Aim: To compare early postoperative voice outcome between visual nerve identification (VNI) and selective intraoperative nerve monitoring (IONM) in high-risk thyroidectomy operations. Materials and methods: All patients undergoing high-risk thyroidectomy operations for thyroid cancer, thyrotoxicosis, and reoperative completion between January 2018 and June 2019 were retrospectively evaluated. Demographic information, type of operation (hemithyroidectomy/reoperation/total thyroidectomy), and nature of thyroid disease were assessed. Comparisons were made between VNI and IONM groups on postoperative clinical hoarseness, endoscopically confirmed recurrent laryngeal nerve (RLN) injury, and the operating time between the VNI group and IONM group. Subgroup analyses were also carried out. Results: Fifty-eight patients with 94 nerves at risk were included in the analysis. Forty-seven patients (81.0%) underwent thyroidectomy with VNI, while 11 patients (19.0%) had IONM. Thirty-six procedures (62.1%) were total thyroidectomy and 22 (37.9%) were hemithyroidectomy. Six patients received concomitant cervical lymph node dissection (10.3%). Indications for surgery included 43 thyroid carcinoma (74.1%) and 15 thyrotoxicosis (25.9%); and of which, 22 (37.9%) were reoperations. Demographics were comparable between the assessed groups. Postoperative clinical hoarseness per nerve at risk was significantly lower in the IONM group compared to the VNI group (0 vs 19.4%, p = 0.046). Endoscopically confirmed recurrent laryngeal nerve injury in IONM group was apparently lower, without statistical significance (0 vs 10.4% p = 0.176). Conclusion: Our data demonstrated that the use of IONM in selected high-risk thyroidectomy surgery significantly reduced early postoperative clinical hoarseness compared to the routine VNI. Clinical significance: The use of IONM in selected high-risk thyroidectomy may improve early postoperative voice outcome.

Aim: The aim of this study is to correlate the thyroid cytology diagnosis with the final histologic diagnosis, which is considered by us as the gold standard diagnostic test. Materials and methods: We studied all the thyroid cytopathology cases performed over the last 5 years at King Salman Military Hospital. We found a total of 1,048 thyroid fine-needle aspiration (FNA) cases, of which 318 cases had a follow-up histologic data. The cases are reported according to the Bethesda system for reporting thyroid cytopathology (BSRTC). The rate of malignancy is calculated for each diagnostic category (DC) as the proportion of malignant cases from the cases with histologic diagnosis. The false-positive cases are defined as the cases diagnosed in FNA as DC V or VI (suspicious for malignancy or malignant) and the following thyroid surgery showed a benign histology. The false-negative cases are those diagnosed in FNA as DC II (benign) and the following thyroid surgery showed a malignant diagnosis. Results: The percentage of false-positive cases for DC V (suspicious for malignancy) is 22.5%, while it is 2.38% for DC VI (malignant). The false-negative cases are those diagnosed in FNA as DC II (benign) and the following thyroid surgery showed a malignant diagnosis (8.7%). However, after reviewing the false-negative cases, eight cases were reclassified retrospectively, as “nondiagnostic”. The malignancy rate for our “atypia of undetermined significance (AUS)” cases is estimated to be between 21% and 35%.

Pancreatic tuberculosis is a rare disease. Patients with pancreatic tuberculosis often present with nonspecific symptoms, such as low-grade fever, weight loss, and abdominal pain, and with or without a history of tuberculosis or pancreatic disease. It can be misdiagnosed on account of low index of suspicion due to its rarity, and its presenting symptoms are shared by other common pancreatic conditions such as pancreatic malignancy. This could result in unnecessary surgery. As this is a treatable disease which does not require surgery, it is imperative to diagnose this condition preoperatively. We report this patient of pancreatic mass presenting as locally advanced pancreatic malignancy, subsequently diagnosed to be pancreatic tuberculosis and successfully managed with antitubercular medications.

