SCORE 13-15

The femoral triangle is defined by the adductor longus muscle medially and the sartorius muscle laterally.
The two muscles meet inferiorly to form the apex, while the superior boundary is the inguinal ligament

Make a curvilinear or longitudinal incision.
Skin flaps are raised medially to the pubic tubercle, laterally to the lateral edge of the sartorius, and superiorly to the level of the umbilicus.
The node-bearing tissue and fat is then dissected off the external oblique, starting approximately 8 to 10 cm above the inguinal ligament. The tissue is swept caudad to the level of the inguinal ligament.
Inferiorly to the inguinal ligament, tissue is mobilized by incising the fascia of the sartorius and adductor muscles. The femoral vessels are skeletonized. Working from the apex of the femoral triangle proximally, all the lymph node-bearing tissue is removed.
If the saphenous vein is to be sacrificed, it is ligated at the saphenofemoral junction with either a vascular staple or a running vascular stitch.
Care must be taken to remove the nodal tissue at the node of Cloquet by gentle retraction of the femoral vein laterally just as it dives under the inguinal ligament.
Sartorius muscle transposition may be performed at this time for coverage of the femoral vessels.
Place closed suction drain(s) in the surgical bed.
Close the subcutaneous layer with absorbable suture.

The skin incision may need to be extended cephalad to the level of the umbilicus.
A separate 8- to 10-cm “kidney transplant” hockey stick incision is made through the external oblique muscle, moving parallel to the inguinal ligament approximately 5 cm cephalad to the ligament.
The internal oblique and transversus abdominis are incised parallel to the direction of the fibers.
The peritoneum is retracted superiorly and medially to expose the external iliac artery and vein.
The ureter is identified and protected. The inferior epigastric vessels are either ligated or identified and protected as well.
Iliac nodal tissue is dissected by skeletonizing tissue anterior to the external iliac vein from the inguinal ligament, moving proximally to the bifurcation of the internal and external iliac vessels. This lymph packet is removed and sent for pathology.
Obturator nodes are located in the lateral pelvic sidewall superficial to the obturator nerve. The nodes are removed with blunt dissection, taking great care to avoid injury to the obturator vessels, which are deep to the obturator nerve.
The fascias of the internal and external oblique muscles are closed with separate running sutures.

most patients with a positive sentinel node biopsy should be observed closely with nodal ultrasounds every 4 months for the first 2 years, every 6 months for years 3 through 5, and then annually.

1. Permissive hypotension
2. MTP
3. Have cell saver available

An appropriate preoperative surgical plan should be in place if a critical neurovascular bundle is in close proximity to the tumor or abuts the tumor.
The incision is made parallel to the long axis of the digit or limb and should include the previous biopsy tract.
Skin flaps are raised and a wide local excision is performed, with at least a 2-cm margin of normal tissue around the tumor.
If soft tissue flap reconstruction is necessary, it is appropriate to enlist the assistance of plastic surgery.
Closed suction drains are left at the discretion of the treating surgeon.

For a patient diagnosed with an AJCC stage I sarcoma (low-grade) who has undergone surgery with appropriate margins, a physical examination every 3 to 6 months for 2 to 3 years, then annually, is appropriate.
A chest x-ray should be considered every 6 to 12 months.
The use of MRI or computed tomography (CT) of the extremity is individualized based on the location of the tumor and the risk of recurrence.
For a patient with an AJCC stage II or III sarcoma who has undergone surgery with appropriate margins, clinical assessment every 3 to 6 months for 2 to 3 years, then every 6 months for the next 2 years, and then annually is appropriate.
Imaging of the surgical bed of the primary tumor (with MRI) plus imaging of the chest (chest x-ray or CT of the chest) is strongly recommended.

