How to cite this article:
Cvasciuc T, Lansdown M, Fraser S. Focused Parathyroidectomy without Intraoperative Parathyroid Hormone Testing: Acceptability after Preoperative Localization with SPECT-CT. World J Endoc Surg 2019; 11 (1):1-5.
Introduction: Intraoperative parathyroid hormone (IOPTH) monitoring is used to confirm the success of parathyroidectomy for primary hyperparathyroidism (PHPT). The aim of this study is to find out if IOPTH is useful during parathyroidectomy for patients with PHPT and positive single photon emission computed tomography (SPECT-CT) imaging.
Materials and methods: A retrospective study of parathyroidectomies for PHPT between 2011 and 2016 in a teaching hospital was performed. Patients\' characteristics (demographics and gender), biochemistry, imaging [ultrasound parathyroids (USSs) and SPECT-CT], type of operation, histology, and persistent disease were identified. Patients were divided into four subgroups according to preoperative imaging, use of IOPTH, and failure rate.
Results: Two hundred and fifty-eight patients were enrolled. About 44.6% of patients had positive and concordant preoperative imaging. Multi-gland disease (MGD) was found in 13.18% of patients on histology. Patients were divided into four subgroups: group 1 (140 patients): positive imaging and focused parathyroidectomy (FP); group 2 (53 patients): positive imaging and nonfocused approach; group 3 (6 patients): disconcordant imaging [negative SPECT-CT but positive ultrasound (US)] and FP; group 4 (57 patients): negative imaging and no FP. The cure rates were 97.86, 94.34, 100, and 87.71%. The overall cure rate was 95%. Within groups 1 and 2, the failure rate was similar if IOPTH was used. IOPTH was used in all patients in groups 3 and 4.
Conclusion: The selective use of IOPTH is an effective operative strategy. Positive SPECT-CT imaging can guide an FP without the need for IOPTH. IOPTH is useful for SPECT-CT-negative patients who are at risk of multi-gland disease (MGD) or to guide FP if single positive imaging.
Clinical significance: Our results and suggestions can guide the use of IOPTH in clinical practice. The selective use of IOPTH suggested by preoperative imaging can be cost-effective and reduce unnecessary time in theater.
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Kumari N, Chaudhary N, Krishnani N. Association of Biochemical and Histological Features with Parafibromin, Galectin-3, and PGP9.5 in Parathyroid Neoplasms. World J Endoc Surg 2019; 11 (1):6-14.
Background: Carcinoma in parathyroid is diagnosed when there is recurrence or metastasis or fulfillment of histological criteria. Immunohistochemical (IHC) markers are used to assist in difficult cases. Associations of IHC markers with unfavorable clinical or histological features that predict aggressive behavior of parathyroid neoplasms have not been reported so far. We planned to study the direct association of IHC markers with biochemical and histological features in parathyroid neoplasms.
Materials and methods: IHC for parafibromin (PF), adenosis polyposis coli (APC), galectin-3 (Gal-3), and PGP9.5 was performed and correlated with biochemical and histological features.
Result: PF loss, Gal-3, and PGP9.5 overexpression alone or in combination showed significant association with one or more features like hypercalcemic crisis; low serum vitamin D; raised serum alkaline phosphatase (ALP); diffuse sheet pattern; predominant oncocytic histology; diffuse macronucleoli; thick fibrous bands; and capsular, vascular, and adjacent tissue invasion. The majority of histological features that significantly correlated with the expression or loss of IHC makers is included in the current criteria for diagnosing malignancy in parathyroid neoplasms.
Conclusion: The presence of hypercalcemic crisis and predominant oncocytic histology showed significant association with IHC markers related to parathyroid malignancy. Inclusion of these features in current criteria may make it more comprehensive for predicting malignancy in parathyroid neoplasms, though the search for reliable factors predicting malignancy still continues.
A recurrent goiter is the regrowth of thyroid tissue after thyroidectomy. The causes of recurrence following surgery for the benign disease can be broadly attributed to inadequate surgery, embryological remnants left behind inadvertently, and the development of a malignancy in the remnant.
