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2nd Year Endocrine Lecture: 2

Lecture to 2nd year medical students on endocrine radiology. Thyroid, parathyroid and pituitary are covered.

Aaron Kamer

on 15 March 2012

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Transcript of 2nd Year Endocrine Lecture: 2

Parathyroid Endocrine Imaging Pituitary Normal Imaging - virtually invisible: Thyroid Parathyroid Carcinoma Hyperplasia Parathyroid Adenoma Nuclear Medicine
CT Nuclear Medicine Ultrasound MRI CT Abnormal Imaging Hyperparathyroidism:
Tertiary Labs: Renal failure (high Creatinine, low GFR), high PTH, low/normal Ca, variable phosphate (high in renal insufficiency and low in vitamin D deficiency) Secondary Hyperparathyroidism
(Renal Osteodystrophy/Vitamin D deficiency) Tertiary Hyperparathyroidism
(Long-standing secondary HPT --> autonomously functioning glands or adenoma) Labs: Hypercalcemia, high PTH Labs: hypercalcemia, hypophosphatemia Primary Hyperparathyroidism
(From the parathyroid gland) *Refractory to medication* IV Inject Technetium-99m-sestamibi or Thallium-201 for initial imaging.
Wait, take images. Recipe Not usually a primary imaging modality.
Parathyroid findings may be discovered incidentally. Nuclear Medicine
CT Normal Imaging Hypothyroidism
Hyperthyroidism Abnormal Imaging Normal Imaging MRI Abnormal Imaging T2 MR Nuclear Medicine Scan
(Tc-99m Sestamibi) IV Inject either Technetium-99m-O4 (pertechnatate) or Iodine-123.
Wait, take images, without and with markers. Ultrasound Recipe Not usually a primary imaging modality.
Thyroid findings may be discovered incidentally. Nuclear Medicine CT and MRI Very common modality for thyroid evaluation. Hypothyroidism Labs: TSH, T4 levels, sometimes thyroid antibody levels Very common
Multiple or single
Autonomously functioning (hot)
Nonfunctioning (cold) Thyroid Nodules Clinical Hypothyroidism 1.Mental and physical “slowing”
2.Cold intolerance
3.Decreased sweating
4.Coarse skin
6.Weight gain
7.Hair loss
8.…and many, many others Primary
Secondary Hypothyroidism Causes Primary Hypothyroidism Secondary Hypothyroidism Tumor
Medications like lithium and dopamine
Sheehan syndrome Autoimmune
Subacute granulomatous thyroiditis
Iatrogenic (radiotherapy, surgery, radiation)
Iodine deficiency Primary: High TSH
Secondary: Low TSH Differentiating Primary and Secondary Hypothyroidism Thyroiditis
Thyroid nodules Functional
Abnormalities Anatomic
Abnormalities Hyperthyroidism Causes Diffuse toxic goiter (Graves disease)
Toxic multinodular goiter (Plummer disease)
Thyrotoxic phase of subacute thyroiditis
Toxic adenoma
Iodide-induced thyrotoxicosis
Thyrotoxicosis factitia
Pituitary tumors producing thyroid-stimulating hormone
Excess human chorionic gonadotropin (molar pregnancy/choriocarcinoma)
Pituitary resistance to thyroid hormone
Metastatic thyroid carcinoma
Struma ovarii with thyrotoxicosis Hyperthyroidism Labs: TSH, T4 levels, sometimes thyroid antibody levels Clinical Hyperthyroidism 1.Nervousness
3.Increased perspiration
4.Heat intolerance
8.Weight loss despite increased appetite
9.Reduction in menstrual flow or oligomenorrhea
11.Tachycardia or atrial arrhythmia
12.Systolic hypertension
13.Warm, moist, and smooth skin
14.Lid lag
17.Muscle weakness
18...and many more. Usually normal thyroid labs
Often from congenital abnormality (piriform sinus position)
Fairly obvious clinically
Limited role of imaging Acute suppurative thyroiditis
Subacute thyroiditis
Chronic thyroiditis Acute suppurative thyroiditis Thyroiditis Subacute Thyroiditis Viral infection
Enlarged Thyroid
Symptoms of Hyperthyroidism
Nuclear medicine imaging helpful
Usually autoimmune process
Two main types Chronic Thyroiditis B and T lymphocyte-mediated autoimmunity, mainly to thyrotropin receptor
Stimulates thyroid hormone production
Antibodies also deposit in the post-septal orbital tissues, causing exophthalmos
