Feasibility of Endoscopic Thyroidectomy via Axilla and Breast Approaches for Larger Goiters: Widening the Horizons.

Scarless (in the neck) endoscopic thyroidectomy (SET) has evolved into a cosmetically preferred alternative to conventional thyroidectomy (ConT). Recently many of our patients are demanding SET; however their goitres are larger than the recommended size of 4-6 cm. Our aim was to compare the outcomes of ET for small (<6 cm) vs large (≥6 cm) goitres and determine its feasibility in such cases. This is a retrospective analysis of prospectively maintained database of patients undergoing ET. Patients were divided into 2 groups: I, small (<6 cm) and II, large goitres (≥6 cm). Their demographic and clinicopathological profiles, operation time, conversion and complication rates, and hospital stay were compared. 99 patients (101 procedures) were included: group I, 60 patients (61 procedures), and group II, 39 patients (40 procedures). Mean tumor size (± SD) was 4.4 ± 0.9 cm and 6.7 ± 1.1 cm in groups I and II, respectively. The groups were comparable with respect to demographic and clinical profile except for mean duration of goiter [30.1 ± 32.6 months (group I) vs 60.5 ± 102.4 months (group I), p = 0.03] and gland weight [21.5 ± 15.3 grams (group I) vs 62.3 ± 51.3 grams (group II), p = 0.001]. Although there was no significant difference between mean operating times, long term perioperative outcomes, and conversion rates, temporary hypocalcaemia and length of stay were longer in group II. One patient had permanent vocal cord palsy (~1%, 1/101); none had permanent hypoparathyroidism. Our results indicate that ET can be offered to a subset of patients with larger goitres desirous of SET with no significant difference in mean operation time, conversions, and long term postoperative complications in experienced hands.

Short Stay Thyroid Surgery: Can We Replicate the Same in Low Resource Setting?

INTRODUCTION: The concept of short stay thyroidectomy has been tested and in practice in the developed world; the same has not been replicated in countries with limited resources due to lack of organized healthcare system. So, in this study, we tried to analyze if short stay thyroid surgery can be performed in a cost-effective way in developing countries and also if the endocrine surgical trainee can deliver these services safely. METHODS: The study was conducted prospectively from January 2013 to July 2014, at Department of Endocrine Surgery, SGPGIMS, Lucknow, India. Study group included patients undergoing short stay hemithyroidectomy whereas matched patients who qualified for inclusion criteria but did not undergo short stay surgery due to various reasons constituted control group. Outcome in both the groups was compared in terms of complication rates, cost benefit, and patient satisfaction. Subgroup analysis was also done for trainee versus consultant performed short stay thyroid surgery. RESULTS: A total of 439 patients with surgical thyroid disorders were evaluated at our institute during the study period and out of these 110 patients (58 cases and 52 controls) fulfilled the inclusion criteria. Younger patients with low socioeconomic status who were paying out of pocket were found to be more inclined to short stay thyroid surgery. There was no significant difference between the two groups in terms of postanesthetic discharge score (PADS), complication rates, and patients satisfaction; however there was significant reduction (p <0.001) in hospital cost in short stay group. In subgroup analysis, procedure time was more in trainee performed surgeries; however there was no significant difference in terms of mean PADS and complication rates. CONCLUSION: Short stay thyroidectomy can provide a better cost-effective alternative to conventional thyroidectomy in patients undergoing thyroid surgery and can be safely performed by endocrine surgical trainees even in a low resource setting.

Changing Profile of Primary Hyperparathyroidism Over Two and Half Decades: A Study in Tertiary Referral Center of North India.

