Aim and objective: Primary hyperparathyroidism (PHPT) is associated with multiple comorbidities and diverse symptomology that often require management with prescribed medications. Parathyroidectomy is an established treatment for PHPT but may also reduce the need for medications required to treat the associated conditions. We examined the changes in dispensed drugs given to a cohort of older adults with PHPT before and following parathyroidectomy. Materials and methods: A publicly available administrative Pharmaceutical and Medical Benefits Scheme database was used for this study. Participants aged >45 years undergoing parathyroidectomy for PHPT were identified by procedure codes for the period 2008 to 2014. Anatomic Therapeutic Chemical codes (ATC) assigned to drugs prescribed to individual participants, pre- and postoperatively, were used to define therapeutic groups and calculate cohort prevalences. Changes in dispensed medications following parathyroidectomy were assessed by the modulation of ATC class prevalence estimates of drugs prescribed using the Autoregressive Integrated Moving Averages (ARIMA) time-series methodology. Results: Six hundred and ten persons aged >45 years (M 72.1, SD 7.0) undergoing parathyroidectomy for PHPT were recruited. Preoperative dispensed treatment prevalences were highest for agents acting on the renin–angiotensin system (48%), dyslipidemia (45%), acid disorders (37%), antibiotics (31%), and analgesics (20%). Treatment prevalences for all ATC defined medications remained either unchanged or increased 3 years postoperatively. Polypharmacy following surgery also increased from an average 5.9 (SD = 4.0, range 0–23) prescribed medications for chronic conditions preoperatively to 7.0 (SD = 4.0) at 2 years (p < 0.001). Conclusion: The prevalence of ATC classified drugs prescribed and dispensed for chronic conditions in older adults with PHPT changed minimally following parathyroidectomy and polypharmacy of dispensed medications increased. Clinical significance: Parathyroidectomy performed in older persons for PHPT has a limited impact on the prevalence of dispensed drugs used to treat many of the associated chronic conditions. Mesh: Big data; Chronic conditions; Drug utilization; Hyperparathyroidism; Polypharmacy; Primary; Surgery.

Aim and objective: To study the clinicopathological profile, risk factors, and outcomes in distant metastasis from differentiated thyroid cancer in a single institution. Materials and methods: A retrospective review of the medical records of 1,408 consecutive patients diagnosed with differentiated thyroid carcinoma (DTC) and managed at Christian Medical College, Vellore, India from January 2004 to December 2013 was performed. There were 108 patients with distant metastasis among this cohort. Results: We had 1,408 DTC patients treated over 10 years, among them 108 patients had distant metastasis (7.7%). Among 1,408 patients, 1,355 (96.2%) were papillary carcinoma thyroid, 49 (3.5%) were follicular, and 4 (0.3%) were Hürthle cell carcinoma. The mean age was 47.84 + 15.4 years ranging from 13 to 75. Age >45 years constitute 60.2%. Among the 108 distant metastasis patients, 85.2% were papillary, and the remaining 14.8% follicular carcinoma. A significant proportion of patients had T3, T4 disease (63.9%) and nodes involved (50%). On logistic regression analysis, the adjusted odds ratio (OR) for detection of metastasis in this series was significantly high for age >45, male gender, follicular cancer or follicular variant papillary thyroid carcinoma (PTC), higher stage T3/T4 primary, and the presence of nodal disease. Of the 108 patients, 64.8% presented with metastases. Among the patients presented with metastatic symptoms, 9.3% had paraparesis or paraplegia. Isolated bone (40.7%) is the commonest site of involvement followed by isolated lung (32.4%) and multiple organ pattern of involvement is the least common (6.5%). All patients with metastatic follicular carcinoma had bony metastasis either alone (81.3%) or rarely with lung (18.7%). The whole-body iodine scan showed positive uptake in 85.7% metastatic patients and was negative in 14.3%. Metastases involving only bone was significantly associated with radioactive iodine avidity. Among the patients who underwent radioiodine therapy, 78.5% have shown a good response to iodine therapy. Patients with age 45 years or patients with bone-only or multiple distant metastatic sites. Metastasectomy was done in 13 patients, curative surgery in 7 and palliative in 6. Conclusion: The prevalence of distant metastasis among our series of DTC is 7.7% with a higher proportion from follicular carcinoma. Significant numbers of patients have distant metastases during the initial evaluation of the primary and it can have a quite morbid presentation like paraparesis and paraplegia in some patients. Bone is the most preferred site of metastases, which requires more studies to evaluate the cause especially in an iodine-deficient country like India. It is possible to treat distant metastases effectively with radioactive iodine therapy as considerable responses are present in most of the patients. Improved efficacy of radioiodine therapy is present in younger patients and for lung metastases. Metastasectomy especially for solitary skeletal metastases is a considerable option. Clinical significance: The pattern of disease in India—the iodine deficiency soil, is different compared to other parts of the world. With the possibility to treat with radioiodine and surgery, extended survival is a possibility in metastatic thyroid disease. When the majority of patients with metastases are diagnosed at presentation, sometimes even presenting with paraplegia, public awareness should be raised to avoid neglecting the thyroid illness.