Treatment with Radioactive Iodine (I-131) Grave's disease Hashimoto Thyroiditis Also autoimmune
May have initially increased T4
Usually decreased T4
I-123 NM study for evaluation - decreased uptake 15-20% chance of cancer
Evaluated with NM and Ultrasound
Might be a cyst
Cold Nodules Multinodular Goiter Common cause of thyroid enlargement
Many imaging modalities
Can cause hyperthyroidism
Treatment is with I-131 ablation or medical thyroid suppression Thyroid Cancer Metabolically active
Can cause hyperthyroidism
<1% incidence of cancer
I-131 treatment
Nuclear Med evaluation Hot Nodules Several histologic types, usually not very agressive (anaplastic is)
Imaged with NM
Biopsy with US
Surgically removed, followed by I-131 treatment
Cancer is followed by thyroglobulin levels and imaging Propylthiouracil (I organification)
Methimazole (I oxidation) Microadenoma Ectopic posterior pituitary Microadenoma
Other masses
Ectopic Neurohypophysis
Empty sella Other Masses Macroadenoma Empty Sella Can cause Acromegaly, Hyperprolactinemia
Difficult to see on imaging
Dynamic enhancement MR
Enhances less than other pituitary tissue Can cause hormone abnormalities, optic chiasm compression
MR evaluation
Snowman appearance
Cavernous sinus invasion Craniopharyngioma
Internal carotid aneurysm
Germ Cell tumor
Arachnoid cyst
Epidermoid cyst
Sarcoid Congenital anomaly
Potential endocrine deficiencies, most often GH Primary or secondary
Often subtle endocrine disturbances
Idiopathic Intracranial Hypertension (Pseudotumor cerebri)
Flattened pituitary along sella floor Women: oligomenorrhea, amenorrhea, infertility or spontaneous lactation.
Men: sexual dysfunction, decreased libido, increased cuddling, gynecomastia. Hyperprolactinemia Presentation Prolactin Level Lab Tests Causes 1.Pregnancy – women only
2.Pituitary adenoma (micro or macro)
6.Random causes: nonfasting sample, excessive exercise, a history of chest wall surgery or trauma, renal failure and cirrhosis. IV Inject Tc-sestamibi
Wait, take images
Wait 3-4 hours
Inject Iodine-123
Wait, take images
Subtract I-123 images from sestamibi or GH-secreting pituitary tumor
GHRH-secreting hypothalamic tumor (rare)
Ectopic GHRH-secreting tumors
Ectopic GH-secreting tumors
Exogenous administration acral overgrowth, visceral overgrowth, insulin antagonism, nitrogen retention, and increased risk of colon polyps/tumors. Pituitary tumor mass effects.
Frontal bossing, thickening of the nose, macroglossia, prognathism.
Women with mild hirsutism.
Multinodular Goiter
Enlarged extremities with sausage-shaped digits.
Oily skin, skin tags Causes Lab Tests Acromegaly Presentation Serum IGF-I
Inability to suppress GH levels on oral glucose tolerance test.
T1 MR (contrast) Case Scenario 1:
46-year-old woman with sudden onset visual disturbance. Case Scenario 2:
23 year-old obese woman with headaches, nausea, vomiting. Gelastic Seizures Hamartoma of the tuber cinereum Case Scenario 3:
37-year-old man with palpable right thyroid mass. Case Scenario 4:
51-year-old woman with tender, enlarged thyroid. She has heat intolerance, increased appetite and anxiety. Case Scenario 6:
61-year-old woman with fatigue and bone pain/myalgias. Case Scenario 7:
72-year-old man with fatigue and kidney stones. Right neck fullness. Craniopharyngioma Pituitary apoplexy Empty Sella in Idiopathic Intracranial Hypertension Hint: What is bright on T1-weighted MR? Parathyroid Carcinoma Cold thyroid nodule: cyst Subacute/viral thyroiditis Ectopic parathyroid adenoma Hint: Normal uptake is 7-25% in our lab. Aaron P. Kamer, MD
Neuroradiology Fellow
February, 2012 Inability to breast-feed (breast milk never "comes in")
Lack of menstrual bleeding
Loss of pubic and axillary hair
Low blood pressure I-131 Treatment 10-15 mCi I-131
Patient precautions
Goal is hypothyroidism Thanks!

Any questions?

Email me: apkamer@iupui.edu Gynecomastia Acromegaly Case Scenario 5:
9-day old with hypothyroidism. Lingual thyroid
Full transcript