Current Issue Volume 10, Number 2 , May-August 2018

EDITORIAL
Alexander Papachristos, Julie A Miller

Surgical Management of Graves' Disease: A Contemporary Perspective

[Year:2018] [Month:May-August] [Volumn:10 ] [Number:2] [Pages:48] [Pages No:iv-v]



Historically, thyroid surgery was feared as a “foolhardy undertaking”1 with a mortality rate of 40%2 until Theodore Kocher pioneered the technique of capsular dissection in the late 1880s, transforming total thyroidectomy into a safe and effective procedure. However, after noticing that total thyroidectomy resulted in “cachexia strumipriva”—a failure to thrive original attributed to chronic asphyxia before the discovery of thyroxine— he abandoned total thyroidectomy and instead utilized a bilateral subtotal approach, in order to avoid hypothyroidism. Kocher reported a series of 900 thyroid operations with a mortality rate of 1% and in 1909 was the first surgeon to be awarded, the Nobel Prize for medicine.2


ORIGINAL ARTICLE
Nathaniel J Walsh, Asif M Talukder, Andrew G Lawson, Amel X Komic, Brian P Bateson, Andrew J Jones, Edward J Kruse

Thyroid Malignancy and Suicide Risk: An Analysis of Epidemiologic and Clinical Factors

[Year:2018] [Month:May-August] [Volumn:10 ] [Number:2] [Pages:48] [Pages No:99-102]



Aim: To date, there has been no specific examination of suicide rates and factors associated with suicide in thyroid cancer. The aim of this study is to examine suicide incidence and associated factors in thyroid cancer patients from 1973 to 2013.

Materials and methods: The Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute was queried to identify patients with thyroid cancer from 1973 to 2013. Comparison data with the general US population were derived from the Centers for Disease Control and Prevention’s (CDC) National Center for Injury Prevention and Control using the Web-based Injury Statistics Query and Reporting System (WISQARS). Standardized mortality ratios (SMRs) and multivariable logistic regression models generated odds ratios (ORs) for the identification of factors associated with suicide.

Results: Overall, 154 suicides among 168,339 patients were identified. There was no statistically significant difference in suicide rate with respect to age, marital status, median household income, surgical intervention, stage at diagnosis, or histologic subtype. On multivariable analysis male gender and Caucasian race were associated with increased risk of suicide with ORs of 5.39 and 3.17 respectively.

Conclusion: Race and gender appear to influence suicide rates in patients with thyroid cancer. Females and whites were more likely to commit suicide as noted previously. There was no statistically significant relationship between suicide and marital status, income, mode of radiation therapy, and the role of surgical intervention. These results, coupled with further studies and analyses, could be used to formulate a comprehensive suicide risk factor scoring system for screening all cancer patients.

Clinical significance: Thyroid cancer is very treatable with excellent long-term survival and outcomes. Improved screening and risk factor stratification in these patients could decrease the incidence of suicide in thyroid cancer patients.

Keywords: Mortality, Standardized mortality ratio, Suicide, Surveillance epidemiology and end results database, Thyroid cancer.

How to cite this article: Walsh NJ, Talukder AM, Lawson AG, Komic AX, Bateson BP, Jones AJ, Kruse EJ. Thyroid Malignancy and Suicide Risk: An Analysis of Epidemiologic and Clinical Factors. World J Endoc Surg 2018;10(2):99-102.

Source of support: Nil

Conflict of interest: None


ORIGINAL ARTICLE
Su A Lui, Jun L Teh, Yong X Gwee, Clifton Tay, Jesse Hu, Kee Y Ngiam, Charles TK Tan, Rajeev Parameswaran, Abu Rauff, Wee B Tan, Wei K Cheah

Surgical Management of Graves' Disease over a 25-year Period in a Single Institution: Comparison of Outcomes between Subtotal Thyroidectomy and Total Thyroidectomy

[Year:2018] [Month:May-August] [Volumn:10 ] [Number:2] [Pages:48] [Pages No:103-107]



Introduction: Surgery is offered to patients with Graves’ disease (GD) refractory to medical or radio-iodine therapy. Total thyroidectomy (TT) has been shown to lower recurrence rates of hyperthyroidism but subtotal thyroidectomy (ST) is thought to be associated with lower risk of postoperative complications. The aim of this study was to compare the postoperative outcomes of TT vs ST in the Singaporean population and identify risk factors that might predispose to treatment failure after ST.

