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.

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.

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.

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 chronicl 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.

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.⁶⁸ Gallium-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.

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.

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.

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.

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.

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.