Recurrence after surgery for the benign disease should be preventable. Subtotal thyroidectomy (STT) was the main operation for goiters until the 1980s. The main issue with a subtotal surgery is a recurrence. One of the primary reasons why STT fails can be attributed to the fact that STT does not treat the underlying generalized disease adequately. The consensus is emerging that the best surgical option for multinodular goiter is total thyroidectomy. Even after “total” thyroidectomy, there is recurrence, what is left behind is related to the three embryological remnants of thyroid, namely pyramidal lobe recurrences, recurrence of the tubercle of Zuckerkandl, and thyrothymic recurrences. The surgical technique at the initial total thyroidectomy must be meticulous, ensuring that all embryological remnants are excised properly.
Goiter recurrence is a failure of surgical treatment of goiter. Inadequate surgery and failure to excise all thyroid tissues are two preventable causes for recurrence. The technique of reoperative thyroidectomy must include capsular dissection, removal of all embryological remnants, and parathyroid autotransplantation.
Surgery for recurrent goiter is challenging. It is thought to entail a higher complication rate and complication rates may be high in inexperienced hands; low complication rates have been achieved in specialized centers. The fear of complications should not deter experienced surgeons from performing reoperative thyroid surgery. In terms of technique, the lateral approach to thyroid offers a good alternative for recurrent goiters. A meticulous technique and parathyroid autotransplantation will help minimize the complication rate.
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Rao SS, Ferdinant J, Shikhil P, Ahmed A, Sathya A, Sadacharan D. von Hippel–Lindau Disease with Multi-organ Cysts and Ticking Pheochromocytoma: A Rare Case. World J Endoc Surg 2019; 11 (1):19-21.
Objective: A rare disease.
Background: von Hippel-Lindau (VHL) disease is an autosomal dominant familial syndrome with a multitude of benign and malignant multivisceral tumors and one-third of them harbor pheochromocytoma (PCC). We intend to present one such rare case and challenges in its surgical management.
Case: A 38-year-old lady presented with hypertension and episodic headache. Biochemical evaluation was suggestive of hypercatecholaminism. Magnetic resonance imaging (MRI) showed the presence of a heterogeneous intensity lesion in the left suprarenal area suggestive of PCC. Multiple cysts were seen in both the kidneys as well as in the pancreatic head and tail. Imaging of the brain and spine showed a left cerebellar and spinal cord hemangioblastoma, respectively. I-131 metaiodobenzylguanidine (MIBG) showed high uptake in the left suprarenal region. After adequate preparation, she underwent left adrenalectomy. Histopathology was consistent with adrenal PCC and the patient was biochemically cured of hypercatecholaminism. The presence of PCC and other manifestations of VHL type 2A were evident in this patient.
Conclusion: The presence of multiple renal and pancreatic cysts can camouflage adrenal tumors intraoperatively. Careful identification, dissection, and differentiation of PCC from these cysts are crucial. Multicentricity and multifocality of PCC are not uncommon in VHL and these patients need lifelong close follow-up for other tumors as well.
Douglas J Chung,
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Chung DJ, Krieger D, Moreno N, Renshaw A, Alonso R, Cava R, Witkind M, Udelsman R. Papillary Thyroid Carcinoma: The First Case of Direct Tumor Extension into the Left Innominate Vein Managed with a Single Operative Approach. World J Endoc Surg 2019; 11 (1):22-25.
Aim: The aim of this study is to report a case of papillary thyroid carcinoma (PTC) with direct intravascular extension into the left internal jugular vein, resulting in tumor thrombus into the left innominate vein.
Background: PTC is the most common of the four histological subtypes of thyroid malignancies,1 but PTC with vascular invasion into major blood vessels is rare.2 The incidence of PTC tumor thrombi was found to be 0.116% in one study investigating 7,754 thyroid surgical patients, and, of these patients with tumor thrombus, none extended more distal than the internal jugular vein.3 Koike et al.4 described a case of PTC invasion into the left innominate vein that was managed by a two-stage operative approach.
