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70 Insulinoma
221
• Management of a malignant lesion.
• Presentation in the setting of a patient with MEN-1
syndrome.
• Situation where insulin level is elevated and C-peptide is
low-normal suggesting exogenous insulin usage.
• Operative intervention in the setting of multiple lesions.
• Situation where you are unable to enucleate a small tumor
due to location.
• Initial surgical plan for a patient with a contained, benign
lesion that is then found to be metastatic at time of initial
operation.
• Management of a pancreatic leak—intraoperatively identied and postoperatively identied.
Clean Kills
• Failure to rule out exogenous insulin use as possible cause
of symptoms.
• Failing to diagnose the disease process with laboratory
analysis prior to proceeding to imaging.
• Failure to identify a state of hyperinsulinemia in a patient
with symptoms of hypoglycemia.
• Failure to discuss symptom control with medical management both pre-operatively or if being used as denitive
care.
• Use of somatostatin scintigraphy as localization study.
• Inability to describe the rationale behind surgical
intervention.
• Performance of a non-formal surgical resection, medical
management, or ablation procedure on a lesion that is suspicious for malignancy.
• Performance of an extensive surgical resection on patient
with a small, benign, supercial lesion.
• Failure to rule out other disease processes associated with
MEN-1.
Bonus Points
• Can biopsy tail of pancreas to evaluate for
nesidioblastosis.
• Most sporadic cases of insulinoma are after 40years of
age, whereas genetic cases are <40 typically.
• Knowledge of modern localization studies using GLP-1
receptor and nuclear tracer studies.
Words ofWisdom
Pancreatic neuroendocrine tumors may be associated with
genetic disorders, although the majority are sporadic. Given
the above, it is crucial to identify those with a genetic component to address all other conditions that may be present.
Establishing the type of PNET and hormonal activity will
assist in the overall treatment of the patient. While the majority of insulinoma lesions are both small and benign, it is prudent to ensure no evidence of malignancy nor metastasis. Be
sure to have a clear understanding of the biochemical workup
as well as imaging modalities.
Summary
The diagnosis and treatment of pancreatic neuroendocrine tumors requires close attention to detail along with
understanding the similarities and differences between
them. Insulinoma specically rst requires understanding the diagnostic laboratory analysis. This is to be followed by appropriate imaging which excludes
somatostatin scintigraphy compared to other PNETs.
Surgical management is then considered and appropriately selected based upon location within the pancreas
and concern for malignancy.
Bibliography
Ali Z. Insulinoma workup: approach considerations, laboratory stud-
ies, imaging studies [Internet]. Kim L, editor. emedicine.medscape.
com; 2022 [cited 2023 Jul 30]. Available from: https://emedicine.
medscape.com/article/283039- workup#c3
Arrington A, Riall T.Endocrine pancreas. In: Sabiston textbook of sur-
gery: the biological basis of modern surgical practice. St. Louis,
MO: Elsevier; 2022. p.159–69.
Christ E, Antwi K, Fani M, et al. Innovative imaging of insuli-
noma: the end of sampling? A review. Endocr Relat Cancer.
2020;27(4):R79–92.
Dream S, Chen H.SCORE. General surgery resident curriculum por-
tal [Internet]. Surgicalcore.org; 2019 [cited 2023 Jul 28]. Available
from: https://portal.surgicalcore.org/
Goldenberg A, Sandau R.Abdominal endocrine. In: Passing the general
surgery oral board exam. NewYork, NY: Springer; 2014. p.35–7.
Libutti S, Taye A.Diagnosis and management of insulinoma: current
best practice and ongoing developments. Res Rep Endocr Disord.
2015;5:125.
Zhuo F, Anastasopoulou C.Insulinoma [Internet]. Treasure Island (FL):
StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.
nih.gov/books/NBK544299/
Part IX
Head and Neck Endocrine
Hyperthyroidism
CandaceL.Ward andRadiZaki
71
Way Question May BeAsked?
