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Book Details
Abstract
Surgery of the Thyroid and Parathyroid Glands empowers the reader to diagnose benign and malignant diseases effectively, implement the latest cutting-edge techniques, and achieve optimal patient outcomes. This surgical reference book encompasses the most up to date state of the art knowledge, presented by world-renown authors in thyroid and parathyroid surgery, in one concise yet comprehensive source, offering the detailed guidance you need to produce the best results.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| Surgery of the Thyroidand Parathyroid Glands | iii | ||
| Copyright | iv | ||
| Dedication | v | ||
| Contributors | vii | ||
| Foreword | xvii | ||
| Preface | xix | ||
| Acknowledgments | xxi | ||
| Contents | xxiii | ||
| Video Contents | xxvii | ||
| Surgery of the Thyroidand Parathyroid Glands | xxix | ||
| Section 1: Introduction | 1 | ||
| Chapter 1: History of Thyroid and Parathyroid Surgery | 3 | ||
| The Early Years | 3 | ||
| The Surgical Revolution | 5 | ||
| Development of Modern Thyroid Surgery | 5 | ||
| Theodor Kocher (1841-1917) | 6 | ||
| Laryngeal Nerves | 9 | ||
| Parathyroid Glands | 11 | ||
| Parathyroid Anatomy and Physiology | 11 | ||
| Parathyroid Surgery | 12 | ||
| Further Parathyroid Advances and Autotransplantation | 12 | ||
| Historical Vignette Of Endocrine Surgery at the Massachusetts General Hospital | 13 | ||
| Reference | 14 | ||
| Chapter 2: Applied Embryology of the Thyroid and Parathyroid Glands | 15 | ||
| The Thyroid Gland | 15 | ||
| Normal Development of Thyroid | 15 | ||
| Genetic Control | 15 | ||
| Anomalous Development of the Thyroid | 15 | ||
| Thyroid Ectopias | 16 | ||
| Thyroid Rests | 16 | ||
| Lingual Thyroid | 17 | ||
| Thyroglossal Duct Cyst | 17 | ||
| Pyramidal Lobe | 18 | ||
| Tubercle of Zuckerkandl | 19 | ||
| Applied importance | 19 | ||
| The Recurrent Laryngeal Nerve | 19 | ||
| Normal Embryology of RLN | 20 | ||
| Anomalous Development of the RLN | 20 | ||
| Implications of Anomalous Development | 20 | ||
| Implications of Anomalous Development | 20e1 | ||
| Applied Embryology of the Parathyroid Glands | 21 | ||
| Generalities | 21 | ||
| Genetic Control and Evolutionary Model | 21 | ||
| Histogenesis | 21 | ||
| Development Process | 21 | ||
| Position of Normal Parathyroid Glands, Anomalies of the Embryologic Migration, and Congenital Ectopias | 21 | ||
| Parathyroid Symmetry | 23 | ||
| Intrathyroidal Parathyroid Glands | 23 | ||
| Anomalies in Parathyroid Number: Infranumerary and Supernumerary Glands | 24 | ||
| Acquired Ectopic Localization | 24 | ||
| Chapter 3: Thyroid Physiology and Thyroid Function Testing | 25 | ||
| Introduction | 25 | ||
| Thyroid Physiology | 25 | ||
| Thyroid Physiology and Pregnancy | 27 | ||
| Thyroid Physiology and Nonthyroidal Illness (Euthyroid Sick Syndrome) | 27 | ||
| Thyroid Tests | 28 | ||
| TSH Assays | 28 | ||
| Measurement of Thyroid Hormone Levels | 29 | ||
| Total T4 and Total T3 | 29 | ||
| Equilibrium Free T4 and Estimates of Free T4 | 30 | ||
| Thyroid Antibodies | 31 | ||
| Thyroglobulin | 31 | ||
| Thyroid Imaging | 32 | ||
| Thyroid Function Testing for Hypothyroidism | 32 | ||
| Signs and Symptoms of Hypothyroidism | 32 | ||
| Thyroid Tests in the Evaluation of Hypothyroidism | 32 | ||
| Subclinical Hypothyroidism | 33 | ||
| Etiology of Hypothyroidism | 34 | ||
| Antithyroid Antibodies in Hypothyroidism | 34 | ||
| Thyroid Imaging in Hypothyroidism | 34 | ||
| Monitoring of Patients with Hypothyroidism | 34 | ||
| Thyroid Function Testing for Thyrotoxicosis | 35 | ||
| Symptoms and Signs of Thyrotoxicosis | 35 | ||
| Thyroid Tests in the Evaluation of Thyrotoxicosis | 35 | ||
| Subclinical Thyrotoxicosis | 36 | ||
| Etiology of Thyrotoxicosis | 36 | ||
| Antithyroid Antibodies in Hyperthyroidism | 36 | ||
| Thyroid Imaging in Thyrotoxicosis | 37 | ||
| Monitoring of Patients with Hyperthyroidism | 37 | ||
| Thyroid Function Testing and Pregnancy | 37 | ||
| Pregnancy and Hypothyroidism | 37 | ||
| Thyroid Function Testing in Nonthyroidal Illness (Euthyroid Sick Syndrome) | 37 | ||
| Conclusions | 38 | ||
| Reference | 38 | ||
| Section 2: Benign Thyroid Disease | 39 | ||
| Chapter 4: Thyroiditis | 41 | ||
| Introduction | 41 | ||
| Hashimoto's Thyroiditis | 41 | ||
| Pathogenesis | 41 | ||
| Clinical Manifestations | 42 | ||
| Clinical Management | 43 | ||
| Sporadic Silent and Postpartum Thyroiditis | 43 | ||
| Pathogenesis | 44 | ||
| Clinical Manifestations | 44 | ||
| Differential Diagnosis | 45 | ||
| Clinical Management | 46 | ||
| Subacute Thyroiditis/De Quervain's Thyroiditis | 46 | ||
| Pathogenesis | 46 | ||
| Infectious Association | 46 | ||
| Autoimmune Association | 46 | ||
| Genetic Association | 47 | ||
| Clinical Manifestations | 47 | ||
| Differential Diagnosis | 47 | ||
| Clinical Management | 48 | ||
| Drug-Induced Thyroiditis | 48 | ||
| Acute Suppurative/Infectious Thyroiditis | 49 | ||
| Etiology and Pathogenesis | 49 | ||
| Clinical Manifestations | 49 | ||
| Laboratory Findings | 50 | ||
| Diagnosis | 50 | ||
| Clinical Management | 50 | ||
| Invasive Fibrous Thyroiditis/Riedel's Thyroiditis | 50 | ||
| Etiology | 50 | ||
| Clinical Manifestations | 50 | ||
| Laboratory Findings | 51 | ||
| Diagnosis and Clinical Management | 51 | ||
| Prognosis | 51 | ||
| Reference | 51 | ||
| Chapter 5: Hyperthyroidism | 52 | ||
| Introduction | 52 | ||
| Epidemiology | 52 | ||
| Section 3: Preoperative Evaluation | 105 | ||
| Chapter 11: The Evaluation and Management of Thyroid Nodules | 107 | ||
| Introduction | 107 | ||
| Identifying Thyroid Nodules for Evaluation | 107 | ||
| Fine-Needle Aspiration | 108 | ||
| Risk Assessment of Thyroid Nodules | 110 | ||
| Clinical Risk Assessment | 110 | ||
| Radiologic Risk Assessment | 110 | ||
| Molecular Risk Assessment | 112 | ||
| Multifactor Risk Assessment | 112 | ||
| Multinodularity | 113 | ||
| Decision Analysis | 113 | ||
| Summary | 113 | ||
| Reference | 114 | ||
| Chapter 12: Fine-Needle Aspiration of the Thyroid Gland | 115 | ||
| Introduction | 115 | ||
| Indications for Thyroid FNA | 115 | ||
| FNA Technique | 116 | ||
| Accuracy of Thyroid FNA | 116 | ||
| Reporting Terminology: The Bethesda System | 117 | ||
| Nondiagnostic Thyroid Aspirates | 117 | ||
| Benign Conditions | 118 | ||
| Goiter | 118 | ||
| Thyroiditis | 119 | ||
| Toxic Goiter | 119 | ||
| Atypia of Undetermined Significance or Follicular Lesion of Undetermined Significance | 119 | ||
| Suspicious for a Follicular Neoplasm/Follicular Neoplasm: Follicular Adenomas and Follicular Carcinomas | 120 | ||
| Hurthle Cell Neoplasms | 120 | ||
| Malignant Tumors | 121 | ||
| Papillary Thyroid Carcinoma | 121 | ||
| Undifferentiated (Anaplastic) Thyroid Carcinoma | 122 | ||
| Medullary Thyroid Carcinoma | 123 | ||
| Malignant Lymphoma | 124 | ||