1. A standard midline incision is made. The colon is mobilized from its attachments sharply. The adjacent flexure may be mobilized, if necessary, to permit the colon to reach the abdominal wall.
2. A 4- to 5-cm transverse incision is made in the right or left upper quadrant over the rectus muscle where the stoma was preoperatively marked. Expose rectus, and divide the posterior rectus sheath.
3. A mesenteric window is constructed between the marginal artery and the mesenteric border of the bowel to avoid compromise. The loop of bowel is delivered through the transverse skin incision, with care taken to ensure that no tension is placed on the bowel loop. The fascial opening should be wide enough to accommodate the bowel and one finger.
4. A transverse semilunar incision is made along the length of the loop of colon. The incision should be long enough to allow visualization of the posterior wall of the colon.
5. The loop colostomy is then matured so that the proximal and distal limbs are separated. Full-thickness 3-0 polyglactin sutures are placed from the bowel wall to the dermis. The stoma is then fitted with an ostomy appliance.

1. Blowhole colostomy / transverse loop colostomy

Magnetic resonance imaging (MRI) is the best imaging modality to assess the integrity of silicone implants.
The FDA recommends MRI screening 3 years after silicone breast implant placement and every 2 years after that.

It is impossible to remove all of the breast tissue with a mastectomy. Patients who have had a mastectomy for cancer can still have local recurrence of their disease. Likewise, a prophylactic mastectomy for risk reduction will never decrease a patient’s risk of breast cancer to zero.
Imaging should be the first course of action for any suspicious lesion in the breast, followed by biopsy if imaging is indeterminate or suspicious.
Mammography is safe in the setting of breast implants. However, it should be performed by trained technologists who will perform implant-displacement views to maximize the amount of breast tissue evaluated.

BIA-ALCL is a rare type of lymphoma associated with breast implants. It occurs most frequently in women with textured implants in those who had a staged procedure with textured tissue expanders.
The lifetime risk is low—estimated at 1 in 30,000 women with textured implants. This is typically a distant event from implant placement; on average, it occurs after 8 to 10 years.
The most common presentation is breast enlargement and a fluid collection around the implant.
Workup for suspected BIA-ALCL should include needle aspiration of the peri-implant seroma, with fluid cytologic and pathologic evaluation.
BIA-ALCL is a highly treatable lymphoma.

For breast enlargement with a negative family history for medications or other disease etiologies - testosterone, luteinizing hormone, estradiol, human chorionic gonadotropin, thyroid-stimulating hormone, and thyroxine.
Routine mammograms or ultrasound for screening or benign etiologies is not indicated in men, unlike in women, particularly if there is not enough breast tissue for examination. However, if one is unsure of the diagnosis, these modalities can be helpful.
For suspected breast cancer, the same National Comprehensive Cancer Network (NCCN) guidelines for imaging in breast cancer in women are indicated in men, with mammogram and ultrasound. Core biopsies should be the biopsy technique. Staging follows the American Joint Committee on Cancer (AJCC) staging system and is based on the tumor-node-metastasis classification.

Total simple mastectomy is the procedure used in men. Sentinel nodes must also be biopsied for clinically node-negative patients concurrently.
Standard of care for positive sentinel nodes is axillary dissection of levels I to II. Mastectomy was an exclusion criterion in the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial and thus does not apply for mastectomy patients.

adjuvant tamoxifen rather than an aromatase inhibitor is recommended. If tamoxifen is contraindicated (eg, if the man has a history of venous thromboembolism/deep venous thrombosis), then use of an aromatase inhibitor with a gonadotropin-releasing analog is recommended;

Neoadjuvant chemotherapy should be considered for men with stage T4 cancers and/or lymph node metastasis. They may also be useful in men with high-risk cancers, such as triple-negative and HER2–positive cancers.

Excision with pathologic examination is necessary if the diagnosis is uncertain.
Large (> 3 cm) or symptomatic lesions usually warrant excision.
Core biopsy demonstrating cellularity or a rapid increase in size of a suspected fibroadenoma warrants excision.
Cryoablation is a safe and effective therapy for selected fibroadenomas.
Phyllodes tumors require complete excision with negative margins. Mastectomy is necessary only when free margins cannot be achieved without it. Involvement of axillary nodes is rare, and axillary sampling is not indicated.

lesions larger than 4 cm, palpable breast lesions, microinvasive disease, or high-grade disease, or in patients with suspicious axillary lymph nodes on physical examination or on ultrasound.

