Can a patient with overt hyperthyroidism (high free triiodothyronine, suppressed thyroid‑stimulating hormone), mildly elevated INR, leukocytosis, and low‑normal serum calcium while on denosumab be cleared for planned wide resection and intramedullary nailing of a giant‑cell tumor?

Surgical Clearance for Hyperthyroid Patient with Giant Cell Tumor

A patient with overt hyperthyroidism (high FT3, suppressed TSH) can proceed to surgery for giant cell tumor resection and intramedullary nailing without achieving biochemical euthyroidism, provided cardiovascular stability is confirmed and appropriate perioperative beta-blockade is implemented. 1

Evidence Supporting Surgery in the Hyperthyroid State

Recent evidence demonstrates that thyroidectomy—and by extension, other surgical procedures—can be safely performed during the hyperthyroid phase without precipitating thyroid storm or increasing perioperative complications when managed by experienced teams. 1 The traditional requirement to achieve biochemical euthyroidism before surgery lacks strong supporting evidence, and preoperative antithyroid treatment does not prevent thyroid storm whether the patient is euthyroid or hyperthyroid at the time of surgery. 1

The critical determinant is cardiovascular stability, not thyroid hormone levels. 1 In hyperthyroid patients who are cardiovascularly stable, thyroid surgery may not need to be delayed and can be performed safely. 1

Preoperative Assessment and Optimization

Cardiovascular Evaluation

• Assess for tachycardia, atrial fibrillation, heart failure, and other cardiac manifestations of hyperthyroidism, as these are the most prominent and dangerous aspects of the hyperthyroid state. 1, 2
• Untreated hyperthyroidism can cause cardiac arrhythmias and heart failure, which are the primary perioperative concerns. 2
• The patient's cardiovascular system must be stabilized before proceeding, with particular attention to heart rate control. 1

Beta-Blockade Implementation

• Initiate beta-adrenergic blocking agents to control peripheral effects of thyroid hormones, particularly cardiovascular manifestations. 1
• Beta-blockers are essential for preventing tachycardia and arrhythmias during the perioperative period. 1
• Note that hyperthyroidism causes increased clearance of beta-blockers with high extraction ratios, so higher doses may be required initially. 3

Additional Considerations for This Patient

Denosumab and surgical timing: The patient is on denosumab for giant cell tumor treatment. Denosumab has emerged as effective treatment for GCTs, with evidence showing significant tumor modification and even complete histological response in some cases. 4 However, the primary indication here is surgical resection with intramedullary nailing, which is the definitive treatment for giant cell tumors requiring stabilization. 5

Mildly elevated INR: Methimazole (if being used for hyperthyroidism) may cause hypoprothrombinemia and increase oral anticoagulant activity. 3 Prothrombin time should be monitored before surgical procedures, and the mildly elevated INR must be corrected preoperatively. 3

Leukocytosis: White blood cell count should be evaluated to rule out agranulocytosis if the patient is on antithyroid drugs, as this is a serious potential complication. 3 However, leukocytosis may also reflect the inflammatory response to the tumor itself.

Low-normal calcium on denosumab: Monitor calcium levels closely, as denosumab can cause hypocalcemia. Ensure adequate calcium and vitamin D supplementation perioperatively. 5

Perioperative Management Algorithm

1. Confirm cardiovascular stability through ECG, echocardiogram if indicated, and clinical assessment of heart rate and rhythm. 1

2. Optimize beta-blockade to achieve heart rate <90 bpm at rest. 1

3. Correct INR to acceptable range for surgery (typically <1.5 for orthopedic procedures). 3

4. Verify adequate calcium levels and supplement as needed given denosumab use. 5

5. Coordinate with anesthesiology and endocrinology to ensure awareness of hyperthyroid state and plan for perioperative monitoring. 1

6. Proceed with surgery once cardiovascular parameters are optimized, regardless of thyroid hormone levels. 1

Common Pitfalls to Avoid

• Do not delay necessary orthopedic surgery waiting for biochemical euthyroidism, as this is not required for safe surgery and delays definitive treatment of the giant cell tumor. 1

• Do not assume euthyroidism prevents thyroid storm—preoperative treatment does not eliminate this risk, and cardiovascular stability is the key protective factor. 1

• Do not overlook the increased clearance of beta-blockers in hyperthyroid patients, which may necessitate higher doses than typically used. 3

• Do not proceed without adequate beta-blockade, as uncontrolled tachycardia and arrhythmias are the primary perioperative risks. 1