Mediastinal goitre - a South African case series.

BACKGROUND: Mediastinal goitres are rare and may be diagnosed late since they are likely to manifest with non-specific cardiorespiratory symptoms especially when there is no visible cervical component. The imaging modality of choice is a contrast-enhanced computed tomography (CT) scan of the neck and chest after incidental finding of goitre on chest X-ray indicated for a condition unrelated to goitre. METHODS: This case series aims to highlight the peculiarity of mediastinal goitre in terms of clinical presentation, surgical approach, airway challenges at anaesthesia, specific complications and final histopathological report. RESULTS: Over a nine-year period, four cases of euthyroid mediastinal goitre underwent sternotomy. The mean age was 57.5 years (45-71) and all patients were female. Most patients presented with non-specific cardiorespiratory symptoms. The difficult airway set was used in all cases and there were two instances of damage to the recurrent laryngeal nerve (RLN). All histopathological reports were benign. CONCLUSION: The presentation of the mediastinal goitres was atypical. Cervical incision and sternotomy were performed in all cases. There were two instances of RLN injury and no malignant histopathology. Despite the potential threat to the airway, all intubations were uneventful.

Early-onset malignant solid tumours in young adult South Africans - an audit based on histopathological records of patients seen at the three academic hospitals in Johannesburg.

BACKGROUND: Malignant tumours in adolescents and young adults (AYA) are referred to as early-onset cancers. This study analysed the histopathological profile of malignant solid tumours in AYA. METHODS: Records of patients who had confirmed malignant solid tumours were retrieved. Data collected included the treating hospital, year of presentation, age and histological diagnosis. The commonly diagnosed malignant tumours in AYA were compared with tumours in older adults. A p-value below 0.05 was considered significant. RESULTS: A total of 61 828 records were retrieved and 29 974 were excluded. Additionally, 1 055 post-excision results from AYA were excluded. Of the remaining 30 799 records, 13.1% (4 032/30 799) were diagnosed in AYA, of which 18.2% (734/4 032) were in-situ lesions. Overall, 11% (3 298/30 065) of invasive tumours were from the AYA. The majority, 81.1% (3 269/4 032), of invasive and non-invasive malignant tumours in AYA were from females. Breast and cervical cancer constituted 29.2% (962/3 298) and 23.2% (766/3 298) of diagnosed cancers in AYA, respectively. Ten (0.3%) cases of prostate and 0.4% (12/3 298) of lung cancers were reported in AYA. CONCLUSION: Eleven per cent of invasive malignancies were diagnosed in AYA and 81% involved females. Cancers of the breast, cervix, skin, and colon were the top four most common tumours in AYA. The burden of breast and colorectal cancer was higher in AYA than in older adults. Prostate cancer is rare in AYA and lung cancer was not among the top 10 malignant tumours in our setting. Over 11% of primary malignant tumours of the anus, breast, cervix, colon, conjunctiva, liver and rectum were diagnosed in AYA.

Experience with insufflation technique in the management of incisional hernia with loss of domain.

BACKGROUND: The loss of intra-abdominal domain makes it impossible to reconstruct the abdominal wall defect without prior correction of container/content mismatch. This study reports on the use of an insufflation technique to enable repair. METHOD: Over an 8-year period, 19 incisional hernia patients with loss of domain between 20% and 50% were treated with an insufflation technique to create sufficient intra-abdominal domain to effect repair. Ambient air was insufflated into the abdominal cavity via an indwelling catheter. After progressive pneumoperitoneum was completed over a period of 10 to 14 days, the hernias were repaired. RESULTS: There were 16 females and three males. The defect size ranged from 7-25 cm. The mean air insufflated was 7.2 litres. After pneumoperitoneum, approximation of the linea alba was possible in all cases with a mean intraoperative predeflation and post-closure peak airway pressure within normal (21 and 20 cmH2O respectively). Tissue repair and implant reinforcement were performed in 17 and two cases respectively. There were three instances of surgical site complications and no 30-day recurrence. CONCLUSION: Repair of incisional hernia with significant loss of domain was made possible by the insufflation technique that enabled tension-free closure of the abdominal wall defect by direct suture, evidenced by the normal peak airway pressure after closure.

The spectrum of abdominal wall desmoid fibromatosis and the outcomes of its surgical treatment.