BACKGROUND: Most of the cases of PHPT in developing countries present in symptomatic stage, some even in very advanced stage but in recent years the trend seems to be changing. This has been corroborated from few recently published literature from developing countries. The scope of this study is to further carry out an in-depth analysis of various clinical and biochemical parameters of PHPT patients at a tertiary care center of northern India. METHODS: In this retrospective analysis, a total of 333 patients with PHPT from the year 1990 to 2016 were studied. The study population was divided into three subgroups based on the time span; 1990-1999 (n = 34), 2000-2009 (n = 112), 2010-2016 (n = 187), and clinical and biochemical parameters were compared. RESULTS: The clinical presentation has evolved progressively with increase in older age group (35 vs 39 vs 43.85, p < 0.001), less patients with musculoskeletal symptoms (85.3 vs 76.8 vs 61%, p = 0.002) and less patients with severe bone disease (29.4 vs 10.7 vs 10.7%, p = 0.088). Biochemical parameters also showed a changing trend with significant decrease in mean S. Alkaline phosphatase (1393 vs 965 vs 414.8 IU/L, p < 0.001) and S. iPTH (837.52 vs 812.89 vs 635.74 pg/mL, p = 0.02). Vitamin D nutrition status is still suboptimal but shows improvement, and more patients are insufficient as compared to previous deficient state (mean S. Vitamin D-10.31 vs 16.16 vs 25.30 ng/mL, p < 0.001). CONCLUSIONS: Our study reveals a change in trend in PHPT which is similar to evolution of this disease in western population and positively corroborated with observations from China, Hong Kong and Turkey.

Selection and characterization of probiotic lactic acid bacteria and its impact on growth, nutrient digestibility, health and antioxidant status in weaned piglets.

The present study was aimed to develop an effective probiotic lactic acid bacteria (LAB) from piglet feces and in vitro characterization of probiotic properties. To confirm host-species specificity of probiotics, the efficacy of isolated LAB on growth, nutrient utilization, health and antioxidant status was observed in early weaned piglets. A total of 30 LAB were isolated from feces of five healthy piglets (28d old). All isolates were Gram positive, cocco-bacilli and catalase negative. Out of thirty LAB isolates, twenty were shortlisted on the basis of their tolerance to pH (3.0, 4.0, 7.0 and 8.0) and bile salts (0.075, 0.15, 0.3 and 1.0%). Whereas, fourteen isolates were selected for further in vitro probiotic characterization due higher (P<0.05) cell surface hydrophobicity to toluene (>45 percent). These isolates fermented twenty-seven different carbohydrates but were negative for ONPG, citrate and malonate. Also enabled to synthesize amylase, protease, lipase and phytase. They were sensitive to penicillin, azithromycin, lincomycin, clindamycin, erythromycin, cephalothin and chloramphenicol and resistant to ciprofloxacin, ofloxacin, gatifloxacin, vancomycin and co-trimoxazole. Except three isolates, all showed antagonistic activity (>60% co-culture activity) against Escherichia coli, Salmonella Enteritidis, Salmonella serotype (ser.) Typhimurium, Staphylococcus intermedius, Staph. chromogenes, Proteus mirabillis, Areomonas veonii, Bordetella bronchioseptica and Klebsialla oxytoca. The isolate Lacp28 exhibited highest tolerance to acidic pH and bile salts (up to 0.3%), phytase activity, cell surface hydrophobicity, antagonistic activity and co-culture assay (>80% growth inhibition). Host specificity of Lacp28 was further confirmed by heavy in vitro adhesion to pig intestinal epithelium cells compared to chicken. Hence, Lacp28 was selected and identified by phylogenetic analysis of 16S rRNA as Pediococcus acidilactici strain FT28 with 100% similarity (GenBank accession nos. KU837245, KU837246 and KU837247). The Pediococcus acidilactici FT28 was selected as potential probiotic candidature for in vivo efficacy in weaned pigs. Thirty-six crossbred piglets (28d) were randomly distributed into three groups (four replicates of three each) namely, basal diet without probiotics (T0) or with Lactobacillus acidophilus NCDC15 (conventional dairy-specific probiotic; T1) or Pediococcus acidilactici FT28 (swine-specific probiotic; T2). At end of the experiment, six piglets of similar body weight were selected to conduct digestion trial for estimation of nutrient digestibility. Results of the study indicated that supplementation of both probiotics improved (P<0.001) FCR compared to control without significant effect in average daily gain and DM intake. However, the apparent digestibility of crude protein and ether extract was better (P<0.01) in pigs fed P. acidilactici FT28 compared control and L. acidophilus fed groups. The total WBC and RBC count, serum glucose, total protein, albumin and globulin concentration was higher (P<0.05) in P. acidilactici FT28 fed group with better (P<0.05) catalase and superoxide dismutase activity measured in erythrocyte. It is concluded that species-specific Pediococcus acidilactici FT28 isolated with potential in vitro probiotic properties and also hold probiotic candidature by showing the potential capabilities with higher nutrient digestibility, heamato-biochemical and antioxidant status compared to control and Lactobacillus acidophilus NCDC15.