Materials and methods: This is a retrospective review of consecutive patients who underwent surgery for GD at a single institution in Singapore. Patients who underwent thyroid surgery for GD between January 1991 and December 2015 were included in the study. The primary outcomes studied were rates of recurrent hyperthyroidism, hypocalcemia, recurrent laryngeal nerve injury, and length of stay postsurgery. The secondary outcome was to compare whether preoperative thyroid function and antibody levels predicted for treatment failure post-ST.

Results: Over a 25-year period, 79 patients underwent ST and 38 patients underwent TT. The rate of hyperthyroidism relapse post-ST was 20.3% compared with 0% post-TT (p < 0.01). There was no difference between the length of stay, or recurrent laryngeal nerve injury between patients who underwent ST compared with TT. Preoperative antibody levels and biochemical hyperthyroidism did not predict treatment failure after ST.

Conclusion: Total thyroidectomy is a more definitive surgical procedure for patients with GD refractory to medical therapy with lower risk of disease relapse and similar temporary and long-term risk of complications when compared with ST.

Keywords: Graves’ disease, Outcome, Thyroidectomy.

How to cite this article: Lui SA, Teh JL, Gwee YX, Tay C, Hu J, Ngiam KY, Tan CTK, Parameswaran R, Rauff A, Tan WB, Cheah WK. Surgical Management of Graves’ Disease over a 25-year Period in a Single Institution: Comparison of Outcomes between Subtotal Thyroidectomy and Total Thyroidectomy. World J Endoc Surg 2018;10(2):103-107.

Source of support: Nil

Conflict of interest: None


ORIGINAL ARTICLE
Sushila Jaiswal, Raghunandan Prasad, Farhana Siddiqui, Hira Lal, Neha Nigam, Azfar Neyaz, Sabaretnam Mayilvaganan, Gyan Chand, Amit Agarwal

Cytomorphological Features of Medullary Thyroid Carcinoma: An Analysis based on 41 Ultrasoundguided Fine-needle Aspiration Specimens

[Year:2018] [Month:May-August] [Volumn:10 ] [Number:2] [Pages:48] [Pages No:108-118]



Introduction: Medullary thyroid carcinoma (MTC) is a malignant tumor of thyroid gland showing parafollicular or C-cell differentiation.

Aims and objectives: The current study was undertaken to evaluate safety of ultrasound-guided thyroid fine-needle aspiration cytology (FNAC) and to assess cytomorphological features of MTC in FNA specimens from 28 patients.

Materials and methods: The study was performed by retrospectively reviewing the clinical and pathological records of MTC cases managed at our institute.

Results: The patients included 18 males and 10 females with a mean age of 45.3 years; 24 specimens were taken from thyroid, 15 from cervical lymph nodes and one each from liver space occupying lesion and chest wall nodule. There was no complication noted during ultrasound-guided FNAC in these patients. The smears had variable cellularity in the form of moderate cellularity in 63% of specimens and low cellularity in 15% of specimens. Cell arrangements were solid cohesive in 39% of cases and microfollicular clusters in 36% of cases. The frequent microfollicles in two specimens prompted the differential of follicular carcinoma. Dispersed population was noted in 90% of specimens. Binucleated and multinucleated cells were seen in 58 and 53% specimens respectively. Only spindle cell morphology was noted in 2% of specimens. Central to eccentric nuclei were present in 39% of specimens, while 13% of specimens showed mainly eccentric nuclei. In all the specimens, neuroendocrine type of salt and pepper-like morphology was present which is best seen with Papanicolaou (Pap) stain. Similarly, cytoplasm showed granules in 78% and fine vacuoles in 29% of specimens. Amyloid appreciated as flecks or aggregates of amorphous pink or gray color was seen in 37% of specimens. No mitosis was noted in any specimen, while necrosis was seen in only in one specimen.

Conclusion: Ultrasound-guided FNAC is a fairly accurate, relatively safe, rapid, and simple tool for preoperative diagnosis of thyroid malignancies. Although the cytological features of MTC are well described, different patterns may pose a diagnostic difficulty.

Keywords: Fine-needle aspiration cytology, Fine-needle aspiration cytology thyroid, Medullary thyroid carcinoma, Thyroid carcinoma.

How to cite this article: Jaiswal S, Prasad R, Siddiqui F, Lal H, Nigam N, Neyaz A, Mayilvaganan S, Chand G, Agarwal A. Cytomorphological Features of Medullary Thyroid Carcinoma: An Analysis based on 41 Ultrasound-guided Fine-needle Aspiration Specimens. World J Endoc Surg 2018;10(2):108-118.

