World Journal of Endocrine Surgery

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2020 | September-December | Volume 12 | Issue 3

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Original Article

Nern H Kao, Adrian JH Koh

Central Compartment Nodal Disease in Small Papillary Thyroid Carcinomas in Singapore

[Year:2020] [Month:September-December] [Volume:12] [Number:3] [Pages:4] [Pages No:109 - 112]

Keywords: Central compartment, Lymph nodes, Metastases, Micropapillary, Papillary thyroid, Thyroid cancer

   DOI: 10.5005/jp-journals-10002-1302  |  Open Access |  How to cite  | 


Background: Prophylactic central compartment clearance has been a debate for early papillary thyroid carcinoma (PTC). The American Thyroid Association recommends total thyroidectomy alone for small tumors without clinical nodes. However, we note a high incidence of nodal disease within our practice. This study aims to evaluate the incidence of metastatic central compartment nodes in small (<4 cm) PTC. Secondary aims included postoperative hypoparathyroidism and recurrent laryngeal nerve injury. Materials and methods: A retrospective cohort study was performed evaluating patients who had thyroid surgery from January 2011 to October 2016. Patients with total thyroidectomy alone were compared with those with prophylactic central neck dissection (pCND). Histology was reviewed for tumor size and nodal disease. Results: One hundred and six patients were recruited for this study. More than half of thyroidectomies with pCND were found to be positive (36/57). This is regardless of tumor size, although tumor >20 mm was more likely to have a nodal disease (OR 2.40 95%; CI 0.58–9.87; p = 0.23). T3 disease was more likely to have a nodal disease (15/21 sides) (OR 1.79; 95% CI 0.56–5.67; p = 0.33). More patients in the pCND arm developed transient hypoparathyroidism (14/22 vs 4/17) but all resolved within a year. One patient developed hoarseness alone while three patients reported dysphagia in the pCND arm compared to one patient in the total thyroidectomy arm with dysphagia. Conclusion: More than half of patients with PTC (<4 cm) have metastatic central compartment nodes. Prophylactic central neck dissection can be safely performed. However, we still lack adequate data on long-term effects.


Original Article

Bhushan Shah, Rajesh Mahesan, Indira Vijayasekar, Bhavini B Shah

Diagnostic Performance of the American College of Radiology Thyroid Imaging Reporting and Data System

[Year:2020] [Month:September-December] [Volume:12] [Number:3] [Pages:4] [Pages No:113 - 116]

Keywords: American College of Radiology Thyroid Imaging Reporting and Data System Classification, Prospective observational study, Thyroid swellings, Ultrasonography

   DOI: 10.5005/jp-journals-10002-1304  |  Open Access |  How to cite  | 


Aim: A study was conducted in our hospital to find the diagnostic performance of the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) in distinguishing benign and malignant thyroid swellings. Materials and methods: A total of 50 subjects were enrolled in this prospective observational study after obtaining consent. Ultrasonography was done in all patients and thyroid swellings were classified by the ACR TI-RADS system. The final diagnosis was made based on histopathological examination. The results were analyzed and the diagnostic indicators of ACR TI-RADS and its individual components were derived. Results: The mean age of the study sample was 44.18 years with a standard deviation of 14.29 years. The most common clinical presentation was multinodular goiter (76%). Benign lesions (80%) were more common than malignant lesions (20%) as diagnosed by histopathological examination. Of these, the most common malignancy was papillary carcinoma (60%). The risk of malignancy of TR1 was 0%, TR2 was 5.6%, TR3 was 10%, TR4 was 54.5%, and TR5 was 100%. The ACR TI-RADS classification system had good sensitivity (80%) and specificity (87.5%) with a diagnostic accuracy of 86%. Conclusion: The study has shown that lower TI-RADS classes were commonly associated with benign lesions and higher TI-RADS classes were frequently associated with malignant lesions. The diagnostic indicators showed that the ACR TI-RADS is a dependable system to detect malignancy in thyroid swellings. Clinical significance: Enlargement of the thyroid gland is a frequent complaint among patients presenting in a hospital. Evaluation of these swellings is required to detect malignancy. Several studies have been done describing the accuracy of Thyroid Imaging Reporting and Data System (TI-RADS), which was proposed by the ACR utilizing ultrasonography in the foreign population. The utility of this system in our population was scarcely studied. This warrants a study to assess the diagnostic performance of this classification and its utility in the Indian population.