A 27-year-old female referred to your ofce by a family practitioner with the recent diagnosis of hyperthyroidism. What
do you want to do?
How toAnswer?
Complete History and Physical
• History:
– Anxiety
– Tremulousness
– Weight loss
– Sweating
– Heat intolerance
– Palpitations
– Hair loss
– Changes in menstruation
– Diarrhea
– Medications (e.g., amiodarone)
• Physical Exam:
– Neck mass or nodules—note if tender
– Exophthalmos
– Erythema nodosum (nodular, edematous legs)
– Radionuclide scan: if workup suggests toxic adenoma
(focused uptake on scan) or toxic multinodular goiter
(MNG; diffuse uptake on scan)
• Tissue diagnosis: not indicated if multinodular goiter or
“hot” nodule identied on imaging
• Surgical management
– Graves’ disease (most common)
Nodules are found in up to 25% of Graves’ patients
Up to 40% risk of malignancy associated with nodule in Graves’
– Toxic multinodular goiter (MNG; Plummer’s disease)
Risk of malignancy in MNG is up to 21%
– Hyperfunctioning adenoma
– Amiodarone-associated thyrotoxicosis (will have neg-
ative radionuclide scan)
• Medical management indicated for:
– Subacute thyroiditis (will have negative radionuclide
scan)
– Riedel’s thyroiditis (invasive brous thyroiditis)
– Factitious thyrotoxicosis (exogenous T4; negative
radionuclide scan)
– Ovarian (struma ovarii=thyroid tissue in ovarian tera-
toma), testicular, pituitary tumors
– Consider medical management in patients with high
likelihood of remission or poor surgical candidates.
Diagnosis
• Laboratory tests
– TSH
– Free T4
– Anti-thyrotropin receptor antibodies (Graves’ disease)
– Anti-thyroid peroxidase antibodies (thyroiditis)
– ESR (elevated in subacute thyroiditis)
• Imaging
– Ultrasound of neck (identify nodules)
C. L. Ward (*) · R. Zaki
Department of Surgery, Einstein Healthcare Network,
Philadelphia, PA, USA
e-mail: radi.zaki@jefferson.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_71
Treatment Options
• Medication
– Propylthiouracil (PTU) or methimazole (MMI)—
highly effective for Graves’ disease (not toxic MNG).
Problem is compliance and medication complications
(i.e., agranulocytosis).
– Can use PTU in pregnant patients.
– Beta blockade is recommended in all patients with
symptomatic thyrotoxicosis.
• Radioactive iodine (I131)
– Good option in older patients.
– Single dose is usually effective in Graves’ disease; can
cause hypothyroidism in >90%.
225
226
C. L. Ward and R. Zaki
– Contraindicated in Graves’ ophthalmopathy (moderate
to severe), pregnant females, lactating females, and
1year prior to pregnancy.
• Glucocorticoids/steroids: rapidly lowers T4 conversion to
T3, however many side effects.
• Surgery:
– Lobectomy or subtotal thyroidectomy for toxic
nodules.
Subtotal thyroidectomy has up to 8% chance of per-
sistence or recurrence at 5years.
– Total thyroidectomy—nearly 0% risk of recurrence.
– Subtotal thyroidectomy
Cosmesis
Pregnant patient in second trimester (after failing
PTU)
Failure of medical management after 1–2years
Compressive symptoms (goiters)
Hyperthyroidism in children
Young women who desire pregnancy
Thyrocardiac patients
Patients with severe exophthalmos
• Surgical preparation
– PTU until surgery.
– Beta blockers prn (if using, must continue periopera-
tively, 8–10days postoperatively).
– Lugol’s solution (KI–iodine) BID—start 10–14 days
prior to surgery → decreases vascularity of thyroid
gland.
– Prepare patient for possible levothyroxine for life—
unable to discern true thyroid status until 1–2 years
postoperatively.