A Rare Complication of Left Open Adrenalectomy.

Chyle leakage after left open adrenalectomy is a quite rare complication. We encountered a young male patient who was operated for left adrenal pheochromocytoma, left laparoscopic adrenalectomy converted to open due to dense adhesions. Postoperatively patient developed chylous fluid drainage on day 2. He was managed conservatively with high protein and MCT oil diet. This case highlights the unusual complication of left adrenalectomy surgery and how it can be managed.

Long-Term Outcome of Follicular Thyroid Carcinoma in Patients Undergoing Surgical Intervention for Skeletal Metastases.

BACKGROUND: A large proportion of follicular thyroid carcinoma (FTC) patients in developing countries present with overt skeletal metastases (SM). These patients often require surgical interventions for prevention of morbidity, palliation of symptoms, and facilitation of radioiodine therapy (RAIT). Scarce literature is available about the long-term outcome of such patients. The aim of this study was to evaluate the long-term outcome of FTC patients undergoing surgical intervention for SM. METHODS: We retrospectively reviewed the data of FTC patients with SM (January 1990-December 2011). Out of 91 patients with SM, 32 had surgical interventions for SM. All had total thyroidectomy performed. RESULTS: The mean age of the patients was 48.5 years (M:F = 1:2). Majority (93.7%) had synchronous metastases and 22% had multiple SM. The surgical interventions for SM included: laminectomy (50%), resection of skull metastases (18.8%), resection of manubrium sterni (18.8%), partial clavicle excision (9.4%), and hemimandibulectomy (3.1%). The main intents were palliation (50%) and facilitation of RAIT (37.5%). 84% patients received RAIT. Median follow-up was 52 months (mean = 50 ± 37). Five- (56 vs 63%) and 10-year (28 vs 23%) overall survival (OS) did not differ significantly (p = 0.968) from those not having interventions for SM. On univariate analysis tumor invasion (p = 0.006) and synchronous presentation of SM (p = 0.043) were significant risk factors for OS, whereas on multivariate analysis tumor invasion (p = 0.006) was significant. CONCLUSIONS: Surgical interventions directed at SM in FTC patients with overt multiple SM might not result in improve OS. However, considering reasonable long-term survival, interventions should be considered for desired palliation and preservation of body function.

Molecular Characteristics of Large Parathyroid Adenomas.

INTRODUCTION: The clinical entity of large parathyroid adenomas (LPTAs) has not been well defined. It is speculated that LPTAs would have biochemical, histological, and molecular characteristics different from small adenomas. Our study aimed to find out occurrence of atypia and carcinomas in large parathyroid lesions and the presence of distinct molecular abnormalities in LPTAs. MATERIALS AND METHODS: We divided the parathyroid lesions into large (>7 g, i.e., LPTAs) and small (<7 g) adenomas. We performed parafibromin, APC (adenomatous polyposis coli), galectin 3, and PGP9.5 (protein gene product 9.5) analysis by immunohistochemistry in adenomas without atypia, atypical adenomas, and carcinomas. RESULTS: Mean serum calcium, alkaline phosphatase, and intact PTH were significantly higher in large parathyroid tumor group. The presence of both atypical adenoma and carcinoma was higher in large parathyroid tumor group. There was higher percentage of atypia in patients with LPTAs >10 g (33%), and 68% of tumors showed at least one marker suggestive of malignancy in this group. Detailed analysis of immunohistochemical features of LPTA >10 g revealed that six patients showed complete loss of parafibromin immunoreactivity (out of these four showed atypia), while seven showed partial loss. In histopathologically proven malignancy (n = 9), six patients showed complete loss of parafibromin staining, 5 (55%) APC negativity, and 45% showed both galectin 3 and PGP9.5 positivity. Three out of these showed all IHC markers s/o malignancy, and all of them had evidence of metastases or recurrence. 32% of atypical adenoma and 13% of atypical adenoma showed complete loss of parafibromin staining, however none developed metastases or recurrence in follow-up (median follow-up 40 months). Loss of parafibromin staining (complete or partial) was higher in LPTA group (56%) than that in small adenoma (39%); however, it was not statistically significant. APC, galectin 3, and PGP9.5 markers suggestive were higher in LPTA group but were not significant. CONCLUSION: LPTAs may show some morphological and immunohistochemical features suggestive of malignancy and can be considered a separate entity. However, the immunohistochemical markers are unable to clearly segregate those LPTAs that may show premalignant potential. Further, we would like to recommend that LPTAs showing complete parafibromin loss together with atypia should be kept under close follow-up.