| Secondary Tumors of the Thyroid | 124 | ||
| Thyroid FNA Complications | 125 | ||
| References | 125 | ||
| Chapter 13: Ultrasound of the Thyroid and Parathyroid Glands | 126 | ||
| Introduction | 126 | ||
| Physics and Principles of Ultrasound | 126 | ||
| Artifacts | 126 | ||
| Doppler | 127 | ||
| Thyroid Ultrasound | 128 | ||
| Role of Ultrasound in the Initial Evaluation of the Thyroid Nodule | 129 | ||
| Ultrasonography Technique and Measurements | 129 | ||
| Ultrasound Characteristics of Thyroid Nodules | 129 | ||
| Size | 129 | ||
| Margins and Halo/Rim | 129 | ||
| Shape | 129 | ||
| Echo Structure | 129 | ||
| Echogenicity | 130 | ||
| Calcifications | 130 | ||
| Vascular Pattern | 130 | ||
| Capsular Contact | 131 | ||
| Elastography | 131 | ||
| Ultrasound Characteristics of Benign Thyroid Nodules | 132 | ||
| Thyroid Cysts | 132 | ||
| Ultrasound Characteristics of Malignant Lesions | 132 | ||
| Papillary Carcinoma | 133 | ||
| Follicular Carcinoma | 133 | ||
| Hurthle Cell Carcinoma | 133 | ||
| Medullary Carcinoma | 133 | ||
| Anaplastic Carcinoma | 133 | ||
| Lymphoma | 133 | ||
| Thyroid as a Site of Cancer Metastases | 133 | ||
| Neck Nodal Assessment | 133 | ||
| Ultrasound Surveillance of Thyroid Nodules over Time | 134 | ||
| Role of Ultrasound in Other Thyroid Gland Diseases | 134 | ||
| Goiter | 134 | ||
| Graves´ Disease | 134 | ||
| Multinodular Goiter | 134 | ||
| Thyroiditis | 134 | ||
| Ultrasound-Guided Thyroid Procedures | 134 | ||
| Thyroid Elastography | 134 | ||
| Sonography of Neck Nodes | 137 | ||
| Equipment and Technique | 137 | ||
| Ultrasound Features of Malignant Nodes (Table13-3) | 137 | ||
| Nodal Distribution | 137 | ||
| Nodal Size | 137 | ||
| Nodal Shape | 137 | ||
| Intranodal Echogenic Hilus | 137 | ||
| Nodal Echogenicity | 140 | ||
| Intranodal Calcification | 140 | ||
| Nodal Border | 140 | ||
| Intranodal Necrosis | 140 | ||
| Nodal Vascularity | 140 | ||
| Contrast Enhancement | 141 | ||
| Elastography of Thyroid Lymph Node Metastases | 141 | ||
| Parathyroid Ultrasound | 141 | ||
| Embryology | 141 | ||
| Normal Anatomy | 141 | ||
| Ectopic Position | 141 | ||
| Vascular Pattern | 141 | ||
| Technical Considerations | 141 | ||
| Power Doppler | 142 | ||
| Aspiration Parathyroid Hormone (PTH) Rinsing | 143 | ||
| Other Issues | 143 | ||
| Summary | 143 | ||
| References | 143 | ||
| Chapter 14: Preoperative Radiographic Mapping of Nodal Disease for Papillary Thyroid Carcinoma | 144 | ||
| Macroscopically Positive versus Microscopically Positive LN Mets | 144 | ||
| The Importance of Radiographic Detection of Macroscopically Positive Nodes Preoperatively | 144 | ||
| Central Neck Nodes | 144 | ||
| Lateral Neck Nodes | 145 | ||
| Preoperative Radiographic Evaluation: US and CT | 145 | ||
| Physical Exam | 145 | ||
| Ultrasound | 145 | ||
| CT Scanning with Contrast | 145 | ||
| References | 147 | ||
| Chapter 15: Pre- and Postoperative Laryngeal Exam in Thyroid and Parathyroid Surgery | 149 | ||
| Introduction | 149 | ||
| Anatomy and Voice | 149 | ||
| Reported Prevalence of Recurrent Laryngeal Nerve Paralysis | 150 | ||
| Glottic Exam and Voice | 151 | ||
| Voice Symptoms with Normal Vocal Fold Mobility | 152 | ||
| Vocal Cord Paralysis without Voice Symptoms | 153 | ||
| Rationale for Preoperative Laryngeal Exam | 153 | ||
| Laryngeal Exam Guidelines | 153 | ||
| Rationale for Postoperative Laryngeal Exam | 154 | ||
| Flexible Laryngoscopy: A Standard Technique to Be Mastered by All Thyroid Surgeons | 154 | ||
| Summary | 155 | ||
| Chapter 16: Laser and Radiofrequency Treatment of Thyroid Nodules and Parathyroid Adenoma | 156 | ||
| Introduction | 156 | ||
| Image-Guided Tumor Ablation | 156 | ||
| Thermal Ablation | 156 | ||
| Laser Ablation | 156 | ||
| Laser Ablation in the Thyroid Gland | 157 | ||
| Technique | 158 | ||
| Procedure | 158 | ||
| PLA Postprocedure Care | 159 | ||
| Side Effects | 160 | ||
| Clinical Results in Benign Cold Nodules | 160 | ||
| Radiofrequency Ablation | 161 | ||
| Radiofrequency Ablation in the Thyroid Gland | 161 | ||
| Technique and Procedure | 161 | ||
| Side Effects | 161 | ||
| Clinical Results in Benign Thyroid Nodules | 162 | ||
| Thermal Ablation Procedures in Autonomously Functioning Thyroid Nodules | 162 | ||
| Follow-up Evaluation after Thyroid Thermal Ablation Procedures | 163 | ||
| Thermal Ablation Procedures in Autonomously Functioning Thyroid Nodules | 163 | ||
| Parathyroid Thermal Ablation | 163 | ||
| Indications of Thermal Ablation Procedures in the Endocrine Neck | 163 | ||
| Benign Cold Thyroid Nodules | 163 | ||
| Other Indications | 163 | ||
| Conclusions | 163 | ||
| References | 163 | ||
| Section 4: Thyroid Neoplasia | 165 | ||
| Chapter 17: Molecular Pathogenesis of Thyroid Neoplasia | 167 | ||
| Introduction | 167 | ||
| Thyroid Neoplasia: An Overview | 167 | ||
| Epidemiology | 167 | ||
| Morphology | 167 | ||
| Prognosis | 167 | ||
| Inheritance | 168 | ||
| Genetics | 168 | ||
| Thyroid Neoplasia: Genetic Alterations Associated with Specific Thyroid Tumors | 168 | ||
| Follicular Adenoma | 168 | ||
| Papillary Thyroid Carcinoma | 169 | ||
| Specific Genetic Alterations in Papillary Thyroid Carcinoma | 170 | ||
| RET/PTC | 170 | ||
| NTRK1 | 170 | ||
| BRAF | 170 | ||
| Section 5: Thyroid and Neck Surgery | 271 | ||
| Chapter 30: Principles in Thyroid Surgery | 273 | ||
| Introduction | 273 | ||
| Extent of Thyroidectomy | 273 | ||
| Extent of Surgery Based on FNA Result | 273 | ||
| Benign | 273 | ||
| Nondiagnostic | 273 | ||
| Follicular or Hurthle Cell Neoplasm | 273 | ||
| Suspicious for Papillary Carcinoma | 274 | ||
| Diagnostic for Medullary Carcinoma, Anaplastic Carcinoma, or Lymphoma | 274 | ||
| Diagnostic for Papillary Carcinoma of the Thyroid | 274 | ||
| Unique Features of Papillary Carcinoma | 274 | ||
| The prevalence and favorable prognosis of small PTC lesions | 274 | ||
| PTC cervical lymph node micrometastasis | 274 | ||
| PTC's robust prognostic risk grouping segregation | 275 | ||
| Extent of Thyroidectomy for PTC 1 cm | 276 | ||
| Total Thyroidectomy for PTC: Additional Considerations | 276 | ||
| Extent of Thyroidectomy for PTC 1 cm (PTMC) | 276 | ||
| Extent of Thyroidectomy for PTC 1 cm (PTMC) Detected on Lobar Specimens: Completion Thyroidectomy | 277 | ||
| Surgical Complications | 277 | ||
| RLN paralysis | 277 | ||
| Hypoparathyroidism | 278 | ||
| Extent of Surgery PTC Summary: Encompass Gross Diseases in Thyroid and Nodes at First Surgery | 278 | ||
| Thyroidectomy in Pregnancy | 279 | ||
| Nomenclature of Thyroidectomy | 279 | ||
| Thyroidectomy Surgical Steps | 279 | ||
| Initial Surgical Considerations | 280 | ||
| Patient Positioning | 281 | ||
| Incision and Flap | 281 | ||
| Strap Muscles and the Midline Airway | 282 | ||
| Lateral Thyroid Region Exposure-Middle Thyroid Vein | 284 | ||