Background: The pursuit of cosmesis and patient satisfaction has led surgeons to push the boundaries of minimally invasive thyroid surgery. We studied the feasibility, results, cosmesis, and patient satisfaction with scarless endoscopic thyroidectomy (SET) using an axillary-breast approach with particular emphasis on initial learning outcomes. Materials and methods: Between January 2016 and 2017, 13 patients (M = 3, F = 10) who met the eligibility criteria that included symptomatic unilateral benign nodules <6 cm (cyst, follicular neoplasm, adenomatous goiter), multinodular goiter, and differentiated microcarcinoma with low risk were offered endoscopic hemithyroidectomy for unilateral disease. Nodules larger than 6 cm, substernal goiter, patients with previous neck surgery, malignancy, and Graves’ disease were excluded. All patients underwent ultrasound evaluation of the thyroid and breast. In our approach (Unilateral Axillary Breast Approach), the 10-mm camera port was placed via the anterior axillary fold with two working 5 mm ports via the ipsilateral shoulder and circumareolar region. Results: Mean operating time was 133 minutes (85–180), with a mean blood loss of 40 mL (25–75). There were no conversions or major complications. One patient experienced transient voice change with complete recovery in 3 weeks. Two patients had chest wall seromas. Pain scores on the visual analog scale at recovery, 6 hours, and on the first postoperative day were 2, 1.8, and 2.3 (range 1–5, 1–3, and 1–4), respectively. The mean length of stay was 2.2 days. Seventy-seven percent (10/13) of patients rated cosmetic results and overall satisfaction as excellent (good—2, unsatisfactory—1). Port insertion and flap raising times showed statistically significant improvements in the second half of the series (p < 0.01). Conclusion: In selected patients, SET offers distinct cosmetic advantages and patient satisfaction with acceptable morbidity rates. It is a useful technique that a thyroid surgeon needs to have in his armamentarium in pursuit of patient-centered treatment goals. This study was performed during the inception of learning and thus is significant in terms of outcomes expected during the early learning curve of this procedure.

