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Surgery of the Thyroid and Parathyroid Glands E-Book

Surgery of the Thyroid and Parathyroid Glands E-Book

Gregory W. Randolph

(2012)

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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