| Inferior Parathyroid | 285 | ||
| Recurrent Laryngeal Nerve | 285 | ||
| Parathyroid Glands | 287 | ||
| Superior Pole and SLN | 290 | ||
| Isthmus | 291 | ||
| Contralateral Surgery: Safety Checklist | 291 | ||
| Thyroid Bed Uptake after Total Lobectomy | 292 | ||
| Closure and Final Steps | 292 | ||
| Dictation and Synoptic Reporting | 293 | ||
| Chapter 31: Minimally Invasive Video-Assisted Thyroidectomy | 294 | ||
| Introduction | 294 | ||
| Preoperative Evaluation and Anesthesia | 294 | ||
| Surgical Technique | 295 | ||
| Operating Room Setup | 295 | ||
| Patient | 295 | ||
| Team (Figure 31-1) | 295 | ||
| Instrumentation (Figure 31-2): MIVAT Kit | 295 | ||
| Operative Technique | 295 | ||
| Preparation of the Operative Space | 295 | ||
| Ligature of the Main Thyroid Vessels | 295 | ||
| Recurrent Laryngeal Nerve and Parathyroid Glands' Identification and Dissection | 297 | ||
| Extraction of the Lobe and Resection | 298 | ||
| Postoperative Treatment | 298 | ||
| Postoperative Care | 298 | ||
| Future Applications of Video-Assisted Approach | 299 | ||
| Conclusions | 299 | ||
| Reference | 299 | ||
| Chapter 32: Surgical Anatomy of the Superior Laryngeal Nerve | 300 | ||
| History | 300 | ||
| Anatomy | 300 | ||
| Physiology and Pathophysiology | 301 | ||
| Surgical Technique | 303 | ||
| Diagnosis of EBSLN Paralysis | 305 | ||
| Incidence of EBSLN Injury | 305 | ||
| Treatment of EBSLN Injury | 305 | ||
| Conclusion | 305 | ||
| Reference | 305 | ||
| Chapter 33: Surgical Anatomy and Monitoring of the Recurrent Laryngeal Nerve | 306 | ||
| Introduction | 306 | ||
| Reported Incidence of RLN Paralysis | 306 | ||
| Laryngeal Exam in All Patients Preoperatively and Postoperatively | 307 | ||
| Preoperative Vocal Cord Paralysis | 307 | ||
| Preop Laryngeal Exam and Intraoperative Electrical Stimulability | 308 | ||
| Visualization of Nerve | 308 | ||
| Surgical Anatomy | 309 | ||
| Vagal Neural Anatomy | 309 | ||
| RLN Neural Anatomy | 310 | ||
| Superior Laryngeal Nerve | 311 | ||
| Microanatomy of the RLN | 311 | ||
| Visual Identification | 311 | ||
| Nonrecurrent RLN | 311 | ||
| RLN Displacement | 312 | ||
| Tubercle of Zuckerkandl | 313 | ||
| Extralaryngeal RLN Branching | 314 | ||
| Functional Variability of RLN Branches: Abductor and Adductor Fibers | 314 | ||
| Galen's Anastomosis | 315 | ||
| RLN-SLN Connections: Significance during Thyroid Surgery | 316 | ||
| RLN and Inferior Thyroid Artery | 316 | ||
| Ligament of Berry | 316 | ||
| Inferior Thyroid Cartilage Cornu: Landmark for the RLN Laryngeal Entry Point | 318 | ||
| SURGICAL Approaches to the RLN | 318 | ||
| General Identification Principles | 319 | ||
| Lateral Approach | 319 | ||
| Inferior Approach | 321 | ||
| Superior Approach | 321 | ||
| RLN Surgical Dissection Tips and Pitfalls | 321 | ||
| RLN Monitoring | 322 | ||
| IONM and Guidelines | 323 | ||
| Categories of Benefit of RLN Monitoring | 323 | ||
| Studies of IONM and Rates of RLN Paralysis | 323 | ||
| IONM Categories of Benefit | 323 | ||
| 1. Neural identification/neural mapping | 324 | ||
| 2. Aid in dissection | 324 | ||
| 3. Prognostication of postoperative neural function and injury lesion site identification | 324 | ||
| Prognostic Testing Errors and How to Avoid Them | 325 | ||
| Past Techniques | 325 | ||
| IONM Standards Guidelines | 325 | ||
| Introduction | 325 | ||
| Basic System Setup | 326 | ||
| Anesthesia | 326 | ||
| 1. Algorithm for optimal tube placement and function (Box 33-1) | 326 | ||
| II. Monitor problem solving: loss of signal algorithm | 328 | ||
| Loss of Signal | 329 | ||
| Mechanism of Injury | 329 | ||
| Intraoperative RLN Stimulation Errors | 330 | ||
| Passive EMG Activity during Thyroid Surgery | 330 | ||
| Normative Human Monitoring Data | 331 | ||
| Standards in waveform definition and assessment | 331 | ||
| Amplitude | 331 | ||
| Threshold | 332 | ||
| Latency | 332 | ||
| Monitoring Safety | 333 | ||
| Validity of Noninvasive Monitoring | 333 | ||
| Indications for Neural Monitoring | 334 | ||
| Continuous Neural Vagal Monitoring (C-IONM) | 334 | ||
| Management of Infiltrated Nerve | 335 | ||
| Management of Neural Injury | 335 | ||
| Severed Nerve | 335 | ||
| Segmental Loss of RLN | 336 | ||
| Blunt, Nontransection Injury | 337 | ||
| Vocal Cord Recovery: Timing and Assessment | 338 | ||
| SLN Monitoring | 338 | ||
| References | 340 | ||
| Chapter 35: Surgery for Locally Advanced Thyroid Cancer: Trachea | 350 | ||
| Introduction | 350 | ||
| Biology of Thyroid Cancer | 350 | ||
| Locally Advanced Thyroid Cancer | 351 | ||
| Initial Evaluation | 351 | ||
| Staging of Tracheal Invasion | 352 | ||
| Surgical Management of Tracheal Invasion: Prognosis and Local Control | 353 | ||
| Operative Technique of Tracheal Resection | 355 | ||
| Operative Steps of Sleeve Resection of the Trachea | 356 | ||
| Reference | 357 | ||
| Chapter 36: Robotic and Extracervical Approaches to the Thyroid and Parathyroid Glands: A Modern Classification Scheme | 358 | ||
| Introduction | 358 | ||
| Goals of Endoscopic Thyroid Surgery | 358 | ||
| Goal 1: To Treat the Disease Effectively | 358 | ||
| Goal 2: To Minimize Long-Term Side Effects of Surgery and to Reduce Complications | 359 | ||
| Goal 3: To Minimize Postoperative Discomfort and Pain | 359 | ||
| Costs and Benefits of Innovation | 359 | ||
| Recent Surgical Innovation | 359 | ||
| Visualization Technology | 359 | ||
| Intraoperative Monitoring | 360 | ||
| Improvements in Instrumentation | 360 | ||
| Improvements in Hemostasis | 360 | ||
| Classification of Surgical Techniques | 360 | ||
| Classification Factors and Definitions | 361 | ||
| Approach: Midline Direct, Regional, Remote | 361 | ||
| Maintenance of the Working Space: Gasless, Insufflation | 361 | ||
| Visualization: Traditional versus Endoscopic/Stereoscopic | 362 | ||
| Instrumentation: Manual versus Robotic | 362 | ||
| Classification of Surgical Approaches | 362 | ||
| Type I Approaches: Midline Direct | 362 | ||
| Type II Approaches: Regional | 362 | ||
| Lateral Cervical Approaches (Insufflating/Gasless, Endoscopic, Manual/Robotic) | 362 | ||
| Submandibular (Gasless, Endoscopic, Manual) | 364 | ||
| Type III Approaches: Remote | 364 | ||
| Anterior Chest Wall (Insufflating, Endoscopic/Stereoscopic, Manual/Robotic) | 364 | ||
| Cirum-mammary (Insufflating, Endoscopic, Manual) | 364 | ||
| Transaxillary (Insufflating/Gasless, Endoscopic/Stereoscopic, Manual/Robotic) | 364 | ||
| ABBA (Insufflating/Gasless, Endoscopic/Stereoscopic, Manual/Robotic) | 365 | ||
| Postauricular-Transaxillary (Insufflating, Endoscopic, Manual) | 365 | ||
| Type IIIm Approaches: Remote Transmucosal | 365 | ||
| Transoral (Insufflation, Endoscopic/Stereoscopic, Manual/Robotic) | 365 | ||
| Outcomes, Concerns, and Future Directions | 366 | ||
| Conclusion | 366 | ||
| Reference | 366 | ||
