FELLOWSHIPS: CURRICULUM

The American Association of Endocrine Surgeons (AAES) is a representative body of surgeons from North America and South America who have a special interest in the surgery of endocrine (thyroid, parathyroid, adrenal, and pancreas) glands. The association was established in 1981 and continues to grow; its membership now includes resident/fellow members, corresponding members (endocrine surgeons from countries throughout the world), honorary members (physicians outside the discipline of surgery who have contributed significantly to the field of endocrine surgical disease), and allied health members (otolaryngologists, urologists, and neurosurgeons who have acquired considerable expertise in the field of endocrine surgery). The AAES is dedicated to the advancement of both the science and art of endocrine surgery. The AAES is committed to maintaining high standards for the practice of endocrine surgery, and to discover and promote the best treatments for endocrine disease in order to improve our patients' lives.

To address the growing need for advanced post-graduate training in endocrine surgery, in 2004 the Executive Council of the AAES mandated the development of a fellowship curriculum to provide a more formalized structure to the existing endocrine surgery fellowships. The goal was to also provide a document to facilitate the development of future fellowship programs, and to ensure similar high quality training across a number of different institutions. The Education & Research Committee of the AAES enumerated the objectives and guidelines for fellowship training in endocrine surgery, and was ratified by the Executive Council in October 2005. This current version has been reviewed and revised by representative members of the AAES Education & Research and Fellowship Committees and is submitted for Council approval.

It is the hope of the AAES Executive Council that these objectives will provide a structure and a framework for endocrine surgery fellows to enhance their postgraduate training. The fellow, the program director and the faculty members of a training unit should utilize this curriculum and strive to meet these objectives. In recognition of the unique strengths and training opportunities at each institution, individual programs also have flexibility in the design of the fellowship rotations and experiences.

ENDOCRINE SURGERY FELLOWSHIP

In 2013, the AAES Executive Council created a formal accreditation process for clinical endocrine surgery fellowship programs. All AAES-accredited fellowship programs fulfill strict criteria and will be reviewed on a regular basis for compliance and re-accreditation. Information regarding available clinical fellowship programs can be found at http://www.endocrinesurgery.org

Candidates for endocrine surgical fellowship training will consist of surgeons who have successfully completed general surgery residency at an accredited general surgery residency program in the United States (or equivalent training outside of the United States); candidates must be board-eligible or board certified to apply.

An endocrine surgery fellowship will be defined as a clinical experience of one academic year.  Length of training may vary depending on the design of the program and the ultimate goals and type of practice pursued by the trainee. A research component may be included, concurrently or in multi-year fellowship programs. All AAES endocrine surgery fellowships must be directed by one or more surgeons who are members of the AAES and have a dedicated expertise in the field of endocrine surgery. The fellowship must offer the potential for exposure to the management of thyroid, parathyroid, adrenal, and neuroendocrine tumors of the pancreas and gastrointestinal tract. Multidisciplinary exposure to endocrinology, medical oncology, pathology, radiology, and genetics is strongly encouraged.

Throughout the fellowship, the trainee should have the opportunity to participate in journal clubs, tumor boards, and research projects directed towards endocrine surgical disease. It is also suggested that the trainee be given the opportunity to attend the annual meeting of the AAES and other AAES-sponsored educational initiatives (such as Endocrine Surgery University), as well as obtain formal instruction and certification in head and neck ultrasound.

OVERALL OBJECTIVES FOR AN ENDOCRINE SURGERY FELLOWSHIP:

  • Demonstrate knowledge of endocrine gland anatomy and physiology, in both the normal and pathologic states.
  • Diagnose endocrinopathies associated with endocrine surgical diseases.
  • Describe the inherited endocrine disorders and the proper application of genetic counseling and testing.
  • Discuss the current controversies, current areas of research, and clinical literature in endocrine surgical diseases.
  • Safely execute the appropriate workup, operation, and postoperative care for patients with endocrine surgical disease.

