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Parathyroid Carcinoma

Video 64.1 Parathyroid Carcinoma: Management Principles with an Illustrative Case Background Parathyroid carcinoma (PC) is a rare but ominous cause of primary hyperparathyroidism (HPT). It accounts for less than 1% of the cases of primary HPT. In a retrospective study of two European cohorts of primary HPT from 2005 to 2014, the incidence of PC in patients with HPT was 0.3% and 2.1%, respectively. This difference…

Revision Parathyroid Surgery

Introduction As many as 10% of patients who had previous operations for primary hyperparathyroidism (PHPT) will experience persistent or recurrent disease after surgery ( Box 63.1 ). Due to the sequelae of PHPT, some of these patients will require reoperative parathyroid surgery. Unfortunately, in contrast to primary parathyroid surgery, which is extremely safe and has a high success rate, reoperative parathyroid surgery is associated with significant…

Parathyroid Management in the MEN Syndromes

Primary hyperparathyroidism (PHPT) is the presence of elevated serum calcium levels combined with inappropriate suppression of parathyroid hormone (PTH). It is most commonly a sporadic disease; however, in a small subset of patients, it can be part of a familial syndrome. These inherited disorders include multiple endocrine neoplasia (MEN) type 1, MEN type 2A, hyperparathyroid-jaw tumor syndrome, familial isolated hyperparathyroidism, and benign familial hypocalciuric hypercalcemia. This…

Surgical Management of Secondary and Tertiary Hyperparathyroidism

Video 61.1 Total Parathyroidectomy with Forearm Autograft for Patients with Advanced Secondary Hyperparathyroidism. Video 61.2 Total Parathyroidectomy with Forearm Autograft for Patients with Advanced Secondary Hyperparathyroidism: Usefulness of IONM. Secondary Hyperparathyroidism Definition Secondary hyperparathyroidism (SHPT) refers to the situation in which a derangement in calcium homeostasis leads to a compensatory increase in parathyroid hormone (PTH) secretion. SHPT requiring parathyroidectomy (PTx) occurs more commonly in progressive chronic…

Surgical Management of Multiglandular Parathyroid Disease

Albright’s 1934 description of primary water clear cell hyperplasia, that involving all four parathyroids represents the first recognition of the concept of primary hyperparathyroidism (PHPT) due to multiple gland disease (MGD) rather than single-gland disease. Although the incidence of this now-unusual condition was to decline, the “New Entity in the Surgery of Hyperparathyroidism,” known as primary chief cell hyperplasia, was described in Cope’s landmark 1958 paper.…

Intraoperative PTH Monitoring During Parathyroid Surgery

Introduction Intraoperative parathyroid hormone monitoring (IPM) has been used since the 1990s to guide the excision of abnormal parathyroid glands in patients with sporadic primary hyperparathyroidism (SPHPT). Currently, many high-volume parathyroid surgeons use IPM, selectively or routinely, to guide parathyroidectomy in patients with primary hyperparathyroidism (PHPT). This surgical adjunct has helped change the operative approach to parathyroidectomy from the traditional bilateral neck exploration (BNE) (which had…

Minimally Invasive Video-Assisted Parathyroidectomy

Introduction Bilateral neck exploration (BNE) with the identification of at least four parathyroid glands and the removal of pathologic parathyroid tissue has represented, for several decades, the standard of treatment of primary hyperparathyroidism (PHPT) (see Chapter 56 , Standard Bilateral Parathyroid Exploration). In experienced hands, this approach has a cure rate of more than 95% with minimal morbidity of usually less than 3%. In spite of…

Minimally Invasive Single Gland Parathyroid Exploration

Video 57.1 Minimally Invasive Parathyroidectomy. Background Subsequent to the first parathyroidectomy documented in the literature (in 1925 by Felix Mandl of Vienna), four-gland exploration via a generous incision was the standard technique until the 1970s and 1980s. The advent of various localization modalities since that time, coupled with the fact that approximately 85% of patients with primary hyperparathyroidism (PHPT) have a solitary adenoma, has led many…

Standard Bilateral Parathyroid Exploration

Video 56.1 Introduction to Chapter 56, Standard Bilateral Parathyroid Exploration. Modern management of parathyroid disease has evolved with the influence of several fundamentally new and important factors. First is the reality that primary hyperparathyroidism (PHPT) is no longer a rare endocrine disorder, but the most common cause of hypercalcemia in the outpatient population; it has an estimated prevalence of 1 in 500 women and 1 in…

Principles in Surgical Management of Primary Hyperparathyroidism

In this chapter, we discuss the current approach to preoperative workup for primary hyperparathyroidism (primary HPT), determine appropriate surgical candidacy, review parathyroid surgical anatomy, and detail a comprehensive search algorithm for surgical exploration. Preoperative Evaluation Background Primary HPT is a common cause of hypercalcemia with approximately 100,000 new cases diagnosed in the United States each year. This number may be an underestimation due to the prevalence…