| Chapter 37: Central Neck Dissection: Indications | 367 | ||
| Introduction | 367 | ||
| Definition | 367 | ||
| Therapeutic Lymph Node Dissection | 367 | ||
| Prophylactic Neck Dissection | 368 | ||
| Conclusion | 372 | ||
| Chapter 38: Central Neck Dissection: Technique | 373 | ||
| Introduction | 373 | ||
| Anatomy and Terminology | 373 | ||
| Preoperative Evaluation | 374 | ||
| Surgical Technique | 375 | ||
| Step 1: Prelaryngeal Dissection | 375 | ||
| Step 2: Pretracheal Dissection | 375 | ||
| Step 3: Paratracheal Dissection | 376 | ||
| Parathyroid Preservation during Paratracheal Dissection | 376 | ||
| Right Paratracheal Dissection | 376 | ||
| Left Paratracheal | 378 | ||
| Bilateral Paratracheal Dissection | 378 | ||
| The Importance of Preoperative Laryngeal Exam | 379 | ||
| Postoperative Considerations | 379 | ||
| Reoperative Considerations | 379 | ||
| Chapter 39: Lateral Neck Dissection: Indications | 382 | ||
| Lymphatic Drainage of the Thyroid Gland | 382 | ||
| The Patterns of Lymph Node Metastases | 382 | ||
| Risk Factors for Lymph Node Metastases | 383 | ||
| Histologic Subtype | 383 | ||
| Tumor Size | 383 | ||
| Tumor Invasion Characteristics | 383 | ||
| Biologic Marker | 383 | ||
| The Prognostic Significance of Lymph Node Metastases | 384 | ||
| The Management of the N0 Neck | 384 | ||
| The Lateral Compartment of the Neck | 384 | ||
| The Central Compartment of the Neck | 384 | ||
| Management of the N Neck | 386 | ||
| Radioactive Iodine for Nodal Metastases | 388 | ||
| Adjuvant Radiation Therapy | 388 | ||
| Chapter 40: Lateral Neck Dissection: Technique | 389 | ||
| Background | 389 | ||
| Historical Overview | 389 | ||
| Anatomy | 389 | ||
| Types of Neck Dissection | 390 | ||
| Technique | 390 | ||
| Incision | 390 | ||
| Flap Elevation | 390 | ||
| Level I | 391 | ||
| Lateral Neck Dissection (Levels II, III, IV) | 393 | ||
| Level V | 394 | ||
| Central Compartment Dissection | 395 | ||
| Closure and Postoperative Care | 396 | ||
| Complications | 396 | ||
| Nerve Injury | 397 | ||
| Carotid Exposure and Rupture | 398 | ||
| Chylous Fistula | 398 | ||
| Chapter 41: Transoral Resection of Parapharyngeal and Retropharyngeal Thyroid Carcinoma Metastases | 399 | ||
| Introduction | 399 | ||
| Operative Technique | 399 | ||
| Discussion | 399 | ||
| Conclusion | 402 | ||
| References | 402 | ||
| Chapter 42: Incisions in Thyroid and Parathyroid Surgery | 403 | ||
| Introduction | 403 | ||
| Historical Perspectives | 403 | ||
| General Principles | 403 | ||
| Individualizing Incisions | 403 | ||
| Location | 403 | ||
| Skin Management | 403 | ||
| Drain Placement | 404 | ||
| Skin Closure | 404 | ||
| Specific Procedure Considerations | 405 | ||
| Standard Open Thyroidectomy | 405 | ||
| Minimally Invasive Thyroidectomy | 405 | ||
| Thyroidectomy with Central Neck Dissection | 405 | ||
| Thyroidectomy with Lateral Neck Dissection | 405 | ||
| Parathyroidectomy | 405 | ||
| Bilateral Parathyroid Surgery | 406 | ||
| Novel Approaches | 406 | ||
| Best Practices | 406 | ||
| References | 406 | ||
| Chapter 43: Technological Innovations in Thyroid and Parathyroid Surgery | 407 | ||
| Introduction | 407 | ||
| Ultrasonic Energy (Harmonic) | 407 | ||
| Bundle Ligation of Superior Pole | 407 | ||
| Electrothermal Bipolar Vessel Sealing System (LigaSure) | 407 | ||
| Laryngeal Nerve Monitoring | 407 | ||
| High-Resolution Endoscopy | 408 | ||
| Minimally Invasive Video-Assisted Thyroidectomy (MIVAT) | 409 | ||
| Other Endoscopic Techniques | 411 | ||
| Robotic Technology | 411 | ||
| References | 411 | ||
| Chapter 44: Surgical Pathology of the Thyroid Gland | 413 | ||
| Introduction | 413 | ||
| Benign Neoplasms: Adenomas and Adenomatous Nodules | 413 | ||
| Variants of Follicular Adenoma | 413 | ||
| Atypical Follicular Adenoma | 413 | ||
| Hyalinizing Trabecular Neoplasm of the Thyroid AKA Hyalinizing Trabecular Adenoma (HTA)/Paraganglioma-Like Adenoma of the Thyro | 414 | ||
| Signet Ring Cell Follicular Adenoma | 414 | ||
| Malignant Neoplasms | 414 | ||
| Papillary Carcinoma | 414 | ||
| Variants of Papillary Cancer | 415 | ||
| Immunohistochemistry of Papillary Carcinoma | 417 | ||
| Molecular Pathology of Papillary Carcinoma | 417 | ||
| Follicular Carcinoma | 417 | ||
| Molecular Pathology of Follicular Carcinoma | 418 | ||
| Well-Differentiated Follicular ``Tumors of Undetermined/Uncertain Malignant Potential´´ | 418 | ||
| Oncocytic (Hurthle Cell) Tumors | 419 | ||
| Insular Carcinoma | 419 | ||
| Poorly Differentiated Carcinoma | 419 | ||
| Anaplastic Carcinoma | 420 | ||
| Follicular-Derived Familial Tumors | 420 | ||
| Medullary Carcinoma | 420 | ||
| Tumors with Thymic or Related Branchial Pouch Differentiation | 422 | ||
| Mucoepidermoid Carcinoma of Thyroid Gland | 422 | ||
| Primary Nonepithelial Tumors of Thyroid | 422 | ||
| Carcinoma in Thyroglossal Duct Cyst and Ectopic Thyroid Tissue | 422 | ||
| Pathologist and Thyroid | 423 | ||
| Intraoperative Assessment of Thyroid Nodules | 423 | ||
| Gross Examination of Thyroid Specimens | 424 | ||
| Histopathologic Reporting of Thyroid Tumors: | 425 | ||
| The Issue of Capsular or Vascular Invasion and the Diagnostic Terminology for Follicular Cancer | 425 | ||
| Reference | 425 | ||
| Section 6: Postoperative Considerations | 427 | ||
| Chapter 45: Pathophysiology of Recurrent Laryngeal Nerve Injury | 429 | ||
| Introduction | 429 | ||
| Variations in Symptoms | 429 | ||
| Configuration of the Paralyzed Vocal Fold | 429 | ||
| Biology of Laryngeal Nerve Injury and Regeneration | 431 | ||
| Why Are Vocal Folds Immobile Despite Reinnervation? | 432 | ||
| Muscle Compartments and Laryngeal Motion | 433 | ||
| Acute Management of the Transected Nerve | 434 | ||
| Implications of Biology for Management of Laryngeal Paralysis | 434 | ||
| Management of Bilateral Paralysis | 435 | ||
| Summary | 435 | ||
| References | 435 | ||
| Chapter 46: Management of Recurrent Laryngeal Nerve Paralysis | 436 | ||
| Introduction | 436 | ||
| Unilateral Vocal Fold Immobility | 436 | ||
| Evaluation | 436 | ||
| History and Physical | 436 | ||
| Videolaryngoscopy | 436 | ||
| Laryngeal Electromyography | 437 | ||
| Radiologic Imaging | 437 | ||
| Direct Laryngoscopy | 437 | ||
| Other Studies | 437 | ||
| Treatment | 437 | ||
| Swallowing Therapy | 437 | ||
| Voice Therapy | 437 | ||
| Surgical Treatment | 438 | ||
| Injection Laryngoplasty | 438 | ||
| Gelfoam injection | 438 | ||
| Carboxymethylcellulose (Radiesse Voice Gel) injection | 438 | ||
| Collagen injection | 439 | ||
| Hyaluronic acid injection | 439 | ||
| Micronized dermis (Cymetra) injection | 440 | ||
| Calcium hydroxylapatite (Radiesse) injection | 440 | ||
| Fat injection | 440 | ||
| Laryngeal Framework Surgery | 440 | ||
| Principles and Theory | 440 | ||
| Preoperative Preparation | 442 | ||
| Adduction Arytenopexy | 442 | ||
