HO IV/V - Endocrine/Breast

Specific Educational Goals and Education

Level: PGY - 4/5

Service: Endocrine/Breast

Supervision: Chief Resident → Attending

All management decisions will be discussed with the senior resident and faculty.

Duty Hours:

Hours are to be logged into New Innovations on a weekly basis and will be reviewed weekly by the Program Director for ACGME violations and reviewed weekly for delinquencies by the Program Coordinator. Over a four week period; you will not average more than 80 hours a work week, you will have one day in seven free of clinical duty, in-house call will be no more frequent than one in three nights, you should receive 10 hours free between all duty periods and after in-house call and you will not be on duty for more than 30 consecutive hours. If you are assigned more hours than mentioned heretofore or have patient care duties that are extending you beyond these limits, it is your responsibility to notify your supervising resident or faculty so arrangements can be made to relieve you.

Educational Activities:

  1. Recommended Reading
    1. Schwartz's Principles of Surgery
    2. SCORE curriculum modules
  2. Conferences
    1. Wednesday Resident Educational Curriculum

Competency Based Performance Objectives:

Patient Care:

Goal: Through the acquired skills and knowledge of general surgery principles the resident can demonstrate the ability to manage disease and injury of the general surgery patient amenable to surgical intervention.

Endocrine Surgery Rotation Objectives:

These objectives outline the knowledge and skills that should be taught, learned, and demonstrated by the completion of general surgery residency. Although the field of endocrine surgery encompasses many uncommon diseases and syndromes, the curriculum is based on common endocrine diseases where the practicing general surgeon is often involved in the care. Other, uncommon syndromes outlined are appropriate for review because of their underlying pathophysiology and presence on standardized examinations. A resident successfully demonstrating all of these objectives will have the appropriate background to perform common endocrine surgical procedures commensurate with his/her skill and expertise.

Thyroid Disease:

Knowledge objectives

In addition to the previous objectives, by the completion of the final clinical year, the general surgery resident should be able to:

  1. Outline the complete evaluation and management of patients with thyroid cancer (papillary, follicular, medullary, anaplastic) including:
    • Preoperative evaluation including radiographic studies
    • Operative approaches including discussion of lobectomy vs. total thyroidectomy
    • Indications for and extent of neck dissection
    • Incidental finding of cancer in resected specimen
    • Metastatic thyroid cancer
    • Large remnant in patient with thyroid cancer
    • Tracheal invasion
    • Esophageal invasion
    • Postoperative treatment, surveillance, and monitoring
  2. Outline the complete evaluation and management of nontoxic multinodular goiter and substernal goiter
  3. Describe approaches for reoperative thyroid surgery
  4. Describe the management of intraoperative recurrent nerve injury

Skill objectives

In addition to the previous objectives, by the completion of the final clinical year, the general surgery resident should be able to:

  1. Interpret thyroid ultrasound images
  2. Perform and interpret head and neck ultrasonography
    • Identify which ultrasound equipment/probes are best used for head and neck ultrasonography.
    • Identify normal structures visualized during ultrasound of the head and neck (thyroid, parathyroid, lymph nodes, trachea, carotid artery, internal jugular vein, inferior and superior thyroid vessels, parotids, submandibular glands)
    • Describe the echogenicity of a visualized structure as hypoechoic, isoechoic, anechoic or hyperechoic relative to the normal thyroid gland
    • Use ultrasound to identify thyroid nodules, parathyroid adenomas and adenopathy
    • Describe which features of a thyroid nodule on ultrasound are more worrisome for malignancy
  3. Perform an ultrasound guided fine needle aspiration biopsy of a thyroid nodule
  4. Assess vocal cord function by flexible laryngoscopy and vocal cord ultrasonography.

Parathyroid disease:

Knowledge objectives

In addition to the previous objectives, by the completion of the final clinical year, the general surgery resident should be able to:

  1. Outline the complete evaluation and management of patients with parathyroid cancer including:
    • Preoperative evaluation including radiographic studies
    • Operative approaches
    • Extent of resection
    • Postoperative treatment, surveillance, and monitoring
  2. Describe in detail the different techniques of focused parathyroidectomy including:
    • Mini incision open
    • Radioguided
    • Video-assisted and endoscopic approaches
  3. Outline the complete evaluation and management of recurrent or persistent hyperparathyroidism, including imaging studies and selective venous sampling.
  4. Describe regional anesthesia for minimally invasive parathyroidectomy
  5. Describe the treatment pathway for MEN 1 and 2A patients, including the order in which the different manifestations should be treated

Skill objectives

In addition to the previous objectives, by the completion of the final clinical year, the general surgery resident should be able to:

