Front Cover 1
Surgical Endocrinology 4
Copyright Page 5
Table of Contents 6
Contributors 8
Preface 12
Glossary 14
Part I: Introduction 16
Chapter 1. The Principles of Endocrine Surgery 18
Confirming the diagnosis 18
The localization of the tumour(s) 18
Safety 19
The need to operate 19
Surgical tactics 19
References 20
Chapter 2. The Molecular Basis of Endocrinology 22
Overview 22
Gene expression 22
Conclusions of relevance to clinical endocrinology 32
Appendix: Definitions 33
References 34
Further reading 34
Chapter 3. The Physiology of the Endocrine System 35
Introduction 35
Neuroendocrinology 36
Circulating hormones 40
Endocrine control of the gastrointestinal tract 43
The molecular approach 46
References 46
Chapter 4. Multiple Endocrine Neoplasia and Molecular Genetics 51
Multiple endocrine neoplasia type 52
Multiple endocrine neoplasia type 57
Conclusion 61
References 61
Chapter 5. Modern Techniques of Hormone Measurement and Their Interpretation 64
Introduction 64
Radioimmunoassay or immunometric assay? 65
Monoclonal antibodies 66
Non-isotopic labels 67
Assay formulations and automation technology 70
Effects of new assay technologies on clinical interpretation of hormone measurements 71
Summary 73
References 73
Chapter 6. Paraendocrine Syndromes 76
Introduction 76
Aetiology 76
Principles of diagnosis and management of ectopic hormone production 77
Ectopic hormone syndromes 77
References 85
Chapter 7. Anaesthetic Considerations in Endocrine Surgery 88
Introduction 88
Anaesthesia for pituitary surgery 88
Anaesthesia for thyroid surgery 90
Anaesthesia for adrenal surgery 93
Anaesthesia for abdominal endocrine surgery 97
Anaesthesia for endocrine surgery during pregnancy 99
Summary 100
References 100
Chapter 8. Endocrine Problems in Pregnancy 102
Thyroid disease and thyroid function in pregnancy 102
Management of the enlarged non-toxic goitre during pregnancy 104
Parathyroid disease and calcium haemostasis in pregnancy 104
Hypoparathyroidism 105
Phaeochromocytoma 105
Pituitary tumour 105
Acromegaly 107
References 107
Chapter 9. Modern Histological Imaging Methods 110
Introduction 110
Techniques 110
Products of the diffuse neuroendocrine system 114
Conclusions 115
References 115
Chapter 10. Legal Aspects of Endocrine Surgery 122
Introduction 122
English law 122
Negligence 122
Damage and causation 124
Damages 126
Consent 127
The consent form 128
What to do if you make a mistake 128
Crown Indemnity 129
Evidence 129
Table of cases 130
Part II: Pituitary Syndromes 132
Chapter 11. Imaging of the Pituitary 134
Plain film assessment of the pituitary fossa 135
CT of the pituitary 137
Magnetic resonance imaging of the pituitary 142
Angiography 146
References 147
Chapter 12. Surgical Pathology of the Pituitary Gland 149
Anterior pituitary 149
Adenomas of the anterior pituitary 150
Classification of pituitary adenomas 152
Tumours other than pituitary adenomas 157
Vascular disorders of the pituitary 160
References 160
Chapter 13. Non-surgical Management of Pituitary Tumours 163
Introduction 163
Prolactinomas 163
Microprolactinomas 165
Acromegaly 166
Cushing's disease 167
Functionless tumours 168
Gonadotrophinomas/TSH-omas 169
Hormone replacement treatment 169
References 170
Chapter 14. The Management of Pituitary Adenomas by Yttrium-90 Interstitial Irradiation 172
Radiological criteria for feasibility of 90Y implantation 172
Choice of irradiation dose for the various types of adenoma 172
Calculation of pituitary dimensions, the required implant position, length of the rods and the required radioactivity 173
The operative procedure 175
Pre- and postoperative management 178
Histological and hormonal response pituitary and adjacent tissues to 90Y implantation 179
Complications 180
Results from 90Y implantation of the various tumour types 180
Conclusions and future strategy 184
Acknowledgements 185
References 185
Chapter 15. Surgery of Pituitary Tumours 188
Introduction 188
Clinical features 188
Symptoms and signs 189
Endocrinology 189