| Medialization Laryngoplasty with Gore-Tex | 442 | ||
| Cricothyroid Subluxation | 442 | ||
| Laryngeal Reinnervation | 442 | ||
| Methods and techniques of the reconstruction of the recurrent laryngeal nerve | 443 | ||
| Ansa cervicalis-to-recurrent laryngeal nerve anastomosis | 443 | ||
| Evaluation after reinnervation | 444 | ||
| Bilateral Vocal Fold Immobility | 444 | ||
| Surgical Treatment | 444 | ||
| Chapter 47: Non-Neural Complications of Thyroid and Parathyroid Surgery | 446 | ||
| Introduction | 446 | ||
| Hypoparathyroidism | 446 | ||
| Hypothyroidism | 447 | ||
| Thyrotoxic Storm | 447 | ||
| Hemorrhage and Hematoma | 448 | ||
| Hypertrophic Scar and Keloid | 449 | ||
| Seroma | 450 | ||
| Infection | 450 | ||
| Aerodigestive Tract Injury | 450 | ||
| Airway Complications | 450 | ||
| Difficult Intubation | 450 | ||
| Tracheomalacia | 451 | ||
| Methylene Blue | 451 | ||
| Rare Complications | 451 | ||
| Conclusion | 451 | ||
| Reference | 452 | ||
| Chapter 48: Endocrine Quality Registers: SurgicalOutcome Measurement | 453 | ||
| Introduction | 453 | ||
| Measurement of Quality: The Science of Improvement | 453 | ||
| Surgical Registries | 453 | ||
| Steps in the Development of a Registry | 453 | ||
| Maintaining Quality | 454 | ||
| Current Status (Results) | 454 | ||
| Thyroid Surgery | 454 | ||
| Thyroid Cytology | 454 | ||
| The Voice and Recurrent Laryngeal Nerve Injury | 454 | ||
| Hemorrhage | 455 | ||
| Infection | 455 | ||
| Hypocalcemia (after Bilateral Surgery) | 455 | ||
| Parathyroid Surgery for Primary Hyperparathyroidism | 456 | ||
| Localization | 456 | ||
| Operative Approach | 456 | ||
| Intraoperative Parathyroid Hormone Assay (IOPTH) | 457 | ||
| Postoperative Hypocalcemia | 457 | ||
| Rate of Persistent Hypercalcemia | 457 | ||
| The Impact of Technology on Outcome | 457 | ||
| Pathology | 458 | ||
| The Voice | 458 | ||
| Reoperative Surgery for Primary Hyperparathyroidism | 458 | ||
| Parathyroid Surgery for Secondary Hyperparathyroidism | 459 | ||
| Outliers | 459 | ||
| Future Developments | 459 | ||
| Education | 459 | ||
| Expansion | 459 | ||
| Extension | 459 | ||
| Exposure | 459 | ||
| Conclusion | 460 | ||
| Reference | 460 | ||
| Chapter 49: Ethics and Malpractice in Thyroid and Parathyroid Surgery | 461 | ||
| Malpractice Issues | 461 | ||
| Introduction | 461 | ||
| Legal Basis of Malpractice | 462 | ||
| The Standard of Care | 462 | ||
| Malpractice Claims and the Parathyroid Glands | 463 | ||
| Ethical Issues | 463 | ||
| Optimizing Informed Consent | 463 | ||
| Ethical Issues in Surgical Innovation and New Technology | 464 | ||
| Ethics and Advertising | 465 | ||
| The Surgeon's Responsibility: Pearls in Responsible Surgical Thyroid and Parathyroid Care | 465 | ||
| Reference | 466 | ||
| Section 7: Postoperative Management | 467 | ||
| Chapter 50: Postoperative Management of Differentiated Thyroid Cancer | 469 | ||
| Classification of Thyroid Tumors | 469 | ||
| Histologic Classification | 469 | ||
| Staging of Thyroid Carcinoma | 469 | ||
| Papillary Thyroid Carcinoma (PTC) | 469 | ||
| Clinical History | 470 | ||
| Follicular Thyroid Carcinoma (FTC) | 471 | ||
| Natural History | 471 | ||
| Poorly Differentiated Carcinoma | 471 | ||
| Surgical Treatment of Thyroid Carcinoma | 471 | ||
| Postoperative Management | 472 | ||
| Iodine 131 Therapy | 472 | ||
| External Beam Radiation Therapy | 473 | ||
| Follow-up | 473 | ||
| Introduction | 473 | ||
| Levothyroxine Treatment | 473 | ||
| Early Detection of Recurrent Disease: Methods | 474 | ||
| Clinical and Ultrasonographic Examinations | 474 | ||
| Radiographs | 474 | ||
| Serum Thyroglobulin (Tg) Determination | 474 | ||
| Iodine 131 Total-Body Scan | 474 | ||
| Postiodine 131 Therapy Total-Body Scan (TBS) | 475 | ||
| Other Imaging Modalities | 475 | ||
| Follow-up Strategy | 475 | ||
| Local and Regional Recurrences | 476 | ||
| Distant Metastases | 476 | ||
| Presentation | 476 | ||
| Treatment of Distant Metastases: Methods | 477 | ||
| Thyroxine Suppression | 477 | ||
| Radioiodine Therapy | 477 | ||
| Side Effects of 131I Exposure for Thyroid Cancer | 478 | ||
| Treatment of Distant Metastases: Results | 478 | ||
| Particular Cases: Distant Metastases in Children | 479 | ||
| Cytotoxic Chemotherapy and Biotherapy | 479 | ||
| Molecular Targeted Therapies | 479 | ||
| References | 479 | ||
| Chapter 51: Postoperative Radioactive Iodine Ablation and Treatment of Differentiated Thyroid Cancer | 480 | ||
| Introduction | 480 | ||
| Radioiodine Remnant Ablation | 481 | ||
| RRA as a Requirement for Postoperative Surveillance in Thyroid Cancer | 485 | ||
| Adaptive Risk Stratification and Use of RRA | 486 | ||
| Dose and Modality of Radioactive Iodine Use for RRA | 486 | ||
| Radioiodine Therapy for Locally Residual Disease | 487 | ||
| Radioiodine Therapy for Distant Metastatic Disease | 488 | ||
| Risks and Side Effects of Radioactive Iodine Treatment | 489 | ||
| Summary | 489 | ||
| Reference | 489 | ||
| Chapter 52: External Beam Radiotherapy for Thyroid Malignancy | 490 | ||
| Differentiated Thyroid Cancer | 490 | ||
| XRT for Gross Disease | 490 | ||
| XRT without Gross Disease | 490 | ||
| Local or Regional Recurrence of Differentiated Thyroid Cancer | 492 | ||
| Anaplastic Thyroid Carcinoma | 493 | ||
| Medullary Thyroid Carcinoma | 494 | ||
| Lymphoma | 495 | ||
| Indolent (Low-Grade) Lymphomas | 495 | ||
| Aggressive Histology Lymphomas | 496 | ||
| Radiotherapy for Metastatic Disease | 496 | ||
| External Beam Radiation Technique | 497 | ||
| IMRT Target Volume Delineation | 497 | ||
| Toxicity from External Beam Radiotherapy | 498 | ||
| Reference | 498 | ||
| Chapter 53: Reoperative Thyroid Surgery | 499 | ||
| Introduction | 499 | ||
| Indications for Revision Surgery | 499 | ||
| Anatomic Changes Following Thyroidectomy | 499 | ||
| Preoperative Workup | 500 | ||
| Serum Thyroglobulin Levels | 500 | ||
| Ultrasonography | 500 | ||
| CT Axial Imaging with Contrast | 500 | ||
| Other Imaging Modalities | 501 | ||
| Positron Emission Tomography with 18-Fluoro-2-deoxy-D-glucose/CT Scanning | 501 | ||
| Iodine-131 Whole-Body Scintigraphy | 502 | ||
| Fine-Needle Aspiration (FNA) | 502 | ||
| Preoperative Details/Documentation | 502 | ||
| Informed Consent | 502 | ||
| Surgical Therapy | 502 | ||
| Reoperative Surgery: Completion Thyroidectomy | 503 | ||
| Preoperative and Intraoperative Investigations | 503 | ||
| Adequate Treatment of Disease at Primary Surgery | 503 | ||
| Surgery Techniques | 503 | ||
| Avoidance of Contralateral Lobe Palpation | 503 | ||
| Timing of Completion Surgery | 503 | ||
| Operative Technique | 503 | ||
| General Principles | 503 | ||
| Lateral (``Backdoor´´) Approach | 503 | ||
| Inferior Approach | 504 | ||
| Superior Approach | 504 | ||
| Reoperative Surgery: Central Neck Dissection-Paratracheal and Superior Mediastinal Dissection | 504 | ||