Source of support: Nil

Conflict of interest: None


ORIGINAL ARTICLE
Nadeesha J Nawarathna, Palitha Ratnayake, Suwin N Hewage, Ranjith JK Senevirathne, Sonali SC Gunatilake, Nimeda L Kariyawasam, Rasika Shyamalie, Priyanga Yogachandran

Association between Nonspecific Chronic Lymphocytic Thyroiditis and Differentiated Epithelial Thyroid Carcinoma: Clinicopathological Analysis of Patients Who underwent Thyroidectomy in a Tertiary Care Center in Sri Lanka

[Year:2018] [Month:May-August] [Volumn:10 ] [Number:2] [Pages:48] [Pages No:119-126]



Introduction: The most common differentiated malignant thyroid neoplasm is papillary carcinoma. The association of concurrent presence of chronic lymphocytic thyroiditis and its subtypes with differentiated epithelial thyroid carcinoma remains controversial.

Objective: To evaluate the epidemiological factors of chronic lymphocytic thyroiditis and association between chronic lymphocytic thyroiditis and its subtypes with differentiated epithelial thyroid carcinoma.

Materials and methods: The histopathological records of 684 patients who underwent thyroidectomy at Teaching Hospital Kandy, Sri Lanka, for a period of 2½ years from January 2013 were reviewed. Their clinical and pathological characteristics were analyzed. Chronic lymphocytic thyroiditis was diagnosed by histology.

Results: Thyroid malignancies were detected in 14.2% of thyroidectomy specimen, of which well-differentiated epithelial thyroid carcinoma was seen in 82%. Chronic lymphocytic thyroiditis was present in 31%, out of which 73.1% were nonspecific chronic lymphocytic thyroiditis and 26.9% were Hashimoto’s thyroiditis. Gender, age, and presence of thyroiditis were significantly associated with papillary thyroid carcinoma. In the analyzed sample, males were more likely to have papillary carcinoma compared with females (p = 0.013). Those with nonspecific chronic lymphocytic thyroiditis were more likely to have papillary thyroid carcinoma (p = 0.002) compared with those without. With increasing age, the proportion of lymphovascular invasion in patients with papillary thyroid carcinoma significantly (p = 0.010) decreases. None of the three factors mentioned were significant predictors of presence of follicular carcinoma, tumor focality, capsular or lymphovascular invasion in papillary or follicular carcinoma.

Conclusion: The presence of nonspecific chronic l ymphocytic thyroiditis is associated with papillary thyroid carcinoma at a given age and gender. Influence of nonspecific chronic lymphocytic thyroiditis on the prognosis of well-differentiated epithelial thyroid carcinoma needs to be investigated further with a larger sample size.

Keywords: Age, Differentiated thyroid carcinoma, Gender, Nonspecific chronic lymphocytic thyroiditis.

How to cite this article: Nawarathna NJ, Ratnayake P, Hewage SN, Senevirathne RJK, Gunatilake SSC, Kariyawasam NL, Shyamalie R, Yogachandran P. Association between Nonspecific Chronic Lymphocytic Thyroiditis and Differentiated Epithelial Thyroid Carcinoma: Clinicopathological Analysis of Patients Who underwent Thyroidectomy in a Tertiary Care Center in Sri Lanka. World J Endoc Surg 2018;10(2):119-126.

Source of support: Nil

Conflict of interest: None


CASE REPORT
John Agzarian, Hisham Quandeel, Irina Bancos, Geoffrey B Johnson, Stephen C Scharf, Geoffrey B Thompson, Joanne Yi, Xiaotun Zhang, K Robert Shen

Use of DOTATATE PET/CT Scan in the Diagnosis and Staging of Thymic Atypical Carcinoid Tumor in a Patient with Secondary ACTH-dependent Cushing Syndrome: Look Twice and Cut Once

[Year:2018] [Month:May-August] [Volumn:10 ] [Number:2] [Pages:48] [Pages No:127-133]



Neuroendocrine thymic tumors represent the least common type of primary thymic tumor with a prevalence of 2 to 5%. We present a case of locally advanced thymic atypical carcinoid tumor diagnosed incidentally while investigating progressive Cushing syndrome. Computed tomography (CT) scan demonstrated a large 2.9 cm exophytic thyroid nodule and a 2.0 cm anterior mediastinal mass. Biopsy of the thyroid nodule demonstrated benign thyroid tissue, and octreotide scan revealed avid uptake in the right thyroid lobe with minimal uptake in the thymic tumor. 68Gallium-1,4,7,10-tetraazacyclododecane-N,N’,N’’N’’’- tetraacetic acid-D-Phe1,Tyr3-octreotate (Ga-68 DOTATATE) positron emission tomography (PET)/CT scan showed intense uptake in the thyroid gland followed by a moderate amount of activity in the anterior mediastinal mass. The patient underwent a median sternotomy and radical thymectomy with en bloc resection of the left innominate vein and primary repair of the superior vena cava (SVC). On further evaluation, the presumed thyroid nodule appeared contiguous with the thymic lesion and separate from the thyroid. Final pathology demonstrated a poorly differentiated 4.4 cm atypical carcinoid tumor with nine positive lymph nodes. On the third postoperative day, the serum cortisol level precipitously decreased to a level of 6.8 μg/dL.
This case highlights the challenges surrounding the diagnosis of hormonally active thymic carcinoids and demonstrates the utility of Ga-68 DOTATATE PET scan in localizing somatostatinpositive neuroendocrine tumors and surgical planning.

