Aim: The incidence of neuroendocrine tumors (NETs) is increasing worldwide. This study presents the epidemiological trends of NETs and survival results from Singapore. Materials and methods: This is a retrospective population-based study of all NETs treated during 1993–2014 in Singapore. The primary outcome studied was trends in incidence of NETs, and secondary outcomes were gender, ethnic and histological variations, and overall survival results. Results: During the study period, 1,725 cases were identified and the age-standardized incidence increased from 0.8 to 3 per 100,000 per year. The mean age of diagnosis was 56.0 (±25.5) years, with the highest incidence among ethnic Chinese (n = 1391, 80.6%) and gender ratio nearly 1:1. Histologically, the tumors were predominantly carcinoid tumor (52.6%) and neuroendocrine carcinoma (40.3%), with tumors arising most commonly in the rectum (26.0%), colon (13.7%), lung and bronchus (13.7%), pancreas (9.4%), stomach (7.1%), small intestine (5.9%), and other organs (24.1%). Majority were G1 (51.9%) and G3 (33.9%) tumors, and of clinical stage I (41.0%) and stage IV (35.9%). The most commonly rendered treatment was surgery alone (36.2%). The 5-year overall survival for the cohort for all NETs was 38.1%, and 10-year survival was 22.0%. Predictors for poor survival in this cohort include primary tumor site, gender, and advancing age. Conclusion and clinical significance: The incidence of NETs in Singapore has markedly increased nearly fourfold over the last two decades, possibly due to improved detection. However, there are various other unevaluated factors that warrant further investigation.

Introduction: Conventional thyroidectomy comprises the main bulk of thyroid surgeries despite the ongoing thrust toward minimally invasive approaches. In young patients, the cosmetic impact of a neck scar can affect the quality of life. The role of skin camouflage on thyroidectomy scars has not been evaluated. We evaluated the acceptance and satisfaction of skin camouflage therapy for conventional thyroidectomy. Materials and methods: Over a 6-month period, 20 patients (M:F 2:18) and mean age 35 (24–44) years with conventional thyroidectomy scars underwent three sessions of the skin camouflage therapy by a trained skin camouflage therapist 4 weeks apart. The Dermatology Life Quality Index (DLQI) form was used to evaluate the usefulness of skin camouflage therapy on thyroidectomy scars. An independent reviewer administered the DLQI questionnaire before and after the skin camouflage therapy sessions. Results: No reported side effects were noted in any patient. The overall DLQI scores pre and postapplication of skin camouflage showed improvement (mean 9.65 vs 10.9, respectively, SD 5.18 SE 1.15, p value <0.294) but did not reach statistical significance. Improvements were also noted in daily activities, leisure, work, choice of clothing, and personal relationships. Patients’ self-confidence during interaction with people showed a statistically significant improvement (SD 0.887, SE 0.198, p value <0.012). In all, 75% (n = 15) respondents expressed a strong liking and satisfaction recommending its use for others and continued usage of skin camouflage at 1-year follow-up. Conclusion: Majority of the patients were very satisfied with the cosmetic effect of skin camouflage and showed significant improvement in their self-confidence.