Differential diagnosis 190
Surgical radiology 190
Bilateral simultaneous inferior petrosal sinus sampling 191
Aims of surgery 191
Surgical treatment 191
Perioperative treatment 195
Complications 195
Surgical results 196
Acromegaly 199
Cushing's disease 200
Nelson's syndrome 200
Other hypersecretory syndromes 201
Non-functioning macroadenomas 201
Pituitary apoplexy 202
Empty sella syndrome 203
Current indications for surgery 203
References 203
Part III: Thyroid 210
Chapter 16. Management of Simple and Non-toxic Goitre 212
Introduction 212
Pathology 214
Clinical presentation 214
Clinical examination 214
Management problems 214
The imaging of the thyroid in multinodular goitre 215
Treatment 215
References 216
Chapter 17. Imaging of the Thyroid 217
Introduction 217
Imaging for hyperthyroidism 217
Imaging for thyroid cancer 221
Imaging for goitre 229
Imaging for ectopic thyroid 232
References 234
Chapter 18. Surgical Pathology of the Thyroid 236
Normal anatomy and histology 236
Hyperplasia 237
Inflammatory enlargement of the thyroid 238
Thyroid tumours 240
Other tumours of the thyroid 246
References 246
Chapter 19. Surgical Anatomy of the Thyroid Gland and the Technique of Thyroidectomy 248
Surgical anatomy 248
Anaesthesia 250
Technique of thyroidectomy 250
Retrosternal goitre 253
Re-exploration of the thyroid 254
Complications 254
References 255
Chapter 20. Surgery of Thyroid Cancer 257
Introduction 257
Aetiology 257
Factors influencing management decisions 259
Operative considerations 263
Presentation, diagnosis and treatment 266
Thyroid cancer in children and adolescents 271
Conclusion 272
References 272
Chapter 21. Thyroid Lymphoma 275
Incidence 275
Associations 275
Presentation 275
Investigations 276
Diagnosis 276
Histology 277
Thyroid lymphoma biology 278
Treatment 280
Prognostic factors 282
Unusual thyroid lymphomas 283
Conclusions 283
Acknowledgements 284
References 284
Chapter 22. Medullary Carcinoma of the Thyroid 287
Introduction 287
Embryology and histology 287
Natural history 288
Symptomatology 288
Diagnostic techniques 289
Treatment 290
Management of metastases 291
Postoperative follow-up 291
Conclusions 292
References 292
Chapter 23. The Radiotherapy and Management of Thyroid Tumours 294
Differentiated thyroid carcinoma 294
Treatment of differentiated thyroid carcinoma 295
Hürthle cell tumours 304
Medullary thyroid carcinoma 305
Anaplastic carcinoma 306
Chapter 24. Medical Aspects of Thyroid Disease 311
Anatomy and physiology 311
Disease processes 311
Drugs and thyroid function 325
References 326
Chapter 25. Management of Thyroid Eye Disease 329
Diagnosis 329
Proptosis 330
Double vision 330
Optic neuropathy 331
Surgical decompression 333
Cosmetic decompression 335
Medical decompression 335
Radiotherapy 336
Lid retraction 337
Double vision treatment 337
Botulinum toxin 337
Ocular muscle surgery 337
Lid surgery 337
Natural history of the condition and timing of surgery 338
Acknowledgement 339
References 339
General reading 340
Chapter 26. Management of the Damaged Recurrent Laryngeal Nerve following Thyroid Surgery 341
Anatomical considerations 341
Recurrent laryngeal nerve palsy 342
Remedial measures for unilateral paralysis 343
References 346
Part IV: Parathyroid Disease 348
Chapter 27. Calcium and Bone Metabolism 350
Plasma calcium homoeostasis 350
Bone calcium homoeostasis 351
Regulation of bone cell activity 353
References 356
Chapter 28. The Medical Management of Hypercalcaemia 358
Introduction 358
Pathophysiology 358
Treatment aims 360
Management of malignant hypercalcaemia 360
Methods of treatment 360
Primary hyperparathyroidism and hypercalcaemia 364
Conclusions 365
References 365
Chapter 29. Imaging of the Parathyroids 368
Introduction 368
Radiological anatomy 369
Non-invasive procedures 369
Intravenous digital subtraction angiography 374
References 377
Chapter 30. Indications for Surgery in Secondary Hyperparathyroidism 379
Pathogenesis and aetiology 379
Treatment 381