Aim: To describe a rare case of synchronous carcinoma cervix metastasizing to the thyroid, while the patient being of therapy for primary cancer. Background: Metastasis to thyroid primarily occurs from lung, kidney, gastrointestinal tract (GIT), and head and neck. Cervix cancer metastasis to thyroid had been rarely reported. Case description: We report an unsealed case of carcinoma cervix metastasizing to the thyroid gland, while being on concurrent chemoradiotherapy for primary malignancy and total thyroidectomy was performed as palliative management. Pathological examination confirmed the thyroid lesion as metastasizing squamous cell carcinoma from the cervix. The postoperative period was uneventful and the patient was referred to radiotherapy department but later developed thrombosis in major neck veins and developed the superior vena cava syndrome. The patient finally succumbed to the disease after 3 weeks. Conclusion: Very few cases of cervix cancer metastasis to thyroid have been reported so far. Synchronous metastasis in such cases is even rarer. Hence, any patients who presents with palpable nodules in the thyroid and have a history of a previous malignancy must be considered for metastatic disease and in female patients the possibility of metastasis from the cervix should be considered and managed as well as evaluated accordingly. Clinical significance: Synchronous metastatic growth in the thyroid is known to have a poor prognosis and although total thyroidectomy is not recommended in metastatic disease, but can be performed as a part of palliative treatment.

Pheochromocytomas (PCCs) are rare endocrine tumors that arise from neural crest cells of the adrenal medulla. They commonly secrete catecholamines and other biological peptides that account for the symptoms namely, hypertension, palpitations, and episodic headaches associated with the condition. However, the symptoms and clinical presentations are highly variable due to variations in catecholamine biosynthesis and secretion because of differences in gene expression. A small proportion of tumors hardly synthesize or release any catecholamines and may have no symptoms and are termed as nonfunctional or subclinical PCCs. The nonfunctional tumors are commonly picked up as incidentalomas and biochemical work-up is usually negative. Undiagnosed subclinical normotensive PCCs could lead to catastrophic consequences during surgery and subsequently.

Endogenous hyperinsulinemic hypoglycemia (EHH) on investigation shows low blood glucose because of excessive endogenous insulin. Adult onset nesidioblastosis is an uncommon cause of EHH in adults and on microscopy shows diffuse proliferation of pancreatic islet cells which bud from ductal epithelium. We herein present a rare case of symptomatic adult onset EHH, the cause for which could not be localized on imaging. A 45-year male patient was admitted with recurrent severe hypoglycemia. Biochemical evaluation confirmed EHH (blood glucose 25 mg/dL; simultaneous serum insulin 56.65 μIU/mL; C-peptide 10.25 ng/mL). Thyroid, cortisol, and other hormone evaluation were normal. All possible preoperative imaging could not localize any abnormal focal lesion in the pancreas. Distal pancreatectomy resulted in complete resolution of hypoglycemia episodes. Histopathology confirmed the diagnosis of nesidioblastosis. Patient was asymptomatic even after 1-year follow-up. In adult patients with EHH with negative imaging studies, nesidioblastosis should be suspected. Symptomatic cases can be successfully treated by distal pancreatectomy with subsequent histopathology giving the final diagnosis.

Introduction: Primary hepatic neuroendocrine tumor (PHNET) is extremely rare and infrequently reported in the literature. Due to the rarity and often asymptomatic clinical features, the diagnosis of PHNET preoperatively is difficult. The aim of the study was to characterize the clinical view, diagnostic tools, and results of surgical treatment of PHNETs. Materials and methods: We report PHNET case with an intraoperatively carcinoid crisis, which is a little-described complication of neuroendocrine tumors (NETs) and can be life-threatening. Published PHNET case series were searched in the PubMed, Medline, and Cochrane Library databases using combinations of relevant terms and were enclosed in the review of the literature. Case Description: A 41-year-old woman was referred due to liver mass incidentally discovered on abdominal ultrasound. The patient underwent resection of hepatic segments: II, III, IVb, V, and cholecystectomy with suddenly hemodynamic instability during surgery. Immunohistochemical and pathological examinations revealed a NETs. Conclusion: This case is interesting because of the rarity of this neoplasm and unexpected life-threatening complications. Primary hepatic neuroendocrine carcinoma should be considered as a possible differential diagnosis in the management of hepatic tumors.

Aim: To present a case of posterior mediastinal goiter successfully delivered through the neck approach. Background: Posterior mediastinal goiters are rare, comprising less than 10% of intrathoracic goiters. They usually manifest with compressive symptoms and warrant definitive surgery to relieve symptoms. Majority require the combined cervicothoracic approach to deal with the goiter. Technique: We intend to discuss a case of retrosternal goiter extending predominantly into the posterior mediastinum, which has been purely delivered by cervical incision. Conclusion: The above technique describes successful and safe extraction of the retrosternal goiter extending primarily into the posterior mediastinum via the cervical approach. Clinical significance: The compressive symptoms were completely resolved after surgical management, thus avoiding a morbid procedure like thoracotomy and its associated complications.