Introduction: Primary hyperparathyroidism (PHPT) is a medical problem whose definitive management is surgery. Preoperative imaging studies for identifying the solitary parathyroid adenoma are a requirement for focused parathyroidectomy in patients with PHPT. There are various imaging modalities for the localization study. Nevertheless, up until now, the gold standard for parathyroid imaging has still not been established. Accurate parathyroid imaging is needed in PHPT cases to support the success of focused parathyroidectomy and prevent increasing patient morbidity due to bilateral neck exploration. Aims and objectives: It is very important for this study to investigate the positive predictive value (PPV) and sensitivity of sestamibi and ultrasonography as preoperative localization techniques. Materials and methods: Literature search has been carried out on Cochrane, PubMed, and the ScienceDirect database site, using a combination of Medical Subject Headings (MeSH) search terms and keywords: “parathyroidectomy,” “primary hyperparathyroidism,” “parathyroid adenoma,” “ultrasound,” “ultrasonography,” “radionuclide imaging,” “sestamibi,” “sensitivity and specificity,” and “predictive values of tests.” A literature search was conducted to look for previous publications, about the sensitivity and positive predictive value of ultrasonography as a technique of localizing preoperative compared with sestamibi in localizing parathyroid adenomas in patients with PHPT. After research articles have been obtained, a selection and examination of journals according to the inclusion and exclusion criteria was conducted. Results: A total of 192 studies were obtained, which are Cochrane (0) study, PubMed (33) studies, and ScienceDirect (159) studies. After screening, 15 studies are selected for review. According to the studies, ultrasonography has a sensitivity of 55–100% and PPV 74–100%. Ultrasonography has a wide range of sensitivity because it is highly operator-dependent depending the expertise of the operator. Ultrasonography by radiologists has a sensitivity of 55–94.6% and PPV 74–97.2%, while ultrasonography by a surgical specialist has a sensitivity of 83–93.2% and PPV 80–85.1%. Sestamibi has a sensitivity of 64–93.3% and PPV 70.5–100%. Limitation of sestamibi includes poor spatial resolution causing low precision in anatomic localization, and there is the use of ionizing radiation. While SPECT/CT has similar sensitivity in localizing parathyroid adenomas located on the retrothyroid and ectopic sites (sensitivity 86.7% and 81.5%; PPV 98.1% and 100%). The study has found that adding ultrasonography to the SPECT/CT examination increased sensitivity, but decreased PPV. Conclusion: Ultrasound examination is very dependent on the operator so that sensitivity varies, influenced by the expertise and experience of the operator in each institution. Ultrasonography can be used as the main modality in localization studies in patients with PHPT in areas that do not have nuclear radiology facilities.

In the era of improved surgical and anesthetic techniques, the day care thyroidectomies have been found to be associated with improved patient performance and convenience, and reduced exposure to hospital-acquired complications leading to reduced overall morbidity. However, these benefits are still questioned due to certain postoperative complications. Aim: The aim of this study was to observe the follow-up of patients undergoing day care thyroidectomy operations and determine the safety of day care thyroidectomy in Indian population. Materials and methods: This was a single center, in-hospital, prospective, uncontrolled observational study. A total number of 50 patients were included in the study. The study was conducted in the Department of Surgical Disciplines, All India Institute of Medical Sciences (AIIMS), New Delhi, with the duration from January 2016 to September 2017. After assessing the inclusion and exclusion criteria, proper workup and taking informed written consent, patients were taken up for day care thyroidectomy. These patients were observed and followed up on day 0, day 7, and day 30 postoperatively for any thyroidectomy-related complications. Results: The mean age for the study population was 35.6 ± 11.27 years (18–60 years). Out of 50, 35 (70%) were females and the female-to-male ratio was 2.25:1. Out of 50 (2%), 1 patient had a postoperative hematoma formation, 2/50 (4%) patients had postoperative transient hypocalcaemia, and 1/50 (2%) patient had postoperative voice changes. Conclusion: This study showed that day care thyroidectomy is a safe and feasible approach with a supporting caregiver and accessible emergency services. Clinical significance: In a developing country like India with limited resources, day care thyroidectomy can provide a safe and better cost-effective alternative to the routinely practiced in-patient thyroidectomy.