Aim and objective: To evaluate the incidence of various locations of enlarged eutopic and ectopic parathyroids in patients of hyperparathyroidism, their imaging features, diagnosis, and surgical confirmation. Materials and methods: A retrospective study conducted at a tertiary institution, where 400 patients operated for hyperparathyroidism from 2012 to 2017 was analyzed. Diagnostic findings of Tc-99m-sestamibi scan and ultrasound were compared with surgical findings and subsequent histopathology. Contrast CT(4D CT) was utilized only in select cases. Results: Of 400 patients single adenoma was seen in 350 patients (87.5%), two or more nodules in 41 patients (10.2%), and carcinoma in 3 cases. Of the 350 solitary adenomas, 291 were juxtaposed to thyroid (83.1%), and ectopic in 59 (16.8%) cases. Ectopic along the thymic tract in 38 cases (10.8%), upper mediastinum 8 cases (2.2%), angle of jaw in 2 cases (0.5%), carotid sheath 2 cases (0.5 %), retroesophageal 2 cases (0.5%) and intrathyroidal in 7 cases (2%). Tc-99m-sestamibi scan was positive in localizing parathyroid nodules in 297 (84.8%) cases, and ultrasound in 339 (96.8%) cases. Of the nodules localized by Tc-99m-sestamibi scan, 82% were true and 3% were false localization at the surgery. Nodules localized by ultrasound were true in 99% and false in 1% cases. Ultrasound localized the nodules in sestamibi negative cases in 12% of patients. Conclusion: Identification of enlarged parathyroids and their differentiation from thyroid nodules and other neck lesions is the key role of imaging. Ultrasound is complimentary to Tc-99m-sestamibi scan and offers significant value addition by precision anatomical localization, characterization and finding additional nodules. Using two imaging modalities of Tc-99m-sestamibi scan and ultrasound, the diagnostic sensitivity is 99% and specificity is 98%. Clinical significance: Localization of all the abnormal parathyroid glands in hyperparathyroidism remains a diagnostic challenge on account of both sensitivity and specificity of the available imaging modalities, as well as anatomical variations in the location of the parathyroid glands. A thorough knowledge of the anatomy, embryology along with the merits and pitfalls of the various available imaging modalities is essential to make an accurate preoperative diagnosis and avoid revision surgeries. Keypoints: • Parathyroid glands are ectopic in 16.8% cases. • Technetium Tc-99m-sestamibi localizes the parathyroid nodules in 85% cases. • Ultrasound detects parathyroid nodules in additional sestamibi negative cases (12%). • Ultrasound gives precise anatomical localization of parathyroid nodules. • With both MIBI and ultrasound, the diagnostic sensitivity is 99% and specificity is 98%.

Background: Postoperative hypocalcemia is a common complication of thyroid surgery. Serum parathyroid hormone (PTH) levels are a useful adjunct in predicting the likelihood of developing hypocalcemia. This can be used in identifying patients suitable for early discharge. However, there has been no consensus on the ideal timing of postoperative serum PTH. Materials and methods: We retrospectively reviewed 122 patients who underwent completion or total thyroidectomy from January 2013 to October 2017. Patient's preexisting clinical data were collated and analyzed. Results: The incidence of hypoparathyroidism and hypocalcemia was 36% and 48%, respectively, within the entire cohort. A normal serum PTH at skin closure was found to have a negative predictive value (NPV) of 96.5% for hypocalcemia with a sensitivity and specificity of 84.6% and 91.7%. The severity of hypocalcemia was found to be inversely related with the timing of the first dose of calcitriol replacement. Patients were more likely to develop severe hypercalcemia at a rate of 18.2% vs 16.7% vs 53.9% (p = 0.05) depending if they received it within 12 hours, between 12 hours and 24 hours, or after 24 hours from surgery. Conclusion: Serum PTH at skin closure can identify patients who are unlikely to develop severe hypocalcemia. It is also useful to identify patients who will benefit from calcitriol replacement early so as to reduce the severity of hypocalcemia.

