Physical

Although it may only give general clues as to the benign or malignant nature of the nodule, a thorough physical examination should be performed. A nodule that is fixed to surrounding structures such as the trachea or strap muscles is most likely malignant. Fixation of the thyroid can also occur with severe chronic thyroiditis, however. Extremely hard thyroid nodules may be malignant, but may also be due to calcifications in benign adenomas. Paralysis of one of the vocal cords strongly suggests...

Postoperative Management

All patients with follicular carcinoma require lifelong treatment with exogenous thyroid hormone to suppress TSH synthesis, the production of which can stimulate the growth of differentiated thyroid cancer. Thyroid-stimulating hormone suppression lowers the recurrence rate of follicular carcinoma by diminishing the stimulation of TSH receptors which are present on the surface of differentiated thyroid tumors.9 Ideally, TSH levels should be suppressed to undetectable levels with the lowest...

Nondiagnostic Biopsies

The situation may also arise that the results of the FNAB are repeatedly nondiagnostic, despite the use of ultrasound guidance to assure an accurate biopsy of the nodule. Nondiagnostic biopsies occur more often with cystic nodules because of the small amount of cellular material. The rate of malignancy in these nodules is extremely low and observation may be appropriate. However, surgery is the only method for providing a definitive diagnosis and should be performed after a repeat nondiagnostic...

Management

Because of the difficulty in differentiating benign from malignant disease and the potential malignant behavior of benign lesions, many surgeons support an aggressive surgical approach for all Hurthle cell neoplasms.5,10 In addition, the majority of patients with Hurthle cell carcinoma do not respond to iodine-131 ablation therapy, rendering thyroidectomy the only effective treatment for malignant disease. Others, however, support a more conservative approach, recommending total thyroidec-tomy...

Laparoscopic Adrenalectomy

Prinz Introduction Laparoscopic adrenalectomy is a relatively new addition to the growing list of minimally invasive surgical procedures. This chapter will discuss the merits of open versus laparoscopic adrenalectomy, the indications for laparoscopic adrenalectomy, and three different techniques of laparoscopic adrenalectomy and their complications. Open versus Laparoscopic Adrenalectomy The adrenal glands are deep retroperitoneal organs. The choice among conventional...

Clinical Presentation and Diagnosis

Most patients with differentiated thyroid carcinoma initially present with nodular thyroid disease or a cervical mass. The nodule is more likely to contain carcinoma in children, adolescents, males, patients exposed to low doses of radiation to the head or neck, and patients older than 60 years of age. Associated symptoms suggesting differentiated thyroid carcinoma include hoarseness from a vocal cord paresis, recent onset or rapid growth of a solitary nodule, dysphagia, hemoptysis, or cervical...

Thyroid Hormone Effects

Virtually no organ or tissue escapes the effects of thyroid hormone. Sufficient amounts are necessary for brain development, normal growth and metabolism. Thyroid hormone affects the rate of synthesis and degradation of many hormones and enzymes. Thyroid hormone raises the basal metabolic rate and stimulates heat production. This may occur by increasing mitochondrial metabolism, by enhancing Na+ K+ ATPase activity, or by increasing futile cycles of carbohydrate or lipid metabolism. Oxygen...

Adrenocortical Cancer

Godellas Introduction Adrenocortical carcinoma is an uncommon neoplasm. Even though many of these tumors are functionally active and secrete steroid hormones, they usually present in an advanced stage. Therefore the overall prognosis for adrenocortical cancer is poor. Complete surgical resection offers patients with this malignancy the only possible chance for cure. Unfortunately, because of late presentation, complete resection is often not possible. As with most other rare...

Table 22 Important clinical factors in the diagnosis of thyroid cancer

History of head and neck irradiation Rapidity of growth Associated symptoms (pain, dysphagia, dysphonia, dyspnea) Growth on thyroid hormone suppression Solitary vs. multiple nodules An extremely firm nodule Fixation to adjacent structures Diameter 4 cm Lymphadenopathy past medical history include symptoms of pheochromocytoma or hyperparathyroidism, long-standing constipation and or diarrhea, hypertension and or episodes of nervousness. These should alert the clinician to the possibility of...