Level I nodes – lateral to the pectoralis minor
Level II nodes – deep to the pectoralis minor
Level III nodes – medial to the pectoralis minor
Rotter nodes – interpectoral lymph nodes between the pectoralis major and pectoralis minor

offered neoadjuvant chemotherapy followed by breast-conserving surgery and radiation therapy after delivery.

Patients often present with eczematoid changes of the nipple and areola.
Skin changes start at the papilla and then spread to the areola.
Patients presenting with these signs should have a full-thickness nipple-areolar skin biopsy performed.
If the biopsy reveals Paget disease, more than 96% of patients will have an underlying malignancy within the breast.

If a patient presents with symptoms concerning for Paget disease of the nipple but has no palpable abnormal findings, the practitioner should initiate an imaging workup, including mammography and possible breast ultrasound and breast MRI.
If any radiographic abnormalities are identified, proceed with image-guided core needle biopsy of the abnormality based on the abnormal imaging modality.
If mammography reveals segmental, clustered, or pleomorphic microcalcifications, stereotactic core needle biopsy is indicated.
If conventional imaging (mammogram and sonogram) and clinical breast examination do not reveal a primary malignancy, breast MRI may be helpful.
If an abnormality is noted on MRI, but mammography and ultrasonography are unremarkable, MRI-directed core needle biopsy may be helpful.
Again, full-thickness nipple biopsy should be performed to confirm the Paget disease.

One surgical option is central partial mastectomy with removal of the nipple-areolar complex en bloc with the underlying malignancy and sentinel node biopsy followed by whole breast radiation.
Mastectomy with sentinel node biopsy is another option.
Patients with a centrally located malignancy are candidates for breast-conserving surgery based on the size of the area involved with relation to total breast volume. When the nipple is to be removed, sentinel node biopsy should be considered at the time of the primary surgery to improve staging accuracy, even in patients with noninvasive disease.
Patients who are undergoing mastectomy should have a sentinel node biopsy at the time of mastectomy, even in the face of noninvasive malignancy, because of the significant limitations of performing sentinel node biopsy after a mastectomy.

tumors greater than 5 cm, involvement of the surgical margins, and disease in the axillary lymph nodes.

high-grade tumors, tumors larger than 2 cm, positive axillary lymph nodes, and a high 21-gene recurrence score.

The Oncotype DX 21-gene recurrence score is a validated prognostic assay that can assist with identifying patients who are both the most likely and least likely to benefit from adjuvant chemotherapy. Currently, this tool is indicated for patients with node-negative, ER-positive, HER2-negative breast cancers who will undergo a 5-year course of endocrine therapy.

Genetic testing should be recommended for patients with known BRCA mutations in family members, personal history of any breast cancer at age 50 or younger or triple-negative breast cancer at age 60 or younger, two or more primary breast cancers, history of young breast cancer (age 50 or younger) in a first-degree family member, personal history of ovarian/fallopian/primary peritoneal cancer, personal or family history of male breast cancer, or two relatives on the same side of the family with breast and/or pancreatic cancer.
Patients with a strong family history of breast cancer but no known genetic abnormalities should begin screening mammography 10 years before the age of onset for the youngest first-degree relative with breast cancer or at age 40.
Surveillance with annual magnetic resonance imaging screening (starting at age 25) and annual mammography (starting at age 30), staggered every 6 months, should be implemented for women with BRCA mutations.
Ovarian cancer screening for women with BRCA mutations should include transvaginal ultrasound, serum cancer antigen-125 (CA-125), and annual pelvic examinations beginning at age 30.

Use of selective estrogen receptor modulators, including tamoxifen or raloxifene, has been shown to reduce contralateral breast cancer risk in women with BRCA1 and BRCA2 mutations.

Treatment is nonoperative, with warm compresses, NSAIDs, and myofascial release.
Symptoms are expected to resolve within 4 to 6 weeks.

Reassurance alone may be an effective treatment for mastodynia.
Decreasing estrogen levels (as with menopause or with discontinuing hormone replacement therapy or oral contraceptives) may reduce breast pain.
Evening primrose oil, vitamin E, and caffeine elimination have not been proven more beneficial than placebo in clinical studies.
Patients with severe breast pain may be treated with tamoxifen, danazol, oral contraceptives, or bromocriptine, but these medications may have significant side effects.
Surgery is not a treatment for breast pain.

