Endocrine and Breast Surgery
Endocrine Surgery
Endocrine glands are complex structures that keep the body in balance by regulating what the organs should do through the hormones they secrete. They are located in various parts of the body. All major processes such as metabolic processes, respiratory and circulatory systems, growth, sexual development, and pregnancy/reproduction are under the control of the endocrine system. Therefore, endocrine diseases manifest with health problems that can affect many aspects of daily life. Endocrine surgery is the specialty area dealing with the surgical treatment of all endocrine diseases. However, accurate diagnosis and complete treatment of these diseases depend on a multidisciplinary approach involving specialists 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 butterfly-shaped gland that lies above the trachea (windpipe). It secretes thyroid hormones (T3, T4, thyroxine), which have vital functions in the body's metabolic balance.
Excess thyroxine (hyperthyroidism) can present with excessive metabolic activity (palpitations, sweating, tremors in the hands, weight loss, hair loss, irritability, osteoporosis, etc.). Deficiency (hypothyroidism) can manifest with symptoms related to decreased metabolic activity (fatigue, weight gain, skin changes, etc.).
Among thyroid diseases, thyroid nodules are the most common. Goiter, thyroid inflammation, and thyroid cancer are other frequent thyroid pathologies.
Thyroid Nodules
Thyroid nodules are fluid-filled or solid masses of various sizes (from the size of a lentil to the size of a walnut) that develop within the thyroid gland. They are common in the general population, especially among women, and their frequency increases with age. Most of these nodules are harmless and benign. Nodules smaller than two centimeters generally do not cause symptoms. In some cases, they are detected by the physician during examination or incidentally during ultrasound imaging. Rarely, when they grow large, they can cause compression symptoms such as hoarseness, difficulty swallowing, and breathing difficulties.
Some thyroid nodules are “cold,” meaning they do not secrete any hormones. Others are “hot,” meaning they secrete hormones, and this uncontrolled secretion can present with the hyperthyroidism symptoms described above.
These nodules carry a 5–10% risk of cancer. Therefore, even though they are generally harmless, regular medical follow-up of thyroid nodules is important. In particular, cold nodules have a higher risk of malignancy and require closer monitoring and advanced testing.
Goiter
An enlargement of the thyroid gland in volume is called a goiter. If nodules accompany goiter, it is called nodular goiter; if there are multiple nodules, it is called multinodular goiter. Many diseases can cause goiter.
Inflammatory Diseases Of The Thyroid
Basedow-Graves disease is an autoimmune condition (where the body reacts against its own tissues). In this disease, abnormal antibodies cause excessive secretion of thyroid hormones, resulting in elevated blood thyroid hormone levels.
Hashimoto’s thyroiditis is another autoimmune disease in which thyroid hormone levels decrease. These diseases can coexist with other autoimmune conditions in the body.
Thyroid Cancer
Thyroid cancers occur when thyroid cells transform into cancer cells. They are among the most common cancers in the population, especially in women. In recent years, due to the increased screening and monitoring of high-risk groups (exposure to radiation, iodine deficiency, etc.), earlier diagnoses have been made, leading to less fatal outcomes. Thyroid cancer, when diagnosed and treated correctly, has a high treatment success rate. It generally presents with a mass in the thyroid and metabolic symptoms.
There are several types of thyroid cancer. The most common and most treatable types are differentiated thyroid cancers (two subtypes: papillary thyroid cancer 80% and follicular thyroid cancer 10%). The type more common in older individuals and more aggressive is anaplastic cancer. Medullary cancers are very rare and often less aggressive.
Diagnosis of Thyroid Diseases
Diagnosis of thyroid diseases is made through neck examination, ultrasound, and detecting changes in thyroid hormone and related blood tests.
In some cases, thyroid scintigraphy is used to determine whether nodules are hot. In particular, cold nodules require evaluation with fine-needle aspiration biopsy (FNAB), where cells are taken and examined under a microscope to rule out cancer suspicion. All nodules with cancer or suspected cancer on FNAB require surgery. Even if the biopsy is benign, periodic follow-up is recommended because, although rare, pathological results can sometimes be misleading. If the nodule grows by 20%, FNAB is repeated, and surgery may be considered.
Treatment Principles in Thyroid Diseases
In some thyroid diseases, only clinical follow-up with regular check-ups is sufficient. However, hyperthyroidism always requires treatment. Initially, medical treatment (anti-thyroid drugs) is used, but if there is no improvement, more aggressive methods such as radioactive iodine or surgical removal of the thyroid gland are considered. In certain high-risk cases (e.g., Graves’ disease, cancer suspicion or presence, large nodules causing clinical problems), surgical intervention may be preferred earlier.
