minimally invasive parathyroidectomy
substantially reduces the likelihood of missing multiglandular disease
compared to planar imaging
Because SPECT imaging has a high rate (7-16 percent) of missed
multiglandular disease, a validated adjunct to exclude multiglandular
disease such as intraoperative parathyroid hormone monitoring
should be routinely utilized.
SPECT-CT adds the ability to discriminate parathyroid adenomas from
other anatomic landmarks, which may facilitate the surgical
procedure
22. SUBTRACTION TECHNIQUE
Even with the addition of SPECT, distinguishing abnormal parathyroid
glands from thyroid pathology can be difficult. If necessary, a
subtraction thyroid scan can be obtained by using two radiotracers
(dual isotope scintigraphy).
The use of technetium plus a second radiotracer such as 123I or
99mTc pertechnetate (thallium) permits selective imaging of the
thyroid gland.
23.
24. ULTRASONOGRAPHY
Sonographic characteristics of parathyroid adenomas include
homogeneous hypoechogenicity and an extrathyroidal feeding vessel
with peripheral vascularity seen on color Doppler imaging
US is highly sensitive in experienced hands and is inexpensive,
noninvasive, and reproducible in the operating room.
As with sestamibi based techniques, the sensitivity of ultrasound for
parathyroid adenoma localization is reduced in patients with thyroid
nodules
25. UTRASONOGRAPHY
Most experts in parathyroid surgery rely on both US and SPECT for
preoperative localization
Combining 99mTc-sestamibi scintigraphy with neck ultrasound
provides high sensitivity (79 to 95 percent) for predicting the location
of a single parathyroid adenoma
No imaging technique, even in combination, accurately predicts
multiglandular disease, and a bilateral neck exploration should be
strongly considered when the studies are discordant, equivocal, or
negative
Disadvantages to the use of US alone include decreased accuracy in
patients with smaller parathyroid gland size, obesity, or mediastinal
glands located behind the clavicles
26.
27.
28. FOUR DIMENSIONAL COMPUTED
TOMOGRAPHY
take advantage of the rapid contrast uptake and washout that is
characteristic of parathyroid adenomas for precise anatomic
localization
4D-CT is particularly useful in the reoperative setting when initial
imaging with sestamibi is negative
The primary disadvantage of 4D-CT is the radiation exposure, which,
compared with sestamibi imaging, results in a >50-fold higher dose
of radiation absorbed by the thyroid.
29.
30. MAGNETIC RESONANCE IMAGING
Parathyroid adenoma characteristics on magnetic resonance imaging
(MRI) include intermediate to low signal intensity on T1 imaging and
high intensity on T2 imaging. Cervical lymph nodes can also have
similar imaging characteristics, which limit the accuracy of MRI.
The reported sensitivity of MRI for abnormal parathyroid tissue
ranges from 40 to 85 percent
31. POSITRON EMISSION
TOMOGRAPHY AND CT
The combination of 11C-methionine positron emission tomography
and computed tomography (MET-PET-CT) uses 11C-methionine as a
radiotracer to identify pathologic parathyroid glands
A prospective study that included 102 patients undergoing a
parathyroidectomy for primary hyperparathyroidism found that MET-
PET-CT scan correctly located a single gland adenoma in 83 of 97
patients (86 percent), with a positive predictive value of 93 percent
32. INVASIVE LOCALIZATION
Invasive procedures, such as selective venous sampling or selective
arteriography, are generally reserved for more definitive localization
in patients who have had prior neck surgery and in whom noninvasive
testing has been unrevealing.
They may also be used in a primary operation for the patient in whom
noninvasive techniques are equivocal or unrevealing, but enthusiasm
for their use is tempered by risks associated with the procedures
33. NEGATIVE IMAGING
should not preclude initial surgery
In such patients, a single adenoma is still the most likely intraoperative finding (62
to 77 percent); however, multiglandular disease is also common (20 to 38 percent).
These patients require bilateral exploration by an experienced parathyroid surgeon
When compared to patients with localized studies, equivalent long-term
biochemical cure rates can be achieved although more extensive surgery may be
needed
In the reoperative setting, negative sestamibi and ultrasound results
usually lead to prompt use of additional noninvasive imaging
modalities such as 4D-CT and/or MRI.
If these studies are also non-localizing, then invasive studies such as arteriography
or selective venous sampling can be performed.
Reoperation with negative imaging is associated with a high failure rate (up to 50
percent) and nonoperative medical management should be considered
34.