Case description: A 58-year-old male presented with a rapidly growing left thyroid mass. Fine needle aspiration cytology (FNAC) suggested PTC and surgical exploration confirmed tumor extension into the left internal jugular vein. Continued dissection revealed a large palpable intraluminal tumor thrombus extending below the clavicle into the mediastinum, necessitating median sternotomy.
Conclusion: Aggressive one-stage surgical resection resulted in successful en bloc extirpation of the tumor, with negative margins. Follow-up at 22 months postoperatively demonstrated no evidence of recurrence.
Clinical significance: This is the first case of PTC extension into the left innominate vein managed with one-stage surgical intervention with curative intent.
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Shilpage S, Fernando R, Munasinghe N, Gunathilaka B. Use of Laryngeal Mask Airway in Total Thyroidectomy in a Patient with Ocular Myasthenia and Graves’ Disease. World J Endoc Surg 2019; 11 (1):26-27.
Background: The association between Graves\' disease (GD) and ocular myasthenia (OM) is well known. Total thyroidectomy gives a permanent “cure” for GD and the literature reports a varying progression of myasthenia gravis (MG) in such patients after surgery. The main issue in patients with MG is the difficulties with the use of muscle relaxants during anesthesia. In the ensuing case report, a patient with OM and GD who had a total thyroidectomy under general anesthesia (GA) with laryngeal mask airway (LMA) without muscle relaxants is described.
Case report: A 40-year-old man was clinically and biochemically diagnosed to have GD. Subsequently, he developed bilateral ptosis which was diagnosed as OM by a neurologist. Though his OM responded to treatment, his GD was not well controlled. He was admitted, monitored, and made euthyroid by adjusting the carbimazole dose. A decision was made to undertake total thyroidectomy for GD, with total intravenous anesthesia and Proseal® LMA without muscle relaxants following a discussion with the anesthetic team. A conventional total thyroidectomy was performed using nerve encountering, parathyroid preserving, and capsular dissection technique. The patient made an uncomplicated recovery.
Conclusion: A technique combining total intravenous anesthesia and a LMA without muscle relaxants for thyroid surgery in a patient with MG has advantages over a standard method. The use of LMA in other thyroid surgeries must be further evaluated for future use.
Clinical significance: Coexistence of MG and GD should be in mind when treating the patients with GD. Individualize the use of muscle relaxants in GA and best to avoid whenever possible.
The unique subtype of co-secreting adrenal tumor especially aldosterone and cortisol co-secreting tumors presents a special challenge because they present with unexplained clinical constellations, may display unique laboratory test results, and impact postoperative care. Here, we describe three cases of co-secreting adrenal tumor. All our three cases had initial diagnosis of hypercortisolism with atypical features like muscle weakness and hypokalemia which led us to evaluate for hyperaldosteronism. Therefore, we suggest that patients of overt or subclinical Cushing\'s syndrome who have atypical features should be screened for hyperaldosteronism and similarly patients with primary hyperaldosteronism, especially those with a larger tumor size (>2.5 cm), should be screened for hypercortisolism to avoid postoperative adrenal crisis.
Papillary thyroid carcinoma increasing in incidence over years. There is always a probability of incidence of papillary thyroid carcinoma in case of primary hyperthyroidism with coexisting thyroid nodules. Among these cases parathyroid adenoma localization with functional imaging is correlated with ultrasonography. In cases of discordant imaging possibility of fine needle aspiration cytology is difficulty and risky. In such a scenario parathyroidectomy with hemithyroidectomy will help in one time procedure which will be curative and guide future treatment.
A 21 years old lady presented with swelling of feet and face. Weight gain and stretch marks with cushingoid features on examination with hirsutism and she had a right adrenal adenoma measuring 3 × 2.5 × 1.5 cm which was black colored. We discuss this black colored adenoma in this image of interest.