Introduction: Blood loss, injury of recurrent laryngeal nerves, and damage of the parathyroid glands are the most dangerous complications during total thyroidectomy. The aim of our study is to compare the combined use of optical magnification and ultrasound hemostatic devices with traditional surgical suture ligation in terms of operating time, hospital stay, and surgical complications as bleeding, hypoparathyroidism, and recurrent laryngeal nerve injuries. Materials and methods: A total of 140 patients undergoing total thyroidectomy for either diffuse or nodular goiter were enrolled between January 2016 and June 2019 at our endocrine surgery unit. A total of 70 patients operated with magnifying loupes and ultrasonic scalpel, defined as group A, were compared with other 70 patients operated without loupes and with the aid of conventional hemostatic devices, named as group B. Results: Demographics were comparable between the assessed groups. Operating time was longer in group B (mean length of 110 minutes vs 79 minutes, p < 0.01). Intraoperative blood loss was lower in group A (22 mL vs 38 mL, p < 0.01). There were no differences between both groups in terms of postoperative bleeding, hematoma formation, pain control, and length of stay. Transient recurrent laryngeal nerve damage was observed in one case in group A and two cases in group B. Transient hypocalcemia secondary to hypoparathyroidism was more common in group B than in group A (31 patients vs 27 patients). Conclusion: In our study, use of magnification loupes and harmonic scalpel is associated with significant reduction of operating/anesthesia time and intraoperative blood loss. Clinical significance: Our results and suggestions can improve the standardized use of magnification loupes and harmonic scalpel in thyroid surgery.

Parathyroid carcinomas are rare tumors that arise in the normally located or an ectopic gland. Here, we present a case of a 36-year-old female patient who presented with a history of generalized bone pain, associated with multiple fractures and with elevated serum calcium, parathyroid hormone (PTH) levels, and low vitamin D levels. Biochemical evaluation suggested primary hyperparathyroidism. Initial technetium-99m sestamibi scan and choline 11 scans were misleading and surgical exploration of the neck and superior mediastinum revealed three small parathyroid glands, right superior and inferior, and left superior, all unremarkable on biopsy. Initial surgery failed to alleviate the symptoms. An ectopic parathyroid adenoma was localized in the precarinal space on a gallium 68 DOTANOC PET scan. Repeat surgery by sternotomy, transpericardial approach, and exploration of the mediastinum with intraoperative PTH monitoring was successful in identification and complete excision of parathyroid carcinoma. Operative management of patients with persistent hyperparathyroidism is difficult despite the new advances in radiological imaging. Patients are better managed with a combined approach of biochemical tests, imaging, and intraoperative parathyroid hormone monitoring.

Aim: To enlighten the treating physician about the importance of tuberculosis (TB) of thyroid. Background: Though the prevalence of TB is high in country like India, TB affecting the thyroid gland is a rare entity due to inherent antibacterial properties of the gland. A high degree of suspicion and thorough clinical knowledge is absolutely necessary for identification of this entity. Case description: A 55-year-old man presented with 8 weeks’ history of swelling in midline of the neck and 2 weeks’ history of pain over the swelling. Blood investigations including the thyroid profile were normal. Clinical examination was suggestive of infected thyroglossal cyst along with multinodular goiter. Ultrasound confirmed the clinical diagnosis and in addition revealed bilateral cervical lymph nodes. Ultrasound-guided fine-needle aspiration cytology (FNAC) of thyroid was inconclusive and FNAC of lymph nodes showed reactive changes. Patient underwent total thyroidectomy along with Sistrunk operation and biopsy of both right- and left-sided cervical lymph nodes. Incidentally, he was diagnosed with hypocortisolism as the patient went in for hypotension intraoperatively, which was managed appropriately. Histopathology revealed TB of the thyroid. Conclusion: Tuberculosis of thyroid, though a rare entity, should be borne in mind and included in the differential diagnosis, particularly in countries with high TB burden. Clinical significance: Identification of such conditions preoperatively can avoid unnecessary surgeries as these conditions can be managed by medical treatment.

