Endocrine Surgery Fellowship

Goals and Objectives

• Demonstrate knowledge and understanding of endocrine gland anatomy and physiology, both the normal and pathological states
• Demonstrate the ability to diagnosis clinical endocrinopathies associated with endocrine surgical diseases
• Develop the knowledge of the inherited endocrine disorders and understand the role genetic counseling and testing
• Have an appreciation of the current controversies and current areas of research in the literature within endocrine surgical diseases
• Demonstrate the ability to apply this knowledge and safely perform the appropriate surgical operation for the given endocrine surgical disease

Inclusions

Develop an understanding of the normal anatomy, histology, physiology, biochemistry of each of the following endocrine glands. Be able to discuss the secretion and homeostasis of the pertinent hormonal secretion of these glands in both the normal and pathological disease states:

• Thyroid gland
  • Thyroxine, thyroid stimulating hormone (TSH), calcitonin
  • Manifestations of hyperthyroidism and hypothyroidism
• Parathyroid gland
  • Calcium / Phosphate / Vitamin D
  • Clinical symptoms and end organ effects associated with hyperparathyroidism (HPT)
  • Short- and long-term manifestations of hypoparathyroidism
• Endocrine pancreas
  • Insulin / Gastrin / Glucagon / Vasoactive Intestinal Peptide (VIP) / Pancreatic Polypeptide (PP) / Somatostatin / Secretin / Cholecystokinin (CCK)
  • Clinical manifestations of hyperinsulinemia
  • Clinical manifestations of Zollinger / Elision syndrome
  • Clinical manifestations of Glucagonoma syndrome
  • Clinical manifestations of VIPoma
• Adrenal glands
  • Aldosterone / Renin / Angiotensin
  • Adrenocorticotropic hormone (ACTH) / Cortisol
  • DHEA-S
  • Catecholamines (epinephrine, norepinephrine, dopamine)
• Gastrointestinal tract
  • Serotonin / Histamine / Motilin / Gastric Inhibitory Peptide / Enteroglucagon / Chromogranin A
  • Manifestations of Carcinoid Syndrome
  • Gastric Physiology
• Hypothalamus / Pituitary gland
  • Oxytocin/Vasopressin / Growth hormone / Melanocyte stimulating hormone / Prolactin

Endocrine Cytopathology and Histopathology

• Thyroid
  • Classification of thyroid malignancies
  • Classification of benign thyroid disease
  • The limitations of Frozen Section results
  • Fine-needle aspiration biopsy (FNA); its application and limitations
• Parathyroid
  • Definitions of hyperplasia vs. adenoma
  • Criteria for parathyroid carcinoma
• Adrenal
  • Classification and diagnosis of adrenal lesions
• Neuroendocrine Tumors (NET) of the GI tract
  • WHO classification of NET
  • Foregut / midgut / hindgut classification
  • Prognostic factors for NET
• Hereditary Endocrine Syndromes
  • Define oncogene and tumor suppressor gene
  • Define for each endocrine hereditary syndrome the chromosomal abnormalities
  • Discuss the role of genetic screening
  • Be able to discuss and differentiate the phenotype and genotype of;
  • MEN I (multiple endocrine neoplasia)
  • MEN IIa
  • MEN IIb
  • Develop a knowledge about the endocrine pathology associated with familial non-MEN syndromes, including:
    • von Hippel Lindau (VHL)
    • Neurofibromatosis
    • Paraganglioma syndromes (SDH-B, SDH-D)
    • Cowden's Disease
    • Familial HPT
    • Jaw-Tumor Syndrome
    • Familial Medullary thyroid cancer (MTC)
    • Carney Complex
    • Carney's Triad

Discuss the pathophysiology, clinical presentation, work-up and treatment (include both surgical and medical options) of the following diseases. Describe the natural history and list any prognostic factors associated with the disease.

• Thyroid
  • A solitary thyroid nodule
  • A multinodular thyroid gland
  • Thyrotoxicosis, including toxic adenoma, Graves' disease and Hashimoto's disease
  • Well-differentiated thyroid cancer (WDTC), including I 131 ablation
  • Rare thyroid malignancies, including MTC, Lymphoma and Anaplastic
• Parathyroid
  • Primary, secondary, and tertiary hyperparathyroidism (HPT)
  • Parathyroid carcinoma
  • Familial forms of HPT
• Endocrine Pancreas
  • Insulinoma
  • Gastrinoma
  • Glucagonoma
  • VIPoma
  • Somatostatinoma
  • PPoma
  • Non-functioning NET of the pancreas
• GI Neuroendocrine Tumors
  • Gastric Carcinoids Type I, II and III - including atypical Carcinoid Syndrome
  • Mid-gut (Carcinoid) tumors - including diagnosis and treatment of Carcinoid Syndrome
  • Appendiceal Carcinoids
  • Rectal Carcinoid Tumors
• Adrenal
  • Primary hyperaldosteronism
  • Endogenous hypercortisolism (Cushing's syndrome vs. Cushing's disease)
  • Pheochromocytoma / Paraganglioma syndromes
  • The incidentally discovered adrenal mass
  • Virilizing adrenal tumors
  • Adrenal cortical carcinoma

