Aim and objective: To find a new predictor of sternotomy with thyroid gland measurements in CT scan. Materials and methods: We performed a retrospective review of our endocrine surgery database between January 2012 and October 2017. We identified 123 patients treated for substernal goiter, 7 required an extra-cervical approach, and 116 a cervical one. The measurement of thyroid gland craniocaudal length, larger diameter of mediastinal component, and the diameter of thoracic inlet were performed in all patients with substernal goiter. ROC analysis was performed to determine craniocaudal length and mediastinal thyroid mass diameter cutoff value, which significantly predict the need of an extra-cervical approach for substernal goiter. Results: The craniocaudal length of thyroid mass below thoracic inlet ≥34.5 mm and the diameter of mediastinal component ≥53.5 mm were significantly associated with the need of an extra-cervical approach ( p = 0.005 and p = 0.015, respectively). We also analyzed the ratio between mediastinal component diameter and thoracic inlet diameter and the ROC analysis of this ratio identified ≥1.24 as the cutoff value with maximum accuracy. A ratio ≥1.24 was significantly associated with the need of sternotomy ( p = 0.03) with a likelihood ratio of 9.09 (IC 4.32-19.51). Conclusion: The ratio between mediastinal component diameter and thoracic inlet ≥1.24 was a significant determining factor for sternotomy. Clinical significance: The ratio we suggest based in CT scan measurements allows the identification of patients who may need sternotomy, permitting referral patients to another hospital with thoracic surgeons and prior preparation of the surgical team. Furthermore, these measurements can be obtained by a trained head and neck surgeon.

Aim and objective: Concomitant thyroid nodules and cancer found incidentally on 18-fluorodeoxyglucose (FDG) positron-emission tomography (PET-CT) in patients imaged for investigation or staging of malignancy have been progressively encountered. Maximum SUV (SUV-max) may aid diagnosis of concomitant thyroid malignancy. Materials and methods: PET/CT scans were reviewed between 2009 and 2014 in which FDG-avid thyroid incidentalomas were included. Patients who were investigated with biopsy or surgery were further assessed to determine the utility of SUV-max, mean, and nodule size as a determinate of malignancy. Results: A total of 325 of 35,586 patients were identified with FDG-avid thyroid incidentalomas (TI)–99 were investigated. The incidence was 0.88%. Forty nine were malignant, with a median SUV-max of 14.5 (range 2.7–60.4). Malignant nodules had higher median SUV-max than benign nodules at a threshold of 5 (p < 0.0001). Receiver operator curve (ROC) analysis demonstrated an area under the curve of 0.66 (95%CI 0.55–0.77, p = 0.005). The sensitivity and specificity were 73.4 and 46.9, respectively. The positive and negative likelihood ratio was 3.12 (95%CI 1.80–5.50) and a negative likelihood ratio of 0.38. Conclusion: As FDG-avid TI can demonstrate variable uptake, SUV-max is not a useful tool to discriminate benign from malignant TI. SUV-max should remain a theoretical adjunctive tool for predicting thyroid cancer. Clinical significance: The threshold for investigating PET-avid thyroid nodules with ultrasound and FNAC (in the context of primary nonthyroidal malignancy) should be determined by the prognosis of the primary malignancy.

Background: The concept of failure to intervene (FTI) was introduced in the context of pancreatic cancer patients with an operable malignancy, who did not undergo surgery. Here, we investigate FTI in the thyroid cancer population. We define patients with operable thyroid cancer with FTI, define risk factors for FTI, and evaluate overall survival. Materials and methods: Patients with histologic codes corresponding to papillary, follicular, or medullary thyroid cancer in the National Cancer Database were identified and divided into three categories: “FTI,” “No Surgery: Intentional (NSI),” and “Surgery.” Risk factors for FTI were studied using univariate and multivariate logistic regression. Survival differences were studied using Cox Hazards modeling. Results: Of those studied, 294,088(96.6%) underwent surgery, 8,939(2.9%) were NSI, and 1,579(0.5%) were FTI. Those in the FTI group were older than the surgery group, more likely to be male, black, have Medicare, or be uninsured [all p < 0.001]. Independent risk factors for FTI were: lack of insurance [OR = 3.79 (2.98–4.82), p < 0.001], stage IVc disease [OR = 3.98 (3.11–5.09), p < 0.001], and Asian [OR = 1.98 (1.56–2.52), p < 0.001] or Black race [OR = 2.08 (1.73–2.50), p < 0.001]. There was a significant overall survival advantage for the surgery group as compared to the NSI [Cox Hazard Ratio = 3.7 95% CI (3.3–4.1), p < 0.001] and FTI groups [Cox Hazard Ratio = 7.0 95% CI (6.7–7.2), p < 0.001]. Conclusion: Nearly 97% of thyroid cancer patients in the United States undergo surgical resection. Not having a surgical resection corresponds to a decrease in survival. Non-white race and lack of insurance were risk factors for FTI. Further work needs to be done to identify and appropriately treat this subset of patients who would benefit from resection.