CLINICAL CURRICULUM:

  1. Describe the normal anatomy, histology, and physiology of each of the following endocrine glands, and explain the secretion and homeostasis of the pertinent hormones in both the normal and pathologic disease states:
    1. Thyroid gland
      1. Thyroxine (T4 and T3)
      2. Effects of thyroid stimulating hormone (TSH)
    2. Parathyroid gland
      1. Parathyroid hormone (PTH)
      2. Calcium / Phosphate / Vitamin D homeostasis
      3. Bone and renal effects of hyperparathyroidism and hypoparathyroidism
      4. The calcium sensing receptor (CaSR)
    3. Endocrine pancreas
      1. Insulin / Gastrin / Glucagon / Vasoactive Intestinal Peptide (VIP) / Pancreatic Polypeptide (PP) / Somatostatin
    4. Adrenal glands
      1. Aldosterone / Renin / Angiotensin cascade
      2. Cortisol
      3. DHEA-S
      4. Catecholamines
    5. Gastrointestinal tract
      1. Serotonin / Chromogranin A
    6. Pituitary gland
      1. Neurohypophysis (posterior pituitary)
        1. Oxytocin
        2. Vasopressin
      2. Adenohypophysis (anterior pituitary)
        1. Growth hormone
        2. Prolactin
        3. Adrenocorticotropic hormone (ACTH)
        4. TSH

  2. Discuss Endocrine Cytopathology and Histopathology:
    1. Thyroid
      1. Classification of thyroid malignancies
      2. Fine-needle aspiration biopsy (FNA);its indications and limitations
      3. Bethesda thyroid FNA classification
      4. The uses and limitations of molecular markers/profiles with FNA
      5. The limitations of frozen section
    2. Parathyroid
      1. Definitions of hyperplasia vs. adenoma
      2. Criteria for parathyroid carcinoma
    3. Adrenal
      1. Classification and diagnosis of adrenal lesions
    4. Neuroendocrine Tumors (NET) of the GI tract
      1. WHO/NANETS classification of NET
      2. Diagnostic criteria of malignancy in NET

  3. Describe the hereditary endocrine syndromes
    1. Define oncogene and tumor suppressor gene
    2. Describe the phenotype and genotype and management of multiple endocrine neoplasia
      1. MEN I
      2. MEN 2a
      3. Familial medullary thyroid cancer (FMTC)
      4. MEN 2b
    3. Describe the endocrine pathology and management of familial non-MEN syndromes including;
      1. von Hippel Lindau (VHL)
      2. Neurofibromatosis
      3. Pheo- Paraganglioma syndromes (SDH and HIF-alpha)
      4. Familial isolated HPT
      5. Hyperparathyroidism Jaw-Tumor Syndrome
      6. Familial non-medullary thyroid cancer
      7. Familial hypocalciuric hypercalcemia (FHH)
    4. Discuss the role and timing of genetic screening

