Endocrine Imaging

11
th
PGES Course
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
USG neck- for discussion
Clinical Diagnosis- Papillary
thyroid carcinoma with
cervical LN metastases
Euthyroid
FT4
TSH
USG neck- for discussion
FNAC thyroid& cervical
LN: PTC
Plan- CECT neck
roadmap for surgery
Imaging- for discussion
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Case-1
Diagnosis
Papillary Thyroid Carcinoma with cervical LN metastases
? lung mets
Plan: Total thyroidectomy +
Central compartment LND +
Right Selective Lymph Node Dissection+ left Modified
Radical neck dissection.
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Total Thyroidectomy+ CCLND +Right Selective Lymph Node Dissection+ Left
Modified Radical Neck Dissection
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Post-operative Course
Uneventful
Prophylactic oral
HPE tumor mass-PTC left
lobe
Left MRND-20/40 +ve
Prophylactic oral
calcium, Vit D2
Follow up- WBRAI
for discussion
Right MRND- 5/6 +ve
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Post op Tg(ng/ml) ATG(IU/ml)
2 months 30.3 <20
I-131 Whole body scan
Pre therapy scan 2 months post op
Anterior Posterior
Dose 5 mCi
L-Thyroxine withdrawal
I-131 Whole body scan
Post therapy scan 2 months post op
Dose 150 mCi
L-Thyroxine withdrawal
Anterior Posterior
L-Thyroxine withdrawal
Snippet: Papillary Thyroid Carcinoma with lymph nodal
metastasis
I-131 Whole body
scan
Anterior
Posterior
SPECT/CT
Follicular thyroid carcinoma
I-131 Whole body
scan
Anterior Posterior
Papillary carcinoma thyroid with lung metastasis
I-131 Whole body
scan
Anterior
Posterior
SPECT/CT SPECT/CT
Cecervical
nodes
ssternum
18F-FDG PET/CT (TENIS SYNDROME)
Urinary
bladder
CERVICA
L NODE
STERNU
MM
URINARY
BLADDER
CERVICAL NODE
PULMONARY
& PLEURAL
NODULES
18F-FDG PET/CT
Role of CT in thyroid malignancies
Not in the characterization of an intrathyroidal lesion
no imaging findings that are histologically specific
Role: to assess the findings related to a thyroid mass,
including
invasion through the thyroid capsule and infiltration of
adjacent 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 2
20/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)
S.Pi- WNL
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
Primary
Plan- imaging
for localization
Primary
Hyperparathyroidism
for localization
Optimization
for surgery
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Imaging
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99mTc MIBI scan
99m Tc MIBI scan
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Early Late
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SPECT/CT
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Case-2
Diagnosis
Primary hyperparathyroidism
Right superior parathyroid adenoma
Plan-
Focused Right superior
parathyroidectomy + Intra-operative
PTH
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Right superior Focused Parathyroidectomy+
Intra-operative PTH
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Pre incision 297(pg/ml)
Pre-excision 249
5 min 56
10 min 47
15 min 45
Post-operative Course
Biochemical & symptomatic
hypocalcemia POD1
IV calcium gluconate, oral calcium IV calcium gluconate, oral calcium
carbonate, Vit D3
Eucalcemic at discharge, symptomatically
improved
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Snippet
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SPECT/CT
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Snippet
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Case no 3
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Case no 3
30/F
c/o Pain abdomen- 1 month
h/o nausea+
h/o headache/ palpitations/ sweating h/o headache/ palpitations/ sweating
O/E- BP 140/90mmHg supine, 140/80mmHg
standing
Lump rt hypochondrium
Interscapular pigmented patch
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Family History
Goiter
MTC ?MTC
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MEN 2A
MTC ?MTC
MTC
Provisional Diagnosis
MEN 2A
Hormonal evaluation
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Imaging and genetic
testing
Alpha blockade + optimization for
surgery under steroid cover
Hormonal evaluation
Rule out other components of
MEN 2
50
Investigations
24hr UMN- >2000 mcg/day (<360)
24hr UNM >3000 mcg/day (<600)