Surgically, depending on the disease, part of the thyroid gland may be removed (unilateral lobectomy, unilateral thyroidectomy), the entire gland may be removed (total thyroidectomy), or lymph nodes along with the thyroid gland may be removed. Preoperative medical treatment may be needed to stabilize thyroid balance.
If there is a single hot nodule, radioactive iodine may be an option, but if it is 2 cm or larger or multiple hot nodules are present, surgery may be necessary. In some cases (spread of cancer to lymph nodes, capsular invasion, tumor size >10 mm), complementary radioactive iodine therapy may be applied six weeks after surgery to prevent recurrence and distant metastases.
Treatment success rates in early-diagnosed papillary and follicular cancers exceed 80%. Recurrences are rare and respond well to combined surgery and radioactive iodine.
Whenever possible, minimally invasive surgical techniques are used, meaning smaller incisions, fewer complications, faster recovery, and minimal scarring. Intraoperative neuronavigation is used to protect nearby critical structures.
In hypothyroidism (underactive thyroid), medical replacement therapy (hormone replacement) is the only treatment option. Replacement therapy is also mandatory in patients who have undergone total thyroidectomy.
Parathyroid Gland
What is the Parathyroid Gland?
The parathyroid glands are four small glands located around the thyroid gland on both sides of the neck. They secrete parathyroid hormone (PTH), which is essential for bone health and regulates the balance of calcium and phosphorus in bones and blood.
Problems in PTH secretion cause fluctuations in blood calcium and phosphorus levels, leading to many non-specific symptoms such as osteoporosis, kidney stones, kidney damage, confusion, memory changes, muscle pain, cramps, irregular heartbeat, and frequent urination.
What Are Parathyroid Gland Diseases?
Excessive growth and uncontrolled hormone secretion in one or more parathyroid glands is called hyperparathyroidism. In other words, the gland is overactive. If only one gland is affected, it is called parathyroid adenoma (90%); if all glands are affected, it is called parathyroid hyperplasia (10%). High PTH levels cause significant imbalances in blood calcium levels, leading to many health problems mentioned above. Adenomas are generally small and benign. Although cancers are rare, close clinical and laboratory follow-up of parathyroid adenomas is crucial.
How Are Parathyroid Gland Diseases Diagnosed?
Hyperparathyroidism manifests with elevated blood calcium levels. This may be detected incidentally during blood tests performed for other reasons or during the investigation of diseases such as osteoporosis, kidney stones, or kidney pain. Blood PTH levels are part of the second stage of diagnostic tests.
Parathyroid adenomas can sometimes be detected by ultrasonography. Special imaging methods such as scintigraphy are used to detect abnormally located parathyroid adenomas.
Current Surgical Treatments For Parathyroid Gland Diseases
If enlargement and overactivity of a gland are detected, that gland is surgically removed — this procedure is called parathyroidectomy. Medical treatments generally provide only temporary improvement; surgery is required to permanently normalize calcium levels. If all glands are diseased (hyperplasia), subtotal parathyroidectomy is performed, leaving part of one gland (usually half) to maintain hormonal balance.
When performed by an experienced surgical team, the procedure is generally completed with a 2–3 cm incision and without complications.
Hypoparathyroidism (PTH hormone deficiency) develops when the parathyroid glands do not function, most often as a complication of thyroid surgery. Low PTH levels cause symptoms due to low calcium levels (muscle cramps, tingling in the lips, fingers, and feet, etc.). Treatment is with synthetic hormone medications.
Parathyroid carcinomas are rare, and treatment approaches are similar to those for parathyroid adenomas.
Adrenal Gland
What is the Adrenal Gland?
Also called the suprarenal gland, the adrenal glands are two endocrine glands located above each kidney. They secrete many essential hormones for our body.
The adrenal gland consists of two distinct layers: the cortex (which secretes three types of hormones involved in processes such as glucose and fat metabolism, blood pressure regulation, and sexual development — cortisol, aldosterone, and androgens) and the medulla (which produces two hormones known as stress hormones — adrenaline and noradrenaline).
Problems in the secretion of these hormones manifest as disorders in the systems they regulate.
What Are Adrenal Gland Diseases?
They can generally be divided into two groups: hyposecretory diseases (underactive glands producing insufficient hormones) and hypersecretory diseases (overactive glands producing excess hormones). The first group is usually managed with medication, while surgical treatment is often used for the second group, either alone or in addition to medical therapy.
