Aim and objective: The relationship between Hashimoto's thyroiditis (HT) and papillary thyroid cancer (PTC) regarding their concurrence and the effect of concurrent HT on the prognosis of PTC has been controversial. In Guatemala, there are no studies of the coexistence of PTC and HT. This study aimed to determine if the presence of HT increased de risk of PTC and to determine if the presence of HT decreases the aggressiveness of PTC. Materials and methods: Clinicopathological data were assessed in all patients (n = 381) with thyroid pathology operated by a single surgical team over a period of 1996 to 2014 in Guatemala City. Of these participants, 115 with histologically confirmed PTC, measures of tumor aggressiveness were compared between patients with PTC and HT and PTC without HT. Results: In our study population, 19% (73/381) of the patients presented HT. After adjusting for age, sex, and nodule size; patients with HT presented more coexisting PTC [OR 2.56 (1.35–4.87)] compared to patients without HT. In the subgroup of patients with PTC (n = 115), 23% (26/115) had to coexist HT. Nodule size, angiovascular invasion, capsular invasion, lymph node metastasis, and extrathyroidal tissue invasion did not differ between patients with PTC with and without HT. Conclusion: The presence of HT in Guatemalan patients increases the risk of PTC, and the presence of HT does not decrease the aggressiveness of PTC. Clinical significance: High prevalence of PTC in patients with HT requires close clinical monitoring of patients.

Aim and objective: Papillary thyroid carcinoma (PTC) constitutes 80% of thyroid cancer cases. It has a high risk for lymph node metastases in both central and lateral compartments of the neck. This study is an attempt to better define the need for level V dissection in PTC, possible predictors of involvement, and rate of complications. Materials and methods: In the General Surgery Department, Minia University Hospital, Egypt, 35 patients diagnosed with PTC were subjected to lateral neck dissection (LND) in the period from October 2015 till January 2019. In LND, we spared the internal jugular vein, spinal accessory nerve, and sternocleidomastoid muscle. All neck specimens were intraoperatively labeled by level for the pathologist. Results: Ten patients (28.6%) were males and 25 (71.4%) were females. Total level V metastases were detected in 20 specimens (38.5%) all having level Vb metastases except three specimens having metastases in level Va (no skip metastases). Level III metastases were more frequent than level V and level II. 67.3% of specimens were positive for extrathyroidal extension (ETE) and 57.7% positive for lymphovascular invasion. Injury of the spinal accessory nerve was detected in one case; 1.9% and chylous leak in one case; 1.9%. Conclusion: In experienced hands, including level V leads to better local control without a high rate of complications. We concluded that formal modified radical neck dissection (MRND) is necessary to reduce the morbidity of reoperation surgery in PTC.

Background: The cure rate of endocrine hypertension following adrenalectomy is heterogeneous. Our aim of the study was to investigate the etiology and cure rate of endocrine hypertension between an Asian and UK cohort. Materials and methods: This is a retrospective study of patients who underwent adrenalectomy from two tertiary centers in Singapore (cohort I) and the UK (cohort II) for endocrine hypertension. Demographic, clinical details, blood pressure data, and cure rates of hypertension were collected and analyzed. Results: Cohort I included 115 patients (59F:56M), the mean age of 50.05 (SD 12.82), and cohort II had 128 patients (65F:63M), the mean age of 52.88 (SD 14.45) during the study period. There was a higher incidence of Conn's adenoma in cohort I, with predominantly left-sided tumors and grade I and II hypertension at presentation (p = 0.001). In contrast, cohort II had pheochromocytoma (PCC) as the most frequent diagnosis, right-sided tumors, and grade II and III hypertension (p = 0.001). Significant differences in the mean pre-op systolic and diastolic BP and choice of antihypertensive medications between the two cohorts were noted (p = 0.001). The hypertension cure rates were similar (70 vs 69%) between the two cohorts. In patients where no cure was achieved, adrenalectomy resulted in a decrease in the pill burden (decreased number of classes and standard dose) in both the cohorts (p = 0.03). The complications rates and overall mortality were comparable between the cohorts. Conclusion: The etiology of adrenal hypertension is different between the East and the West. Adrenalectomy cured hypertension in the majority of the patient and reduced pill burden where no cure for hypertension was achieved.

Aim and objective: To report our recent experience with bilateral simultaneous retroperitoneoscopic adrenalectomy for severe ectopic Cushing's syndrome (CS) and discuss the risk of severe thromboembolic events (TEs) in such patients. Background: Patients with CS have an increased risk of arterial and venous TEs. For patients with severe ectopic CS not responding to the medical blockade, bilateral adrenalectomy is indicated to relieve symptoms. Case description: Three patients underwent a bilateral simultaneous retroperitoneoscopic adrenalectomy for severe ectopic CS. The minimally invasive procedure was completed in all patients, with total operative times ranging from 70 to 120 minutes and negligible overall blood loss. All patients developed perioperative TEs despite being on prophylactic dosages of low molecular weight heparin (5,000 U Dalteparin). Postoperative hospital stay was prolonged (6–20 days) due to complex medical needs and difficult physical rehabilitation. During follow-up (6–20 months), mobility and functional status improved significantly in all patients. All remain on daily adrenal replacement with no biochemical signs of recurrent hypercortisolism. Conclusion: Bilateral simultaneous retroperitoneoscopic adrenalectomy for severe ectopic CS is feasible, safe, and advantageous in selected centers with sufficient surgical expertise. The risk of developing a TE for these patients is extremely high and international guidelines should be developed. Clinical significance: The risk of development of TE for the patient with severe ectopic CS in the presence of a disseminated malignancy is extremely high. In addition to following current guidelines on anti-TE prophylaxis, we consider that all patients should undergo a formal lower limb duplex ultrasound scan at the time of initial surgical workup, to select those patients who need to be started on early therapeutic dose anticoagulation if the presence of a TE is confirmed.

