The Outcome of Papillary Thyroid Cancer Associated with Graves' Disease: A Case Control Study.

INTRODUCTION: Thyroidectomy is now a less popular therapeutic option for Graves' disease. The frequency of thyroid nodule and the cancer risk of these nodules accompanying Graves' disease are controversial. The outcome of thyroid cancers coexisting with Graves' disease is debated. STUDY DESIGN: Designed as retrospective case control study of papillary thyroid cancers associated with Graves' disease and those with euthyroid background. Pathological characteristics and outcome of papillary thyroid cancers in the two groups were compared. RESULTS: The tumour characteristics did not differ significantly in the groups. The patients were followed for a mean period of 77.32 months and found significant incidences of disease progression in patients with papillary thyroid cancer associated with Graves' disease (p = 0.034; OR 2.747, CI 1.078-7.004). Disease progression as new distant metastases mostly in skeletal locations was high in this group compared to euthyroid group (p = 0.027; OR 4.121, CI 1.008-15.600). There was higher incidence of cumulative metastatic diseases in papillary thyroid cancer associated with Graves' disease. CONCLUSION: Papillary thyroid cancers associated with Graves' disease show aggressive biological behaviour and favoured site of distant metastases was osseous locations. Early diagnosis by routine screening of Graves' disease patients with ultrasound imaging and aspiration studies is recommended.

Lack of Association of B-type Raf Kinase V600E Mutation with High-risk Tumor Features and Adverse Outcome in Conventional and Follicular Variants of Papillary Thyroid Carcinoma.

INTRODUCTION: Somatic B-type Raf kinase (BRAF) V600E mutation in exon 15 was frequently found in high frequencies associated with papillary thyroid cancer (PTC). The phenotype of these cancers expressed aggressive clinical and pathological features. The present study aimed to assess the prevalence of BRAF V600E mutation among conventional and follicular variants of PTC and its association with aggressive tumor factors and outcome. STUDY DESIGN: Patients who were operated and received further treatment for PTC during 2012 were included in the study. BRAF V600E mutation analysis was done by extracting genomic DNA from tumor tissue. RESULTS: Of the 59 patients included in the study, 51% harbored BRAF V600E mutation, but the mutation status was not associated with aggressive tumor factors and adverse outcome. CONCLUSION: BRAF V600E mutation was not significant predictor of aggressive tumor behavior in conventional and follicular variants of PTC.

Correlation between the Cernea Classification of External Branch of Superior Laryngeal Nerve in Relation to the Ultrasound-based Volume of Thyroid Gland.

INTRODUCTÍON: Goiter is a very common problem dealt with by surgeons. Surgical treatment of thyroid requires removal of a part (hemi) or whole of the gland (total thyroidectomy). The external branch of the superior laryngeal nerve (EBSLN) is an important but less researched structure to be preserved during surgery. Various studies have described the incidence of different types of EBSLN, but have not described regarding the relationship between the change in volume of the gland to the nerve. MATERIALS AND METHODS: A prospective analysis of 100 patients who underwent total thyroidectomy in our department was done. All patients underwent preoperative ultrasonography and the volume of the gland was calculated. Intraoperatively, the EBSLN was identified and preserved prior to ligating the superior thyroid vessels. The nerve was classified as per the Cernea classification. The gland was divided into high and low volume, taking 20 ml as the cutoff. The incidence of Type 2 nerve in a low-volume gland was compared with that of a high-volume gland. RESULTS: In 100 patients (200 nerves), 191 nerves were identified. The nerve was type 1 in 56/200 (28%), Type 2a in 116/200 (58%), and Type 2b in 19/200 (9%) patients. In large-volume glands, Type 2 nerve was more common (87%). CONCLUSION: Dissection of thyroid gland requires expertise to preserve the EBSLN. Large volume glands pose a more difficult challenge, as the gland is more closer to the nerve.

Is intraoperative parathyroid hormone monitoring necessary in symptomatic primary hyperparathyroidism with concordant imaging?

INTRODUCTION: Symptomatic primary hyperparathyroidism (PHPT) is still seen frequently in referral centers all over India. These patients require parathyroidectomy and this study aimed to assess the roll of intraoperative parathyroid hormone (PTH) assay when concordant results of two localization studies were available. STUDY DESIGN: We analyzed the case records of patients who underwent parathyroidectomy for PHPT from January 2005 to June 2015. RESULTS: Of 143 patients included in the study, technetium 99m methoxyisobutylisonitrate dual phase scintigraphy showed true positive images in 93.7% and high definition ultrasonography in 84.6% of patients. Concordance in localization studies was observed in 121 (84.6%) patients, successful parathyroidectomy was done in 117 (96.7%) patients with concordant localization studies. Intraoperative PTH monitoring showed 97.84% sensitivity and 75% specificity and predicted failure in 2 patients with concordant imaging. However, re-exploration was not successful in these patients. CONCLUSION: When concordant result is available between parathyroid scintigraphy and anatomical imaging surgical cure rate is high in trained hands. Re-exploration is unlikely to be successful since these patients require higher imaging.