| General Principles | 504 | ||
| Anatomic and Surgical Boundaries of Central Neck Compartment Surgery | 505 | ||
| Operative Technique | 505 | ||
| Step 1: Patient Positioning | 505 | ||
| Step 2: The Incision Line | 505 | ||
| Step 3: Local Anesthetic Infiltration of Incision Site | 505 | ||
| Step 4: Excision of Scar and Skin Flap Elevation | 505 | ||
| Step 5: Delineation of the Internal Jugular Vein as the Lateral Extent of Dissection | 505 | ||
| Step 6: Management of Strap Muscles | 505 | ||
| Step 7: Exposure of Common Carotid Artery | 506 | ||
| Step 8: Identification of the RLN | 506 | ||
| Step 9: Identification and Attempted Preservation of Parathyroid Glands | 506 | ||
| Step 10: Paratracheal Dissection and Microdissection of the RLN | 506 | ||
| RLN Invasion | 507 | ||
| Step 11: Superior Mediastinal Dissection | 507 | ||
| Step 12: Upper Central Compartment Dissection | 507 | ||
| Step 13: Check Dissection Specimen for Parathyroid Tissue / Reimplantation | 507 | ||
| Step 14: Final Hemostasis and Surgical Bed Preparation | 507 | ||
| Step 15: Wound Closure | 508 | ||
| Postoperative Management | 508 | ||
| Parathyroid Gland Preservation | 508 | ||
| Autotransplantation of Parathyroid Tissue | 508 | ||
| Adjunctive Techniques in Revision Surgery | 508 | ||
| Radioguided Revision Thyroid Surgery | 508 | ||
| Ultrasound-Guided Revision Thyroid Surgery | 509 | ||
| Lateral Neck Dissection | 509 | ||
| Complications | 509 | ||
| Outcomes of Revision Thyroid Surgery for Recurrent Disease: Thyroglobulin | 509 | ||
| Reference | 510 | ||
| Chapter 54: Ablative Percutaneous Ultrasound-Guided Ethanol Injection for Neck Nodal Metastases in Papillary and Sporadic Med | 511 | ||
| Neck Nodal Metastases in Differentiated Thyroid Carcinoma | 511 | ||
| Initial Management of NNM in PTC and MTC | 511 | ||
| Trends in the Management of Recurrent/Persistent NNM in PTC and MTC | 512 | ||
| First Use at Mayo of PUEI in the Management of NNM in DTC | 512 | ||
| PUEI Case 1 | 513 | ||
| PUEI Case 2 | 513 | ||
| Development of Mayo PUEI Practice 1991-2010 | 514 | ||
| Initial Reporting of Mayo's PUEI Experience from 1993 through 2000 | 515 | ||
| Subsequent Reports of PUEI for Treating Recurrent PTC | 517 | ||
| Future Directions for PUEI in DTC Management | 518 | ||
| Chapter 55: Medical Treatment for Metastatic Thyroid Cancer | 520 | ||
| Introduction | 520 | ||
| Drug Development | 520 | ||
| Thyroid Cancer Genetics | 520 | ||
| Novel Agents in Thyroid Cancer | 521 | ||
| Vandetanib (ZD-6474) | 521 | ||
| XL-184 | 521 | ||
| Motesanib (AMG-706) | 521 | ||
| Sorafenib (bay 43-9006) | 522 | ||
| Sorafenib and Tipifarnib | 522 | ||
| Axitinib (AG-013736) | 522 | ||
| Pazopanib (GW-786034) | 523 | ||
| Sunitinib (SU-011248) | 523 | ||
| Thalidomide and Lenalidomide | 523 | ||
| Celecoxib | 523 | ||
| Vorinostat | 524 | ||
| Romidepsin (FK228, Depsipeptide) | 524 | ||
| Gefitinib | 524 | ||
| Bortezomib | 524 | ||
| Imatinib | 524 | ||
| Combretastatin A4 Phosphate (Fosbretabulin) | 524 | ||
| Ongoing Trials | 525 | ||
| Lessons Learned from Clinical Trials in Thyroid Cancer | 525 | ||
| Trial Design | 525 | ||
| Duration of Therapy | 527 | ||
| Patient Population | 527 | ||
| Measuring Efficacy | 527 | ||
| Understanding Efficacy | 527 | ||
| Resistance | 527 | ||
| Moving Forward | 527 | ||
| Section 8: Parathyroid Surgery | 529 | ||
| Chapter 56: Primary Hyperparathyroidism:Pathophysiology, Surgical Indications,and Preoperative Workup | 531 | ||
| Clinical Presentation | 531 | ||
| Skeleton | 532 | ||
| Bone Densitometry | 532 | ||
| Bone Histomorphometry | 533 | ||
| Fractures | 533 | ||
| Nephrolithiasis | 533 | ||
| Other Organ Involvement | 533 | ||
| Pathology | 534 | ||
| Clinical Course with and without Surgery | 534 | ||
| Surgery | 535 | ||
| Medical Management | 535 | ||
| Drug Treatment | 536 | ||
| Oral Phosphate | 536 | ||
| Bisphosphonates | 537 | ||
| Estrogen Therapy and Selective Estrogen Receptor Modulators | 537 | ||
| Calcimimetic Agents | 537 | ||
| Unusual Presentations | 537 | ||
| Neonatal Disease | 537 | ||
| Primary Hyperparathyroidism in Pregnancy | 537 | ||
| Acute Primary Hyperparathyroidism | 537 | ||
| Parathyroid Cancer | 537 | ||
| Normocalcemic Primary Hyperparathyroidism | 538 | ||
| Chapter 57: Guide to Preoperative Parathyroid Localization Testing | 539 | ||
| Introduction | 539 | ||
| Localization Studies | 539 | ||
| Radiology-Based Studies | 539 | ||
| Ultrasonography | 539 | ||
| Surgeon-Performed versus Radiologist-Performed Ultrasound | 540 | ||
| Computed Tomography | 540 | ||
| Magnetic Resonance Imaging | 540 | ||
| Nuclear Medicine-Based Studies | 541 | ||
| Introduction | 541 | ||
| Historical Perspective | 542 | ||
| Sestamibi | 542 | ||
| Tetrofosmin | 542 | ||
| Positron Emission Tomography | 542 | ||
| Sestamibi: Summary | 542 | ||
| Invasive Procedures | 542 | ||
| Fine-Needle Aspiration | 542 | ||
| Parathyroid Arteriography | 542 | ||
| Selective Venous Sampling | 542 | ||
| Unique Scenarios | 543 | ||
| Posteriorly Located Upper Gland (PLUG) Adenomas | 543 | ||
| Localization Studies During Pregnancy | 543 | ||
| Localization Studies for MEN 1, Secondary, and Tertiary Hyperparathyroidism | 544 | ||
| Algorithms for First-Time Operations and Recurrent/Persistent Disease | 544 | ||
| Conclusion | 544 | ||
| References | 544 | ||
| Chapter: 58 Principles in Surgical Managementof Primary Hyperparathyroidism | 546 | ||
| Preoperative Evaluation | 546 | ||
| Surgical Indications | 546 | ||
| Asymptomatic primary HPT SurgicalGuidelines | 546 | ||
| Preoperative History and PhysicalExamination | 547 | ||
| History | 547 | ||
| Physical Exam | 547 | ||
| Preoperative Lab Work | 547 | ||
| Preoperative Genetic Assessment | 548 | ||
| Familial Syndromes and Genetic Testing | 548 | ||
| Multiple Endocrine Neoplasia Type 1 (MEN 1) | 548 | ||
| Multiple Endocrine Neoplasia Type 2A (MEN 2A) | 548 | ||
| Hyperparathyroidism-Jaw Tumor Syndrome(HPTJT) | 548 | ||
| Autosomal Dominant MildHyperparathyroidism (ADMH) | 548 | ||
| Familial Hypocalciuric Hypercalcemia (FHH) | 549 | ||
| Neonatal Severe Hyperparathyroidism (NSHPT) | 549 | ||
| Familial Isolated Hyperparathyroidism (FIHPT) | 550 | ||
| History and Physical ExaminationFindings That May IndicateGenetic Disorder | 550 | ||
| Vitamin D and primary HPT | 550 | ||
| Normocalcemic Primary Hyperparathyroidism | 550 | ||
| Localization Testing | 551 | ||
| Uniglandular versus Multiglandular Disease | 551 | ||
| Double Adenoma | 551 | ||
| Asynchronous Multiglandular Disease | 551 | ||
| Localization Testing | 551e1 | ||
| Intraoperative PTH: A Functional Criteria for Uniglandular versus Multiglandular Disease | 552 | ||
| Histology | 552 | ||
| Molecular Genetics of Primary Hyperparathyroidism | 552 | ||
| Clonality of Sporadic Parathyroid Tumors | 552 | ||