Original Article

Huynh Q Khanh, Nguyen L Vuong, Tran Q Tien

Factors Associated with the Efficacy of Radiofrequency Ablation in the Treatment of Benign Thyroid Nodules

[Year:2020] [Month:September-December] [Volume:12] [Number:3] [Pages:5] [Pages No:117 - 121]

Keywords: Goiter, Radiofrequency ablation, Thyroid nodule, Volume reduction ratio

   DOI: 10.5005/jp-journals-10002-1309  |  Open Access |  How to cite  | 


Background: Minimally thermal treatments, including radiofrequency ablation (RFA), have been widely used for benign thyroid nodules (BTNs). However, factors related to the efficacy are not consistent among studies. Therefore, this study aimed to investigate factors associated with the efficacy and the risk of having multiple RFA sessions in the treatment of BTNs. Materials and methods: We performed a retrospective study of 83 patients with 96 BTNs undergoing RFA from 2018 to 2019. Clinical and ultrasound evaluations were performed before and after RFA 1, 4, 10, and every 6 months afterward. Efficacy outcomes were volume reduction ratio (VRR), symptom and cosmetic scores, and the requirement of multiple RFA sessions. Results: Female was predominant (86%) and the median age was 45 years. Most nodules were solid (64%) with a median volume of 3 mL. Two (2%) minor complications occurred and median time of follow-up was 17 months. The VRR reached to 56.7, 77, 89.4, and 92.8% at 4, 10, 16, and 22 months after the RFA, respectively. The symptom and cosmetic scores also significantly reduced. Multiple RFA sessions were required in 14 nodules (15%). Male had lower VRR of 5.59% than female, while mixed and cystic nodules had higher VRR of 4.88 and 12.7% compared with solid nodule. Larger nodule increased the risk of multiple RFA sessions. Conclusion: Radiofrequency ablation is a safe and effective treatment for BTNs. Gender and solidity associate with VRR, but the large nodule is the risk factor of multiple sessions. More studies are required to reduce the risk of multiple RFA sessions.


Original Article

Kushagra Gourav, Shruti Singh

A Novel Scoring System to Correlate Preoperative Adrenal Imaging with Final Histology in Predicting Malignancy: A Retrospective Institutional Data Analysis

[Year:2020] [Month:September-December] [Volume:12] [Number:3] [Pages:6] [Pages No:122 - 127]

Keywords: Adrenal mass, Adrenocortical carcinoma, Adrenal Surgery, Contrast-enhanced computed tomography

   DOI: 10.5005/jp-journals-10002-1310  |  Open Access |  How to cite  | 


Background and aim: To investigate whether preoperative contrast-enhanced computed tomography (CECT) will be able to differentiate benign adrenal mass from malignant mass by applying a combination of morphological criteria and correlating it with the final histopathology. Materials and methods: Thirty-six patients planned for surgery were assessed preoperatively with CECT abdomen and based on CT findings a score of 0 to 6 was given depending on the size of the lesion, margin, density, abutment/infiltration to surrounding structures, necrosis, and calcification which was further correlated with their final histopathology. Statistical test used: The reliability of the total score was checked using receiver operator characteristic (ROC) analysis. Results: Out of 36 patients, 28 were benign and 8 were malignant pathology. The presence of abutment, ill-defined margins, and necrosis on CT was found significantly more in patients with malignant pathology (p = 0.009, p = 0.005, and p = 0.009, respectively). The most sensitive and specific parameters in predicting malignancy based on CT were heterogeneity and ill-defined margins, respectively (100 and 94.6%, respectively). The cut-off score of four has a sensitivity, specificity, NPV, and PPV of 75, 82.1, 54.55, and 92%, respectively. The mean scores for benign and malignant were 2.21 ± 0.315 and 4.25 ± 1.581, respectively (p = 0.001). Conclusion: This novel scoring method including heterogeneity, margins, abutment, and necrosis plays a key role in predicting malignancy accurately on CT scans.



Meriem Yazidi, Marwa Ben Jemaa, Ibtissem Oueslati, Fatma Chaker, Melika Chihaoui

Prolonged Hyponatremia after Pituitary Surgery: A Case Report and Literature Review

[Year:2020] [Month:September-December] [Volume:12] [Number:3] [Pages:4] [Pages No:128 - 131]

Keywords: Cerebral salt-wasting syndrome, Hyponatremia, Pituitary gland, Syndrome of inappropriate secretion of antidiuretic hormone, Transsphenoidal surgery

   DOI: 10.5005/jp-journals-10002-1305  |  Open Access |  How to cite  | 


Hyponatremia is commonly seen after pituitary surgery. It generally occurs within the first week after surgery and is usually moderate and asymptomatic. However, it may be severe and prolonged in some cases. Different etiologies can explain this hyponatremia. The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is one of the most common etiologies, but other differential diagnoses must be ruled out before making this diagnosis. In this article, we present a case of prolonged hyponatremia caused by SIADH occurring after transsphenoidal surgery for a non-functioning pituitary macroadenoma. We revise the different etiologies of hyponatremia following pituitary surgery and their treatment.