Differentiated thyroid cancer includes both papillary thyroid carcinoma and follicular thyroid carcinoma (FTC). It is known to be indolent and is usually limited to the thyroid at the time of presentation. Synchronous case presentation of a thyroid swelling with a regional lymph node and solitary distant renal metastasis is a not so common presentation in FTC. We report the clinical, radiological, and pathological features in addition to management of a case of FTC in a 56-year-old female who presented with a neck swelling and upon diagnostic workup, a solitary renal swelling was discovered, which was diagnosed as metastasis from the original thyroid lesion. Our case shows both regional lymphatic spread and distant hematogenous spread to the kidney. Lymphatic spread has been described in the literature with FTC, but is uncommon. Distant metastasis through hematogenous spread can occur but most often to lungs and bones. Hematogenous metastasis to the kidney is extremely rare. Aim: To present a very rare presentation of FTC with the kidney being the only site for hematogenous metastasis and conduct a focused literature review on similar cases and illustrate the pathological and molecular bases for diagnosis.

Background: Adrenal cysts are uncommon and generally asymptomatic, thus often discovered only incidentally. In the case described here, two giant bilateral adrenal cysts were diagnosed in an emergency setting based on the onset of acute compressive symptoms. Only after a complete diagnostic workup aimed at excluding any suspicion of malignancy, the patient underwent elective and adrenal-preserving surgery. Case description: A 26-year-old man was hospitalized in the emergency room for abdominal pain and dyspepsia. The ultrasound (US) scan showed two giant masses of both the adrenals. The workup allowed a diagnosis of nonfunctioning giant adrenal cysts, one with evidence of intracystic bleeding. Bilateral surgery was indicated and, on both sides, a wide resection of the cyst wall was performed laparoscopically, trying to preserve the adrenal function. At follow-up, the patient shows no evidence of recurrent disease. Conclusion: Despite an acute onset of compressive symptoms that led the patient to hospitalization in an emergency setting, the symptoms of the patient were cured at first. A correct and thorough subsequent workup was then performed that allowed to make a diagnosis of bilateral giant adrenal cysts without any sign of malignancy. This diagnosis indicated a bilateral adrenal-sparing decompressive procedure that, after follow-up, resulted in long-term cure. Clinical significance: A correct imaging played a key role in planning the treatment since it could exclude any suspicion of malignancy, thus allowing to indicate a “functional” approach aimed at avoiding a lifelong and difficult-to-manage substitutive therapy in a young patient.

Aim: To describe a rare clinical syndrome related to secondary hyperparathyroidism (SHP). Background: Sagliker syndrome is a rare entity associated with long-term untreated SHP that results in severe renal osteodystrophy with typical skeletal deformities (mostly craniofacial), high levels of parathormone (PTH), and difficult medical control of the disease. Adequate treatment of the secondary hyperparathyroidism generally includes a surgical approach, and is essential to stop the progression of the disease. Case description: We present the case of a 26-year-old African male with chronic kidney failure on dialysis since the age of 15 and severe SHP (PTH > 5,000 pg/L). He presented with craniofacial dystrophy, benign facial bone tumors, depression, and long-bone fractures. After failure of medical treatment, he underwent total parathyroidectomy with parathyroid autotransplant with normalization of the serum parathormone. “Hungry bone syndrome” was verified postoperatively. After 2 years of follow-up, the skeletal changes were stabilized without regression of the clinical spectrum. No recurrence of secondary hyperparathyroidism was identified at 1 year of follow-up. Conclusion: Identification of this syndrome is of clinical significance, allowing the identification of a subgroup of patients with predicable failure of the medical treatment of secondary hyperparathyroidism and who benefit from surgical treatment to stop the progression of the skeletal changes. Clinical significance: The early identification of this clinical syndrome may allow for better outcomes with reduced morbidity.

Lymph nodal metastases in differentiated thyroid cancers (DTC) occur in 30–90% of all cases.¹ A major question remains about the therapeutic benefits of a more or less extensive lateral lymphadenectomy as metastases to levels I and V are infrequent, and extensive dissections may add to the morbidity. We herein report a case of papillary carcinoma thyroid with bilateral level I–V lymph node metastases.

Toothpaste sign is imparted by the fine vaso nervosum running over the white RLN resembling a popular toothpaste.