Parathyroid Disease

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The need for isolated parathyroidectomy in MEN type II patients is rare. As discussed above, we usually perform routine total parathyroidectomy with

Figure 17-13. This patient with multiple endocrine neoplasia (MEN) type IIB had recurrent elevation of calcitonin levels 20 years after total thyroidectomy for medullary thyroid cancer (MTC). Redo central neck dissection and bilateral functional neck dissections (microdissection) were performed. A, View of the trachea and dissected central and left paratracheal compartment. The photograph was taken from the patient's left side. The patient's head is to the right and the chest is to the left. CA = left carotid artery; IA = innominate vein; LJV = left jugular vein; LRN = left recurrent laryngeal nerve; T = trachea; VN = left vagus nerve. Note markedly enlarged nerves characteristic of MEN type IIB. B, Surgical specimen from the same patient. The photograph shows central and upper mediastinal nodes (level VII), bilateral paratracheal nodes (level VI), and bilateral jugular chain and posterior triangle nodes (levels II, III, IV, and V). Microscopic foci of MTC were found in paratrachal dissection specimens. Reproduced with permission from Moley JF. Medullary thyroid cancer. In: Clark OH, Duh QY, editors. Textbook of endocrine surgery. Philadelphia: WB Saunders; 1997. p. 108-18.

Figure 17-13. This patient with multiple endocrine neoplasia (MEN) type IIB had recurrent elevation of calcitonin levels 20 years after total thyroidectomy for medullary thyroid cancer (MTC). Redo central neck dissection and bilateral functional neck dissections (microdissection) were performed. A, View of the trachea and dissected central and left paratracheal compartment. The photograph was taken from the patient's left side. The patient's head is to the right and the chest is to the left. CA = left carotid artery; IA = innominate vein; LJV = left jugular vein; LRN = left recurrent laryngeal nerve; T = trachea; VN = left vagus nerve. Note markedly enlarged nerves characteristic of MEN type IIB. B, Surgical specimen from the same patient. The photograph shows central and upper mediastinal nodes (level VII), bilateral paratracheal nodes (level VI), and bilateral jugular chain and posterior triangle nodes (levels II, III, IV, and V). Microscopic foci of MTC were found in paratrachal dissection specimens. Reproduced with permission from Moley JF. Medullary thyroid cancer. In: Clark OH, Duh QY, editors. Textbook of endocrine surgery. Philadelphia: WB Saunders; 1997. p. 108-18.

autotransplantation at the time of thyroidectomy, regardless of gross appearance of the parathyroid glands. Should hyperparathyroidism occur at a later time in these patients with forearm grafts, surgical removal of a portion of the graft can be done under local anesthetic in an outpatient setting. If, at the time of the initial neck exploration, the parathyroids are left in situ, subsequent development of hyperparathyroidism requires re-exploration of the neck with identification and removal of all four glands followed by autotransplantation.

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