turk health expert
turk health expert

Endocrine and Breast Surgery

ENDOCRINE SURGERY

Endocrine glands are complex structures that regulate the functions of organs and maintain balance in the body through the hormones they secrete. They are found in various regions of the body. Metabolic processes, the respiratory and circulatory systems, growth, sexual development, pregnancy, and reproduction are all controlled by the endocrine system. Therefore, endocrine disorders give rise to health problems that can affect many aspects of daily life. Endocrine surgery is a specialized field that deals with the surgical treatment of all endocrine disorders. However, the accurate diagnosis and complete treatment of these diseases depend on the collaborative multidisciplinary approach of experts in endocrinology, radiology, pathology, nuclear medicine, oncology, and endocrine surgery.

In particular, the thyroid, parathyroid, and adrenal glands are important endocrine glands within the scope of endocrine surgery.

THYROID GLAND

The thyroid gland is a small gland that extends in a butterfly-shaped manner over the trachea (windpipe). It secretes thyroid hormones (T3-T4-Thyroxine), which have crucial roles in the body's metabolic balance.

An excess of thyroxine (hyperthyroidism) can manifest as excessive metabolic activity (rapid heartbeat, sweating, tremors in the hands, weight loss, hair loss, irritability, osteoporosis, etc.). On the other hand, a deficiency (hypothyroidism) can lead to decreased metabolic activity (fatigue, weight gain, changes in the skin, etc.).

Thyroid nodules are the most common thyroid gland disorders. Goiter, thyroid inflammation, and thyroid cancer are other frequently observed thyroid pathologies.

Thyroid nodules

Thyroid nodules are masses of varying sizes (ranging from the size of a lentil to that of a walnut), filled with fluid or solid content, that occur within the thyroid gland. They are commonly seen in the population, particularly in women, and their frequency increases with age. The majority of these nodules are benign and harmless. Nodules smaller than two centimeters usually do not cause any symptoms. In some cases, they may be noticed by the physician during examination or detected during an ultrasound imaging study. Rarely, when they reach a large size, they can cause hoarseness, swallowing difficulties, and breathing problems due to compression.

Some thyroid nodules are "cold," meaning they do not produce any hormones. Others are "hot" and actively secrete hormones. This uncontrolled hormone secretion can manifest itself with the symptoms described above, indicating a condition of hyperthyroidism.

These nodules carry a risk of cancer, approximately 5-10%. Therefore, even though they are generally benign, regular medical monitoring of thyroid nodules is important. Especially for cold nodules, which have a higher risk of malignancy, closer monitoring and further investigations are necessary for proper control.

Goiter

The enlargement of the thyroid gland in terms of volume is referred to as goiter. When goiter is accompanied by a nodule, it is called nodular goiter, and when there are multiple nodules, it is referred to as multinodular goiter. There are many diseases that can cause goiter in clinical practice.

Inflammatory diseases of the thyroid

Graves' disease is an autoimmune disorder where the body's immune system mistakenly attacks its own tissues. In this disease, abnormal production of antibodies leads to excessive secretion of thyroid hormones. Blood levels of thyroid hormones are elevated.

Hashimoto's Thyroiditis, on the other hand, is another autoimmune disease characterized by decreased levels of thyroid hormones. These diseases can coexist with other autoimmune disorders in the body.

Thyroid gland cancers

Thyroid cancers are cancers that occur when thyroid cells transform into cancer cells. They are among the commonly observed cancers in the population, with a higher incidence in women. In recent years, due to increased monitoring and control of high-risk groups (such as exposure to radiation, iodine deficiencies, etc.), early diagnosis has become more common, leading to less fatal outcomes. Thyroid cancer, when diagnosed and treated correctly, has a high success rate in treatment. Thyroid cancers generally present with nodules and metabolic symptoms.

There are several types of thyroid cancer. The most common and highly treatable type is differentiated thyroid cancer, which has two subtypes: papillary thyroid cancer (80%) and follicular thyroid cancer (10%). Anaplastic cancers are more commonly seen in the elderly and are more aggressive. Medullary cancers are very rare and often do not exhibit aggressive behavior.