Discuss the peri-operative management of the following:

• Thyroid
  • Thyroid storm and thyrotoxicosis
  • Graves’ disease / Hashimoto's disease
• Parathyroid
  • Hypercalcemic crisis
  • Hungry bone disease
  • Vitamin D deficiency
• Adrenal
  • Pheochromocytoma / Paraganglioma syndromes - including blockade
  • Hyperaldosteronism
  • Endogenous hypercortisolism
  • Adrenal insufficiency crisis (Addison's disease)
• NET
  • Insulinoma / Gastrinoma
  • Carcinoid syndrome and carcinoid crisis

Outline the differential diagnosis of:

• Thyroid
  • Suppressed TSH level
  • Elevated serum thyroxine level
  • Lateral neck mass
  • Airway obstruction
• Parathyroid
  • Hypercalcemia
  • Elevated PTH level
• NET
  • Hypoglycemia
  • Hypergastrinemia
  • Secretory diarrhea
• Adrenal
  • Elevated Cortisol levels
  • Surgical hypertension

Be able to describe and develop the surgical skills to perform safely many of the following surgical procedures. Recognize the potential complications and alternative treatment options of each procedure:

• Thyroid
  • A retrosternal goiter
  • Thyroid lobectomy
  • Total / near-total thyroidectomy
  • Compartment-oriented lymph node dissections of the neck
  • Reoperative / completion thyroidectomy
• Parathyroid
  • Finding the inferior parathyroid glands
  • Finding the superior parathyroid glands
  • Finding ectopic parathyroid glands
  • Reoperative parathyroidectomy
• Adrenal
  • The left adrenal gland (anterior, laparoscopic and posterior)
  • The right adrenal gland (anterior, laparoscopic and posterior)
  • Retroperitoneal lymph node dissection
• Neuroendocrine Tumors
  • The head of the pancreas
  • The body / tail of the pancreas
  • GI NET disease. including bowel resection and mesenteric nodal dissection
  • Principles of liver resection and radiofrequency ablation

Identify and discuss potential areas of controversy in the field of endocrine surgery, including:

• Zollinger-Ellison syndrome (with and without MEN I)
• Genetic screening for familial endocrine syndromes
• Operative approach to HPT - including imaged directed, unilateral and four-gland exploration with and without iPTH
• Management of WDTC - including I131 ablation, utilization of rhTSH, and cancer surveillance
• Utility of laparoscopic adrenalectomy for large tumors.

Understand the role and apply the appropriate utilization of the following imaging and diagnostic studies in the surgical management of endocrine surgical disease:

• Imaging modalities:
  • Ultrasound
    • Understand the role and importance of surgeon-performed ultrasound
    • Identify normal structures visualized during ultrasound of the head and neck, and be able to identify thyroid nodules, parathyroid adenomas and adenopathy
    • Be able to use US to identify which features of a thyroid nodule on ultrasound are more worrisome for malignancy and perform a fine needle aspiration of thyroid and parathyroid.
  • CT, MRI, PET
    • Scintigraphy, including meta-iodo benzylguanine [MIBG], sestamibi, Octreotide scan, NP-59 scan
    • Selective venous sampling (parathyroid and adrenal)
    • Intraoperative tumor localization (gamma probe, Intra-Op U/S)
  • Diagnostic assays:
    • TSH, T3, T4, thyroglobulin
    • Calcitonin
    • PTH and intra-operative PTH assays
    • Chromogranin A
    • Urinary 5-HIAA
    • Insulin: Glucose ratio
    • Metanephrine (plasma and urinary)
    • Urinary free Cortisol / Midnight Salivary Cortisol
    • Dexamethasone suppression testing
    • Cortisyn stimulation testing
    • Aldosterone / Renin
  • Pathological assessment
    • FNA of the thyroid gland (limitations and selective utilization)
    • Frozen sections (limitations and appropriate utilization)
    • Immunohistochemical staining, including Ki67
    • Diagnostic criteria of malignancy in NET

Research and Critical Appraisal

• Understand the design of both clinical and basic science research studies
• Develop a basic understanding of the statistical methods applied to various study designs
• Develop a basic knowledge of molecular biology as it applies to endocrine surgical diseases
• Be able to critical appraise the medical literature.
• Develop a research question in Endocrine Surgical disease and pursue an appropriate research project during the fellowship with the goal toward peer review publication

Enabling Objectives

Complete a detailed evaluation of patients suspected of having an endocrine disease. Collaborate in the diagnostic work up of patients and direct the appropriate investigations.