Parathyroid cysts are exceedingly uncommon but should remain a differential in the evaluation of a patient with a cystic neck lump. Case reports in the literature are few and far between and there are no universally defined guidelines as to the diagnosis and management of this condition. In this paper, we review the existing literature regarding the epidemiology, etiology, and clinical presentation of parathyroid cysts. We evaluate the existing diagnostic modalities, discuss their benefits and limitations, and discuss key considerations in the management of this little-known condition.

Aim and objective: Report a very rare case of atypical parathyroid adenoma in pregnancy presenting as a hypercalcemic crisis, acute pancreatitis, and acute kidney injury and also discuss the issues related to localization of parathyroid adenoma, management of hypercalcemia and its complications, and timing of surgery. Background: Primary hyperparathyroidism (PHPT) is rare in pregnancy and often unrecognized, as serum calcium is not routinely measured and the physiological changes of pregnancy can mask its diagnosis. In addition, non-specific gastrointestinal symptoms associated with hypercalcemia can mimic that of early pregnancy. Vitamin D deficiency can mask hypercalcemia associated with PHPT. Case description: A 29-year-old pregnant lady of 23 weeks of gestation presented to the emergency department with an acute abdomen and was diagnosed to have a hypercalcemic crisis associated with acute pancreatitis and acute kidney injury. The evaluation revealed PHPT with parathyroid adenoma. While in hospital she developed complications such as pneumonia, sepsis, anemia, and hypoalbuminemia and was managed by a multidisciplinary team. Subsequently, when her condition was stable, she underwent parathyroidectomy. Histopathology of the specimen revealed atypical parathyroid adenoma. By elective cesarean section at 39 weeks of gestation, she delivered a healthy female baby weighing 2.8 kg. Presently, 1 year after surgery, she has remained eucalcemic. Conclusion: Hypercalcemia due to PHPT is often unrecognized in pregnancy. Correct diagnosis with localization of adenoma, along with appropriate medical treatment and surgery will improve maternal and fetal outcomes. Clinical significance: A high index of clinical suspicion is needed for the diagnosis of PHPT in pregnancy. Vitamin D deficiency can mask hypercalcemia associated with PHPT. Effective medical and surgical management will lead to better outcomes.

Aim and objective: Ganglioneuromas (GNs) are rare, benign tumors arising at peripheral autonomic ganglion sites. Their diagnosis is challenging and typically reliant on a histopathological diagnosis. We present two case studies of adrenal GN managed within our department alongside a review of the literature concerning the diagnosis and management of these unusual entities. Materials and methods: We documented the presentation, investigation, and management of two patients with adrenal GN. Additionally, we conducted a literature review based on searching PubMed utilizing the term “adrenal ganglioneuroma”. Results: Both patients presented with an incidental indeterminate adrenal mass on imaging and underwent further laboratory investigations, abdominal ultrasound, computed tomography, and magnetic resonance imaging. In both cases, laparoscopic adrenalectomy was performed with specimens demonstrating adrenal GN on histopathological analysis. Our literature review further demonstrated the infrequency of these lesions and the difficulty involved in their diagnosis. Conclusion: Ganglioneuroma occurs rarely in the adrenal gland usually without preceding clinical symptoms. Diagnosis is challenging and care must be taken to exclude malignant neuroblastoma and ganglioblastoma.

Aim: To discuss an unusual presentation of parathyroid adenoma with management. Background: Primary hyperparathyroidism (PHPT) is characterized by hypercalcemia with elevated levels of parathyroid hormone (PTH). Parathyroid adenoma is the underlying cause in 85% of patients with PHPT. Case description: A 49-year-old woman presented with acute abdominal pain and was diagnosed to have acute pancreatitis. Routine investigations revealed hypercalcemia (serum calcium > 14 mg/dL) and elevated PTH (1,440 pg/mL). Initial ultrasound imaging of the neck showed an ill-defined hypoechoic space-occupying lesion with a cystic component in the lower pole of the right lobe of the thyroid gland. This was followed by a Sestamibi scan and SPECT CT. The patient underwent surgery after proper preoperative preparation. The level of PTH was reduced to 293 pg/mL on the first postoperative day. Serum calcium measured remained within normal limits. Conclusion: Pancreatitis is a rare presentation of parathyroid adenoma, but the diagnosis must be kept in mind while treating patients. Clinical significance: Patients with recurrent unexplainable pancreatitis should be worked up for parathyroid adenoma.

Aim and objective: This report highlights a case of a pancreatic tail pseudocyst mimicking an adrenal lesion during laparoscopic adrenalectomy for left-sided pheochromocytoma. Background: Minimally invasive adrenalectomy has become the gold standard for surgical excision for most adrenal lesions. There are, however, potential complications including injury to surrounding vital structures related to such minimally invasive procedures and can result in devastating consequences. Excellent knowledge of local anatomy with imaging correlation is mandatory to avoid complications. Case description: A 59-year-old woman presented initially with severe pancreatitis and was found to have a left adrenal incidentaloma on cross-sectioning imaging. Subsequent functional workup was suggestive of a pheochromocytoma and she underwent laparoscopic left adrenalectomy. Intraoperatively, a lesion in close proximity to the left kidney was initially thought to be the adrenal lesion but was found to be a pseudocyst arising from the tail of the pancreas instead upon further dissection. The left adrenal tumor was eventually resected without any complications. Conclusion: The pancreatic tail lesion can be mistaken to be a left adrenal tumor during laparoscopic left adrenal surgery. Significant findings: This case again highlights the importance of careful dissection of surgical planes and preoperative assessment of imaging for endoscopic adrenalectomy.