  4. Discuss the pathophysiology, clinical presentation, diagnosis, work up, and treatment (include both surgical and medical options) of the following diseases. Describe the surgical indications, natural history, and prognostic factors associated with the disease:
    1. Thyroid
      1. Thyroid nodule
      2. Multinodular goiter
      3. Substernal goiter
      4. Hypothyroidism
      5. Hyperthyroidism / Thyrotoxicosis
        1. Graves’ disease
        2. Toxic MNG
        3. Toxic adenoma
        4. Thyroiditis (e.g. Hashitoxicosis)
      6. Well-differentiated thyroid cancer of follicular cell origin
        1. Extent of surgery
          1. Thyroid
          2. Central compartment
          3. Lateral compartment
        2. Radioiodine ablation
        3. TSH Suppression
        4. Surveillance and staging
          1. Thyroglobulin and anti-thyroglobulin
          2. Imaging
      7. Medullary thyroid cancer
        1. Preoperative workup
        2. Sporadic vs inherited
        3. Timing of prophylactic surgery in RET mutation positive
        4. Extent of surgery
        5. Staging
        6. Surveillance
          1. Calcitonin and CEA
          2. Imaging
      8. Anaplastic thyroid cancer
        1. Surgical indications
        2. Treatment options
        3. Staging
      9. Thyroid lymphoma
      10. Metastases to the thyroid
    2. Parathyroid
      1. Primary hyperparathyroidism (including normocalcemic and normohormonal forms)
      2. Secondary and tertiary hyperparathyroidism (renal)
      3. Parathyroid carcinoma
    3. Endocrine pancreas
      1. Insulinoma
      2. Gastrinoma
      3. Glucagonoma
      4. VIPoma
      5. Somatostatinoma
      6. Non-functioning (PPoma)
      7. MEN-1 pancreas
    4. GI Neuroendocrine Tumors
      1. Foregut and gastric carcinoids -including atypical carcinoid syndrome
      2. Mid-gut carcinoid tumors – including diagnosis and treatment of carcinoid syndrome
    5. Adrenal
      1. The incidentally discovered adrenal mass
      2. Primary hyperaldosteronism
      3. Endogenous hypercortisolism (Cushing's syndrome vs. Cushing's disease)
      4. Pheochromocytoma / Paraganglioma syndromes
      5. Virilizing and feminizing adrenal tumors
      6. Adrenal cortical carcinoma

  5. Describe the peri-operative management of the following:
    1. Thyroid
      1. Thyroid storm
      2. Graves’ disease / hyperthyroidism
      3. Hypothyroidism
    2. Parathyroid
      1. Hypercalcemic crisis
      2. Hungry bone syndrome
      3. Vitamin D deficiency
      4. Permanent hypoparathyroidism
    3. Adrenal
      1. Pheochromocytoma / Paraganglioma syndromes –including blockade
      2. Hyperaldosteronism workup and localization including selective venous catheterization
      3. Endogenous hypercortisolism- including steroid management
      4. Adrenal insufficiency crisis
    4. NET
      1. Functioning pancreatic tumors especially insulinoma, gastrinoma, and glucagonoma
      2. Carcinoid syndrome and carcinoid crisis
    5. Surgical Complications
      1. Hematoma
      2. Recurrent laryngeal nerve injury (unilateral and bilateral)
      3. Hypocalcemia (temporary and permanent)

  6. Summarize the differential diagnosis of:
    1. Thyroid
      1. Low TSH level
      2. Elevated serum thyroxine level
      3. Lateral neck mass
      4. Airway obstruction
      5. New onset dysphonia
    2. Parathyroid
      1. Hypercalcemia
      2. Elevated PTH level
      3. Recurrent / persistent hypercalcemia following parathyroid surgery
    3. NET
      1. Hypoglycemia
      2. Hypergastrinemia
      3. Secretory diarrhea
    4. Adrenal
      1. Elevated cortisol levels
      2. Secondary hypertension

  7. Describe the safe performance of the following procedures, and the indications, the potential complications and alternative treatment options of each procedure:
    1. Thyroid
      1. Retrosternal goiter resection – cervical approach
      2. Thyroid lobectomy
      3. Total / near-total thyroidectomy
      4. Compartment oriented lymph node dissections of the neck
        1. Central neck dissection
        2. Modified radical neck dissection
      5. Reoperative / completion thyroidectomy
      6. Resection of locally invasive carcinoma with tracheal/esophageal invasion
    2. Parathyroid
      1. Finding the inferior parathyroid glands
      2. Finding the superior parathyroid glands
      3. Finding ectopic and supernumerary parathyroid glands
      4. Reoperative parathyroidectomy
      5. Parathyroid  autotransplantation
      6. Resection of the mediastinal parathyroid gland
    3. Adrenal
      1. Open and minimally-invasive adrenalectomy