Aim: The objective of this work was to review the different conditions and characteristics of thyroid nodules that suggest surgical treatment. Background: A systematic literature searching was carried out in main databases (Medline, PubMed, EMBASE, LILACS, Google Academic, SciELO, and The Cochrane Library). The search was restricted to scientific papers published after 2005; only previous works that were inexcusable, specific references were included. The quality and consistency of the recommendations of treatment of thyroid nodules were systematically reviewed and assessed with the AGREE and AGREE-II guidelines. The different conditions and characteristics of thyroid nodules that suggest surgical treatment must be defined by valid, reliable, independent, and easily applied clinical-therapeutic guidelines. Several prestigious organizations from America, Europe, and Asia have developed guidelines containing recommendations for the surgical management of thyroid nodules. However, these recommendations may differ, and that could lead to confusion in many cases. Homogeneous guidelines are required to decide in which cases a thyroid nodule should be treated with a surgical intervention. Review results: Currently, fine needle aspiration under ultrasound guidance (FNA) has allowed cytological evaluation of non-palpable thyroid nodules from 2 mm in diameter. Nowadays, both ultrasound and FNA define–in most cases–whether or not a nodule requires surgery. Conclusion: Not all thyroid nodules require surgery. Surgical treatment is indicated in nodules with confirmed diagnosis or suspected malignancy, when the cytology of an FNA is undetermined, when goiter produces compressive symptoms, in cases of cervicothoracic goiters, recurrent cysts, or when the nodule grows during the follow-up. Clinical significance: To identify clinical and cytological characteristics in thyroid nodules to decide in which cases a thyroid nodule should be treated with surgery.

Pheochromocytoma is a rare adrenal gland tumor, which can present bilaterally but not all cases have indications of bilateral adrenalectomy. Hereby presenting a case of a young girl of bilateral adrenal pheochromocytoma for which bilateral adrenalectomy (right side cortical sparing) was done. Correct diagnosis and timely intervention are important to prevent lifelong complications.

We report a highly unusual case of medullary carcinoma thyroid with normal serum calcitonin and tuberculous lymphadenitis mimicking metastatic neck nodes. A 26-year-old married woman was diagnosed with sporadic medullary carcinoma of thyroid on fine needle aspiration cytology (FNAC). Preoperative ultrasonography (USG) and contrast-enhanced computed tomography (CECT) neck suggested a metastasis in level IIB neck nodes. Patient underwent total thyroidectomy with central neck dissection with right modified neck dissection type III. Final histopathological report revealed medullary carcinoma thyroid (MTC) with tubercular lymphadenitis, none of 47 nodes retrieved had metastasis. She remains disease free after 2 years following surgery.

Aim: To describe a rare case of bilateral pheochromocytoma in a young male presenting with two episodes of myocardial infarction. Background: Pheochromocytoma is a catecholamine-producing tumor which arises from the adrenal medulla or rarely from an extra-adrenal site. It may present with a wide range of clinical symptoms and signs, ranging from headache, palpitations, and paroxysmal hypertension to rare events such as cardiomyopathy, cardiogenic shock, seizures, and intracranial bleeding. Case description: We report a case of a 39-year-old male who presented to us with complaint of pain abdomen, palpitation, episodic headache, and shortness of breath for last 1 year. He also had history of two episodes of myocardial infarction during the last 9 months. After careful history, examination and investigations he was diagnosed as a case of bilateral functional adrenal pheochromocytoma with secondary cardiomyopathy. Bilateral open transperitoneal adrenalectomy was done and patient improved symptomatically. Histopathology of the specimen confirmed the diagnosis of bilateral benign pheochromocytma. Owing to this rare presentation of a very rare tumor this case is being reported here. Conclusion: Functional pheochromocytoma rarely presents with cardiomyopathy and myocardial infarction. There should be a high level of suspicion if a young patient presents with myocardial infarction in the normal coronary angiography. Clinical significance: This case illustrates an uncommon presentation of pheochromocytoma presenting with two episodes of myocardial infarction in a young man with normal coronary angiography. A high suspicion index for pheochromocytoma is required in such cases.