– Treatment: IVF, sedatives, O2 (consider intubation),
antipyretics/cooling blankets, MMI/PTU, corticosteroids, beta blockers (control cardiac arrhythmias),
Lugol’s solution, treat precipitating cause.
Common Curveballs
• There will be a hot nodule.
• Will have postoperative complication of:
– Laryngeal nerve injury
– Hematoma
– Hypothyroidism
– Hypocalcemia
– Injury to external branch of superior laryngeal nerve or
internal branch (risk of aspiration—sensory to the
vocal cords, more likely with bilateral).
– Recurrent hyperthyroidism
• Patient will be pregnant (second trimester)—know what
happens to the fetus.
• Patient will fail medical therapy.
• Asked to describe subtotal thyroidectomy (leave 3–5 g
tissue behind).
• Asked how to prepare patient prior to surgery.
• Patient will have nodule that will be a malignancy (chang-
ing scenarios) on US, FNA, or nal pathology.
• Patient will develop thyroid storm.
What is the benet of doing a total thyroidectomy over
lobectomy with isthmusectomy?
Postoperative Complications
• Hematoma—be prepared to open neck at bedside if airway is compromised.
• Recurrent or superior laryngeal nerve injury—hoarseness, airway compromise if bilateral.
• Hypocalcemia—if parathyroids failed to be preserved.
Measure calcium postoperatively or consider starting
empiric calcium and vitamin D supplementation.
• Thyroid storm: initiated by physiologic stresses (surgery,
anesthesia, MI, infection, childbirth).
– Presents with fever, tachycardia, arrhythmias, conges-
tive heart failure, nausea, vomiting, hepatic failure,
mental status change (agitation, delirium, psychosis,
stupor, coma).
– 8–25% mortality risk
– Increased risk if not euthyroid preoperatively or with
large glands. Can occur intraoperatively or
postoperatively.
– Differentiate from malignant hyperthermia (MH)—
end-tidal CO
rises in MH but not in thyroid storm.
2
Clean Kills
• Not making correct diagnosis.
• Not knowing indications for surgery.
• Not knowing how to treat/recognizing thyroid storm.
• Not ruling out adenoma/malignancy.
• Not checking anti-thyrotropin antibodies/thyroid US,
T4/TSH.
• Not being comfortable with discussion of complications
of thyroidectomy.
Summary
Surgical treatment for hyperthyroidism has clear indications and therefore could be an easy kill for you. So take
your time to make the diagnosis. If the question does involve
a young female, you must be able to counsel pregnancy
treatment options. If hyperthyroidism is the topic, be prepared for a thyroid storm because the forecast is rain.
71 Hyperthyroidism
227
Bibliography
Boutzios G, Vasileiadis I, Zapanti E, et al. Higher incidence of
tall cell variant of papillary thyroid carcinoma in Graves’
disease. Thyroid. 2014;24:347–54. https://doi.org/10.1089/
thy.2013.0133.
Mohamed TZ, Sultan AAEA, Tag El-Din M, et al. Incidence and
risk factors of thyroid malignancy in patients with toxic nodular goiter. Int J Surg Oncol. 2022;2022:1054297. https://doi.
org/10.1155/2022/1054297.
Padda IS, Nguyen M. Radioactive iodine therapy. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan
[updated 2023 Jun 3]. Available from: https://www.ncbi.nlm.nih.
gov/books/NBK557741/
Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid
Association guidelines for diagnosis and management of
hyperthyroidism and other causes of thyrotoxicosis. Thyroid.
2016;26:1343–421.
Shim SR, Kitahara CM, Cha ES, Kim S-J, Bang YJ, Lee WJ.Cancer risk
after radioactive iodine treatment for hyperthyroidism: a systematic
review and meta-analysis. JAMA Netw Open. 2021;4:e2125072.