S. Calcium 9.0/4.8 mg/dl
USG neck- multiple hypoechoic
lesions B/L thyroid lobes
FNAC thyroid- MTC
S. Calcium 9.0/4.8 mg/dl
S. Pi 4.0 mg/dl (2.5-4.5)
S. Calcitonin- 637 pg/ml (<11).
S-CEA- 19.76 mcg/ml (<6)
FNAC thyroid- MTC
RET mutation analysis- codon
634 mutation
Imaging- for discussion
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Rt Open Adrenalectomy+ Lt cortical sparing adrenalectomy
Total thyroidectomy+ central compartment LND
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Post-operative Course
Oral feeds on POD2
Hydrocortisone infusion
HPE- Bilateral pheochromocytoma,
Medullary throid carcinoma
RET mutation- codon 634
Follow up: UMN&UNM WNL
Hydrocortisone infusion
gradually tapered, switched
over to oral hydrocortisone
Genetic testing of family
members
Follow up: UMN&UNM WNL
S. CEA 5.36mcg/mL (<6) ( pre-operative value-
19.76)
Stimulated cortisol- HPA axis not
recoveredReplacement oral steroids continuing
S. Calcitonin- 9 pg/mL (<11) ( pre-operative
value- 637)
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Family History
Goiter
MTC ?MTC
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MEN 2A
MTC ?MTC
MTC
Brother of Case no 3
MEN 2A-MTC+ rt
adrenal
pheochromocytoma
Rt laparoscopic adrenalectomy after adequate alpha
blockade
Admitted at present
Plan-Total thyroidectomy+central compartment LND
I-131 MIBG Scan,72 hrs
Anterior Posterior
68
Ga-DOTA-NOC PET/CT
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31/M
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Investigations
T4
TSH
S. Cortisol
Aldosterone
PRA
Urinary Cortisol -481 mcg/24 hrs
WNL
WNL
ONDST-538
LDDST-472
S. ACTH- WNL
UMN
UNM
Urinary Cortisol -481 mcg/24 hrs
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 syndrome
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Clinical Diagnosis
Left adrenocortical carcinoma
Cushings syndrome Cushings syndrome
Plan:
Optimization
Left open adrenalectomy
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Left Open Adrenalectomy
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Radio-Isotope Imagi
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
The term adrenal incidentaloma is reserved for
adrenal lesions that are 4 cm or smaller.
In an adrenal incidentaloma, In an adrenal incidentaloma,
First, whether the mass is hormonally active or
inactive.
Second, these lesions must be defined as benign or
malignant.
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If HU < 10 in NCCT, it is an adenoma.
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NCCT
HU = 21
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Portal venous phase (70 sec)
HU = 74
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Delayed ( 10 minutes)
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
Recurrent episodes of
loss of consciousness
after strenuous exercise
or prolonged sleep x 2
months
No h/o headache,
vomiting, seizures
Evaluated in Gorakhpur
Documented low Blood
sugars (32mg/dl and
42mg/dl) during episodes
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Clinical Diagnosis
Multiple Endocrine Neoplasia type 1
Insulinoma
Primary Hyperparathyroidism
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Imaging
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Laparotomy
Bidigital palpation
Intra-op blood sugar monitoring
Intraoperative USG showed two
lesions
Intra-op USG
Distal pancreatectomy & Splenectomy
Bilateral neck exploration with subtotal
parathyroidectomy with cervical
thymectomy
(1) at the tip of tail of pancreas
(2) proximal to the first lesion ,in
the body.
Spleen enlarged with firm lesion
at the superior surface
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Intra-operative Findings
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Specimen photograph
Rt superior
Rt inferior
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Lt inferior
109
Post operative course
Biochemical hypocalcemia on
POD1, no clinical hypocalcaemia-
oral Calcium and Vitamin D
Distal pancreatico-splenectomy specimen:
multifocal pancreatic neuroendocrine
tumor with splenic infarct
Parathyroid glands: parathyroid
HPE
No hyperglycaemia
Serial post op USG: No evidence
of peripancreatic collection
Parathyroid glands: parathyroid
hyperplasia.
Immunohistochemistry : tumor cells
positive for synaptophysin and
chromogranin.
Ki-67 ( MIB 1 ) proliferation index 3%
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Follow up:
No s/o hypocalcemia,
S. Calcium and RBS- WNL
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Neuroendocrine tumors in triple phase CT
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In another case where triphasic CT study was
negative, Arterial Stimulation & Venous
Sampling (ASVS) was performed
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ASVS
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Thank You
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