| Parathyroid Oncogene Rearrangement/Overexpression | 552 | ||
| Parathyroid Tumor Suppressor Gene Inactivation | 553 | ||
| Parathyroid Surgical Anatomy | 553 | ||
| Normative Parathyroid Parameters | 553 | ||
| Parathyroid Number | 553 | ||
| Parathyroid Weight | 553 | ||
| Parathyroid Gland Characteristics:the “Gliding Sign” | 553 | ||
| Parathyroid Gland Symmetry | 553 | ||
| Parathyroid Glands and Planeof Recurrent Laryngeal Nerve | 553 | ||
| Parathyroid Vascular Anatomy | 554 | ||
| Parathyroid Gland Position | 554 | ||
| Embryologic Variation | 554 | ||
| Inferior Parathyroid Gland Normal andExpanded Normal Positions (PIII) | 554 | ||
| Inferior Parathyroid Gland Ectopia | 555 | ||
| Superior Parathyroid Gland: Normal and Expanded Normal Locations (PIV) | 555 | ||
| Superior Parathyroid Gland Ectopia | 557 | ||
| Extreme Parathyroid Ectopia:Embryologic Rests and SupernumeraryGlands | 557 | ||
| Acquired Migration | 557 | ||
| Locations of Missed AdenomasBased on Reoperative Series | 557 | ||
| Intrathyroidal Adenoma | 557 | ||
| Thyroidectomy duringParathyroidectomy | 558 | ||
| Parathyroid Exploration: Surgical Technique | 559 | ||
| General Principles | 559 | ||
| Technique of Surgery/Search Algorithm | 560 | ||
| Step 1: Normal Parathyroid Gland Locations | 562 | ||
| Step 2: Search for the Missing Gland | 562 | ||
| Missing inferior parathyroid gland | 563 | ||
| Missing superior parathyroid gland | 563 | ||
| Step 3: Dissection for the Fifth Gland | 563 | ||
| Step 4: Considerations for Closure | 564 | ||
| Mediastinal Adenoma | 564 | ||
| Surgical Technique for Multiglandular Disease | 564 | ||
| Parathyroid Surgery Failure | 564 | ||
| Reasons for Failure | 565 | ||
| How to Avoid Failure? | 565 | ||
| Surgical Controversies | 565 | ||
| Postoperative Assessment | 565 | ||
| Measurement of Serum Calcium | 565 | ||
| Measurement of Postoperative PTH (pPTH) | 565 | ||
| References | 566 | ||
| Chapter 59: Standard Bilateral Parathyroid Exploration | 567 | ||
| Anatomy and Embryology Relevant for Bilateral Parathyroid Exploration | 567 | ||
| The Rationale for Bilateral Parathyroid Exploration | 570 | ||
| Diagnosis | 570 | ||
| Treatment | 570 | ||
| Rationale for Parathyroid Surgery and Bilateral Exploration | 571 | ||
| Preoperative Planning: Parathyroid Localization Studies | 572 | ||
| Surgical Technique of Bilateral Parathyroid Exploration | 572 | ||
| Strategy for Finding the ``Missing´´ Parathyroid | 575 | ||
| Situation 1 | 575 | ||
| Situation 2 | 576 | ||
| Situation 3 | 576 | ||
| Situation 4 | 576 | ||
| Situation 5 | 576 | ||
| Situation 6 | 576 | ||
| Situation 7 | 576 | ||
| Situation 8 | 577 | ||
| Postoperative Management | 577 | ||
| Special Considerations in Bilateral Parathyroid Exploration | 578 | ||
| Tissue Handling | 578 | ||
| Cryopreservation | 578 | ||
| Parathyroid Reimplantation and Remnant Size | 578 | ||
| Summary | 578 | ||
| References | 579 | ||
| Chapter 60: Minimally Invasive Single Gland Parathyroid Exploration | 580 | ||
| Considerations for Performing MIP | 580 | ||
| Candidates for MIP | 580 | ||
| Anatomic Considerations in MIP | 580 | ||
| A Standard Parathyroid Nomenclature System | 581 | ||
| Preoperative Imaging | 582 | ||
| Operative Preparation and Techniques | 583 | ||
| Anesthesia Considerations | 583 | ||
| Surgeon's Operating Room Checklist | 584 | ||
| Patient Positioning and Preparation | 584 | ||
| Front-Door Technique | 584 | ||
| Marking and Making the Incision | 584 | ||
| Mobilization of the Thyroid Gland | 585 | ||
| Expected Location of Inferior Parathyroid Glands | 585 | ||
| Dissection of the Inferior Parathyroid Adenoma | 585 | ||
| Back-Door Technique | 585 | ||
| Marking and Making the Incision | 585 | ||
| Creating the Flaps | 585 | ||
| Exposing the Internal Jugular Vein | 585 | ||
| Mobilization of the Thyroid Gland | 586 | ||
| Identification of the Superior Parathyroid Gland | 586 | ||
| Specimen Assessment | 587 | ||
| Wound Closure | 588 | ||
| Other Procedures/Accessories | 588 | ||
| Postoperative and Follow-Up Care | 588 | ||
| References | 589 | ||
| Chapter 61: Minimally Invasive Video-Assisted Parathyroidectomy | 590 | ||
| Introduction | 590 | ||
| Preoperative Localization Studies | 590 | ||
| Intraoperative PTH Assay | 590 | ||
| Minimally Invasive Parathyroidectomy | 591 | ||
| Techniques for MIP | 591 | ||
| Minimally Invasive Radio-Guided Parathyroidectomy | 591 | ||
| Open Minimally Invasive Parathyroidectomy | 592 | ||
| Video-Assisted and Endoscopic Techniques | 592 | ||
| Endoscopic Parathyroidectomy | 592 | ||
| Video-Assisted Parathyroidectomy by the Lateral Approach (VAP-LA) | 593 | ||
| Minimally Invasive Video-Assisted Parathyroidectomy (MIVAP) | 593 | ||
| Indications for MIVAP | 593 | ||
| MIVAP: Surgical Procedure | 594 | ||
| Patients and surgical team position | 594 | ||
| Anesthesia | 594 | ||
| Surgical technique | 594 | ||
| Results of MIVAP | 596 | ||
| Advantages and Disadvantages of MIVAP | 596 | ||
| MIP: Evidence-Based Recommendations | 598 | ||
| References | 599 | ||
| Chapter 62: Local Anesthesia for Thyroid and Parathyroid Surgery | 600 | ||
| Regional Anesthesia for Thyroid Surgery | 600 | ||
| Regional Anesthesia for Parathyroid Surgery | 600 | ||
| Contraindications for Regional Anesthesia in Patients Undergoing Thyroid or Parathyroid Surgery | 601 | ||
| Regional Anesthesia for Parathyroid and Thyroid Surgery: Technique | 601 | ||
| Conclusions | 604 | ||
| Reference | 604 | ||
| Chapter 63: Intraoperative PTH Monitoring during Parathyroid Surgery | 605 | ||
| Introduction | 605 | ||
| History of Intraoperative PTH Monitoring | 605 | ||
| Which Patients Benefit from IPM-Guided Parathyroidectomy? | 606 | ||
| Intraoperative PTH Monitoring as an Adjunct during Parathyroidectomy | 606 | ||
| IPM Protocol for Intraoperative Blood Sampling | 606 | ||
| Intraoperative Scenarios and Troubleshooting | 607 | ||
| Intraoperative Criteria in Predicting Operative Success | 608 | ||
| Limitations of Intraoperative PTH Monitoring with the ``50% PTH Drop´´ Criterion | 609 | ||
| Prediction of Size of the Remaining Normally Secreting Parathyroid Glands | 609 | ||
| Prediction of PTH Levels in Postoperative Normocalcemic Patients | 610 | ||
| Late Recurrence | 610 | ||
| Secretion of the First Gland Excised in Patients with Multiglandular Disease | 610 | ||
| Prevent Operative Failure in All Patients | 610 | ||
| Protocol and Criteria Dependence | 610 | ||
| IPM Cost | 610 | ||
| Results of Parathyroidectomy Guided by IPM | 611 | ||
| Other Applications for Intraoperative Rapid PTH Assays | 611 | ||
| Biochemical Fine-Needle Aspiration | 611 | ||
| Differential Internal Jugular Venous Sampling | 611 | ||
| Summary | 611 | ||
| Reference | 612 | ||
| Chapter 64: Radio-Guided Parathyroid Exploration | 613 | ||
| Introduction | 613 | ||
| Principles of Radio-Guided Parathyroid Surgery | 613 | ||