Neck Mass
CandaceL.Ward andElenaPaulusLamb
72
Rule of 80s after age 40:
• 80% nonthyroid neck masses in adults are neoplastic
• 80% of neoplastic masses are malignant
• 80% of malignant masses are metastatic
• 80% malignancies in adults are squamous cell
carcinomas
• 80% of metastatic are from primaries above level of
clavicle
Be wary of a neck mass in an infant, in the midline, or in
an HIV+ patient (lymphoma).
Way Question May BeAsked?
A 43-year-old male presents to the ofce with a mass in his
left neck. It is non-tender and has been there for about
3months. He has a signicant smoking history. What do you
want to do?
How toAnswer?
• Complete history, focusing on cancer risk factors and
natural history of the lesion
– Age (very important here)
– Location (again, very important)
– Duration
– Drainage (branchial cyst?)
C. L. Ward (*)
Department of Surgery, Jefferson Einstein Medical Center
Philadelphia, Philadelphia, PA, USA
E. P. Lamb
Department of Breast Surgery, Jefferson Einstein Medical Center
Philadelphia, Philadelphia, PA, USA
e-mail: elena.lamb@jefferson.edu
– Pain
– Hoarseness (suggests recurrent laryngeal nerve
invasion)
– Dysphagia (suggest esophageal invasion)
– Systemic symptoms (“B symptoms” with lymphoma)
– Tobacco/Alcohol use
– History (HIV+, prior malignancy)
– Previous head/neck surgery (suspicious mole/mela-
noma removed? Was it an overlying parotid gland?)
• Physical Exam
– Location
– Tenderness
– Fixed vs. mobile
– Movement with swallowing
– Pulsatile (the rare carotid body tumor)
– Sinus (branchial cyst)
– Nasopharynx
– Oral cavity
– Larynx
– Neck (thyroid)
– Other lymph node basins (axillary, groin)
– Skin
– Breast
– Abdomen (palpable liver/spleen)
• Diagnostic Tests
– Blood tests (as always, complete labs, CBC with dif-
ferential; in select cases, calcitonin/calcium levels,
thyroid hormones, and examination of blood smear).
– Imaging rst—ultrasound to characterize lesion.
– FNA (critical here and helpful in neck masses!).
– CXR (lung or mediastinal pathology).
– CT scan of the face/neck (sinuses/oral cavity/naso-
pharynx/larynx) or chest/abdomen/pelvis if indicated
based on biopsy or physical exam.
– +/− Thyroid scan (again, useful to evaluate thyroid/
parathyroid).
– +/− MRI.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_72
229
230
Differential Diagnosis
Midline Lateral Supraclavicular
Thyroglossal duct cyst Lymph node—Infected vs.
metastatic
Dermoid cysts Branchial cleft cyst Parotid gland Tularemia
Pyramidal lobe of
thyroid
Lymph node—Infected vs.
metastatic
Submandibular/preauricular
mass
Lymph node Lymphadenitis
Salivary gland Toxoplasmosis
C. L. Ward and E. P. Lamb
Inammatory
etiologies
Tuberculosis
Cat scratch
Sarcoidosis
Viral
Treatment
• Thyroglossal duct cyst
– Mobile midline neck masses in close proximity to
hyoid bone that rise with swallowing. Frequently
infected; must excise due to recurrent infections and
small risk of malignant transformation.
– US neck to conrm presence of normal thyroid prior to
excising cyst.
– Excision with the middle portion of the hyoid bone and
follow any tissue to base of the tongue (Sistrunk procedure). Do not perform while actively infected.
• Branchial cleft cyst
– May present as stulas, cysts, abscesses, or sinus
tracts. Always require surgical excision due to small
risk of malignant transformation. Ten percent are bilateral, most commonly seen in the rst decade of life.
Utilize knowledge of anatomic/embryologic pathway
to ensure complete excision.
– First branchial cleft: opening at preauricular area or
angle of mandible, passes through facial nerve.
– Second (most common): opening anterior border of
sternocleidomastoid (SCM), passes between carotid
bifurcation.
