VCU DEATH AND COMPLICATIONS CONFERENCE

Brief Overview of Case  Diagnosis:  Papillary thyroid cancer  Primary hyperparathyroidism  Procedure:  Total thyroidectomy, neck exploration and parathyroid biopsy  Complication:  Error 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 4 yo  Tympanostomy 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 18 th :  Admitted for vomiting and hypercalcemia  Jan 19 th & 20 th :  Thyroid US/sestamibi scan and FNA showed papillary carcinoma  Jan 25 th - 27 th:  To OR for total thyroidectomy, neck exploration and parathyroid biopsy  Intraop PTH: > thyroidectomy > 21.5 > 9.2 > 5  Calcium: 14.6 > 11.4 > 10.5 > 9.5 > 8.7 > 8.6 > 8.3  Discharged Jan 27 th with calcium 1250 mg tid, synthroid, calcitriol  Jan 30 th  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