Amiodarone can be a life-saving medication; however, it can also cause amiodarone-induced thyrotoxicosis (AIT). Though rare, AIT is a complex and life-threatening side effect, which can cause significant cardiac dysfunction and lead to cardiac failure. Primary treatment is with thionamides, perchlorates, and steroids. However, a small subgroup does not respond and their cardiovascular function continues to deteriorate. This select group is referred for a semi-elective total thyroidectomy. Without surgical removal of their thyroid gland, these patients will continue to deteriorate, with a 30 to 50% mortality rate for those not operated on.

The aim of this case series was to assess for any indicators as to when these patients should be referred for total thyroidectomies and the efficacy of this method of treatment.

A case series of patients with AIT treated with a total thyroidectomy from 1998 to 2015 was used to assess the efficacy of and indicators for surgery.

Total thyroidectomy results in efficient and significant improvement in the patient's biochemistry and symptoms. The patient's symptoms and options for medical therapy have an influence on the duration of the trial of medical therapy.

Surgery is an effective and efficient treatment for AIT. However, there does not appear to be a specific indicator for when this treatment should be instigated. A case-by-case approach should be adopted when treating these complicated patients.

Clinicians should see surgery as an effective and efficient treatment for AIT. The timing of surgery should be assessed on a case-by-case basis considering the patient's clinical status and therapeutic options and not as a last resort.

Dickfos M, Franz R. Efficacy of the Surgical Management of Amiodarone-induced Thyrotoxicosis. World J Endoc Surg 2017;9(3):79-87.

Hypocalcemia is a common complication of thyroidectomy. We aimed to assess compliance with a targeted calcium and calcitriol supplementation protocol and hypothesized that it would allow safe early discharge without an increase in readmissions.

In 2009, we instituted a targeted early postoperative calcium and calcitriol supplementation protocol based on postoperative parathyroid hormone (PTH). We retrospectively reviewed all patients who had a total or completion thyroidectomy over a 4-year period prior to protocol implementation (group I: 2005—2008) and over a 5-year period after protocol implementation (group II: 2010—2014), as well as all patients operated on in the private setting with the senior author over a 1-year period (group III: 2013). Endpoints for analysis were clinically significant hypocalcemia, protocol compliance, hospital length of stay (LOS), and readmission for hypocalcemia.

Compliance with the protocol was high; however, the accuracy of supplementation prescription was significantly lower in group II than in group III (p < 0.0001). Mean corrected calcium on postoperative day 1 was significantly higher in groups II (2.29 mmol/L) and III (2.27 mmol/L) compared with group I (2.15 mmol/L; p < 0.0001). Forty (30.5%) patients had clinically significant hypocalcemia in group I, compared with 21 (10.8%) in group II, and 2 (3.3%) in group III (p < 0.0001). The LOS was significantly decreased after protocol introduction (p < 0.0001).

Selective prophylactic calcium supplementation reduces LOS after total thyroidectomy.

Introducing a new management protocol in the public hospital system poses challenges with compliance; however, it was successful in lowering rates of symptomatic hypocalcemia and LOS without an increase in the readmission rate.

Osborne J, Papachristos A, Skandarajah A, Gorelik A, Hng D, Miller J. Selective Prophylactic Calcium Supplementation reduces Length of Stay after Total Thyroidectomy. World J Endoc Surg 2017;9(3):88-93.

This study examined patients with concurrent medullary thyroid carcinoma (MTC) and papillary thyroid carcinoma (PTC) with the primary objective of identifying factors that can determine the dominant subtype that will dictate recurrence.

The cancer registry at our tertiary care referral center was reviewed to identify all patients from 1995 to 2015 who had been diagnosed with both MTC and PTC on initial total thyroidectomy. Patient demographic, pathology, and recurrence data were collected and reviewed.

Nineteen patients met the inclusion criteria. Seventeen patients had separate foci of MTC and PTC, and two patients had mixed tumors of medullary and follicular or medullary and the follicular variant of PTC. Thirteen patients had a preoperative diagnosis of MTC, and all 13 had MTC as the higher stage tumor on final pathology. Of these, eight patients had recurrent disease, all of which recurred as MTC. In the six patients with concurrent MTC and PTC who did not have MTC as the preoperative diagnosis, the PTC was the higher stage tumor. Only one patient in this group recurred with PTC, none with MTC. No patients have had recurrent disease that was a different subtype from their preoperative diagnosis or the higher stage tumor.

The concurrent findings of MTC and PTC in the same patient may result in challenging patient counseling, management, and follow-up. In this series of 19 patients with concurrent PTC and MTC, the subtype of recurrence in all 9 patients with recurrent disease was determined by the preoperative diagnosis and higher stage tumor.

The incidental discovery of a second subtype of differentiated thyroid cancer should not alter management of the primary tumor. Patients should be treated in accordance with the preoperative diagnosis and higher stage tumor.