Introduction: Ki-67 antigen was originally defined by the prototype monoclonal antibody Ki-67 detected by immunizing mice with nuclei of the Hodgkin lymphoma cell line L-428.² The name derived from Kiel (city of origin) and the number of the original clone in the 96-well plate. Ki-67 has been thoroughly investigated in cases of both benign and malignant thyroid nodules. However, few previous studies have focused on a potential link between prognostic factors of papillary thyroid carcinoma (PTC) and the Ki-67 proliferative index. The objective of this study was to determine the prognostic significance of Ki-67 levels and PTC. We compared Ki-67 levels against the metastasis, age, completeness of resection, invasion, and size (MACIS) tumor scoring system. By correlating Ki-67 with poor prognostic features of thyroid carcinoma, we aimed to predict tumor recurrence in PTC. Materials and methods: A total of 46 PTC patients who had underwent surgery from 2006 to 2012 were involved in this study. All of the surgical specimens were analyzed for Ki-67 through immunohistochemistry (IHC), and two independent pathologists evaluated the Ki-67 staining results. We compared Ki-67 levels with various prognostic factors for PTC. Results: There was no significant relationship between the Ki-67 index and age, tumor size, cervical lymph nodes involvement, or complete tumor removal during initial surgery (p value > 0.05). However, there were significant links between Ki-67 levels and extrathyroidal extension (p value = 0.006), vascular invasion (p value = 0.006), and distant metastasis (p value = 0.005). Ki-67 was significantly reduced among the low-risk group for recurrent PTC (p value = 0.007). Tumor recurrence at 3 years was significantly correlated with high Ki-67 levels (p value = 0.01).

We report a rare case of intrathyroidal parathyroid adenoma (ITPA) of a 17-year-old girl with ectopic ITPA with diagnostic and therapeutic challenges due to the rare ectopic location and association with multiple lytic bone lesions. Parathyroid adenoma (PA) is the most common cause of primary hyperparathyroidism. It is a benign tumor and is generally presented as solitary adenoma. Identification of ITPA by imaging characteristics is sometimes difficult, being often an intraoperative discovery that requires special surgical strategy.

Adrenal cysts are rare and uncommon disease with only around 600 cases reported so far. Cystic lesion in right hypochondria is usually of hepatic in origin. The right adrenal cyst may sometimes be confused as the hepatic hydatid cyst. We herein report the case of a patient with the adrenal pseudocyst who initially presented with features of the hepatic hydatid cyst.

Cavernous hemangioma of the adrenal gland is a rare, non-functioning benign neoplasm. It is mostly a unilateral lesion and appears commonly at the age of 50 and 70 years. Most of the patients are asymptomatic and detected as incidentaloma. A 60-year-old man was incidentally found to have a right adrenal lesion during contrast-enhanced computed tomography (CECT) examination for chronic abdominal pain. The right adrenal lesion from the CECT abdomen measured 7 cm in diameter with features of adrenal carcinoma. Open right adrenalectomy was performed with the findings of 8 cm well-circumscribed right adrenal lesion with minimal adhesion to the inferior surface of the liver. The surgery was uneventful and the patient recovered well completely. The final histopathological examination confirmed a benign cavernous hemangioma. Adrenal cavernous hemangioma, which is a rare benign vascular malformation, might be difficult to be distinguished preoperatively from adrenal carcinoma because of the large size and similar features from computed tomography (CT) scan. Surgical excision is recommended due to the risk of spontaneous tumor rupture and the difficulty of ruling out malignancy.

Aim: To present a case of Hürthle cell carcinoma at an extraordinary site, and to contribute to the understanding and management of this tumor. Background: Hürthle cell carcinomas are a dangerous but uncommon variant of thyroid follicular carcinoma, exhibiting invasive potential, they have a propensity to metastasis to distant sites. Therefore, swift diagnosis and management with multidisciplinary input are warranted. We humbly present a case of Hürthle cell carcinoma in the supraclavicular region. Case description: A 44-year-old woman, with a prior history of follicular thyroid adenoma, was found to have a mass measuring 20 × 15 × 18 mm on the left supraclavicular region. Magnetic resonance imaging (MRI) and fine needle aspiration biopsy were suspicious of follicular thyroid neoplasm. Positron emission tomography-computed tomography (PET–CT) revealed two lesions with avid fluorodeoxyglucose (FDG)-avid uptake, one corresponding to the original supraclavicular location and one in the left iliac crest. Subsequently, histological analysis following surgical excision of the supraclavicular mass revealed a lobulated Hürthle cell tumor. The patient underwent further cervical lymph node dissection, with one supraclavicular node demonstrating infiltration by Hürthle cell carcinoma. Postoperatively, the patient underwent radioactive iodine (RAI) therapy to which she responded well, and currently remains well at follow-up. Conclusion: Hürthle cell carcinomas are a rare but aggressive variant of follicular thyroid carcinomas. Known for their malignant potential, this case underscores the vigilance required for the diagnosis and management of these tumors as their sites of metastasis may be most extraordinary, as illustrated in this report. Swift diagnosis and multidisciplinary management of these tumors are paramount. Clinical significance: Hürthle cell carcinomas have been demonstrated to metastasize to the most extraordinary sites, we present a unique case of Hürthle cell carcinoma which reinforces the notion and hope to contribute to its understanding.