Limitations of medical treatment and the need for surgery 382
Parathyroid surgery 384
References 385
Chapter 31. Surgical Pathology of the Parathyroids in Primary and Secondary Hyperparathyroidism 387
Anatomy 387
Histology 387
Histological evaluation of parathyroid function 389
Hyperparathyroidism 390
References 395
Chapter 32. Surgery of the Parathyroids 397
Anatomy of the parathyroid 397
Implications of the various sites of parathyroid glands 399
Peroperative localization of the parathyroid 399
Management of various parathyroid pathologies 403
Concomitant thyroid pathology at exploration 405
The surgical treatment of secondary and tertiary hyperparathyroidism 407
Summary 408
References 408
Part V: Adrenal 410
Chapter 33. Phaeochromocytoma and Related Tumours 412
Introduction 412
Origin and prevalence of phaeochromocytoma 412
Associated disorders 413
Clinical features of phaeochromocytoma and their pathophysiological basis 414
Biochemical diagnosis of phaeochromocytoma 416
Localization 420
Management 422
Special circumstances 423
References 424
Chapter 34. Syndromes of Corticosteroid Excess 428
Historical 428
Anatomy 428
Biochemistry of adrenal hormones 428
Glucocorticoids and Cushing's syndrome 429
Cushing's syndrome 430
Treatment of Cushing's syndrome 436
Mineralocorticoids and primary hyperaldosteronism 439
Primary hyperaldosteronism 440
Conclusion 442
References 442
Chapter 35. Imaging of the Adrenals 448
Anatomy 448
Imaging modalities 450
Diseases of the adrenal gland 452
References 462
Chapter 36. Surgical Pathology of the Adrenal Cortex and Medulla 464
Anatomy 464
Adrenal cortex 464
Adrenal insufficiency 469
Adrenal medulla 470
Adrenal medullary hyperplasia 472
References 473
Chapter 37. Surgical Anatomy and Surgery of the Adrenal Glands 475
Introduction 475
Background and history 475
Anatomy 476
Physiology 477
Pathology and indications for surgery 477
Preparation for surgery 478
Surgical techniques 479
Postoperative management 483
References 483
Chapter 38. Neuroblastomas 485
Introduction 485
Surgical considerations 487
References 489
Chapter 39. Masculinizing and Feminizing Syndromes 490
Introduction 490
Normal sexual differentiation 490
Masculinizing syndromes (Female pseudohermaphroditism) 493
Feminizing syndrome (male pseudohermaphroditism) 496
Management of ambiguous genitalia — a practical approach 499
References 499
Part VI: Endocrine Tumours of the Gut 502
Chapter 40. Diagnosis and Medical Management of Gastroenteropancreatic Tumours 504
Introduction 504
Histology 504
Radioimmunoassays 504
Clinical syndromes 505
Tumour localization 507
Treatment 507
Summary 509
References 509
Chapter 41. Surgical Aspects of Carcinoid Tumours 511
Introduction 511
Small bowel carcinoids 512
Specific features of the more clinically important tumours 512
Carcinoid syndrome 514
Conclusion 518
References 518
Chapter 42. Surgery of Endocrine Tumours of the Pancreas 520
General features 520
Insulinoma 521
Nesidioblastosis 525
Gastrinoma 525
VIPoma 530
Glucagonoma 531
Somatostatinoma 531
PPoma 531
Other rare secreting tumours 531
References 534
Chapter 43. Imaging Endocrine Tumours of the Gut 538
Islet cell tumours of the pancreas 539
Carcinoid tumours 547
Interventional radiology 550
Imaging sequence 552
References 552
Chapter 44. Management of Secondary Endocrine Tumours of the Liver 555
Introduction 555
Tumour types 555
Diagnosis 555
Objectives of therapy 556
Pre-treatment 556
Treatment options 557
Surgical approaches 558
Results 561
Conclusions 563
References 563
Chapter 45. Surgical Pathology of Endocrine Tumours of the Alimentary Tract 565
General features of endocrine neoplasms of the alimentary tract 565
Oesophagus 566
Stomach 566
Duodenum 567
Jejunum and ileum 567
Appendix 567
Large bowel 568
Endocrine tumours of the pancreas 568
References 570
Part VII: Tests 572
Chapter 46. Some Commonly used Endocrine Diagnostic Tests 574
Pituitary—adrenal 574
Posterior pituitary 577
Growth 576
Adrenal 578
Thyroid 581
Pancreas 582
Miscellaneous 584
Index 586