35.
36. PARATHYROID EXPLORATION
Parathyroidectomy provides definitive therapy for PHPT and is
performed for
all patients with symptomatic disease
patients with familial disease
patients with asymptomatic disease who have decreased glomerular filtration rates,
osteoporosis, serum calcium >1 mg/dL above normal, or age less than 50 years.
parathyroid cancer
parathyroid crisis
for selected patients with persistent or recurrent primary hyperparathyroidism.
41. MINIMALLY INVASIVE APPROACH
Including
endoscopic and video assisted approach + intra-operative PTH monitoring
Radioguided parathyroidectomy using a gamma probe
Best reserved for
patients who have unilateral pathology as detected by imaging,
without thyroid disease
with no family history of multiple endocrine neoplasia
No evidence of parathyroid carcinoma
42. INTRA-OPERATIVE MONITORING
Intraoperative parathyroid hormone monitoring
A reduction of at least 50 percent from the baseline following excision of the
hyperfunctioning gland is an accepted standard for intraoperative confirmation of
success
False-positive intraoperative PTH findings (defined as a >50 percent decrease)
followed by recurrent hyperparathyroidism should raise suspicion for a multiple
endocrine neoplasia (MEN) syndrome.
43. INTRA-OPERATIVE MONITORING
Radioguided parathyroidectomy
The use of a radioguided probe has been advocated by some to serve as a useful
adjunct in parathyroid exploration. The technique involves intravenous
administration of technetium-99m labeled sestamibi approximately two hours
preoperatively
Using sestamibi uptake as an indirect measure of parathyroid gland hyperfunction,
the surgeon uses a handheld gamma probe in conjunction with preoperative
imaging results to focus the incision over the site of greatest radioactivity
Once the suspected offending gland or glands are removed, intraoperative PTH
monitoring is utilized to confirm adenoma excision of identify multiglandular
disease, and the gamma probe is also used to survey the surgical bed.
An ex vivo radioactivity count >20 percent above background is a possible
threshold for completion of the exploration
44. BILATERAL NECK EXPLORATION
Should be considered for the following patients
patients with negative (non-localizing) preoperative imaging studies or when
bilateral foci are detected
Most forms of hereditary hyperparathyroidism
Concomitant thyroid disease requiring surgical resection
Lithium associated hyperparathyroidism
Normal parathyroid tissue should not be removed. If PTH does not
decrease, auto-transplantation should be considered.
45. PARATHYROID CARCINOMA
Rare cause of primary hyperparathyroidism.
Is difficult to distinguish from parathyroid adenoma based on preoperative
evaluation
May be suggested by
A solitary tumor greater than 3 cm in diameter.
A firm, irregular, lobulated mass.
A dense, fibrous capsule surrounding the tumor producing a white or gray-brown tint.
Invasion of, or adhesion to, surrounding structures
Lymph node metastasis (present in 3 to 19 percent of parathyroid cancer cases).
Cystic features.
The presence of these operative findings in patients with preoperative
calcium levels greater than 14 mg/dL,and parathyroid hormone levels
greater than three times the normal value, are highly suggestive of
parathyroid carcinoma
46. PARATHYROID CARCINOMA
Patients suspected of parathyroid carcinoma should undergo an en-
bloc resection of the parathyroid tumor with the ipsilateral thyroid
lobe and isthmus, and a central neck dissection (level VI).
It is important to avoid capsular violation or tumor spillage (eg, with
biopsy).
A modified lateral neck dissection is not required in the absence of
clinical nodal involvement
47. PARATHYROID CYSTS
Parathyroid cysts are uncommon, but can cause severe hypercalcemia
and other symptoms.
If noted before surgery, the cyst fluid should be aspirated for PTH
assay. The optimal treatment is surgical resection. Meticulous
dissection should be employed to avoid cyst rupture because this can
lead to elevated intraoperative PTH levels which may prolong the
surgical procedure
51. CLINICAL VALUE OF IMAGING
some noteworthy information can be obtained by performing 99mTc-
MIBI parathyroid scintigraphy in SHPT
detection of ectopic glands (pre-operative map) thus avoiding surgical failure or
reducing the extent of dissection
identification of an eventual supernumerary fifth gland (present in 10 % of
individuals and frequent cause of persistence/recurrence)
identification of the parathyroid gland with the lowest 99mTc-MIBI uptake intensity,
intended to be partially autografted or maintained.