Diagnosis in Thyroid Diseases

The diagnosis of thyroid gland diseases is made through neck examination, ultrasound, thyroid hormone levels, and other thyroid-related blood tests.

In some cases, thyroid scintigraphy is needed to determine if nodules are "hot" nodules. Especially for the evaluation of cold nodules, a fine needle aspiration biopsy is required, which is performed with a thin needle. So, the collected cells need to be examined under a microscope to eliminate the suspicion of cancer. Based on the results of the fine needle aspiration biopsy, all nodules that are identified as cancer or suspicious for cancer need to be surgically removed. Even if the biopsy results come back clean, regular monitoring of the nodule is recommended. This is because, although it is unlikely, pathological results can sometimes be misleading. If there is a 20% increase in the size of the nodule, repeating the needle biopsy may be considered before deciding on surgery.

Treatment Principles in Thyroid Diseases

In some cases of thyroid diseases, regular clinical follow-up with periodic doctor visits is sufficient. However, the presence of hyperthyroidism always requires treatment. In treatment, the initial approach is to use medical therapy (anti-thyroid drugs) to correct the condition. If there is no improvement, more aggressive methods such as radioactive iodine therapy or surgical removal of the thyroid gland may be considered. However, in certain high-risk cases (such as Graves' disease, suspicion or presence of cancer, large nodules causing clinical problems, etc.), surgical intervention may be preferred before the medical treatment stage in the early phase.

Surgically, depending on the condition of the disease, a portion of the thyroid gland can be removed (unilateral lobectomy, unilateral thyroidectomy), the entire gland can be removed (total thyroidectomy), or the thyroid gland along with lymph nodes can be removed. Prior to surgery, in some patients, it may be necessary to maintain thyroid balance as much as possible through medical treatment.

If there is a single hot nodule, "radioactive iodine" treatment options may be considered. However, if the hot nodule measures 2 cm or larger, or if there are multiple hot nodules, then surgical treatment may be necessary. In some cases (such as cancer spreading to the lymph nodes, cancer involving the capsule surrounding the thyroid, and the cancer diameter being larger than 10 mm), adjuvant radioactive iodine therapy can be administered six weeks after surgery. Radioactive iodine therapy is effective in preventing cancer recurrence and distant metastases. The principle of radioactive iodine therapy is based on the absorption of radioactive iodine by the thyroid gland and its destruction of the gland.

The treatment success rate for papillary and follicular cancers exceeds 80% with early diagnosis. Recurrences are rare, and the combination of surgery and radioactive iodine therapy yields good treatment response.

Minimal invasive techniques are used in the surgical procedures of suitable patients. This means the smallest incision, minimal complications, quick recovery, and minimal surgical scar. Furthermore, during surgery, the damage to important structures in close proximity should be prevented using neuronavigation.

In cases of underactive thyroid function (hypothyroidism), medical treatment (hormone replacement therapy) may be the only treatment option. Hormone replacement therapy is also necessary in patients who have undergone total thyroidectomy and no longer have any thyroid tissue producing hormones.

PARATHYROID GLAND

What is the parathyroid gland?

Parathyroid glands are four small glands located on either side of the thyroid gland in the neck. They secrete parathyroid hormone (parathormone, PTH), which is vital for maintaining the balance of calcium and phosphorus in the bones and blood, crucial for bone health in the body.

Problems during PTH secretion can cause fluctuations in blood calcium and phosphorus levels, leading to non-specific symptoms such as osteoporosis (bone loss), kidney stones, kidney damage, confusion, memory changes, muscle pain, cramps, irregular heartbeat, and excessive urination.

What are parathyroid gland diseases?

Excessive enlargement and uncontrolled hormone secretion in one or more parathyroid glands are referred to as hyperparathyroidism. In other words, the glands are hyperactive. If one of the glands is affected, it is called parathyroid adenoma (90% of cases), and if all the glands are affected, it is called parathyroid hyperplasia (10% of cases). Due to elevated levels of PTH, significant imbalances in blood calcium levels occur, leading to the aforementioned health problems. Adenomas are generally small and tend to be benign. While parathyroid cancers are rare, close clinical and laboratory monitoring of parathyroid adenoma is crucial.