Primary hyperparathyroidism presenting as hypercalcemic crisis: Twenty-year experience.

CONTEXT: To study hyperparathyroid-induced hypercalcemic crisis (HIHC). AIMS: We see very advanced cases of primary hyperparathyroidism (PHPT) and therefore, we sought to determine the incidence of HIHC in our surgically-treated PHPT patients, clinical presentation, and short- and long-term results with the use of bisphosphonate therapy and expeditious parathyroidectomy over a 20-year period at a single institution. SETTINGS AND DESIGN: Retrospective review of PHPT patients at Department of Endocrine Surgery, a tertiary care referral center. MATERIALS AND METHODS: Retrospective review of 177 patients of advanced PHPT who underwent parathyroidectomy at a single institution from 1989 to 2010. All patients with serum calcium ≥14 mg/dl (≥3.5 mmol/l) were included in HIHC group. STATISTICAL ANALYSIS: Analysis of variance (ANOVA) was used to determine differences between groups. Data is expressed as mean ± standard error of the mean (SEM); P values less than 0.05 were considered significant. RESULTS: We observed a higher incidence of HIHC (n = 37, 21%) with higher incidence of pancreatitis (n = 5, 13.5%). Crisis patients had heavier (6,717 mg) glands. Use of bisphosphonate therapy in seven crisis patients resulted in quicker lowering of serum calcium (mean: 4.5 vs 14.6 days in other crisis patients, P = 0.027) permitting early surgery. The incidence of postoperative hypocalcemia was not higher in these patients. Although the parathyroid adenoma was common pathology in both the groups, the incidence of parathyroid carcinoma was higher in crisis group (10.8%). Outcome with regards to postoperative eucalcemia was similar in both groups. CONCLUSIONS: Crisis patients are at risk of developing pancreatitis. Bisphosphonate therapy has the potential to quickly lower the serum calcium permitting early surgery without added risk of postoperative hypocalcemia. Successful and sustained eucalcemia with excellent long-term survival is possible with use of bisphosphonates and semi-emergent, focused parathyroidectmy.

Role of telemedicine technology in endocrine surgery knowledge sharing.

INTRODUCTION: This retrospective study was designed to assess the outcome of telemedicine technology supportive of educational collaboration among endocrine surgery peers and its impact on knowledge and skill development. MATERIALS AND METHODS: The study was carried out in the Department of Endocrine Surgery in collaboration with School of Telemedicine and Biomedical Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India, during October 1999-December 2012. Telemedicine activities were divided into various modules (e.g., case/problem-based learning, clinical grand rounds, postgraduate course/continuing medical education/conference). Endocrine surgeons participating in such sessions were divided into two groups (faculty and residents). A multimodule questionnaire was constructed based on a Likert scale (2-7 points) to test various aspects (e.g., technical performance, role in knowledge exchange, skill development, level of satisfaction, and future recommendations). Responses were expressed in proportions, and the chi-squared test was used to find the differences in opinions of the study groups. RESULTS: The questionnaire was sent to 38 surgeons, of whom 36 replied (response rate, 94.74%); of these respondents, 14 were faculty and 22 were residents. More than 80% of participants felt that the technology helped in learning new things and strengthening relations with peers, whereas >90% were of the view that it helped in knowledge exchange and development of skills as well as was helpful in supporting clinical decisions. More than 90% of participants were satisfied and enjoyed using this technology and also were of the opinion that the technology should be integrated into other specialties. Satisfaction with the technology was excellent to good for 94.44% of participants. Both faculty and residents were of the same opinion, and there was no significant difference in their replies. CONCLUSIONS: Knowledge sharing in a collaborative environment using telemedicine technology has been found successful in a low-resource setting and is now adopted in the departmental educational program.

Prospective study to compare peri-operative hemodynamic alterations following preparation for pheochromocytoma surgery by phenoxybenzamine or prazosin.