Keywords: DOTATATE, Mediastinal, Positron emission tomography, Thymic carcinoid.

How to cite this article: Agzarian J, Quandeel H, Bancos I, Johnson GB, Scharf SC, Thompson GB, Yi J, Zhang X, Shen KR. Use of DOTATATE PET/CT Scan in the Diagnosis and Staging of Thymic Atypical Carcinoid Tumor in a Patient with Secondary ACTH-dependent Cushing Syndrome: Look Twice and Cut Once. World J Endoc Surg 2018;10(2):127-133.

Source of support: Nil

Conflict of interest: None


CASE REPORT
Chanchal Rana, Niraj Kumari

Hurthle Cell Adenoma and Papillary Microcarcinoma in Thyroid: Collision Tumors

[Year:2018] [Month:May-August] [Volumn:10 ] [Number:2] [Pages:48] [Pages No:134-136]



The combination of more than one thyroid carcinoma variants has been reported very rarely which includes combination of follicular carcinoma with papillary carcinoma, medullary carcinoma with follicular carcinoma and anaplastic, and follicular and papillary carcinoma with follicular adenoma. We report another combination of Hurthle cell adenoma with incidental occurrence of micropapillary carcinoma adding to the group of collision tumors in thyroid.

Keywords: Collision tumor, Hurthle cell adenoma, Papillary microcarcinoma.

How to cite this article: Rana C, Kumari N. Hurthle Cell Adenoma and Papillary Microcarcinoma in Thyroid: Collision Tumors. World J Endoc Surg 2018;10(2):134-136.

Source of support: Nil

Conflict of interest: None


CASE REPORT
Christos S Christoforides, Ioannis Papandrikos, Ilias Zorbas, Gerasimos Kritikos, Ioannis Pateras, Dimitrios Vlachodimitropoulos, Angelos Kalovidouris, Kyriakos Vamvakidis

Intrathyroidal Lymphoepithelial (Branchial) Cyst: Diagnostic and Management Challenge of a Rare Entity

[Year:2018] [Month:May-August] [Volumn:10 ] [Number:2] [Pages:48] [Pages No:137-141]



Intrathyroidal lymphoepithelial (branchial) cysts are very rare, and only few cases have been previously reported worldwide. Here, we report on a case of a male patient with such a rare histological finding after a routine left hemithyroidectomy performed for a nearly 4 cm cystic left thyroid lobe lesion. The patient was an 80-year-old man, fact that makes, to our knowledge, our patient the oldest in the current literature. Through a review of the existing literature, we concluded that although some entities are extremely rare, they should also be taken under consideration in everyday clinical differential diagnosis of otherwise common medical cases, such as our presented case. Such cases pose a differential dilemma for the clinical doctor in order to make a correct diagnosis, if that is possible, and then proceed with the efficient treatment.

Keywords: Branchial cyst, Case report, Intrathyroidal, Lymphoepithelial cyst, Rare, Thyroid cyst.

How to cite this article: Christoforides CS, Papandrikos I, Zorbas I, Kritikos G, Pateras I, Vlachodimitropoulos D, Kalovidouris A, Vamvakidis K. Intrathyroidal Lymphoepithelial (Branchial) Cyst: Diagnostic and Management Challenge of a Rare Entity. World J Endoc Surg 2018;10(2):137-141.

Source of support: Nil

Conflict of interest: None


CASE REPORT
Richard J Egan, Rakan Kabariti, Daniel L Hopkins, Michael J Stechman, David M Scott-Coombes

Thyroid Sarcoidosis as a Rare Explanation of Resistance to Radioactive Iodine in Graves' Disease.

[Year:2018] [Month:May-August] [Volumn:10 ] [Number:2] [Pages:48] [Pages No:142-144]



Background: Sarcoidosis is a multiorgan idiopathic inflammatory disease that involves the thyroid gland in 1 to 4.6% of the cases.