If a woman is premenopausal, tamoxifen should be considered. If she is postmenopausal, tamoxifen, raloxifene, or an aromatase inhibitor are all risk-reducing options. The standard dose of tamoxifen is 20 mg/d for 5 years. Low-dose tamoxifen (5 mg/d for 3 years) is less preferable. However, this is an option if the woman poorly tolerates the 20-mg dose.

smaller size (< 4-5 cm), homogenous appearance, low attenuation on computed tomography (CT), and loss of signal on opposed-phase magnetic resonance imaging (MRI) sequences.

malignant lesion are larger size (> 5-6 cm), irregular borders, higher attenuation, and no loss of signal on opposed-phase MRI.

Follow-up imaging with an adrenal CT scan should be performed at 6 months and then annually for 1 to 2 years.
Repeat biochemical testing with plasma fractionated metanephrines and an overnight dexamethasone test should be performed at 1 year and annually for up to 5 years.
Suspected adrenal myelolipomas (> 4 cm) should be followed, and the patient should not undergo adrenalectomy unless he or she has symptoms or the radiographic diagnosis is uncertain.
Indications for adrenalectomy during follow-up include interval growth of the adrenal lesion (≥ 1 cm), emergence of evidence of hormone hypersecretion on biochemical testing, or symptoms of hormone hypersecretion (eg, features of Cushing syndrome).

The superior parathyroid glands are located posterolateral to the RLN.
The inferior parathyroid glands are located anteromedial to the RLN.

Laboratory values of elevated PTH along with elevated calcium are diagnostic for primary hyperparathyroidism. - also PTH, phosphate, urinary calcium values
A sestamibi scan is useful in localizing the hyperactive gland.
Ultrasound is also useful in locating the hyperactive gland.
If imaging is negative but primary hyperparathyroidism is still suspected, real-time PTH monitoring can be performed in the operating room after the suspected gland has been removed.
It is important to note that localization studies should not be used to establish the diagnosis of primary hyperparathyroidism or to determine management; they should be performed after a decision to perform surgery is made.

Sestamibi scans may be enhanced by combination with three-dimensional imaging (SPECT), a subtraction thyroid scan, or fusion with computed tomography images. Use of each protocol varies according to institutional experience and geography.
Cervical ultrasound can be used, particularly because this can also detect thyroid pathology. Disadvantages include the fact that this modality is highly user dependent, leading to a sensitivity of 70% to 96%.
Combined ultrasound and sestamibi imaging increases the accuracy of localization (79%-95%) compared to either technique alone.
Recently, four-dimensional computed tomography has emerged as a useful localization modality. This relies on the rapid uptake and washout of contrast by parathyroid adenomas. Its main advantage is the provision of precise anatomical detail, particularly in reoperative cases. However, this is offset by increased cost, significantly increased radiation exposure (more than 50 times higher than sestamibi), and a lack of availability in many centers.

Severe hypercalcemia
Progressive and debilitating hyperparathyroid bone disease
Refractory pruritus
Progressive extraskeletal calcification or calciphylaxis
Otherwise unexplained myopathy

Aggressive fluid resuscitation of fluids at 200 mL/h is the first line of treatment.
Dialysis may be required if the patient cannot tolerate fluid.
Steroids and calcitonin may be used.
Bisphosphonates should be used with caution because they have a long half-life and may lead to hypocalcemia.

Markedly elevated serum calcium (1 mg/dL [0.25 mmol/L] above normal)
Bone density at the hip, lumbar spine, or distal radius less than 2.5 standard deviations below peak bone mass (T-score < –2.5)
Previous asymptomatic vertebral fracture
Presence of nephrolithiasis or nephrocalcinosis on radiograph, ultrasound, or computed tomography scan
Creatinine clearance less than 60 mL/min
24-hour urinary calcium more than 400 mg/d (> 10 mmol/d)
Age younger than 50 years

Screening tests include a 24-hour urine collection of free cortisol and a low-dose dexamethasone suppression test (1 mg).
If any of the screening tests are elevated, ACTH-dependent or ACTH-independent (ACTH < 10 pg/mL) hypercortisolism should be determined.