Beninato T, Kluijfhout WP, Drake FT, Shen WT, Suh I, Duh QY, Clark OH, Gosnell JE. Preoperative Diagnosis predicts Outcomes in Patients with Concurrent Medullary and Papillary Thyroid Carcinoma. World J Endoc Surg 2017;9(3):94-99.

To correlate selected clinical and ultrasonographic (US) characteristics with the final histopathological diagnosis in patients with atypia of undetermined significance (AUS) and follicular lesion of undetermined significance (FLUS), and whether this information can be used in planning the surgical approach.

It is a retrospective study including the operated cases of AUS/FLUS from 2011 to 2014 treated at one center.

This cohort included 87 women and 28 men. To test for independence between categorical variables, the chi-square test was used. There was no significant correlation between age or US variables and final pathological diagnosis. However, final diagnosis of malignancy was higher in men compared with women (64.3 and 41.4% respectively; p = 0.035). Furthermore, a significant association between the diagnosis of repeated fine needle aspiration biopsy (FNAB) and the final pathological diagnosis was noted (benign vs malignant, p = 0.005).

The FNAB has a significant role in the assessment of thyroid nodules. Our results showed no correlation between age, US variables, and the risk of malignancy. Male gender is associated with higher risk of malignancy.

Determining the risk of malignancy and prediction of surgical outcome may help triaging cases for repeat FNA or proceeding to surgery.

Alqahtani S, Alsobhi S, Alsalloum RI, Najjar SN, Al-Hindi HN. Surgical Outcome of Thyroid Nodules with Atypia of Undetermined Significance and Follicular Lesion of Undetermined Significance in Fine Needle Aspiration Biopsy. World J Endoc Surg 2017;9(3):100-103.

Neuroendocrine tumors (NETs) of the thyroid are rare tumors. Medullary thyroid carcinoma (MTC) is an exact NET of the thyroid gland, arising from the parafollicular cells (C cells). It has unique features like immunohistochemically and biochemically calcitonin positivity and amyloid deposits. In this case report, a rare thyroid tumor is presented, which has neuroendocrine staining properties and does not produce serum or cytoplasmic calcitonin.

The patient was a 45-year-old woman who underwent total thyroidectomy because of the countless multiple thyroid nodules and a suspicion about a nodule at the right lobe. On histopathological examination, there was a tumor in the left thyroid lobe that measured 0.4 cm. Tumor immunohistochemical staining was positive for synaptophysin, chromogranin A (neuroendocrine cell markers), and thyroglobulin (Tg), and thyroid transcription factor-1 (TTF-1; follicular cell markers). The staining was negative for calcitonin.

There are thyroid tumors that are calcitonin-negative and Tg-positive called calcitonin-negative NETs. Careful interpretation and distinction between MTCs are needed at these tumors because they may have different biologic behaviors, and calcitonin negativity makes follow-up of patients challenging.

Özden S, Colak A, Saylam B, Cengiz Ö. Primary Calcitonin-negative Neuroendocrine Tumor. World J Endoc Surg 2017;9(3):104-108.

Srivastava PK, Jaiman R. Adrenal Angiomyolipoma with Gastric Outlet Obstruction. World J Endoc Surg 2017;9(3):109-110.

Said S, Muhammad R, Othman HA, Othman S, Rashid NFA, Zin RRM. Adrenal Schwannoma: A Rare Type of Adrenal Incidentaloma. World J Endoc Surg 2017;9(3):111-114.

We aim to define and refine the surgical technique for dealing with intraluminal thrombus of great vessels in advanced differentiated thyroid carcinoma (DTC) to reduce the morbidity.

Venous tumor thrombus from DTC is a rare occurrence with sequelae that cause increased morbidity and early mortality. Management of such patients poses a challenge to surgeons.

We define the surgical planning and road map for surgical management of advanced DTC with tumor thrombus involving the internal jugular vein (IJV) and superior vena cava (SVC) by sacrificing one IJV and retrieving the thrombus from the SVC by Fogarty catheter. This technique has minimal morbidity with good outcome.

By appropriate planning and meticulous surgical techniques, we can aggressively manage patients of advanced DTC with venous tumor thrombus and reduce the morbidity.

By surgical techniques leading to complete surgical resections and saving native vital structures, we can aim for successful aggressive surgical management of advanced DTC with venous tumor thrombus.

Dhanda M, Anand A, Vijayant D, Sonkar AA, Singh KR, Ramakant P, Mishra A. Surgical Techniques for Dealing with Intraluminal Thrombus of Great Vessels in Advanced Differentiated Thyroid Carcinoma. World J Endoc Surg 2017;9(3):115-117.

Kumar SS, Mayilvaganan S, Majumdar G, Agarwal SK, Tewari P, Agarwal A. Adrenocortical Carcinoma with Inferior Vena Cava Thrombus extending up to Right Atrium: Evaluation and Management. World J Endoc Surg 2017;9(3):118-119.