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GS60 General Surgery and Thoracic Surgery Surgical Endocrinology Toronto Notes 2019
Local/Regional Recurrence
• recurrenceintreatedbreastoripsilateralaxilla
• 1%peryruptomaximumof15%riskofdevelopingcontralateralmalignancy • 5xincreasedriskofdevelopingmetastases
Metastasis
• bone>lungs>pleura>liver>brain
• treatmentispalliative:hormonetherapy,chemotherapy,radiation • overallsurvivalofmetastaticbreastcanceris36-60mo
Surgical Endocrinology
Thyroid and Parathyroid
• seeEndocrinology,E21
Thyroidectomy
• indications:thyroidcancer,symptomaticthyroidmassorgoitre,andmedicallyrefractoryGraves' disease or hyperthyroidism
• contraindications:uncontrolledseverehyperthyroidism(i.e.Graves'disease)duetoriskofintra- operative or post-operative thyroid storm
• pre-operativeworkup:thyroidU/Sforthyroidnodules,FNAfornodules≥1cmwithsuspiciousU/S features or for most nodules ≥1.5 cm with low suspicion U/S features, U/S of the neck for lesions suspicious for papillary or medullary thyroid cancer, and CT neck for preoperative staging when advanced disease is suspected
• complications:hypocalcemiasecondarytohypoparathyroidism,recurrent/superiorlaryngealnerve injury, neck hematoma, infection, and thyrotoxic storm
Parathyroidectomy
• indications:symptomaticprimaryhyperparathyroidismduetoeffectsofPTHonboneorkidneys, asymptomatic primary hyperparathyroidism with specific laboratory criteria (elevated serum Ca2+, marked hypercalciuria, Cr clearance <30% normal, bone density reduction with T score <2.5, <50 yr)
• contraindications:familialhypocalciurichypercalcemia
• pre-operativeworkup:99mTcsestamibiscanning,±SPECTorCT,U/S
• complications:recurrent/superiorlaryngealnerveinjury,post-operativehypocalcemia,infection,and
bleeding
Adrenal Gland
• seeEndocrinology,E30
• functionalanatomy
■ cortex: glomerulosa (mineralocorticoids), fasciculata (glucocorticoids), and reticularis (sex steroids)
■ medulla: catecholamines (epinephrine, norepinephrine)
• typesofadrenaltumours:functional(e.g.Cushing’ssyndrome,Conn’ssyndrome)ornon-functional
INCIDENTALOMA
• adrenalmassdiscoveredbyinvestigationofunrelatedsymptoms
Epidemiology
• benignadenoma(38%)>metastasestoadrenal(22%)>>cyst,carcinoma,pheochromocytoma, neuroblastoma
• metastasistoadrenalglandfrom:lung>breast,colon,lymphoma,melanoma,andkidney
• peakincidenceofcarcinoma:femalesage50-60,riskdecreaseswithincreasingageandmalegender
Investigations
• MRI,CT:size>6cmisbestpredictorofprimaryadrenalcarcinoma(92%are>6cm)
• functionalstudies
■ pheochromocytoma: 24 h urine epinephrine, norepinephrine, metanephrine, normetanephrine, vanillylmandelic acid (VMA)
■ Cushing’s: 24 h urine cortisol or 1 mg overnight dexamethasone suppression test
■ aldosteronoma: electrolytes, aldosterone:renin level, saline suppression test if appropriate ■ adrenal androgens: 17-OH progesterone, and dehydroepiandrosterone (DHEAS)
• FNAbiopsy:ifsuspectmetastasistoadrenal(mustexcludepheochromocytomafirsttopreventa hypertensive crisis)
■ indicated if history of cancer or patient is smoker
• iodocholesterolscintigraphy:maydistinguishbenignvs.malignantdisease