BACKGROUND: Desmoid fibromatosis (DF) arises in musculoaponeurotic structures, most commonly the rectus abdominis muscle. It is locally aggressive with no propensity for metastasis. The aim was to describe the spectrum of abdominal wall DF and its surgical treatment and outcome at a tertiary institution. METHODS: All abdominal wall DF resected from 2007 to 2019 were retrospectively analysed. The tumours had a fullthickness abdominal wall excision. The defect was reconstructed with biological implants covered by either skin edge undermining or split skin graft. Histological diagnosis was based on characteristic morphological and immunohistochemistry parameters. Parameters analysed were demographics, lesion size, procedure performed and outcomes. RESULTS: Eleven female patients with a median age of 29 years (range 21-61) presented with rapid growth over 6-24 months of anterior abdominal wall tumours with a median maximum resected diameter of 163 mm (range 63-200 mm). There was no specific complication related to the abdominal wall reconstruction. With a median follow-up of 5 years (range 1-11 years), all patients displayed an asymptomatic abdominal wall bulge (eventration). One patient has had a small recurrence currently being observed. CONCLUSION: Striking features of DF tumours at Chris Hani Baragwanath Academic Hospital (CHBAH) were their location, rapid growth, female gender and large size. Biological implant without complex plastic surgery techniques result in good outcomes, though the rate of progression of eventration to hernia is unknown.

The role of surgery in Conn's syndrome - a case of refractory hypertension secondary to an aldosterone secreting adenoma.

SUMMARY: Primary aldosteronism, eponymously known as Conn's syndrome, has recently gained recognition as the most common cause of endocrine hypertension. Unilateral subtypes, such as aldosterone secreting adenomas, are managed surgically and are potentially curable. The background of refractory hypertension and hypokalaemia in a forty-year-old man raised suspicions of Conn's syndrome which was localised to an aldosterone secreting adenoma in the right adrenal gland. The patient underwent a laparoscopic intraperitoneal right adrenalectomy which resulted in normalisation of his plasma aldosterone concentration as well as improved blood pressure control.

Unusual histopathologies of the appendix.

INTRODUCTION: Appendicitis is the most common surgical emergency. Most commonly it is a result of luminal occlusion that leads to ischaemia and eventually to perforation with resultant localised or diffuse peritonitis. Unusual causes have been documented including viral infections, parasites, tuberculosis and neoplasms. These conditions are important to recognise, as they may need additional specific management. This study endeavours to identify the incidence and type of unusual histopathology of appendicitis. METHOD: A retrospective review of histopathological reports of appendix specimens obtained during appendectomies done between January 2012 and December 2014 in the three academic hospitals of Johannesburg - Chris Hani Baragwanath Academic Hospital (CHBAH), Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), and Helen Joseph Hospital (HJH). All specimens were examined by pathologists of the National Health Laboratory Services (NHLS). RESULTS: A total of 2 408 histopathology results were obtained from the NHLS. 164 specimens were excluded because they were part of colonic resection for unrelated conditions. Of the 2 244 specimens included, 8.1% were normal, 52.7% showed acute appendicitis and 30.1% showed complicated appendicitis. Unusual pathology comprised 5.3% (119/2 244). The median age of all patients was 25.6 years (0-88yrs) and the gender distribution was 61.9% males and 38.1% females. The most common unusual causes were parasites (37%), mainly schistosomiasis (24.3%), followed by neoplasm (20%) and fibrous obliteration (14.2%). CONCLUSION: All appendectomy specimens must be submitted to the pathologist for histological diagnosis. It is important that the result be checked before the patient is discharged as further specific treatment may be indicated.

"The profile of thyroid cancer in patients undergoing thyroidectomy at Chris Hani Baragwanath Academic Hospital.

BACKGROUND: The histological type of thyroid cancer in well-resourced countries is predominantly papillary. Follicular carcinoma is predisposed by iodine deficiency that was present the Black population of South Africa until salt iodination in 1995. The aim of this study was to analyse the profile of thyroid cancer in Black South Africans from January 2001 to December 2017 and to identify any temporal changes in thyroid cancer histological subtypes since salt iodination. METHOD: Histopathological reports of patients who underwent thyroidectomy for cancer at Chris Hani Baragwanath Academic Hospital in Johannesburg, South Africa between January 2001 and December 2017 were retrospectively assessed. Data captured included name, age, gender, race, the date when the specimen was sent and the detailed histopathological report. RESULTS: Of the 143 thyroidectomies performed for malignancy, papillary thyroid cancer was the predominant type (65%) with a papillary to follicular thyroid cancer ratio of 4:1. Follicular, medullary and anaplastic cancers were 16.8%, 9.8% and 2.8% respectively. The reports were incomplete in 5 cases and there were 3 non-epithelial neoplasms. CONCLUSION: There is a gradual temporal increase in the frequency of resected papillary cancer over a 16 year period while follicular has remained static. These changes may be attributable to better salt iodination.