Diseases in this group include pheochromocytoma (a tumor arising from the medulla causing episodes of palpitations, hypertension, and facial flushing), Conn’s syndrome (characterized by low potassium, hypertension, weakness, and fatigue), and Cushing’s syndrome (caused by excess cortisol secretion, presenting with a rounded face, skin changes, weight gain, muscle loss, increased hair growth, osteoporosis, etc.).
Diagnosis Of Adrenal Gland Diseases
Diagnosis involves measuring blood levels of the relevant adrenal hormones and detecting adrenal masses using imaging methods such as ultrasound, CT, MRI, or scintigraphy.
Current Surgical Treatments For Adrenal Gland Diseases
Today, most adrenal gland surgeries are performed using minimally invasive laparoscopic (keyhole) techniques. This allows the diseased gland to be removed, enabling the patient to regain health in a short time. However, adrenal diseases require a multidisciplinary approach and must be followed jointly by multiple specialties.
Breast Surgery
Breast surgery is the general term for all surgical procedures that alter the structure of the breast. Although less common in men than women, these surgeries may sometimes be performed for cosmetic/psychological reasons (breast augmentation, breast reduction, etc.). However, they are most often performed to treat significant underlying medical conditions.
The most common and important medically indicated breast surgery is breast cancer surgery.
Other common medical problems requiring breast surgery include:
- Benign breast tumors
- Breast cysts
- Inflammatory breast diseases (mastitis)
Breast Cancer Surgery
Breast cancer is the most common cancer in women and one that can have highly favorable outcomes when diagnosed early and treated correctly. Treatment may involve radiotherapy, chemotherapy, hormonal therapy, and surgery, either alone or in combination. Surgery is usually the first choice, followed by one or more complementary treatments.
The choice of surgical method depends on factors such as tumor size, location, extent of spread, and prior treatments. This decision is critical for treatment success and optimal patient comfort.
At Emsey Breast Surgery Unit, each patient’s condition is evaluated individually with a multidisciplinary approach, and the most appropriate surgical method is chosen in consideration of the patient’s preferences.
The aim of breast cancer surgery is to remove the tumor mass while preserving as much healthy tissue as possible. In some cases, this can be achieved by removing only the tumor, but in others, part or all of the healthy breast tissue may also need to be removed. In advanced cases, axillary lymph nodes may also be removed.
Sometimes, to facilitate surgery and tumor removal, chemotherapy or hormone therapy is given beforehand to shrink the tumor — this is called neoadjuvant therapy.
In some patients, reconstructive breast surgery is performed after tumor removal to restore the breast’s appearance.
If the cancer recurs (local recurrence), further surgery may be necessary, usually involving a more aggressive approach than the initial operation.
Main Surgical Techniques In Breast Cancer
- Conservative (Breast-Conserving) Surgery
This approach aims to preserve as much normal breast tissue as possible and is suitable for localized, early-stage tumors. Procedures such as lumpectomy, tumorectomy, or segmentectomy target only the tumor area, but a margin of healthy tissue is also removed for safety. Pathological examination is essential to confirm clean surgical margins; if margins are positive, further surgery is required. This method generally requires follow-up radiotherapy. - Non-Conservative Surgery (Mastectomy)
Mastectomy involves removing the entire breast and is indicated when the tumor is large, multifocal, or when conservative surgery fails to achieve clean margins, or in cases of recurrence after radiotherapy.
Types of mastectomy include:
- Total Mastectomy: Removal of all breast tissue with the overlying skin (sometimes preserving the skin - subcutaneous mastectomy - for better reconstruction results).
- Modified Radical Mastectomy: Removal of the entire breast, nipple, most or all axillary lymph nodes, and the pectoral fascia while preserving the chest muscles.
Post-mastectomy, drains are placed to remove accumulated fluid, and activity restrictions are advised until healing is complete. Complications may include pain, numbness, limited arm movement, and lymphedema (arm swelling due to lymph circulation impairment), which can require prolonged rehabilitation.
Oncoplastic Breast Surgery
Combines cancer removal with aesthetic reconstruction to minimize psychological impact from breast loss. Reconstruction may be immediate (primary) or delayed (secondary), depending on patient condition, tumor characteristics, and planned additional treatments. Techniques include implants, lipomodelling, autologous reconstruction, and flaps.
Lymph Node Surgery
Breast cancer may spread to nearby lymph nodes, so lymph node procedures may be part of surgical planning:
- Sentinel Lymph Node Biopsy: Removal of the first lymph node(s) receiving drainage from the tumor area to check for cancer spread.
- Axillary Lymph Node Dissection: Removal of lymph nodes in the armpit if cancer is present beyond sentinel nodes, often performed with mastectomy.