Participate and manage the pre- and post-operative care of patients undergoing surgery of the thyroid, parathyroid, adrenal and neuroendocrine tumors.

Perform and/or assist in the performance of the following surgical procedures:

• Thyroid
  • A retrosternal goiter / multinodular goiter
  • Thyroid lobectomy
  • Total / near-total thyroidectomy
  • Compartment-oriented lymph node dissections of the neck
  • Reoperative / completion thyroidectomy
  • Direct laryngoscopy
  • Head and neck U/S
• Parathyroid
  • Finding the inferior parathyroid glands
  • Finding the superior parathyroid glands
  • Finding ectopic parathyroid glands
  • Reoperative parathyroidectomy
  • Imaged directed / unilateral / four gland exploration
  • Subtotal / total parathyroidectomy with autotransplantation
• Adrenal
  • The left adrenal gland (anterior, laparoscopic and posterior)
  • The right adrenal gland (anterior, laparoscopic and posterior)
  • Retroperitoneal lymph node dissection
  • En bloc retroperitoneal dissection for malignancy
• Neuroendocrine Tumors
  • Resection / enucleation of NET in the pancreas
  • NET associated with MEN I syndrome (Thompson Procedure)
  • GI NET disease including bowel resection and mesenteric nodal dissection
  • Perform / understand the principles of liver resection and radiofrequency ablation

Be able to interpret and appropriately order endocrine diagnostic testing and imaging studies for each of the following endocrine glands:

• Thyroid
• Parathyroid
• Adrenal
• GI NET
• Endocrine pancreas

Spend quality time working under the direct supervision of a cytopathologist and anatomical pathologist.

Spend quality time with the Endocrinology service, focusing on pre-operative evaluation of endocrine surgical diseases. Knowledge gained should include the peri-operative management of hormones, including insulin, octreotide, and thyroid hormone.

To have exposure to and/or to work with colleagues in other disciplines related to the diagnoses and treatment of endocrine surgical disease, such as:

• Nuclear medicine
• Medical oncology
• Genetics
• Interventional radiology
• Gastroenterology

Be able to evaluate patients with complex endocrine disease and present a differential diagnosis and an appropriate algorithm for their care.

Gain experience in performing clinical and/or basic science research. Be able to collect and analyze data. Participate and/or present at journal club and surgical rounds related to endocrine surgical diseases. Develop experience in writing articles and orally presenting research studies at local and national meetings.

Goals and Objectives

• Understand the design of both clinical and basic science research studies.
• Develop a basic understanding of the statistical methods applied to various study designs.
• Develop a basic knowledge of molecular biology as it applies to endocrine surgical diseases.
• Be able to critically appraise the medical literature.
• Develop a research question in endocrine surgical disease, conduct a study, evaluate the results, and create a presentation or a manuscript suitable for a peer review publication.
• The fellow will be expected to present his/her work in a variety of settings, including Mass General Department of Surgery Research Seminars, as well as at national meetings.

Inclusions

All fellows are required to attend and participate in the weekly conferences and meetings, including:

• Departmental Grand Rounds: The fellow will be responsible for selecting topics for resident education and coordinating the meetings.
• Endocrine Surgery ward rounds: The Endocrine Surgery fellow will coordinate with the general surgery residents specific cases and topics for discussion. The trainee will direct the conference and formulate teaching aims for residents and medical students.
• Endocrinology fellows’ conference: S/he would also present a case and topic of discussion at one of the meetings during the year.
• Center for Clinical Effectiveness (CCES) meeting. The CCES sponsors the department of surgery databases (including the endocrine surgeries database such as the Collaborative Endocrine Surgery Quality Improvement Program - CESQIP). At the meeting, outcomes research projects that are ongoing at Mass General and Brigham and Women's Hospital are presented. The trainee will attend the monthly meeting in order to gain exposure to database organization and development, as well as outcomes research. The trainee will also present at one of the meetings on the status of endocrine surgery research at Mass General.
• Seminars in cancer biology and endocrinology.
• Active participant in lab meetings.

Supervision and Evaluation

The fellow will meet two days per week with the project mentor and the program director to go over the research plan, new ideas and any difficulties. These meetings will be one on one; recent research will be reviewed as well as discussing recent work from other labs, important unsolved questions in the field and strategies for approaching them. The fellow will meet with the program director on a quarterly basis to assess whether or not personal goals and objectives are being met and to review the evaluations from the previous quarter.