Info

The lymphatics of the pancreas empty into the regional lymph nodes. The lymphatic drainage of the pancreatic head is primarily to the anterior and posterior pancreaticoduodenal nodes, with these nodes then draining predominantly to para-aortic nodes. There is some drainage to the thoracic duct, cisterna chyli, and lumbar lymphatic trunks. Lymphatics from the body and tail mainly drain to retroperito-neal nodes at the splenic hilum and superior body lymph nodes. Inferior head, inferior body, and...

Carcinoid Tumors

The term karzinoid was originally introduced by Oberndorfer in 1907 to describe small intestinal tumors that behave in a less aggressive manner than the more common adenocarcinomas.1 Since then carcinoids have been described as benign or malignant, clinically functioning or nonfunctioning, and endocrine or nonendocrine tumors which arise from Kulschitzsky or enterochromaffin cells. These cells have characteristic light microscopy and histochemical features such as argen-taffin and argyrophilic...

Adrenal Incidentaloma

Godellas Introduction Computerized tomography (CT) is frequently used to evaluate patients with abdominal complaints. With the high quality of current CT scanners, many unsuspected adrenal masses are identified during this process. These masses are commonly called adrenal incidentalomas. They have a prevalence of 0.3-5 in patients having CT scans for reasons other than adrenal pathology or metastatic work-up.1-4 In patients undergoing CT scanning who do not have a history of...

Glucagonoma

Prinz While much less common than insulinomas or gastrinomas, glucagonomas are also neuroendocrine tumors that are associated with an extremely distinctive clinical syndrome. Glucagonomas are tumors that originate from the alpha cells of the pancreatic islets, which produce and secrete glucagon. The excess production of gluca-gon results in the characteristic glucagonoma syndrome, which includes diabetes, a unique rash, weight loss, anemia and thromboembolic...

Pathology Pathogenesis and Carcinogenesis

The pathology of papillary and follicular thyroid carcinoma differs in many aspects, but both malignancies originate from the thyroid follicular cell. Papillary carcinoma is an unencapsulated tumor with papillary and follicular architecture, consisting of single layers of thyroid cells arranged around vascular stalks that form papillae. The cells are characterized by overlapping nuclei with a ground-glass appearance, longitudinal grooves, and invaginations of cytoplasm into the nuclei....

Somatostatinoma

Somatostatin is a cyclic tetradecapeptide produced by the delta cells of the dispersed neuroendocrine cell system. Delta cells are predominantly found in the fundal and antral regions of the stomach as well as in the pancreatic islets. Lesser numbers of these cells can be found in the gastrointestinal tract. Somatostatin inhibits the secretion of most of the gut hormones including chole-cystokinin, gastric inhibitory peptide, gastrin, motilin, pancreatic polypeptide, secretin, and vasoactive...

Pheochromocytoma

Pheochromocytomas are catecholamine-producing neuroendocrine tumors arising from the adrenal medulla or extra-adrenal sympathetic ganglia (paragangliomas). Pheochromocytomas occur with a prevalence of approximately 1-2 per 100,000 adults.1 They account for 0.1-1 of cases of hypertension.2 The first report of a pheochromocytoma discovered at autopsy was by Frankel in 1886.3 The first successful removal of a pheochromocytoma was in 1926 by Cesar Roux in Lausanne, Switzerland.4 Later the same...

Cushings Syndrome

Buffalo Hump And Diabetes

Prinz Introduction Definition In 1932, Harvey W. Cushing defined a syndrome he called pituitary basophilism. Muscular weakness, truncal obesity, abdominal striae, diabetes and hypertension characterized this clinical complex. Today, the condition resulting from chronic glucocorticoid excess due to any source is known as Cushing's syndrome, as opposed to the pituitary-derived Cushing's disease. Cushing's syndrome is a rare disorder, with a prevalence of 10...

Thyroiditis

Thyrotoxicosis secondary to thyroiditis is uncommon. It is typically transient and self-limited. It may occur as a result of chronic lymphocytic or Hashimoto's thyroiditis, silent or painless thyroiditis, subacute or de Quervain's thyroiditis and h radioiodine-induced thyroiditis. Silent, subacute and radioiodine-induced thyroiditis M are all characterized by the inability to trap iodine, follicular cell destruction and release of preformed thyroid hormone resulting in thyrotoxicosis with a low...