Ensure that the patient stops all medications that could affect potassium, renin, angiotensin, and aldosterone levels, such as spironolactone, angiotensin-converting enzyme inhibitors, diuretics, and beta-adrenergic blockers.
Obtain plasma renin and aldosterone levels to calculate the plasma aldosterone to renin ratio. A ratio of more than 30 ng/dL per ng/(mL · h) and an absolute aldosterone level of 15 mg/dL together have a high sensitivity (about 90% or more) for a diagnosis of primary hyperaldosteronism.
Order a 24-hour urine free cortisol and/or two bedtime salivary cortisol levels to rule out Cushing syndrome.
Obtain plasma free metanephrines to rule out pheochromocytoma. If this test is positive, a 24-hour urine free metanephrine level is recommended for confirmation.

Administer 2 to 3 L of normal saline intravenously over 4 to 6 hours (to increase intravascular volume and then check plasma aldosterone levels. Alternatively, give the patient 5000 mg sodium orally daily for 3 days and then test her 24-hour urine aldosterone excretion.
Aldosterone levels that remain elevated (are not suppressed) in either of these situations support a diagnosis of primary aldosteronism.
To improve localization, ensure that the CT of the abdomen/pelvis is performed with less than 3-mm slices (thin-cut).
Adrenal vein sampling can be performed via interventional radiology to help localize an aldosterone-producing tumor when none is visible on CT. This is an invasive test and should be done only by someone familiar with it because the results are operator dependent. An aldosterone level in one adrenal vein that is four times higher than the other confirms the site of the aldosterone (see figure). Some argue that this procedure should be performed routinely in patient older than 40 years of age because such patients have a higher risk of nonfunctional adrenal adenomas. These could be inappropriately interpreted as the aldosteronoma causing the patient's symptoms.

For a laparoscopic transabdominal approach, the patient is put on a bean bag and placed in the right lateral decubitus position with the kidney rest elevated.
The costal margin should be over the break in the bed.
The bed should be flexed, the bean bag solidified, and the patient secured, ensuring that the umbilicus is left free as a landmark for the procedure.
The patient should be slightly less than fully lateral (approximately 80-degree angle; see figure).

Plan to stop all antihypertensive medications postoperatively except beta-blockers and clonidine. Wean these off appropriately. Have the patient return for frequent blood pressure checks, or discharge with a home blood pressure cuff if able for daily measurements. If patients remain hypertensive in the short term, restart medications in a stepwise fashion.

1. Methimazole / PTU (PTU preferred for pregancy)
2. RAI
3. Beta blockade

A sustained cure is obtained in 25% of patients on ATMs, in 75% of patients undergoing RAI, and in 99% of patients undergoing thyroidectomy.
RAI is contraindicated during pregnancy or lactation for 1 year after treatment. It is also contraindicated in children and in patients who smoke because of an increased risk for eye disease.
Surgery is recommended for patients with concurrent nodular thyroid disease or large goiters. It is also recommended for patients with severe cases of thyrotoxicosis.
Surgical risks include hypoparathyroidism and recurrent laryngeal nerve injury.

Primary hypothyroidism is characterized by a high TSH concentration and low serum free T4. Subclinical hypothyroidism is defined as a normal T4 concentration in the setting of elevated TSH levels.

1. Screening - plasma metanephrines
2. Confirmation - urinary catecholamines and metanpehrines
3. CT / MRI - MRI bright ont T2 imaging, do not lose signal intesity on opposed phase chemical shift imaging sequences
4. MIBG scanning - biochemically ocnfirmed diagnosis but non localizing CT / MRI , or those with suspected metastatic pheo