BACKGROUND: Prospective studies comparing the efficacy of selective versus nonselective alpha blockers for preoperative preparation of pheochromocytoma (PCC) are lacking. In this prospective nonrandomized study, we compared the outcome of preoperative preparation with phenoxybenzamine (PBZ) and prazosin (PRZ) in terms of perioperative hemodynamic alterations. METHODS: The study was conducted at a tertiary referral center from July 2010 to December 2012. Thirty-two patients with PCC underwent operation after adequate preparation with PBZ (n = 15) or PRZ (n = 17). Five pediatric and adolescent patients were excluded because of different hemodynamics in this population. Perioperative monitoring was done for pulse rate (PR) and blood pressure(BP) alterations, occurrence of arrhythmias, and time taken to achieve hemodynamic stability. Groups were compared with the Mann-Whitney test, Student's t test, and the χ2 test as applicable. RESULTS: Patients in the two groups were similar in age,gender, 24 h urinary metanephrine and normetanephrine levels, and type of procedure. Patients prepared with PRZ had significantly more intraoperative episodes of transient hypertension (systolic BP ≥ 160 mmHg) and hypertensive urgency (BP >180/110 mmHg) (p 0.02, 0.03, respectively). More patients receiving PRZ suffered from transient severe hypertension (SBP ≥ 220 mmHg) (p 0.03). The PRZ group also had more median maximum SBP (233 mmHg vs PBZ 181.5 mmHg) (p = 0.01) and lesser median minimum SBP (71 mmHg vs PBZ 78 mmHg) (p 0.03). No significant differences were found between the study groups for changes in PR, postoperative BP alterations,occurrence of arrhythmias, and time taken to achieve hemodynamic stability. CONCLUSIONS: PBZ was found superior to PRZ in having fewer intraoperative hemodynamic fluctuations.

Quality of life (QoL) in patients with benign thyroid goiters (pre- and post-thyroidectomy): a prospective study.

BACKGROUND: Preservation of quality of life (QoL) seems an important therapeutic goal in patients with benign thyroid diseases. The aim of the present study was to investigate the impact of thyroidectomy on QoL in patients with benign goiters and to assess the significance of various factors affecting the outcome. METHODS: A prospective study consisting of 100 patients with benign goiters was conducted between November 2009 and March 2011. Patients completed a disease-specific ThyPRO questionnaire to assess QoL before and 6 months after thyroidectomy. Preoperative and postoperative scores were compared; and univariate and multivariate analyses were performed. RESULTS: Mean age of the patients was 40.5 years (M:F = 1:4.3); 82 % of the patients had nodular goiters, and the remaining 18 % had diffuse disease. None of the patients had overt thyroid dysfunction at the time they completed the questionnaire. Operative treatment for 54 % of the patients involved total thyroidectomy, whereas 46 % underwent hemithyroidectomy. None of these patients developed any permanent morbidity following surgery. Mean scores of QoL in the 12 domains examined were low and improved significantly (p < 0.001) after surgery: symptoms, 19.4 versus 0.7; fatigue, 29.5 versus 1.5; vitality, 44.4 versus 3.0; memory and concentration, 25.7 versus 1.5; nervousness, 29.6 versus 1.8; psychological well-being, 33.9 versus 1.3; mood swings, 34.9 versus 0.8; relationship, 15.4 versus 1.4; daily activity, 18.7 versus 1.3; sex life, 20.9 versus 1.7; appearance, 14.7 versus 1.0; and overall, 27 versus 5.5. On univariate analysis, weight of goiter was found to be significantly associated with improvement in the scores of the memory and concentration domain (p = 0.03). On multivariate analysis, factors significantly associated with improvement in different domains were young age (nervousness, p = 0.009), female gender (fatigue, p = 0.02), and weight of goiter (symptoms, p = <0.001; vitality, p = <0.001; and memory and concentration, p = <0.001). CONCLUSIONS: Patients with benign goiters experience significant improvement in QoL after thyroidectomy.

Intra-operative parathyroid hormone kinetics and influencing factors with high baseline PTH: a prospective study.