Lithium-induced parathyroid dysfunction: A new case.

Lithium salts are widely used in psychiatric practice and are known to induce thyroid dysfunction. Lithium-induced parathyroid dysfunction is rare. We are reporting a case of hyperparathyroidism in a 28-year-old female patient who was on lithium carbonate for 2 years, when she developed osteopenia and girdle girdle-type muscle weakness. Biochemical parameters showed hyperparathyroidism with shift of calcium creatinine clearance ratio to 0.013, indicating an error in threshold of calcium sensing receptor. The patient eventually required parathyroidectomy and the histology of the gland showed atypical features.

Hypocalcaemia following total thyroidectomy: An analysis of 806 patients.

BACKGROUND: Permanent hypocalcaemia following thyroidectomy causes considerable morbidity. This prospective observational study aims to define the factors likely to predict hypocalcaemia following total thyroidectomy. MATERIALS AND METHODS: Patients who were subjected to total thyroidectomy during January 2005 to December 2009 were followed up for a minimum period of 1 year. Efficacy of an intraoperative parathyroid hormone assay to predict hypocalcaemia was validated. RESULTS: Overall incidence of hypocalcaemia was 23.6% (n = 190) and that of permanent hypocalcaemia was 1.61% (n = 13). Onset was delayed up to 3(rd) postoperative day in 13 patients. Hypocalcaemia was significantly associated with thyroidectomy for Grave's Disease (P = 0.001), Hashimoto's thyroiditis (P = 0.003), and with incidental parathyroidectomy (P = 0.006). The intraoperative assay of parathyroid hormone showed low sensitivity (0.5) and satisfactory specificity (0.9) in predicting hypocalcemia. CONCLUSION: Hypocalcemia could manifest late in the immediate postoperative period and this may explain latent hypocalcemia. High incidence of hypocalcaemia noted in Grave's Disease could be due to the autoimmunity since same feature was noted associated with Hashimoto's thyroiditis and the incidence of hypocalcaemia was not high in the subgroup with toxic nodular goiter. The incidence of hypocalcemia was not affected by age or sex.

Gastric carcinoma-a rare presentation.

Over the last 10 years there has been increasing evidence of a strong association between Idiopathic Deep vein thrombosis (IDVT) and occult malignancy. A review of world literature puts this new clinical entity as 4 -25%10. This mandates screening all cases of IDVT for a hidden malignancy. We report a case of advanced gastric carcinoma presenting as upper limb DVT with pulmonary embolism.

Is total thyroidectomy justified in multinodular goitre.

Role of total thyroidectomy in treatment of patients with benign diseases of thyroid gland remains controversial. The hypothesis behind the study is that total thyroidectomy can be performed in all benign thyroid diseases with equal rate of immediate and late complications compared with those of subtotal thyroidectomy. The retrospective case control study was done by reviewing the case records of patients with benign thyroid diseases involving both lobes operated during May, 2002 to September, 2004. The minimum follow-up period was 3 years. Of the 189 patients included in the study 94 underwent total thyroidectomy and 95 patients underwent subtotal thyroidectomy. There was no incidence of permanent recurrent laryngeal nerve paralysis in both groups. Temporary unilateral recurrent laryngeal nerve paralysis occurred in 3 patients (3.2%) in total thyroidectomy group and 1 (1.1%) patient in subtotal thyroidectomy group, which was not statistically significant (p = 0.307). Temporary hypocalcaemia was noted in 10 patients of total thyroidectomy group (10.6%) and 3 patients of subtotal thyroidectomy group (3.2%). Permanent hypocalcaemia was noted in 2 patients each in total thyroidectomy group and subtotal thyroidectomy group (p = 0.991). Total thyroidectomy is an acceptable alternative to subtotal thyroidectomy in benign diseases, considering the higher rate of postoperative morbidity in recurrent goitres.

Telementoring in endocrine surgery: preliminary Indian experience.

Telemedicine is starting to play an important role in the health field in India. In this case report we describe the successful use of telementoring to remove a parathyroid tumor in a patient with residual hyperparathyroidism after two previous unsuccessful attempts in tumor excision. A 21-yr-old patient crippled with advanced hyperparathyroidism was taken up for third-time exploration at Amrita Institute of Medical Sciences (AIMS), Kochi, with guidance from the Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, using telemedicine technology. These two centers are located 2,500 km apart, and telementoring from the more experienced endocrine surgeons at SGPGIMS resulted in successful tumor localization and removal. For this session both the institutions were provided with a dedicated 512 Kbps very small aperture terminal (VSAT) link and two-way video-audio connectivity. Even though two previous explorations were unsuccessful, with the help of telemedicine technology the same surgeon was successful in locating and removing the tumor. The video and audio quality was of good enough quality for the expert at SGPGIMS to guide the team at AIMS satisfactorily. The patient benefited since he did not have to travel to a far-off specialized center for surgery. This case report testifies to the usefulness of telemedicine in the field of surgery, especially in developing countries, which have few medical experts in certain specialized areas.