Alpha-receptor blockade should be administered in preparation for surgery for pheochromocytoma, which is curative in more than 90% of cases. The goal of this blockade is to control hypertension and tachycardia. The alpha-blocker should be started at a low dose and be gradually titrated to effect for 10 to 14 days prior to surgery.
Phenoxybenzamine has been used most commonly but has become limited in the United States by the high cost of outpatient therapy.
Beta-blockers should never be given before alpha-blockers because they may precipitate a hypertensive crisis and cause acute cardiac decompensation.
Patients should be encouraged to drink fluids liberally as the blockade proceeds and volume capacity expands.
Because of the potential for acute hypertension during surgery, intraoperative monitoring with an arterial line is indicated.
Hypertensive exacerbations may occur during surgery with anesthesia induction, carbon dioxide insufflation, and tumor manipulation. It can be managed with intravenously administered alpha blockade and beta blockade

measurement of calcitonin, carcinoembryonic antigen (CEA), genetic screening for RET mutation. Concomitant pheochromocytoma must also be ruled out with measurement of plasma-free metanephrines and normetanephrines.

For low-risk, clinically node-negative tumors, thyroid lobectomy is advocated.
For high-risk tumors, tumors greater than 4 cm, tumors with gross extrathyroidal extension (T4) or clinically apparent nodal disease (N1) or distant disease (M1), a total thyroidectomy should be performed along with possible central (level VI) lymph node dissection.
In clinically node-negative patients with PTC and FTC, the role of prophylactic central lymph node dissection is controversial.
If gross or cytologically confirmed metastatic disease is present, neck dissections (central and/or lateral) are performed.
Nonmetastatic MTC should be treated with total thyroidectomy and bilateral central (level VI) neck dissection.

Large tumors (> 4.0 cm)
Distant metastases
Gross extrathyroidal extension or aggressive histologic features
Tumors from 1 to 4 cm with high-risk histologies, vascular invasion, or cervical lymph node metastases

Diagnosis can be made on FNA. Occasionally, an incisional biopsy is required for diagnosis.
Thyroid lymphoma responds well to chemotherapy with rituximab, cyclophosphamide, doxorubicin (hydroxydoxorubicin), vincristine (Oncovin), prednisone (R-CHOP) and radiation.

PTC / Follicular carcinoma
Clinically positive lymph nodes
Micrometastasis found on FNA preoperatively
T3 or T4 lesions
Extrathyroidal extension

MTC

a rapidly enlarging mass with suspicion of malignancy, cosmetic issues, and compressive symptom
FNA biopsy should be done when there is a discrete thyroid nodule to rule out lymphoma and thyroid carcinoma.

Fasting blood glucose
Serum potassium
24-hour urine cortisol
Corticotropin (ACTH)
Low-dose dexamethasone test: fasting serum cortisol at 8 am following a 1-mg dose of dexamethasone at bedtime
Serum adrenal androgens
Plasma-fractionated metanephrines or urinary metanephrines and catecholamines
Plasma renin/plasma aldosterone level
Serum estradiol in men and postmenopausal women
CT of the chest and abdomen to look for metastases to the liver, lymph nodes, and lungs
Bone scan to look for bony metastases
Possible positron emission tomography (PET) scan (may miss small lesions)

Incomplete resection
High-grade disease (Ki-67 > 10% or > 20 mitoses/HPF)
Intraoperative tumor spillage
Vascular or capsular invasion

Incomplete resection
High-grade disease (Ki-67 > 10% or > 20 mitoses/HPF)
Intraoperative tumor spillage
Vascular or capsular invasion

CT is 80% sensitive for neuroendocrine tumors and demonstrates arterial enhancement.
Gastrinomas, glucagonomas, and nonfunctioning pancreatic tumors express high levels of somatostatin receptors and can be imaged with a radiolabeled form octreotide, a somatostatin analog. However, insulinomas express relatively scant levels of subtype 2 somatostatin receptors and are less likely to be detected.
Arterial stimulation with hepatic venous sampling involves injection of a stimulating secretagogue, secretin for gastrinomas or calcium gluconate for insulinomas, into arteries supplying the pancreas with hepatic venous sampling.

1. Yearly biochemcial testing for pheochromocytoma
2. MEN 2A - before 5 years, MEN2-B before 1 year

The planned surgical technique for parathyroid carcinoma is en bloc resection of the tumor and any contiguous structures to which it may be adherent, including the ipsilateral thyroid lobe or the recurrent laryngeal nerve, which should be sacrificed if clinically involved.
If preoperative findings indicate lymph node involvement, a therapeutic ipsilateral cervical compartment lymph node dissection is indicated.