| Radio-Guided Parathyroidectomy | 613 | ||
| Preoperative Evaluation | 613 | ||
| Preoperative Localization | 613 | ||
| Anesthesia and Other Operative Considerations | 613 | ||
| Equipment | 614 | ||
| Radiotracer Injection | 614 | ||
| Basic Principles | 614 | ||
| Protocol | 614 | ||
| Protocol 1: Wisconsin | 614 | ||
| Background Counts | 614 | ||
| Finding the Hyperfunctioning Gland: In Vivo Counts | 614 | ||
| Removal of the Parathyroid Gland: Ex Vivo Counts and the ``20% Rule´´ | 615 | ||
| Protocol 2: Arkansas | 616 | ||
| Use of the Gamma Probe | 616 | ||
| Confirmation of Cure with Intraoperative PTH Monitoring | 616 | ||
| Postoperative Care | 616 | ||
| Applications of Radio-Guided Parathyroidectomy | 616 | ||
| Ectopic Glands | 616 | ||
| Negative 99mTc-sestamibi Scan | 617 | ||
| Recurrent Disease | 617 | ||
| Hereditary Hyperparathyroidism | 617 | ||
| Obesity | 617 | ||
| Radioguidance in the Extremes of Age: Pediatric and Geriatric Patients | 617 | ||
| Secondary and Tertiary Hyperparathyroidism | 617 | ||
| Parathyroid Cancer | 618 | ||
| Advantages to Radio-Guided Parathyroid Surgery | 618 | ||
| Omission of Frozen Section | 618 | ||
| Reduction of Operative Time and Costs | 618 | ||
| No Added Morbidity | 618 | ||
| Quality of Life | 618 | ||
| Disadvantages of Radio-Guided Parathyroid Surgery | 618 | ||
| Learning Curve and Errors | 618 | ||
| High Cure Rates without Radioguidance | 618 | ||
| Added Costs | 619 | ||
| Coordination of 99mTc-sestamibi Injection and Surgery | 619 | ||
| Radiation Exposure | 619 | ||
| Future Directions | 619 | ||
| Conclusions | 619 | ||
| References | 619 | ||
| Chapter 65: Surgical Management of Multiglandular Parathyroid Disease | 620 | ||
| Histopathology and Surgical Anatomy | 620 | ||
| Gross Appearance and Histopathology | 620 | ||
| Number of Parathyroid Glands | 622 | ||
| Vascular Supply | 623 | ||
| Normal Parathyroid Anatomy | 623 | ||
| Glandular Symmetry | 624 | ||
| Technique of Parathyroid Exploration | 625 | ||
| Positioning of the Patient and Skin Incision | 625 | ||
| Fascial Layers | 625 | ||
| Exposure of the Parathyroids | 626 | ||
| Ectopic Glands in Patients with HPT | 627 | ||
| Palpation | 630 | ||
| Glandular Excision | 630 | ||
| Thymectomy and Central Compartment Dissection | 630 | ||
| Glandular Biopsies | 630 | ||
| Subtotal versus Total Parathyroidectomy | 630 | ||
| Surgical Techniques and Strategies | 631 | ||
| Subtotal Parathyroidectomy | 631 | ||
| Total Parathyroidectomy and Autotransplantation | 632 | ||
| Cryopreservation of Parathyroid Tissue | 632 | ||
| Familial HPT | 633 | ||
| MEN 1-Associated HPT | 633 | ||
| MEN 2-Associated HPT | 635 | ||
| Familial Isolated HPT | 635 | ||
| HPT Jaw Tumor Syndrome | 635 | ||
| Familial Hypocalciuric Hypercalcemia | 635 | ||
| Secondary HPT | 636 | ||
| HPT in Chronic Kidney Disease | 636 | ||
| Long-Term Dialysis Patients | 636 | ||
| Patients with Kidney Transplants | 636 | ||
| Pathogenesis and Histopathology | 637 | ||
| Localization Diagnosis | 637 | ||
| Surgical Procedure: Chronic Dialysis Patients | 637 | ||
| Surgical Procedure: Renal Transplant Patients | 637 | ||
| Preoperative Care | 637 | ||
| Postoperative Course | 637 | ||
| Complications | 637 | ||
| Lithium-Induced HPT | 638 | ||
| Preoperative Localization and Intraoperative PTH Measurements | 638 | ||
| References | 638 | ||
| Chapter 66: Surgical Management of Secondary and Tertiary Hyperparathyroidism | 639 | ||
| Definition | 639 | ||
| Secondary Hyperparathyroidism | 639 | ||
| Epidemiology | 639 | ||
| Pathogenesis, Histopathology, and Pathophysiology | 639 | ||
| Medical Treatment | 640 | ||
| Clinical Symptoms | 641 | ||
| Surgical Indications | 641 | ||
| Surgical Procedures | 642 | ||
| Preoperative Examination and Management | 643 | ||
| Surgical Approach | 643 | ||
| Calcium Replacement Therapy after PTx | 644 | ||
| Function of Autografted Parathyroid Tissue | 645 | ||
| Clinical Improvement by PTx | 645 | ||
| Mortality and Complications | 645 | ||
| Persistent and Recurrent HPT | 645 | ||
| Tertiary Hyperparathyroidism: Persistent Hyperparathyroidism after Successful Kidney Transplantation | 646 | ||
| Clinical Manifestation | 646 | ||
| Medical Treatment and Surgical Indication | 647 | ||
| Surgical Procedures | 647 | ||
| Reference | 647 | ||
| Chapter 67: Parathyroid Management in the MEN Syndromes | 648 | ||
| Multiple Endocrine Neoplasia Type 1 | 648 | ||
| Genetic Testing in MEN 1 | 648 | ||
| MEN 1-Associated Hyperparathyroidism | 648 | ||
| Indications for Surgery | 649 | ||
| Surgical Treatment of MEN 1-Associated HPT | 650 | ||
| Less Than Subtotal Parathyroidectomy | 650 | ||
| Subtotal Parathyroidectomy | 650 | ||
| Total Parathyroidectomy with Forearm Autograft | 651 | ||
| The Role of Transcervical Thymectomy | 651 | ||
| Treatment of Persistent or Recurrent MEN 1-Associated HPT | 652 | ||
| Multiple Endocrine Neoplasia Type 2A | 652 | ||
| Genetic Testing in MEN 2A | 652 | ||
| MEN 2A-Associated HPT | 653 | ||
| Indications for Surgery | 654 | ||
| Surgical Treatment of MEN 2-Associated HPT | 654 | ||
| Treatment of Persistent or Recurrent MEN 2A-Associated HPT | 655 | ||
| Use of Intraoperative Adjuncts during Parathyroidectomy for MEN-Associated HPT | 655 | ||
| Nonsurgical Management of Persistent or Recurrent MEN-Associated HPT | 655 | ||
| Conclusion | 656 | ||
| Reference | 656 | ||
| Chapter 68: Reoperation for Sporadic Primary Hyperparathyroidism | 657 | ||
| Introduction | 657 | ||
| Indications for Reoperation | 657 | ||
| Operative Planning | 658 | ||
| Operation | 660 | ||
| Postoperative Complications | 663 | ||
| Conclusion | 664 | ||
| Reference | 664 | ||
| Chapter 69: Parathyroid Carcinoma | 665 | ||
| Introduction | 665 | ||
| Clinical Presentation | 665 | ||
| Incidence | 666 | ||
| Etiology and Molecular Pathogenesis | 666 | ||
| Pathology | 668 | ||
| Macroscopic and Microscopic Features | 668 | ||
| Immunohistochemistry | 670 | ||
| Flow Cytometry | 670 | ||
| Medical Management | 670 | ||
| Surgical Management | 670 | ||
| Surgery for Recurrent Disease | 671 | ||
| Radiotherapy | 671 | ||
| Chemotherapy | 672 | ||
| Staging | 672 | ||
| Prognosis | 672 | ||
| Summary | 672 | ||
| Chapter 70: Surgical Pathology of the Parathyroid Glands | 673 | ||
| Development and Anatomy | 673 | ||
| Hyperparathyroidism | 673 | ||
| Primary Hyperparathyroidism | 673 | ||
| Parathyroid Adenoma | 673 | ||
| Differential Diagnosis | 676 | ||
| Parathyroid Carcinoma | 676 | ||
| Primary Chief Cell Hyperplasia | 677 | ||
| Other Familial Hyperparathyroidism Syndromes | 678 | ||
| Primary Clear Cell Hyperplasia | 678 | ||
| Secondary and Tertiary Hyperparathyroidism | 679 | ||
| Parathyromatosis | 679 | ||
| Cysts | 679 | ||
| Secondary Tumors | 679 | ||
| Hypoparathyroidism | 680 | ||
| References | 680 | ||
| Index | 681 |