Ankita Roy, Muhammad H Khan, Joseph Frazzetta, Adam S Kabaker, Steven De Jong

Undescended Parathyroid Adenomas: A Leading Cause of Persistent Primary Hyperparathyroidism

[Year:2020] [Month:September-December] [Volume:12] [Number:3] [Pages:4] [Pages No:132 - 135]

Keywords: Case report, Minimally invasive parathyroidectomy, Primary hyperparathyroidism, Undescended parathyroid adenoma

   DOI: 10.5005/jp-journals-10002-1306  |  Open Access |  How to cite  | 


Aim: We present the case of a 64-year-old man with symptomatic primary hyperparathyroidism (PHPT) who was found to have a rare undescended parathyroid adenoma (UPA). While UPAs have a low prevalence, they are challenging cases for endocrine surgeons. We include background information and a summary of the literature of UPAs and presentation, workup, management, and outcomes of this patient. Introduction: Undescended parathyroid adenomas are rare ectopic glands that are found above the upper pole of the thyroid gland.1 They are difficult to localize on routine imaging and require strategic preoperative planning to determine the surgical approach. Case description: A 64-year-old man presented to our tertiary care center with symptomatic PHPT. Sestamibi with SPECT/CT showed a 1.4 cm focus of uptake in the left upper neck that was suspicious for an ectopic UPA. Conclusion: With appropriate preoperative imaging and planning, the patient was able to undergo curative minimally invasive parathyroidectomy. The patient had an uncomplicated postoperative recovery with resolution of symptoms and normalization of calcium and parathyroid hormone (PTH) levels. Clinical significance: Undescended parathyroid adenomas are difficult to locate and are a leading cause of persistent PHPT, failed cervical explorations, and patient morbidity.2 Preoperative imaging is key to localizing these adenomas for successful first-time explorations and minimally invasive parathyroidectomies.



Michael Scheidt, Daniel Hubbs, Adam Kabaker, Steven De Jong

Completely Intrathyroidal Parathyroid Adenoma in a Patient with a Previously Failed Cervical Exploration

[Year:2020] [Month:September-December] [Volume:12] [Number:3] [Pages:4] [Pages No:136 - 139]

Keywords: Ectopic parathyroid, Hyperparathyroidism, Intrathyroidal parathyroid, Parathyroidectomy

   DOI: 10.5005/jp-journals-10002-1307  |  Open Access |  How to cite  | 


Aim: This case report highlights the importance of preoperative imaging and the clinical considerations a surgeon must have intraoperatively while searching for an ectopic parathyroid adenoma. Background: Primary hyperparathyroidism is a disorder of autonomous function of either one or multiple parathyroid glands. Definitive treatment requires resection of the autonomous gland. Resection at the initial operation is important as reoperative patients are at a higher risk of having complications. Ectopic locations of parathyroid glands are common with a reported incidence of 6–22%. Due to the greater embryonic migration distance of the inferior parathyroid glands, they have greater anatomic variation compared to the superior glands and are often more difficult to identify. True intrathyroidal parathyroid adenomas are a rare subset of ectopic parathyroids that must be considered when a parathyroid adenoma cannot be identified. Case: A rare case of a completely intrathyroidal parathyroid adenoma in a patient with a previously failed cervical neck exploration. Conclusion: This case demonstrates that in the setting of inconclusive imaging, one's clinical acumen, and anatomical and embryologic knowledge must be utilized in a systematic approach to identifying parathyroid adenomas. After other ectopic locations are excluded, a thyroid lobectomy should be considered to treat a completely intrathyroidal parathyroid adenoma. Clinical significance: Anatomical variation should always be accounted for when faced with a missing parathyroid gland.



Noor SM Barhan, Muhammad FN Raduan, Nor FA Rashid, Fauziah Ahmad, Yahya M Aripin

Awake Thyroidectomy: Safe, Effective, and Elegant

[Year:2020] [Month:September-December] [Volume:12] [Number:3] [Pages:2] [Pages No:140 - 141]

   DOI: 10.5005/jp-journals-10002-1308  |  Open Access |  How to cite  | 


Safe and margin-free resection of thyroid cancer is feasible with local or regional anesthesia. We present a case of awake thyroidectomy performed under combined local anesthesia and superficial cervical plexus block, with excellent patient satisfaction.



Amrin Israrahmed, Mayilvaganan Sabaretnam, Raghunandan Prasad

Role of a “Skeletal Survey” in Primary Hyperparathyroidism: Its Importance and a Format-based Checklist for Clinicians

[Year:2020] [Month:September-December] [Volume:12] [Number:3] [Pages:6] [Pages No:142 - 147]

   DOI: 10.5005/jp-journals-10002-1303  |  Open Access |  How to cite  | 


Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia and its presentation has appeared to have changed from classical disease presentation of bones, stones, moans, and groans to asymptomatic mild mood swings. However, in the developing world, still there are fair proportions of patients who present with classical presentation and they present with advanced target diseases. One such manifestation is a bone disease. Skeletal surgery was employed and is still being employed for surgery of the bone and joints and we discuss the role of the skeletal survey in PHPT.


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