– Third: opening at the lower border of SCM, passes
posterior to the internal carotid artery. May be intimately connected with the superior laryngeal nerve.
– Excise entire cyst tract, using “stepladder” technique if
long tract. Third branchial cleft cyst may require thyroid lobectomy to entirely excise the piriform sinus.
• Biopsy of neck mass→carcinoma—goal is now to locate
the primary for appropriate management.
– Nasopharyngeal laryngoscopy in your ofce.
– Dental evaluation, nutrition, speech/swallow evalua-
tion and treatment, smoking cessation as indicated.
– CT or MRI with contrast of skull base through thoracic
inlet, CT thorax, PET/CT if CT or MRI fails to reveal
an identied primary.
– Squamous cell carcinoma
HPV and EBV testing—if HPV positive, considered an oropharyngeal cancer; if EBV positive, considered a nasopharyngeal cancer.
Excisional biopsy under anesthesia + exam under
anesthesia with:
• Panendoscopy of upper aerodigestive tract
Direct laryngoscopy
Rigid esophagoscopy
Rigid bronchoscopy
• Biopsies of nasopharynx, base of tongue, pyri-
form sinus.
Excision of primary site (if found) and bilateral
modied radical neck dissection (MRND) if primary crosses midline (i.e., base of tongue).
– Adenocarcinoma
CT scan of neck/chest/abdomen/pelvis
Bilateral mammograms
EGD
Barium enema/colonoscopy
If primary found, this represents stage 4 disease and
chemotherapy may be offered.
If no primary found, excisional biopsy+ipsilateral
modied radical neck dissection.
– If unable to identify primary:
Examination under anesthesia+biopsy of area of
clinical concern.
Consider tonsillectomy.
Panendoscopy of upper aerodigestive tract
• Direct laryngoscopy and nasopharynx
evaluation
• Rigid esophagoscopy
• Rigid bronchoscopy
CT chest/abdomen/pelvis with contrast or PET/CT
if not previously performed.
Send for ER/PR receptors and mucin stain (rule out
breast, melanoma, and lymphoma).
• Lymph node=Thyroid
– See chapter on thyroid nodule.
– If thyroid tissue within lymph node, this is locore-
gional disease (N1) by denition.
• Lymph node=Lymphoma
– Excisional biopsy of node
– CT scan neck/chest/abdomen/pelvis
– Bone marrow biopsy (stage IV disease)
72 Neck Mass
231
– Stage disease (number of nodal groups/which side of
diaphragm)
– Chemotherapy (CHOP)
Post-op radiation to neck should be considered after radi-
cal neck dissection
Surgical pearls:
• If not obviously invasive, preserve nerves as able.
• Be prepared to describe the lymph nodes resected in an
MRND and the structures that are traditionally
preserved.
Steps in radical neck dissection:
• T-incision
• Locate and protect mandibular and cervical branches of
facial nerves
• Divide anterior facial vessels
• Remove contents of submental and submandibular
triangles
• Ligate external jugular vein close to subclavian
• Protect spinal accessory, phrenic, brachial plexus while
removing fat/lymphatic tissue in posterior triangle
• Low division of omohyoid behind SCM
• Division of SCM
• Open carotid sheath and ligate internal jugular vein close
to clavicle
• Ligate submaxillary duct
In modied radical neck dissection, the following are
preserved:
• Spinal accessory nerve
• Internal jugular vein
• SCM
• Seroma under skin ap
• Chylous stula in left neck dissection
• Carotid blowout post-op
• Damage to any nerve (phrenic, spinal accessory, vagus,
hypoglossal)
Clean Kills
• Not knowing the different algorithms between FNA yielding squamous cell carcinoma, lymphoma, versus.
adenocarcinoma
• Not having a broad differential diagnosis or systematic
plan for identication of primary lesion
• Not performing FNA
• Not knowing surgery for:
– Thyroglossal duct cyst
– Most common branchial cleft cyst
• Not being able to describe modied neck dissection or
difference from complete radical dissection
Summary
General surgeons are less likely to have to manage
advanced or complex head or neck cancers, however a
neck mass of unknown etiology is a common presentation
in both the oral boards and the general surgical ofce.