  8. Explain the role and application of the following in the management of endocrine surgical disease:
    1. Imaging modalities:
      1. Ultrasound (especially surgeon-performed)
      2. Cross-sectional imaging (CT, MRI)
      3. Scintigraphy including MIBG, sestamibi, octreotide scan, FDG-PET
      4. Selective venous sampling (parathyroid and adrenal)
      5. Selective arterial calcium infusion for PNET
    2. Procedures:
      1. Laryngoscopy
      2. Recurrent laryngeal nerve monitoring
      3. Parathyroid cryopreservation
      4. Enucleation vs resection of pancreatic NET
    3. Diagnostic assays:
      1. TSH, T3, T4,
      2. TPO antibodies
      3. Thyroid stimulating immunoglobulin (TSI)
      4. Calcitonin and CEA
      5. PTH / intra-operative PTH assays
      6. Chromogranin A
      7. Urinary 5-HIAA
      8. Metanephrines (plasma and urinary)
      9. Urinary free cortisol / Midnight salivary cortisol
      10. Dexamethasone suppression testing
      11. Plasma Aldosterone / Plasma Renin

  9. Collaborate with disciplines complementary to endocrine surgery including but not limited to:
    1. Endocrinology
    2. Oncology
    3. Pathology
    4. Radiology
    5. Genetics

  10. Conduct research and critically appraise the literature
    1. Describe the design of both clinical and basic science research studies
    2. Develop an understanding of the statistical methods applied to study designs
    3. Critically appraise the medical literature.
    4. Develop a research question in endocrine surgical disease and pursue an appropriate research project during the fellowship with the goal toward peer reviewed publication

RECOMMENDED READING / REFERENCE LIST

Endocrine Surgery Textbooks

  • Textbook of Endocrine Surgery (Second Edition)  Edited by: Orlo H. Clark, Quan-Yang Duh, and Electron Kebebew.  ISBN: 978-0-7216-0139-7
  • Endocrine Surgery. Principles and Practice.  Editors: Johnathan Hubbard, William B. Inabnet, Chung-Yau Lo. ISBN: 978-1-84628-880-7
  • Endocrine Neoplasia. Editor: Cord Sturgeon. ISBN 978-1-4419-0857-5

Endocrine Surgery Training

  • Pasieka JL. Kindred spirits of the endocrines: the training of future endocrine surgeons. J Surg Oncol 2005;89(3):202-205.

Thyroid

  • Cooper DS, Doherty GM, Haugen BR, et al. Revised American Thyroid Association guidelines taskforce on thyroid nodules and differentiated thyroid cancer. Thyroid 2009;19(11):1167-1214.
  • Kloos RT, Eng C, Evans, DB. Medullary thyroid cancer: management guidelines of the American Thyroid Association. Thyroid 2009;19(6):565-612.
  • Smallridge RC, Ain KB, Asa SL, et al. American Thyroid Association guidelines for management of patients with anaplastic thyroid cancer. Thyroid 2012:22(11):1104-1139.
  • Bahn RS, Burch JB, Cooper DS, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid 2011;21(6):593-646.
  • National Comprehensive Cancer Network Thyroid Carcinoma Guidelines. www.nccn.org
  • Carty SE, Cooper DS, Doherty GM, et al. Consensus statement on the terminology and classification of central neck dissection for thyroid cancer. Thyroid 2009;19(11):1153-1158.
  • Stack BC Jr, Ferris RL, Goldenberg D, et al. American Thyroid Association consensus review and statement regarding the anatomy, terminology, and rationale for lateral neck dissection in differentiated thyroid cancer. Thyroid 2012;22(5):501-508.
  • Cibas ES, Ali SZ. The Bethesda system for reporting thyroid cytopathology. Thyroid 2009;19(11):1159-1165.
  • Rosenthal MS, Angelos P, Cooper DS, et al. Clinical and professional  ethics guidelines for the practice of thyroidology. Thyroid 2013;23(10):1203-1210.
  • Terris DJ, Snyder S, Carneiro-Pla D, et al. American Thyroid Association statement on outpatient thyroidectomy. Thyroid 2013;23(10):1193-1202.
  • Carty SE, Doherty GM, Inabnet WB, et al. American Thyroid Association statement of the essential elements of interdisciplinary communication of perioperative information for patients undergoing thyroid cancer surgery. Thyroid 2012;22(4):395-399.

