Chapter 38

1. There has been a paradigm shift in the surgical management of Graves’ disease with increased use of total or near-total thyroidectomy, rather than subtotal thyroidectomy.

2. Familial nonmedullary thyroid cancer is increasingly being recognized as a separate entity. Surgeons must be aware of the potential for false negative fine-needle aspiration biopsy in this setting.

3. Total thyroidectomy is the surgical treatment of choice for most thyroid cancers, provided complication rates are low.

4. The widespread use of positron emission tomography scanning for staging various malignancies and ultrasound for vascular screening is leading to an increased incidence of thyroid incidentalomas. Management should be based on assessment of the individual patient’s risk following complete clinical and fine-needle aspiration biopsy evaluation.

5. Focused mini-incision parathyroidectomy, after appropriate localization, has become the procedure of choice for the treatment of sporadic primary hyperparathyroidism.

6. Parathyroidectomy has been shown to improve the classic and so-called nonspecific symptoms and metabolic complications of primary hyperparathyroidism.

7. Very high calcium and parathyroid hormone levels in a patient with primary hyperparathyroidism should alert the surgeon to the presence of a possible parathyroid carcinoma.

8. Subclinical Cushing’s syndrome is characterized by subtle abnormalities in corticosteroid synthesis, and many of its manifestations appear to be treated by adrenalectomy.

9. Fine-needle aspiration biopsy has a very limited role in the evaluation of adrenal incidentalomas unless the patient has previously had a cancer and should only be performed after appropriate biochemical studies have been performed to rule out pheochromocytoma.

10. Adrenocortical cancer can be difficult to diagnose even on pathology examination so that continued follow-up of patients with resected seemingly benign tumors is advised.

### Historical Background

Goiters (from the Latin guttur, throat), defined as an enlargement of the thyroid, have been recognized since 2700 b.c. even though the thyroid gland was not documented as such until the Renaissance period. In 1619, Hieronymus Fabricius ab Aquapendente recognized that goiters arose from the thyroid gland. The term thyroid gland (Greek thyreoeides, shield-shaped) is, however, attributed to Thomas Wharton in his Adenographia (1656). In 1776, the thyroid was classified as a ductless gland by Albrecht von Haller and was thought to have numerous functions ranging from lubrication of the larynx to acting as a reservoir for blood to provide continuous flow to the brain, to beautifying women’s necks. Burnt seaweed was considered to be the most effective treatment for goiters.

The first accounts of thyroid surgery for the treatment of goiters were given by Roger Frugardi in 1170. In response to failure of medical treatment, two setons were inserted at right angles into the goiter and tightened twice daily until the goiter separated. The open wound was treated with caustic powder and left to heal. However, thyroid surgery continued to be hazardous with prohibitive mortality ...

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