This topic is largely aimed at how well the examinee is
able to elicit appropriate history and physical exam ndings to dictate an appropriate differential diagnosis. Keep
in mind where squamous cell carcinoma and adenocarcinoma arise and allow that to guide your workup. Do not
forget to ask about symptoms that could lead you to a
primary malignancy (i.e., difculty swallowing or new
onset hoarseness).
Common Curveballs
• Metastatic thyroid cancer
• FNA will be indeterminate
• Scenario will switch several times from squamous cell
carcinoma to adenocarcinoma to lymphoma
• Melanoma overlying parotid gland (modied radical neck
dissection + supercial parotidectomy)
• Won’t be able to identify primary site
• Will nd primary site and be asked how to perform
resection
Bibliography
Amos J, Shermetaro C.Thyroglossal duct cyst. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2023. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK519057/.
Coste AH, Lofgren DH, Shermetaro C. Branchial cleft cyst. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;
2023. Available from: https://www.ncbi.nlm.nih.gov/books/
NBK499914/.
Referenced with permission from the NCCN clinical practice guide-
lines in oncology (NCCN Guidelines
V.2.2023. National Comprehensive Cancer Network, Inc; 2023.
Available from: NCCN.org.
®
) for head and neck cancers
Hyperparathyroidism
CandaceL.Ward andRadiZaki
73
Way Question May BeAsked?
A 61-year-old female with an elevated calcium level on routine blood tests presents from her primary care ofce with
her only complaint of fatigue. What do you want to do?
Sometimes you will be given symptoms of renal stones,
abdominal pain, constipation, arthralgia, myalgia, depression, ulcers, pancreatitis, osteitis brosa cystica, but rarely
all of the symptoms associated with elevated calcium (renal
stones, bone pain, constipation, fatigue, ulcer, depression,
emotional lability, sleep problems).
How toAnswer?
• Complete history and physical
– History:
Any symptoms related to hypercalcemia—renal
stones, abdominal pain, constipation, arthralgia/
myalgias, depression, ulcers, pancreatitis, osteitis
brosa cystica, emotional lability, psychosis.
Ask about radiation exposure and where exposure
might have occurred.
Medications.
Past medical history—renal disease will help determine type of hyperparathyroidism. Hypercalcemia
may also be the primary presenting complaint in
malignancy (inpatient setting).
– Physical: perform a complete physical exam, but
unlikely to have signicant ndings.
End-stage renal disease with severe hypercalcemia
may result in calciphylaxis.
• Diagnosis
– Laboratory tests:
Repeat serum calcium level, consider ionized calcium level to conrm.
Obtain other basic labs including CBC, BMP, magnesium, phosphorus, hepatic function panel.
• Correct serum calcium using albumin level.
• Can calculate chloride: phosphate ratio (>30
suggestive of primary hyperparathyroidism).
Check vitamin D level.
Parathyroid hormone level (malignancies do not
have elevated PTH).
24-hour urine calcium (use to diagnose hypercalcemic hypocalciuria).
Treatment
• Indications for Asymptomatic Patients
– Serum calcium ≥1.0mg/dL than normal.
– Creatinine clearance <60mL/min.
– Bone mineral density −2.5 z-score at any site and/or
previous fracture fragility.
– Age <50years.
Localization (in Order)
• Ultrasound: attempt to identify any potential adenomas.
Also evaluate any thyroid nodules that may require preoperative evaluation.
• Sestamibi scan: 80% are positive, however if negative still
most likely to have single adenoma.
• CT or MRI only when rst two are negative.
• If all negative, surgical exploration is indicated.