Case report: We report a case of a 36-year-old man who was diagnosed with Graves’ disease and initially treated with block and replace regimen followed by radioactive iodine (RAI), both of which were unsuccessful. The patient subsequently underwent an uncomplicated total thyroidectomy. Subsequent histological evaluation of the thyroid tissue demonstrated granulomatous inflammation consistent with a diagnosis of sarcoidosis. This was the index presentation of this diagnosis with no previous symptoms or clinical manifestations related to sarcoidosis.

Conclusion: Using this case as an example, we therefore conclude that relative resistance of Graves’ thyrotoxicosis to treatment may be due to a novel underlying presentation of sarcoidosis.

Clinical significance: Sarcoidosis of the thyroid gland should be considered as part of the clinical differential diagnosis in cases of treatment-resistant thyrotoxicosis.

Keywords: Case report, Graves’ disease, Sarcoidosis, Thyroidectomy.

How to cite this article: Egan RJ, Kabariti R, Hopkins DL, Stechman MJ, Scott-Coombes DM. Thyroid Sarcoidosis as a Rare Explanation of Resistance to Radioactive Iodine in Graves’ Disease. World J Endoc Surg 2018;10(2):142-144.

Source of support: Nil

Conflict of interest: None


HOW I DO IT
Roma Pradhan

Managing Adrenal Tumors in Children: Tricks and Tips

[Year:2018] [Month:May-August] [Volumn:10 ] [Number:2] [Pages:48] [Pages No:145-146]



Adrenal tumors are extremely rare in childhood, except in Brazil, so that their clinical manifestations remain poorly known by pediatricians. In children, the most common manifestation of adrenal tumors is the appearance of pubic hair and other signs of virilization. Isolated androgen secretion is present in 40% of children’s tumors vs 9% in adults. These tumors also have no reliable set of criteria for malignancy. Therefore, all suspected adrenal tumors must be managed as adrenocortical carcinomas (ACCs) until the final diagnosis is made. All children should be treated in endocrine oncologic centers with experienced endocrine surgeons in a highly interdisciplinary setting.

Keywords: Adrenal tumor, Adrenocortical carcinoma, Pediatric.

How to cite this article: Pradhan R. Managing Adrenal Tumors in Children: Tricks and Tips. World J Endoc Surg 2018;10(2):145-146.

Source of support: Nil

Conflict of interest: None


ENDOCRINE IMAGE
Roma Pradhan, Pallavi Shinde, Soumya Pattnaik, Siddharth Sathaye, Sashi Raj, Mohammad Nazar, Sofia Batool, Aradhana Sinha, Tshering D Bhutia

Challenges faced in operating a 3 Kilogram Thyroid Cancer

[Year:2018] [Month:May-August] [Volumn:10 ] [Number:2] [Pages:48] [Pages No:147]



A case of a 60-year-old male who presented to the endocrine surgery outpatient department with complaints of neck swelling for last 6 years with h/o rapid growth for 1½ months, associated with 3 Ds, i.e., dysphagia, dysphonia, and dyspnea. Fine-needle aspiration cytology was reported as suspicious for a follicular neoplasm. On examination, he was found to be having a huge nodular goiter with impending ulceration of overlying skin. Operability and difficult intubation were serious challenges. Patient was taken up for surgery. Intubation was a challenge for the anesthetist. Awake intubation was tried but because of plenty of tortuous multiple vessels in oral cavity, there was bleeding and the vision was obscured. As informed by our anesthetist, the air bubbles coming from the trachea during patient’s breathing was the only guide for her to direct the endotracheal tube. At operation, left carotid was found to be encased, but could be separated with sharp dissection. Left internal jugular vein and left vagus were encased, could not be saved, and hence, sacrificed. Right recurrent laryngeal nerve and right superior and inferior parathyroid were preserved. Thus, a total thyroidectomy could be performed. The specimen weighed 3 kg (Fig. 1). After removal of the 3 kg mass, patient had difficulty in holding his head upright due to postural compensation. Postoperatively, patient had difficulty in swallowing, which was evident by pooling of saliva during laryngoscopy postoperatively; however, right vocal cord was mobile. Literature is sparse about the problem which the patient developed after removal of huge goiter weighing more than 3 kg. This is probably the largest thyroid cancer operated in India.

Keywords: Complication, Postural drop, Thyroid cancer.

How to cite this article: Pradhan R, Shinde P, Pattnaik S, Sathaye S, Raj S, Nazar M, Batool S, Sinha A, Bhutia TD. Challenges faced in operating a 3 Kilogram Thyroid Cancer. World J Endoc Surg 2018;10(2):147.

Source of support: Nil

Conflict of interest: None


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