How is the diagnosis made in parathyroid gland diseases?

Hyperparathyroidism manifests itself through an increase in blood calcium levels. This condition can be incidentally detected through routine blood tests for unrelated reasons, or it can be identified during the investigation of diseases such as osteoporosis, kidney stones, and kidney pain. Furthermore, blood PTH levels are included in the diagnostic workup as a secondary measure.

Parathyroid adenomas can sometimes be detected through ultrasound. Special diagnostic methods like scintigraphy are also used to identify parathyroid adenomas with abnormal locations.

What are the current methods used in the surgical treatment of parathyroid gland diseases?

When growth and excessive functioning are detected in a gland, it is surgically removed. This procedure is called parathyroidectomy. Medical treatments generally offer temporary improvements, and surgical intervention is necessary to permanently restore calcium levels to normal. If all glands are affected, meaning there is hyperplasia, a subtotal parathyroidectomy is performed, in which a portion of one gland (usually half) is left while removing all the glands. It is believed that the remaining parathyroid tissue is sufficient for maintaining the body's balance.

When the surgical procedure is performed by an experienced team, it is usually completed with a 2-3 cm incision and without any complications.

Hypoparathyroidism (insufficient levels of PTH hormone) occurs when the parathyroid glands do not function properly. This condition is almost entirely a complication of thyroid surgeries. Symptoms due to low calcium levels, caused by decreased PTH levels, may include muscle cramps, tingling in the lips, fingers, and feet, and so on. The treatment involves the use of artificial hormone medications.

Parathyroid carcinomas are rare, and their treatment approaches are similar to those of parathyroid adenomas.

ADRENAL GLAND

What is the adrenal gland?

The adrenal glands, also known as suprarenal glands, are two secretory glands located above each kidney that secrete many important hormones for our body.

The adrenal gland consists of two different layers. The cortex layer secretes three types of hormones that play a role in processes such as glucose and fat metabolism, blood pressure regulation, and sexual development: cortisol, aldosterone, and androgens. On the other hand, the medulla layer produces two hormones known as stress hormones: adrenaline and noradrenaline.

Problems in the secretion of these hormones manifest as dysfunctions in the systems they regulate.

What are adrenal gland diseases?

Generally, two different groups of diseases can be mentioned: hyposecretory diseases, where the glands function inadequately or produce insufficient hormones and hypersecretory diseases, where the glands overwork or produce excessive hormones. In the first group of diseases, attempts are made to correct the condition through medication supplementation, while surgical treatment options are generally used in addition to medical treatments for the second group of diseases.

Among these diseases, Phaeochromocytoma (a tumoral disease caused by masses originating from the medullary layer, characterized by symptoms such as palpitations, hypertension, and flushing attacks), Conn Syndrome (a disease characterized by low potassium levels in the blood, hypertension, fatigue, and weakness), and Cushing's Syndrome (a disease characterized by excessive cortisol secretion and the clinical presentation caused by high levels of cortisol. It manifests with swollen face, skin manifestations, weight gain, muscle mass loss, increased hair growth, osteoporosis, etc.) can be mentioned.

How is the diagnosis made in adrenal gland diseases?

The diagnosis is obtained by measuring the blood levels of relevant hormones belonging to the adrenal gland and determining the location of adrenal gland masses through imaging methods such as ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and scintigraphy.

What are the current methods used in the surgical treatment of adrenal gland diseases?

In modern times, the majority of surgical procedures for the adrenal gland are performed using a minimally invasive approach, namely laparoscopic surgery, which is a closed method. With this method, the diseased gland can be removed, allowing the patient to recover their health quickly. However, it should be noted that adrenal diseases require a multidisciplinary approach and must be followed by several areas of expertise working together.

BREAST SURGERY

Breast surgery is the general term used for surgical procedures that alter the structure of the breast. Although not as common as in women, these surgeries can also be performed in men and are sometimes chosen due to cosmetic or psychological concerns (such as breast augmentation or reduction surgeries, etc.). However, they are generally performed with the aim of correcting an underlying significant medical issue.

The most commonly performed and important surgical procedure among these types of surgeries with medical indications is breast cancer surgery.