BACKGROUND AND OBJECTIVE: Intra-operative parathyroid hormone (IOPTH) kinetics and therefore the efficacy of IOPTH utilization as a predictor of cure are likely to be affected by baseline IOPTH levels, vitamin D deficiency and parathyroid weight. PATIENTS AND METHODS: Consecutive subjects with primary hyperparathyroidism (PHPT, n = 51) undergoing parathyroidectomy with IOPTH monitoring were studied prospectively during the period October 2009-November 2011. Samples were collected pre-incision, pre-excision and post-excision (5, 10, 15 min). Iterative analysis of IOPTH kinetics and half-life calculation was carried out in subgroups. Nonparametric testing was used for group statistics. RESULTS: Hypovitaminosis D (25(OH)D3 < 50 nm) was present in 39 (76%), serum PTH > 1000 ng/l in 23 (45%), and giant parathyroid adenoma (weight > 3000 mg) in 23 (45%). The percentage drop at 10 min was significantly higher in large adenomas (weight > 3000 mg). Miami and 5 min criteria showed the highest negative predictive value and maximum accuracy. The average percentage IOPTH drop observed at 5 min post-excision was 79.8%. Kinetic analysis showed a mean half-life of PTH of 2.57 ± 0.27 min (range: 0.07-11.55). CONCLUSION: IOPTH monitoring is reliable even in patients with extremely high baseline IOPTH value, with a greater percentage drop at 5 and 10 min post-excision. In patients with high baseline IOPTH, a 50% decay in PTH value at 5 min may be indicative of cure, obviating the need for 10 and 15 min samples. IOPTH kinetics are altered by adenoma weight but not affected by vitamin D status or baseline IOPTH levels.

Assessment of swallowing function impairment in patients with benign goiters and impact of thyroidectomy: a case control study.

BACKGROUND: Swallowing-related quality of life (QoL) in patients with benign thyroid goiters is not much studied. The aim of this study was to assess swallowing function impairment in patients with benign goiters, compare it to a control population, and also find the impact of thyroidectomy and various factors on the outcome of swallowing function. METHODS: We performed a prospective case-control study from September 2009 to September 2011 which consisted of 124 patients who were to undergo primary thyroid surgery and 100 age- and sex-matched controls. A translated and validated modified swallowing quality-of-life (SWAL-QOL) questionnaire was used to assess patients' perception of dysphagia. Presurgery scores of patients and controls and pre- and postsurgery scores (>6 months after surgery) of patients were compared. RESULTS: The mean age of males and females in the control and patient groups were 37.7 vs. 39.5 years and 37.4 vs. 39.8 years, respectively. Twelve patients (9.7%) complained of dysphasia at presentation. Sixty-three patients (50.8%) underwent total thyroidectomy and 61 (49.2%) had hemithyroidectomy at the time of initial evaluation, 75, 23.4, and 1.6% of patients were euthyroid, hyperthyroid, and hypothyroid, respectively. Presurgery scores of patients in all of the 11 domains of the SWAL-QOL were lower compared to those of controls. Comparing separately with the matched controls, females had significant differences in nine domains (except for sleep and fatigue) of the SWAL-QOL questionnaire but males did not. Postoperatively, both male and female patients showed significant improvement in the scores of all the domains. Female gender, hyperthyroidism, thyroid nodularity, retrosternal extension, procedure, and weight of the resected specimen were the factors associated with significant improvement in various domains. CONCLUSION: Dysphagia seems to be an underestimated problem in patients with benign goiters. Uncomplicated thyroidectomy results in significant improvement in swallowing-related QoL irrespective of patient profile and extent of thyroidectomy.

Fetal MRI in the pre-operative diagnosis and assessment of secondary abdominal pregnancy: a rare sequela of a previous caesarean section.

Secondary abdominal pregnancy is a rare type of ectopic pregnancy. Following fertilization, the blastocyst escapes from the uterine cavity and implants in the peritoneal cavity. The early antenatal diagnosis and identification of the site and extent of placental implantation in an abdominal pregnancy are important to prepare for the eventual surgery. We present the case of a 24-year-old patient presenting with loss of fetal movement at 26 weeks of gestation for whom an abdominal pregnancy was suspected on ultrasonography and later confirmed on magnetic resonance imaging (MRI). She had one caesarean section in the past. The MRI findings suggested a scar dehiscence. She was eventually managed surgically, and the unviable fetus was removed. Abdominal pregnancies must be treated as emergencies. They usually present with complications such as fetal death and intra-abdominal hemorrhaging and can be easily missed on routine antenatal ultrasonography. The exact anatomical relationships of the fetus, the placenta, and vital maternal intra-abdominal structures can be accurately delineated with MRI, which greatly aids the management of patients with abdominal pregnancy. A proposed imaging protocol and technical suggestions for improving the diagnostic capability of ultrasonography and MRI in abdominal pregnancies have been provided to aid in the appropriate evaluation of suspect cases.