Parathyroid Cancer

Godellas Introduction Cancer of the parathyroid gland is an exceptionally rare entity. Its classic presentation and course is similar to that, as first described by de Quervain in 1909, of a patient with a large, locally invasive neck mass, that progressed to lung metastases after removal of the neck lesion.1 Although not mentioned in his initial report, many patients also present with marked hypercalcemia. Unfortunately, it is frequently difficult to differentiate a parathyroid...

Aldosteronoma

Aldosteronomas, often referred to as aldosterone-producing adenomas, are the most common cause of primary aldosteronism, a surgically correctable type of hypertension that occurs in 0.5-2 of all hypertensive patients.1,2 As first described by Conn 45 years ago, primary aldosteronism is a syndrome characterized by hypertension, depletion of potassium, retention of sodium, and suppression of plasma renin activity (PRA), all of which are caused by an elevation in plasma aldosterone. Idiopathic...

Parathyroid Reoperations

Schell, Robert Udelsman Introduction Parathyroidectomy, when performed by experienced surgeons, results in a success rate that exceeds ninety-five percent. Unfortunately, a subset of patients fail initial exploration persistent primary hyperparathyroidism HPT , or develop recurrent HPT following what appeared to be successful parathyroidectomy. Depending upon the skill of the surgeon performing the initial neck exploration, between five and thirty percent of patients who undergo neck...

Parathyroid Autotransplantation

This chapter's title suggests a constraint to consider only autotransplantation of parathyroid glands. Although at present parathyroid transplants are, indeed, restricted to autotransplantation that may not be the case forever and an introductory review of terminology is warranted. The term autotransplantation implies movement of parathyroid tissue from one location to another location in the same individual. Relocation of the resected tissue may be done at the time of parathyroidectomy termed...

Table 42 Symptoms and signs of thyrotoxicosis

Nervousness Anxiety Irritability Increased appetite Weight loss or gain Palpitations Heat intolerance Excessive sweating Tremulousness Tachycardia Systolic hypertension Supraventricular arrhythmias Widened pulse pressure Hyperreflexia Resting tremor Increased frequency of bowel movements Impaired fertility, oligomenorrhea or amenorrhea Reduced libido Warm, moist smooth skin Thinning hair or hair loss Onicholysis Muscle weakness Gynecomastia Eyelid retraction, lid lag and stare Once the...

Complications of Thyroid Surgery

Thyroid surgery has progressed dramatically since the mid-1850s when half or more of the patients undergoing this operation would die from the procedure. Currently, thyroidectomy is a very safe operation which has an associate mortality rate that approaches zero. In other words, the mortality of a thyroidectomy is really the mortality of a general anesthetic. The morbidity associated with thyroid surgery is also very low. Nevertheless, the complications of thyroidectomy remain a matter of...

Embryology and Anatomy

During the 4th and 5 th weeks of life, brachial arches begin to develop as neural crest cells migrate into the future head and neck region of the embryo. Each arch consists of a core of mesenchyme covered externally by surface ectoderm and internally by endoderm. Externally the arches are separated by branchial groves and internally by extensions of the pharynx called branchial pouches. The superior parathyroid glands arise from the fourth branchial pouch. The ventral portion of the fourth...

Subhash Patel Introduction

The term 'goiter' is often used to describe enlargement of the thyroid gland. It is derived from the Latin word 'tumidum gutter' meaning the swollen throat. Extension of the goiter beyond the confines of the neck into the thoracic cavity with more than 50 of the mass inferior to the thoracic inlet is called substernal goiter or the intrathoracic goiter. Since the earliest description by Haller in 1749, many distinguished surgeons like Billroth, Kocher, Halsted, Mikulicz, Mayo, Criles, and Lahey...

Cytodiagnostic Categories

It is crucial for the clinician to fully understand the cytopathology report after a fine-needle biopsy. Cytopathology terms may be confusing for the inexperienced individual. The results of FNAB can be divided into four major diagnostic categories benign, malignant, indeterminate and nondiagnostic. The results of the FNAB will then guide the management of the thyroid nodule Fig. 2.1 . Several benign causes of thyroid nodules can be accurately and reliably diagnosed by cytology. Colloid nodules...