Primary hyperparathyroidism (PHPT) is classically characterized by stone and bone disease, clinical bone involvement is seldom seen nowadays (<5% of patients). In PHPT, classical skeletal involvement can be the first sign but due to rarity of its occurrence it is no longer included in the differential diagnosis of such manifestations of skeletal diseases. Radiological (X-ray and CT scan) findings of osteitis fibrosa cystica include lytic or multilobular cystic changes [brown tumors] and these lesions can be easily misinterpreted as metastatic carcinoma, oteoclastoma, fibrous dysplasia, and especially giant cell tumor that has almost same radiological and histological features if serum calcium and parathyroid hormone (PTH) are not assessed, which are elevated only in PHPT. Conclusion: When radiographic evidence of a lytic lesion and hypercalcemia are present, PHPT should always be considered in the differential diagnosis. Key messages: Primary hyperparathyroidism most often is due to a parathyroid adenoma. Due to elevated PTH levels bone resorption increases, leading to polyostotic lesions and a reduction in bone mineral density. Osteitis fibrosa cystica eventually develops in patients with advanced disease and patients often require parathyroidectomy as a definitive treatment.

Thyroid storm (TS) is an endocrine emergency demanding prompt and intensive treatment. Several risk factors are involved in precipitating TS and should be prevented in patients with thyrotoxicosis. Withdrawal of antithyroid drugs is probably the main risk factor for TS. Treatment with oral or intravenous drugs (antithyroid agents, steroids, and iodine) is required. Other measures are needed, such as plasmapheresis, diuretics, supportive care, and management of systemic complications such as cardiorespiratory failure. Finally, precipitating factors must be controlled. Nevertheless, some patients do not respond to therapy and their lives further deteriorate, creating circumstances in which thyroidectomy should be considered. We report the case of a 42-year-old woman with a previous history of thyrotoxicosis, diagnosed 18 years earlier, who was noncompliant with her therapy. Her medication was stopped before she came to our emergency unit with multinodular goiter, severe dyspnea, edema, tachycardia, and malnutrition. Thyroid storm was diagnosed, and she was transferred to the intensive care unit. She was treated with intensive antithyroid drugs, glucocorticoids, iodine solution, a β-blocker drug, and support measures. Due to rapid deterioration of her health in the absence of a reduction in thyroid hormone response, total thyroidectomy was decided. After surgery, the patient was well, with recovery of respiratory function and reduction in thyroid hormone levels. She was discharged with normal parameters. Consequently, if patients with thyroid storm continue to deteriorate despite medical treatment, thyroidectomy should be considered at centers with the necessary expertise.

In the present day, modern thyroid surgery, the endocrine surgeon, and the patient have the option of many different modalities of technology that has revolutionized thyroid surgery at the expense of increased financial burden, and insurance is not available to cover these new technologies in the developing world. We describe our “poor man's neuromonitoring” where the only thing the surgeon needs is the intent to have a conversion intermittently and this guides the knife-happy surgeon near recurrent laryngeal nerve (RLN) dissection.