Other common medical conditions that may require breast surgery, aside from cancer surgery, can be examined under the following headings:

  • Benign tumors of the breast

  • Breast cysts

  • Inflammatory diseases of the breast (mastitis)

    BREAST CANCER SURGERY

    Breast cancer is one of the most common cancers, particularly in women, and favorable results can be achieved with early diagnosis and appropriate treatment. In breast cancer, depending on the stage of the disease and the overall condition of the patient, radiotherapy, chemotherapy, hormonal therapy, and surgical treatments can be used separately or in combination with each other. Generally, surgical options are preferred as the initial approach. After the removal/clearance of the affected tissue/areas by various surgical methods, one or more of the other treatment modalities are added as complementary measures.

    Important criteria such as tumor size, location, extent of spread, and previous treatments are taken into consideration when determining the appropriate surgical method to be applied. This decision-making stage is crucial for the success of the entire treatment process and ensuring a high level of patient comfort.

    At our Breast Surgery Unit, each patient's overall condition is individually evaluated through a multidisciplinary approach, taking into consideration the patient's preferences, in order to determine the most appropriate surgical method.

    The goal in breast cancer surgery is to remove the tumor mass while preserving the surrounding healthy tissue as much as possible. In some cases, this goal can be achieved by removing only the tumor tissue. However, this may not always be possible. In some patients, it may be necessary to remove a portion or the entire healthy breast tissue along with the tumor tissue. In advanced cases, the removal of the axillary lymph nodes is also added to the breast surgery.

    Sometimes, chemotherapy or hormone therapy is administered before surgery to reduce the size of the tumor and facilitate its removal. This procedure is generally referred to as Neoadjuvant therapy.

    In some patients, a series of corrective breast surgeries, classified as breast reconstruction surgery, are performed to repair the breast damage that occurs after tumor surgery.

    In some cases, revision surgery may be necessary. Briefly, revision surgery is a surgical procedure performed when the tumor, previously removed through surgery, recurs in the same area, and generally a more aggressive approach is preferred compared to the previous procedure.

    Basic Surgical Methods Applied in Breast Cancer:

    In breast cancer surgery, although various surgical methods are described, they can generally be grouped into two main categories. The first category is conservative breast surgeries, where efforts are made to preserve the breast tissue. The second category is mastectomies, where the entire breast is removed.

    Conservative Breast Surgery

    Conservative breast surgery is a type of surgery that aims to preserve the normal breast tissue to the highest extent possible. It is a suitable method for tumors with well-defined boundaries, limited progression, and early diagnosis.

    These procedures, also known as lumpectomy or segmentectomy, specifically target only the tumor tissue or the limited area where the tumor is located. However, it is essential to ensure that no tumor tissue is left behind after the procedure. Therefore, as a safety margin, the tumor is removed along with a small amount of surrounding healthy tissue. During or after the surgery, a pathological examination under a microscope is performed to demonstrate that the surgical margin is clear of tumor tissue. If the surgical margin is not clear, the surgery is repeated, and more tissue is removed.

    Although the breast's structure may not be entirely normal after surgery using this method, the aim is to maintain the natural appearance to the maximum extent possible. This procedure is generally followed by radiotherapy. The procedure is performed under general anesthesia or local anesthesia through a small incision. Regular medical follow-up after surgery is crucial for preventing tumor recurrence and detecting it early.

    Conservative / Non-Conservative Breast Surgery: Mastectomy

    Surgical procedures in which the entire breast tissue is removed are referred to as mastectomy. It is performed in cases where the tumor tissue is large or when there are multiple tumors. Additionally, mastectomy should be considered if tumor cells remain in the surgical margin tissue that should be clear in conservative treatments mentioned above, or if the breast tumor recurs after radiotherapy.

    There are several types of mastectomy that a physician can choose based on the patient's overall medical condition:

    Total mastectomy

    Lymph nodes, nerves, and the muscles of the chest are preserved, while the remaining breast tissue, along with the underlying muscle's fascia (pectoral fascia), is removed in this surgical method. The nipple may also be removed. If the patient's medical condition allows, efforts are made to preserve the skin covering the breast. This procedure is called "subcutaneous mastectomy," which results in fewer visible scars and allows for more satisfactory outcomes in breast reconstruction.