  1. Perform a parathyroidectomy (preferably both full neck exploration and minimally invasive), including
    • Intraoperative identification and resection of adenoma
    • Intraoperative identification of normal parathyroid glands
    • Intraoperative identification of hyperplasia
    • Reimplant a parathyroid gland
  2. Participate in or perform re-exploration for persistent or recurrent hyperparathyroidism.
  3. Assess vocal cord function either by flexible transnasal endoscopy or indirect laryngoscopy.
  4. Interpret a neck ultrasound, demonstrating the thyroid gland, adjacent structures and a parathyroid adenoma or hyperplasia.
    • Identify which ultrasound equipment/probes are best used for head and neck ultrasonography
    • Identify typical locations where an abnormal parathyroid may be visualized during ultrasound of the head and neck
    • Use ultrasound to identify parathyroid adenomas, hyperplastic parathyroids and learn about the ultrasound features that help differentiate them from thyroid nodules and adenopathy.
    • Participate in or learn the protocol and value of performing a fine needle aspiration of a parathyroid with measurement of PTH levels on the needle washout.

Adrenal disease:

Knowledge objectives

In addition to the previous objectives, by the completion of the final clinical year, the general surgery resident should be able to:

  1. Describe congenital adrenal hyperplasia.
  2. Describe the surgical approaches to pheochromocytoma.
  3. Review all the surgical options/approaches for adrenalectomy and the indications for each.
  4. Describe the intraoperative management of patients with pheochromocytoma during surgery regarding anesthetic management, surgical technique, and pre and postoperative care.
  5. Identify the distinguishing characteristics of extraadrenal pheochromocytomas.
  6. Describe the evaluation and treatment of multiple endocrine neoplasia type 2 syndrome in a patient with adrenal lesions.
  7. Describe the treatment options for a patient with malignant pheochromocytoma.
  8. Identify the steps for a safe and successful right and left laparoscopic transabdominal adrenalectomy.
  9. Be familiar with operative technique (positioning, steps of the operation)
  10. Describe the diagnosis and treatment of paragangliomas.
  11. Be familiar with common complications following adrenalectomy and ways to avoid them.
  12. 12. Be comfortable with maintenance or physiologic dosing of steroids and florinef following bilateral adrenalectomy.
  13. Be comfortable with conversion of steroid supplementation. (ex: Dexamethasone, Solumedrol, hydrocortisone)
  14. Understand indications and technique of subtotal adrenalectomy
  15. Have an understanding of intraoperative medical management of adrenergic crisis.

Skill objectives

In addition to the previous objectives, by the completion of the final clinical year, the general surgery resident should be able to:

  1. Perform an adrenalectomy (open or laparoscopic), including patient positioning, dissection, resection, and postoperative care.

Gastrointestinal neuroendocrine tumors:

Knowledge objectives

In addition to the previous objectives, by the completion of the final clinical year, the general surgery resident should be able to:

  1. Describe the diagnostic approach including biochemical evaluation, ancillary studies, and recommended localization methods for the following tumors:
    • Gastrinoma
    • Insulinoma
    • Glucagonoma
    • VIPoma
    • Somatostatinomas
    • Nonfunctional neuroendocrine tumors
  2. Describe the indications for surgery, operative approaches, and expected outcomes for the following tumors:
    • Gastrinoma
    • Insulinoma
    • Glucagonoma
    • VIPoma
    • Somatostatinomas
    • Nonfunctional neuroendocrine tumors
  3. Understand how to diagnose and treat the syndrome of post gastric bypass hypoglycemia
  4. Outline an algorithm for surgical management of carcinoid tumors based on site, size, and presence of carcinoid syndrome.
  5. Outline the follow up of patients who have undergone resection of carcinoid tumors.
  6. Outline the management of liver metastases of the neuroendocrine tumors.

Familial endocrinopathies and multiple endocrine neoplasia syndromes:

Familial endocrinopathies are rare entities; however they have important screening and treatment implications. Because of their rarity only knowledge objectives are incorporated in this section of the curriculum.

Knowledge objectives

By the completion of the final clinical year, the general surgery resident should be able to:

  1. Describe the components of each of the following multiple endocrine neoplasia (MEN) syndromes, their mode of inheritance, and the frequency of expression of each component:
    • MEN type 1
    • MEN type 2A
    • MEN type 2B
  2. Outline the diagnostic approach for each of the MEN syndromes.
  3. Describe the treatment, including timing of operative approach, for each component of the following syndromes:
    • MEN type 1
    • MEN type 2A
    • MEN type 2B
  4. Outline recommended genetic testing for patients suspected of having one of the MEN syndromes.
  5. Outline the recommended screening for kindred of patients with the different MEN syndromes.
  6. Outline the recommended follow up of patients with the different MEN syndromes.
  7. Describe the prognosis for each of the MEN syndromes.