Medullary thyroid cancer: clinico-pathological profile and outcome in a tertiary care center in North India.

BACKGROUND: Recent advances in genetic screening have ushered in a new era in diagnosis and management of medullary thyroid cancer (MTC). However, the same is not true for a resource-poor country, where clinicians are still struggling to diagnose and adequately manage this relatively uncommon thyroid malignancy. We hereby present our experience of managing MTC at a tertiary care referral center in North India. METHODS: This was a retrospective study conducted between January 1990 and July 2009. Demographics, clinical profiles, details of surgical procedures, and follow-up records were reviewed. RESULTS: A total of 71 patients with MTC were identified. Mean age of this group was 39.9±14.1 years, and men outnumbered women 1.7:1. Some 84.5% of patients had seemingly sporadic MTC, and 15.5% had familial MTC (MEN2a=14.1%, MEN 2b=1.4%). All patients had a thyroid nodule at the time of presentation. Mean tumor diameter was 4.9 cm. Cervical lymphadenopathy, mediastinal lymphadenopathy, extrathyroidal invasion, and distant metastases were present in 59%, 7.2%, 10%, and 4.2% of patients, respectively. Staging showed that 4.8% of patients were stage I, 17.5% stage II, 14.3% stage III, and 63.6% stage IV. Treatment was as follows: 92.6% of patients had total thyroidectomy (primary or secondary); 67.6% central compartment lymph node dissection, 62.3% lateral cervical lymph node dissection, and 7.2% trans-sternal mediastinal lymph node dissection performed. Some 66.7% of patients suffered from persistent hypercalcitoninemia, and 11.4% of those underwent reoperation. The 5-year and 10-year overall survival (OS) was 74.6% and 58%, respectively. CONCLUSIONS: The majority of the patients with MTC presented at stage IVa, contributing to the high rate of persistent hypercalcitoninemia. Despite a policy of observation and intervening only in overtly symptomatic patients with persistent hypercalcitoninemia, overall survival (OS) in our study was comparable to other series, reinforcing the belief that persistent hypercalcitoninemia has an indolent course in most patients.

Long-term outcome of differentiated thyroid carcinoma: experience in a developing country.

BACKGROUND: The presentation and outcome of differentiated thyroid carcinoma (DTC) in developing countries are different from the developed nations. We report the clinicopathologic profile and long-term outcome of DTC in an iodine-deficient area (IDA) in a developing country. METHODS: This retrospective study included 302 patients with DTC operated between 1989 and 2002. These patients had been followed up for a minimum period of 5 years after surgery. Clinicopathological profile, intervention, and follow-up details were noted. RESULTS: Mean age of the patients was 42 +/- 14 years. Mean follow-up period was 80 +/- 34 (24-196) months. Papillary thyroid carcinoma (PTC), follicular thyroid carcinoma (FTC), and poorly differentiated thyroid carcinoma (PDTC) was present in 62, 30, and 8% patients, respectively. Mean tumor size was 3.5 cm. Tumor multicentricity was noted in 40% of PTC, 22.2% of FTC, and 25% of PDTC patients. Lymphadenopathy was observed in 45, 10, and 67% patients with PTC, FTC, and PDTC, respectively. Extrathyroidal invasion and distant metastasis were observed in 36.8% (PTC 33%; FTC 36%; PDTC 71%) and 27% (PTC 17%; FTC 44%; PDTC 42%) of cases, respectively. Twenty percent of patients had synchronous metastases. Risk stratification ratio was 1:1.8 (high-risk vs. low-risk). Initial operative procedure was total thyroidectomy in 86.5% cases, and therapeutic lymph node dissection was performed in 37% cases. A total of 77.2% patients received adjuvant radioiodine therapy. Disease recurred in 26.6% of patients (thyroid bed recurrence 1.7%), and 21.2% patients died during follow-up. Overall survival (OS) rate at 10 years in both low-risk and high-risk groups of FTC (80 and 54%) was inferior to PTC (94 and 62%). Five-year OS for PDTC was 50%. Tumor multicentricity was a significant risk factor for OS in the low-risk group, whereas the presence of skeletal metastases and extrathyroidal invasion were significant factors for OS in the high-risk group. CONCLUSIONS: Advance stage at presentation and proportionately high rates of FTC and PDTC contribute to poor outcome of DTC in developing countries. Despite dismal outcome, total thyroidectomy seems to prevent thyroid bed recurrence in surviving patients.