Guide to Preoperative Parathyroid Localization Testing

Video 54.1 Introduction to Chapter 54, Guide to Preoperative Parathyroid Localization Testing. Introduction The skill of an experienced parathyroid surgeon remains the most important asset in identifying abnormal parathyroid glands. Results of initial operations for primary hyperparathyroidism (PHPT) are similar with or without preoperative imaging. Historically, more than 95% of patients have been cured after bilateral cervical exploration by experienced parathyroid surgeons without the help of…

Primary Hyperparathyroidism: Pathophysiology, Surgical Indications, and Preoperative Workup

Primary hyperparathyroidism (PHPT) is characterized classically by hypercalcemia and levels of parathyroid hormone (PTH) that are frankly elevated or inappropriate in the presence of hypercalcemia. Patients with the disease today in the United States bear little resemblance to those with the severe disorder of “stones, bones, and groans” described by Fuller Albright and others in the 1930s. Then, patients typically had skeletal manifestations described as osteitis…

Medical Treatment Horizons for Metastatic Differentiated and Medullary Thyroid Cancer

Video 52.1 Introduction to Chapter 52, Medical Treatment Horizons for Metastatic Differentiated and Medullary Thyroid Cancer. Introduction Metastatic differentiated thyroid cancer (DTC) and medullary thyroid cancer (MTC) are rare tumors with limited treatment options and an overall poor response to cytotoxic chemotherapy. Oral small molecule inhibitors targeting several different oncogenic pathways relevant to thyroid cancers have emerged over the past decade. Development of such kinase inhibitors…

Nonsurgical Treatment of Thyroid Cysts, Nodules, Thyroid Cancer Nodal Metastases, and Hyperparathyroidism: The Role of Percutaneous Ethanol Injection

Video 51.1 Floating Debris Video 51.2 Percutaneous Ethanol Injection: Cyst Injection Video 51.3 Percutaneous Ethanol Injection: Toxic Adenoma Video 51.4 Percutaneous Ethanol Injection: Metastasis Video 51.5 Ultrasound Cord Check Introduction Thyroid neoplasms and cysts are common in the general population. The primary intervention offered to these patients in the United States is surgical removal. Despite the advances in surgical training and techniques, surgery carries a 2%…

Reoperative Thyroid Surgery

Video 50.1 Introduction to Chapter 50, Reoperative Thyroid Surgery Introduction Approximately one-third of patients with differentiated thyroid cancer (DTC) have tumor recurrence, and most are diagnosed within 10 years of initial treatment. Locoregional recurrences may arise in the thyroid bed, the central or lateral neck, the mediastinum, or, rarely, invasive to the trachea or the muscle overlying the thyroid bed. The mortality from locally recurrent DTC…

External Beam Radiotherapy for Thyroid Malignancy

Introduction Surgery is, with the exception of lymphomas described in this chapter, the mainstay of therapy for all types of thyroid cancer. However, if there is an increased risk of recurrence, further additional treatment may be warranted. In differentiated thyroid cancer (DTC), also described elsewhere, this is often in the form of radioactive iodine. However, in DTC, if the risk of locoregional recurrence is high and…

Postoperative Radioactive Iodine Ablation and Treatment of Differentiated Thyroid Cancer

Video 48.1 Introduction to Chapter 48, Postoperative Radioactive Iodine Ablation and Treatment of Differentiated Thyroid Cancer. Introduction The role of radioactive iodine (RAI) therapy in the postoperative management of patients with newly diagnosed differentiated thyroid cancer (DTC) is a highly controversial topic. Endocrinologists and nuclear medicine physicians strongly differ in their opinions regarding the diagnostic and therapeutic uses of RAI therapy in the postoperative setting. This…

Postoperative Management of Differentiated Thyroid Cancer

Goals of Postoperative Management Differentiated thyroid cancer (DTC) is being diagnosed with increasing incidence, but the mortality rate has remained low. The vast majority of these tumors are low-risk cancers, limited to the thyroid gland, which have a 20-year disease-specific survival rate close to 100%. Current recommendations aim to best adapt adjuvant therapy and follow-up to each patient and each cancer, avoiding overtreatment and oversurveillance of…

Ethics and Malpractice in Thyroid and Parathyroid Surgery

Video 46.1 Introduction to Chapter 46, Ethics and Malpractice in Thyroid and Parathyroid Surgery. Ethical Issues Optimizing Informed Consent One of the central ethical challenges for surgeons is to ensure that patients have given adequate informed consent before having an operation. Certainly, informed consent for surgery is much more than just a patient’s signature on a consent form. In fact, informed consent for surgery is best…

Quality Assessment in Thyroid and Parathyroid Surgery

Video 45.1 Introduction to Chapter 45, Quality Assessment in Thyroid and Parathyroid Surgery. Increasing focus has been placed on the quality of care physicians and hospitals provide to ensure excellent health outcomes for their patients. Thyroid and parathyroid operations are often performed in the outpatient setting with overall low morbidity and rare mortality, but variation in care and outcomes between institutions and providers suggests there is…