• Venous sampling reserved for failed exploration.
Procedure
For adenoma
C. L. Ward (*) · R. Zaki
Department of Surgery, Einstein Healthcare Network,
Philadelphia, PA, USA
e-mail: Radi.zaki@jefferson.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_73
• If sestamibi +, excise single gland.
• If not localized pre-op, must identify all four glands prior
to excision.
233
234
C. L. Ward and R. Zaki
• If intra-op PTH level is available, wait 10–15min and a
50% drop from pre-op level is conrmatory.
• Frozen sections can be done, and pathologist should conrm adenoma and enlarged gland by weight.
• If intra-op PTH level is not available, must biopsy all
glands for frozen section. Re-implant in sternocleidomastoid or arm if 3.5 excision is done.
For hyperplasia
• Take all four glands and autotransplant half of a gland
into sternocleidomastoid muscle (or non-dominant
forearm).
– Cryopreservation of half of a gland in case the reim-
planted gland dies.
– Parathyroidomas are a risk of reimplantation—benign
masses that can be excised, which is easier in the forearm than in the neck.
• If intra-op PTH available, should draw after all four
glands removed to test for fth gland.
For cancer
• PTH level typically in >1000. En bloc resection of parathyroid gland, ipsilateral lymph nodes, thyroid
lobectomy.
If you cannot nd a gland:
– Parathyromatosis
• Cannot nd four glands.
• There will be more than four glands.
• Part of a MEN syndrome—all hyperplasia, not adenomatous disease.
• Post-op hypocalcemia.
• Post-op airway compromise.
• Post-op hoarseness.
• Pt sent to you after previously failed neck exploration
elsewhere.
• Asked to comment on why four-gland exploration better
than exploration on just one side (to justify whatever position you offer).
• Pt may present very subtly with only fatigue or renal
stones.
• Innocent questions like, “How does PTH work?”(increase
bone resorption, increases renal resorption of Ca and
renal secretion of phosphorus, and stimulates vit D
formation).
• Management of hypercalcemic crisis (treat with IVF,
Lasix, steroids, calcitonin, surgery when stable).
• Parathyroid carcinoma.
• Negative sestamibi scan (see above)—better for adenomatous disease, not very good for hyperplasia.
• May ask what if intra-op PTH level increases after excision of adenoma. Answer, double adenoma and explore.
• Know medications Sensipar (cinacalcet), Rocaltrol
(calcitriol).
• Upper gland—check paraesophageal, retrolaryngeal
spaces, posterior mediastinum, and perform ipsilateral
thyroid lobectomy.
• Lower gland—check tracheoesophageal groove, carotid
sheath, thymus, thyroid, anterior mediastinum.
• If still cannot nd gland, follow post-op Ca/PTH levels.
May require CT thorax +/− repeat sestamibi scan to
locate gland.
• You will not fail a scenario if you cannot nd a gland, as
long as you did not hurt the patient.
Common Curveballs
• Post-op has persistently elevated calcium or comes back
6 months with elevated calcium. Be methodical with
complete workup including calcium, phosphorus, and
PTH levels; MRI, sestamibi, U/S; one of four choices:
– Missed adenoma (most likely)—could be a fth gland,
in mediastinum, or on same side
– Missed hyperplasia
– Parathyroid carcinoma
Clean Kills
• Failing to rule out MEN syndrome.
• Failing to rule out common causes of hypercalcemia.
• Performing median sternotomy rst time around when
nd only three glands.
• Finding a single adenoma and stopping operation.
• Not knowing how to deal with post-op persistent
hypercalcemia.
• Not knowing indications for surgery.
• Not knowing how to deal with post-op complications.
• Not knowing where to look for “missing” upper or lower
gland.
Bonus Points
• Able to manage post op hypocalcemia.
• Knows about squamous cell lung cancer and possible
paraneoplastic syndrome.
• Can describe use of intraoperative neo-probe with MIBI.