Parathyroid

  • Bilezikian JP, Khan AA, Potts JT Jr, Third International Workshop on the management of asymptomatic primary hyperparathyroidism. Guidelines for the management of asymptomatic primary hyperparathyroidism: Summary statement from the third international workshop. J Clin Endocrinol Metab 2009;94(2):335-339.
  • Eastell R, Arnold A, Brandi ML, et al. Diagnosis of asymptomatic primary hyperparathyroidism: proceedings of the third international workshop. J Clin Endocrinol Metab 2009;94(2):340-350.
  • Silverberg SL, Lewiecki EM, Mosekilde L, et al. Presentation of asymptomatic primary hyperparathyroidism: proceedings of the third international workshop. J J Clin Endocrinol Metab 2009;94(2):351-365.
  • Udelsman R, Pasieka JL, Sturgeon C, et al. Surgery for asymptomatic primary hyperparathyroidism: proceedings of the third international workshop. J J Clin Endocrinol Metab 2009;94(2):366-372.
  • Khan A, Grey A, Shoback D. Medical management of asymptomatic primary hyperparathyroidism: proceedings of the third international workshop. J J Clin Endocrinol Metab 2009;94(2):373-381.
  • Rubin MR, Bilezikian JP, McMahon DJ, et al. The natural history of primary hyperparathyroidism with or without parathyroid surgery after 15 years. J Clin Endocrinol Metab 2008;93(9):3562-3470.

Adrenal

  • National Comprehensive Cancer Network. Neuroendocrine tumors. www.nccn.org
  • Zeiger MA, Thompson GB, Duh QY, et al. American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical guidelines for the management of adrenal incidentalomas. Endocr Pract 2009;15(Suppl 1):1-20.
  • Funder JW, Carey RM, Fardella C, et al. Case detection, diagnosis, and treatment of pateints with primary aldosteronism: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2008;93(9):3266-3281.
  • Nieman LK, Biller BM, Findling JW, et al. The diagnosis of Cushing’s syndrome: an Endocrine Society Clinical Practice guideline. J Clin Endocrinol Metab 2008;93(5):1526-1540.
  • Jimenez C, Cote G, Arnold A, Gagel RF. Review: Should patients with apparently sporadic pheochromocytomas or paragangliomas be screened for hereditary syndromes? J Clin Endocrinol Metab 2006;91(8):2851-2858.

Neuroendocrine Tumors

  • National Comprehensive Cancer Network. Neuroendocrine tumors. www.nccn.org
  • Brandi ML, Gagel RF, Angeli A, et al. Consensus guidelines for diagnosis and therapy of MEN Type 1 and Type 2. J Clin Endocrinol Metab 2001;86(12):5658-5671.
  • Vinik AI, Woltering EA, Warner RR, et al. NANETS consensus guidelines for the diagnosis of neuroendocrine tumor. Pancreas 2010;39(6):713-734.
  • Kulke MH, Anthony LB, Bushnell DL, et al. NANETS treatment guidelines: Well-differentiated neuroendocrine tumors of the stomach and pancreas. Pancreas 2010;39(6):735-752.
  • Chen H, Sippel RS, O’Dorisio S, et al. The North American Neuroendocrine Tumor Society Consensus Guideline for the diagnosis and management of neuroendocrine tumors. Pancreas 2010;39:775-783.

 

Revised 10/15

© 2016 AAES

Questions: Should you have any questions, please contact AAES Headquarter at
859-402-9810
or info@endocrinesurgery.org

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