    Modified radical mastectomy

    Modified radical mastectomy is a surgical method used when breast cancer has spread to the lymph nodes in the armpit or in cases of inflammatory breast cancer.

    In modified radical mastectomy, the entire breast, nipple, most or all of the lymph nodes in the armpit, and the tissue covering the chest muscles (pectoral fascia) are removed. The chest muscles are usually preserved in this procedure. Radical mastectomy, in comparison to modified radical mastectomy, is a more aggressive surgical method that is rarely performed today. It involves the removal of more muscles, lymph nodes, and tissue.

    Mastectomy procedures are performed under general anesthesia. Plastic tubes or drains are placed in the surgical areas after the operation and they remain for a period of time. These drains are effective in draining accumulated fluid and facilitate the surgeon's monitoring of the surgical site. After a short period of follow-up, the patient is discharged from the hospital, and the drains are removed at home after a certain period of monitoring. The drain holes are closed with stitches. Permission from the physician should be obtained for activities involving heavy lifting, exercises, swimming, and driving after surgery. For conservative surgeries, approximately two weeks of recovery time may be needed before returning to work, while for mastectomy, it may take approximately four to six weeks.

    Just like in breast-conserving surgeries, regular follow-ups with general surgery and oncology specialists are crucial after mastectomy surgeries as well.

    Complications such as pain, numbness, and difficulty in arm and shoulder movement may occur after mastectomy procedures.

    Lymphedema, which is swelling in the arm due to impaired lymphatic circulation, can be considered as a significant complication that patients may experience after surgery. Lymphedema treatment requires a longer rehabilitation program compared to other complications and, unfortunately, in some cases, it can be permanent.

    After mastectomy surgeries, some patients may experience significant psychological health issues that need to be taken seriously, such as body image disturbances and depression, due to the loss of breast tissue. Oncoplastic breast surgery (breast cancer aesthetics) is a surgical procedure that has shown successful results in preventing psychological issues related to breast loss in recent years. These surgical techniques involve selecting the surgical procedure that will cause the least damage and also include the reconstruction of tissue after potential loss.

    In breast reconstruction surgeries, the primary focus is on restoring breast volume, followed by achieving symmetry between the two breasts and reshaping the nipple-areolar complex. This restoration process can be performed in the same session as tumor surgery (primary reconstruction) or at a later stage after the initial surgery (secondary reconstruction). It should be noted that the possibilities of breast reconstruction (implant, lipomodelling, autologous reconstruction, flap, etc.) can vary from patient to patient, and the physician will make the most appropriate decision by taking into account the patient's preferences. Variables used in making decisions for reconstruction surgery include the type of primary surgery, the amount of tissue removed from the breast, the amount of remaining healthy tissue, the presence of additional treatments such as radiotherapy that may cause issues with the skin, and overall health conditions.

    Operations targeting the lymph node

    Malignant tumors of the breast, if not diagnosed in the early stages, can spread to various regions/organs of the body (metastasis). In breast cancer, the surrounding lymph nodes are usually the first tissues affected. Therefore, during the planning of treatment to determine the stage of cancer, the physician may perform procedures targeting the lymph nodes:

    Sentinel lymph node biopsy-surgery

    The sentinel lymph node is the first lymph node where lymph fluid drains from the tumor site, making it the initial destination for the spread of cancer cells. Therefore, the absence of tumor cells in the sentinel lymph node is considered an indication that the tumor has not advanced further and is in the early stage. To determine this, a biopsy is performed by taking a sample from the sentinel lymph nodes, which is then examined under a microscope for pathological analysis. The results obtained will affect the treatment options and the course of the disease. The more the tumor has advanced, the more aggressive surgical methods are preferred, and the risk of recurrence becomes higher.

    Axillary lymph node surgery

    When breast cancer cells surpass the sentinel lymph nodes, their next destination is the axillary lymph nodes, located in the armpit area. The involvement of axillary lymph nodes will not only impact surgical approaches but also alter the content of additional treatment modalities. In such cases, along with mastectomy surgery, clearance of the axillary region is necessary.

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