Demographic and histological subtypes of Hurthle cell tumours of the thyroid in a South African setting.

BACKGROUND: Report of Hurthle cells following fine needle aspiration cytology from a thyroid nodule raises possibility of Hurthle cell carcinoma (HCC), which is a distinct entity and accounts for 3-10% of thyroid malignancies. AIM: To determine if there are demographic and histopathological features which may be used to differentiate HCC from Hurthle cell adenoma (HCA). METHOD: Histopathology records of patients who had thyroidectomy from January 2001 to October 2015 were reviewed. Data retrieved included indications for thyroidectomy, patients' demographics, histology and preoperative FNAC results. RESULTS: At total of 2641 records were reviewed of which 25.6% (676/2641) were for neoplasms. 15.8% (107/676) of the neoplasms were Hurthle cell neoplasms (HCNs) and 25.2% (27/107) of HCNs were HCCs. 77.2% (71/92) of HCAs and 77.8% (21/27) of HCCs were from female patients. Preoperative FNAC results were available for 54.2% (58/107) and were suspicious of HCN in 12.1% (7/58). Average tumour size for HCCs and HCAs was 4.9 ± 2.7 cm and 3.5 ± 2.0 cm, respectively. The difference was statistically significant with a p-value of 0.016. The risk of malignancy increased from 11.1% in HCNs less than 1 cm to 53.8% for tumours which were greater than 4 cm in diameter. CONCLUSION: HCNs are more common in females. The likelihood of HCC rises as the size of the HCN increases. Malignancy rate exceeds 50% for HCNs which are greater than 4 cm in diameter.

Sonar guided focused parathyroidectomy under cervical block.

BACKGROUND: Presentation of hyperparathyroidism varies and is highly non-specific. The automated calcium analyzer has made the diagnosis easy. Similarly, the advent of Sestamibi scan has paved the way to minimally invasive parathyroidectomy indicated for parathyroid adenoma. There is no uniformity in the extent of minimally invasive parathyroidectomy that is done through limited incision under radio or sonar guidance and endoscopically. In this study, we are presenting the focused parathyroidectomy performed under sonar guidance and superficial cervical block (SCB). The prerequisite is concordant preoperative Sestamibi and ultrasound imaging. METHOD: A two-year review of parathyroidectomies performed between January 2013 and December 2014. OBJECTIVE: To reflect on the result of sonar-guided focused parathyroidectomy under SCB. RESULTS: There was good correlation between the pre-operative imaging, the intra-operative findings and the postoperative histology result of the 15 cases analysed. CONCLUSION: The focused parathyroidectomy under SCB yielded a good result with concordant preoperative Sestamibi and ultrasound findings.

Incidental cancer in multinodular goitre post thyroidectomy.

BACKGROUND: The risk of malignancy in patients with multinodular goitre (MNG) is approximately 7.2%. The gold standard for diagnosis of thyroid cancer is fine-needle aspiration biopsy (FNAB). Unsuccessful, inconclusive or suspicious results mandate further investigations. The concern is that with a benign FNAB result there is no indication for surgery unless the patient has compression symptoms or cosmetic issues, but the risk of missed malignancy is nevertheless present. OBJECTIVE: To determine the prevalence and histological features of incidental cancers in patients who had thyroidectomy for MNG. METHOD: Records of patients who underwent thyroidectomy between January 2005 and December 2010 at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa, were retrospectively reviewed. Data retrieved included demographic characteristics of the patients, type of thyroidectomy, thyroid function test results, FNAB cytology and final histology results. RESULT: A total of 166 thyroidectomies were performed on 162 patients, the majority (139) of whom were females. The mean age was 46 years (range 15 - 79 years). A total of 120 pre-operative FNABs were available for analysis, 78 of which were suggestive of benign nodular goitre; 70 benign FNAB results were histologically confirmed to be MNG after thyroidectomy. Incidental malignancy was found in four of 70 cases of MNG (5.7%); all were papillary carcinomas, predominantly (75.0%) the follicular variant. CONCLUSION: The risk of missing cancer in patients with MNG was 5.7%. The commonest histological subtype of thyroid cancer found in MNG was papillary carcinoma.