Familial medullary thyroid carcinoma

Knowledge objectives

By the completion of the final clinical year, the general surgery resident should be able to:

  1. Describe the mode of inheritance of familial medullary thyroid cancer (FMTC).
  2. Outline the diagnostic evaluation, including genetic testing, of FMTC.
  3. Outline the recommended treatment, including the role of prophylactic thyroidectomy, for FMTC.
  4. Outline the recommended screening for kindred of patients with the different MEN syndromes.
  5. Outline the recommended follow up of patients with FMTC.
  6. Describe the prognosis for FMTC.
  7. Compare and contrast the evaluation and management of FMTC with sporadic medullary thyroid cancer.

Familial papillary thyroid carcinoma:

Knowledge objectives

By the completion of the final clinical year, the general surgery resident should be able to:

  1. Describe the diagnostic criteria for familial papillary thyroid cancer (FPTC).
  2. Describe the mode of inheritance of FPTC.
  3. Outline recommended screening for FPTC.
  4. Outline the recommended treatment of FPTC.
  5. Outline the recommended follow up of patients with FPTC.
  6. Describe the prognosis for FPTC.
  7. Compare and contrast the evaluation and management of FPTC with sporadic papillary thyroid cancer.

Familial non-MEN hyperparathyroidism:

Knowledge objectives

By the completion of the final clinical year, the general surgery resident should be able to:

  1. Describe the diagnostic criteria for familial non – MEN hyperparathyroidism (FHPTH).
  2. Describe the mode of inheritance of FHPTH.
  3. Outline recommended screening for FHPTH.
  4. Compare and contrast the evaluation and management of FHPTH with sporadic primary hyperparathyroidism.

Breast Disease:

Knowledge objectives

In addition to the previous objectives, by the completion of the final clinical year, the general surgery resident should be able to:

  1. Gather, organize, analyze and integrate essential and accurate information about patients with locally advanced and inflammatory breast cancer.
  2. Construct patient centered treatment plans based on analysis of diagnostic information, scientific evidence, and clinical judgement for patients with benign and malignant breast disease.
  3. Demonstrate knowledge of seminal studies in breast cancer care.
  4. Demonstrate knowledge of the management of high risk genetic mutations including:
    • BRCA 1 and 2
    • PALB2
    • CHEK2
    • PTEN
    • CDH1
  5. Formulate a surgical plan for patients with breast cancer based on history and physical, imaging, patient preference, guidelines and scientific evidence.
  6. Outline an algorithm for the evaluation and treatment of locally advanced or inflammatory breast cancer.
  7. Formulate a management approach for in-breast, chest wall, or loco-regional recurrence of breast cancer.
  8. Evaluate the role of surgery in stage IV breast cancer, including the resection of metastases and the role of loco-regional therapy.
  9. Establish a follow up plan for the post-operative management, monitoring, and surveillance of patients with benign and malignant breast disease.
  10. Demonstrate consideration of survivorship in breast cancer care.
  11. Demonstrate knowledge and indications for basic oncoplastic surgery techniques including:
    • Parenchymal flaps
    • Round block mastopexy
    • Racquet mastopexy
    • Reduction mammoplasty

Skills objectives

In addition to the previous objectives, by the completion of the final clinical year, the general surgery resident should be able to:

  1. Interpret breast imaging studies including:
    • Mammogram
    • Ultrasound
    • MRI
  2. Perform a palpable lumpectomy including:
    • Appropriate incision placement
    • Adequate margin dissection
    • Parenchymal flap closure
  3. Perform a seed and/or wire localized lumpectomy including:
    • Appropriate incision placement based on imaging and intraoperative localization with the probe
    • Adequate margin dissection based on preoperative review of imaging
    • Appropriate evaluation of intraoperative specimen radiograph and management of visually close margin
    • Parenchymal flap closure
  4. Perform a sentinel node biopsy including:
    • Injection of appropriate tracers
    • Identification of sentinel nodes
    •  Incision placement
    • In vivo localization and dissection of lymph nodes
    • Application of the 10% rule in determining lymph nodes to be removed
  5. Perform a simple mastectomy and portions of a nipple sparing mastectomy including:
    • Incision placement
    • Dissection of skin flaps to extirpate breast tissue while leaving adequate blood supply
    • Dissection of the nipple areolar complex
    • Removal of breast from chest wall, including pectoralis fascia
    • Drain placement and closure
  6. Perform an axillary lymph node dissection including:
    • Incision placement
    • Identification of the axillary vein, long thoracic, and thoracodorsal nerves
    • Removal of level I and II axillary lymph nodes
    • Drain placement and closure
  7. Evaluate and manage arm lymphedema as a side effect of breast cancer treatment.