Prevalence of hypothyroidism in benign breast disorders and effect of thyroxine replacement on the clinical outcome.

BACKGROUND: The aim of this study was to determine the prevalence of hypothyroidism in patients with benign breast disorders (BBD). We then asked if thyroxine replacement in hypothyroid patients has any impact on the clinical outcome of the BBD. METHODS: This prospective study included 201 women with BBD. None of the included patients had previously suspected hypothyroidism. Clinical, laboratory, and follow-up details of the patients were noted. Baseline serum thyroxine, thyroid-stimulating hormone (TSH), and prolactin estimation was done in all cases. Thyroid peroxidase antibody (TPOAb) estimation was done in hypothyroid patients and/or patients with a goiter. In addition to the standard conservative management protocol, hypothyroid patients were given thyroxine replacement therapy. Their response to treatment was assessed at 3-month intervals. The clinical outcomes of euthyroid and hypothyroid groups were compared. RESULTS: The mean age of the patients was 34 +/- 8 years, and the mean length of follow-up was 13.0 +/- 4.2 months. The overall prevalence of hypothyroidism was 23.2% (nipple discharge 37%, mastalgia 23%, lump/lumpiness 17.4%). The rate of hypothyroidism and the mean serum TSH concentration were significantly higher among patients with nipple discharge than among those with mastalgia (P = 0.001) or a lump (P = 0.01). In all, 39% of hypothyroid women had TSH concentrations >10 mIU/l, and 53% had an elevated TPOAb titer. BBD symptoms were alleviated in 83% of the hypothyroid patients with only thyroxine replacement. The final clinical outcomes of hypothyroid patients with nipple discharge and mastalgia were significantly better than that of their euthyroid counterparts (P = 0.028 and 0.001, respectively); no significant difference was noted in patients with lumpiness (P = 0.144). CONCLUSIONS: All women with BBD should be screened for hypothyroidism because the prevalence of hypothyroidism is high among this group and correction of hypothyroidism results in significant clinical improvement of BBD in most of these patients.

Adrenal incidentalomas: experience in a developing country.

BACKGROUND: The incidence of adrenal incidentalomas is rising worldwide. There is a concern about malignancy in large incidentalomas. There are few published articles from developing countries on this entity. The aim of this study was to analyze the clinical presentation, functional status, and final diagnosis of adrenal incidentalomas and, in particular, to look into the incidence of adrenal cortical carcinoma (ACC) in large adrenal incidentalomas managed at a tertiary referral hospital in northern India. METHODS: This is a retrospective study (January 1991-December 2005) of 59 patients with adrenal incidentaloma managed at our department. The mean tumor diameter was 7.8 +/- 4.0 cm. In all cases, clinical details, radiology findings, laboratory findings, intervention details, histology findings, and follow-up data were noted. Six patients in which the mass was ultimately found to arise from extra-adrenal tissue were excluded from final analysis RESULTS: Mean age of the patients was 46 +/- 12 years (M:F = 1:1.1). The incidentaloma measured more than 3 cm in 91% of cases and more than 6 cm in 70% of cases. The clinical scenarios leading to detection of incidentaloma included abdominal (56.6%), genitourinary (24.5%), and systemic complaints (15.1%) and routine medical checkup (3.7%). Most of cases were found by ultrasonography (n = 41), and remaining by CT scan (n = 10), and MRI (n = 2). The incidence of functioning tumors was 41.5% (hypercatecholinism 37.7 % and hypercortisolism 1.9%). Forty-nine patients were operated on. The important final pathology included ACC (7.5%), pheochromocytoma (PCC) (43%), adrenal cysts (13.2%), myelolipoma (11.3%), and inflammatory lesions (9.4%). CONCLUSION: In our experience, the incidence of PCC was high among large adrenal incidentalomas while that of ACC was lower than expected. Inflammatory lesions contribute to a significant number of cases of incidentaloma in developing countries. Adrenalectomy is a justified procedure for large incidentalomas, although the concern may not always be an underlying malignancy.