The initial step is liberal intravenous fluid resuscitation.
Then loop diuretics are added to induce excretion of Ca from the body after intravascular volume has been restored and urine output has normalized.
Other useful medications or interventions in the context of severe hypercalcemia include:
Phosphate supplementation (to correct compensatory hypophosphatemia associated with hypercalcemia)
Bisphosphonates (pamidronate), which inhibit osteoclastic bone resorption
Calcimimetic agents (cinacalcet)
Calcitonin blocks bone resorption, which also increases urinary calcium excretion
Denosumab (Prolia), a monoclonal antibody, which prevents the development of osteoclasts
Peritoneal or hemodialysis

Serial Ca and PTH measurements are required.
If an elevated Ca or PTH is found, a thorough imaging workup should be performed with the intention of localizing the site of recurrence. Ultrasound, sestamibi scan, whole-body CT, MRI, and positron emission tomography scan and/or bone scan be used.
The most likely site for recurrence is local—likely related to incomplete resection or intraoperative tumor spillage.
Fine needle aspiration can be used for suspected recurrence or metastasis.
If local recurrence is identified, reexploration and resection is the next step.
The most likely sites for metastatic disease are the lungs, liver, and bone. Resection is recommended for metastatic disease to treat associated hypercalcemia.

When performing MRND, it is not necessary to divide the SCM unless it is directly invaded by the tumor. The neck dissection can be completed adequately by moving the muscle medially and laterally and working beneath it.
On the left side, one must identify the thoracic duct at the junction of the innominate vein and the internal jugular and subclavian veins. If it is injured, it should be ligated to prevent a chyle leak or chylous fistula.
The SAN can be identified on the anterior border of the trapezius muscle in the lower part of the neck or on the posterior border of the SCM 1 cm above Erb point (a plexus of cervical cutaneous nerves on the posterior border of the SCM).
The phrenic nerve is seen on the anterior surface of the anterior scalene, which is the posterior border of the lateral neck dissection. Careful dissection is necessary to prevent the phrenic nerve from being lifted with the specimen.
The vagus nerve is found in the carotid sheath between the common carotid artery and the internal jugular vein.
The facial vein is often ligated to obtain adequate exposure of the hypoglossal nerve when removing upper jugular lymph nodes.

This involves removal of all level VI lymph nodes.
The borders of this operation are hyoid bone (superior), innominate artery (inferior), carotid artery (lateral), deep cervical fascia (posterior), and superficial layer of the deep cervical fascia (anterior)

The patient is placed supine, and a shoulder roll is placed. The patient’s head is turned away from the operative site, and the operating table is rotated such that the anesthesia machine sits opposite to the operative side.
The skin is divided along a Blair incision, which consists of a sickle-shaped preauricular incision curved under the earlobe, along the hairline of the neck and with submandibular or cervical extension.
An anterior skin flap is developed deep to the platysma muscle/superficial muscular aponeurotic system and elevated off of the anterior border/capsule of the parotid gland. Similarly, a posterior skin flap is elevated off the tail of the gland and to the posterior edge of the sternocleidomastoid muscle. Ideally, the greater auricular nerve is identified and spared, although sacrifice of this nerve is not uncommon and sometimes unavoidable; it results in a minor numbness of the earlobe.
The parotid gland is carefully mobilized and dissected from the anterior aspect of the sternocleidomastoid muscle, external jugular vein, the mastoid tip, and tragal cartilage.
Attention is then given to identifying the main trunk of the facial nerve, which is then traced anteriorly where the bifurcation is identified. The branches of the bifurcation and further branches are traced distally into the parotid gland as far as needed to reach beyond the tumor. Once an adequate margin of parotid tissue is obtained beyond the tumor, the parotid tissue can be transected and the nerve dissection is halted. If the tumor lies in the deep lobe, the overlying facial nerve branches are gently moved aside, and the deep lobe is delivered and separated from its attachments to the superficial lobe.
The wound is inspected for hemostasis, and a drain is placed in the wound. The wound is closed using absorbable sutures.