Indian Journal of Endocrine Surgery and Research

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Volume 18, Number 2, July-December 2023
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MESSAGE FROM THE DESK OF EDITOR IN CHIEF

Pooja Ramakant

Message from the Desk of Editor-in-Chief

[Year:2023] [Month:July-December] [Volume:18] [Number:2] [Pages:1] [Pages No:iv - iv]

   DOI: 10.5005/ijesr-18-2-iv  |  Open Access | 

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MESSAGE FROM THE PRESIDENTS DESK

PV Pradeep

Message from the President's Desk

[Year:2023] [Month:July-December] [Volume:18] [Number:2] [Pages:1] [Pages No:v - v]

   DOI: 10.5005/ijesr-18-2-v  |  Open Access | 

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Original Article

Komal Gupta, Kamal Kataria, Shipra Agarwal

The Impact of Preoperative Cytology on Type of Surgery in Patients with NIFTP

[Year:2023] [Month:July-December] [Volume:18] [Number:2] [Pages:4] [Pages No:41 - 44]

Keywords: Cytodiagnosis, Endocrine surgery, Follicular thyroid carcinoma, Papillary thyroid carcinoma

   DOI: 10.5005/jp-journals-10088-11219  |  Open Access |  How to cite  | 

Abstract

Objective: Non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) is a recent nomenclature that being used to emphasize on benign nature of the non-invasive encapsulated follicular variant of papillary thyroid carcinoma (FVPTC). Our study aimed to compare the preoperative characteristics of NIFTP with the invasive FVPTC. Materials and methods: This retrospective study identified 124 patients during the year 2016–2020 who were diagnosed with NIFTP or FVPTC. Clinical characteristics and fine needle aspiration cytology (FNAC) characteristics were compared between the two groups. Results: A total of 35 NIFTP (28.23%) and 89 FVPTC (71.77%) patients were identified. The FNAC diagnosis of Bethesda category V or VI was present in 20 (22.47%) patients with FVPTC compared to 4 (11.43%) patients with NIFTP (not statistically significant). Patients with NIFTP more frequently underwent hemithyroidectomy compared to FVPTC (77.14% vs 51.69%: p-value = 0.01). Patients who underwent hemithyroidectomy were found to be younger compared to total thyroidectomy (33.98 ± 11.79 vs 41.07 ± 13.24: p-value = 0.02). Fine needle aspiration cytology diagnosis of Bethesda category V or VI was present in 17 (33.33%) patients with total thyroidectomy vs 7 (9.59%) with hemithyroidectomy (p-value = 0.001). Patients with hemithyroidectomy were more frequently diagnosed with NIFTP vs total thyroidectomy (36.99% vs 15.69%, p-value = 0.01). Conclusion: Hemithyroidectomy was performed more frequently in younger patients and less frequently in Bethesda category V or VI cytology. Patients who underwent hemithyroidectomy were more frequently diagnosed as NIFTP vs total thyroidectomy.

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Original Article

Sahithi Priya Boddukura, Dhalapathy Sadacharan, Ganapathi Selvambigai, Uma Devi, Sai Vishnu Priya, Mano Zac Mathews, Dinesh Goli

Association of Thyroid Malignancy and Graves’ Disease: A South Indian Tertiary Care Center Perspective

[Year:2023] [Month:July-December] [Volume:18] [Number:2] [Pages:4] [Pages No:45 - 48]

Keywords: Graves disease, Micro-PTC, Papillary thyroid carcinoma, Prognosis, Total thyroidectomy

   DOI: 10.5005/jp-journals-10088-11220  |  Open Access |  How to cite  | 

Abstract

Aim and background: Papillary thyroid carcinoma (PTC) is not uncommon in nodules associated with Graves’ disease (GD). We intend to assess the likelihood of malignancy in GD especially in those without discrete nodules in a tertiary care center. Materials and methods: Data collected from the Department of Endocrine Surgery of all GD patients who underwent total thyroidectomy at Madras Medical College between August 2022 and August 2023 were retrospectively analyzed from a prospective database. Based on histopathology, these GD patients were subdivided into malignant (group A) and non-malignant (group B) and analyzed based on various parameters. Results: Eight of 35 patients who underwent total thyroidectomy for GD had PTC of which 5 were female. About 7/8 (87.5%) patients had no radiological nodules and the mean tumor size was 0.83 cm. And 7/35 patients had nodules, with 1 diagnosed with PTC on histopathology. Majority of the FNAC from these nodules were Bethesda 2 and one was Bethesda 3. About 25% of group A cases showed macrocalcifications and 12.5% showed microcalcification. There was no aggressive histology or lymph nodal metastases. Mean FT4, mean FT3, mean TSH in group A and group B were 3.1 ± 1.35 vs 2.6 ± 1.02, 10.9 ± 3.4 vs 8.5 ± 1.7, 0.2 ± 0.4 vs 0.3 ± 0.53, respectively and FT3 was significantly high in group A. Conclusion: Graves’ disease has a strong association with PTC even without sonological nodules. Except for significantly high free T3 levels we could not find any other predictive factors. Clinical significance: Graves’ disease reported higher incidence of malignancy even without any suspicious preoperative pointers. This may tilt the pendulum toward surgery as definitive strategy.

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Original Article

Subbiah Shanmugam, Sathiyaseelan Balakrishnan

Intraoperative Parathyroid Hormone Levels: A Predictor of Postoperative Hypocalcemia in Total Thyroidectomy for Thyroid Cancer Patients

[Year:2023] [Month:July-December] [Volume:18] [Number:2] [Pages:4] [Pages No:49 - 52]

Keywords: Endocrine, Parathyroid hormone, Thyroid, Thyroid cancer, Thyroid surgery, Total thyroidectomy

   DOI: 10.5005/jp-journals-10088-11221  |  Open Access |  How to cite  | 

Abstract

Background: During parathyroidectomy, intraoperative parathyroid hormone (ioPTH) levels are commonly utilized as a sign of parathyroid gland function. However, they are not commonly utilized in thyroid cancer surgery. The ability to successfully identify individuals at risk for postoperative hypocalcemia may reduce morbidity by initiating early replacement treatment and identifying patients who can be safely discharged from the hospital. Aims and objective: To determine whether the use of ioPTH assay can accurately predict postoperative calcium levels following total or completion thyroidectomy in thyroid cancer patients. Materials and methods: We analyzed the ioPTH of all patients who underwent total thyroidectomy with or without neck dissection in our institution for thyroid cancer and neoplasm. In postoperative period, serum calcium was measured in those patients on POD 1 and POD 6. The ioPTH levels are correlated with postoperative calcium levels. Results: In our study, we included 35 patients who underwent total thyroidectomy in our institution. Postoperative histopathological examination revealed 30 patients had papillary carcinoma, three had follicular carcinoma, one had medullary carcinoma, and one without any malignancy. Out of 35 patients, 14 patients showed biochemical hypocalcemia in immediate postoperative period. Among these 14 patients, 10 patients had clinical signs/symptoms of hypocalcemia. Out of these 14 patients, 12 patients had ioPTH levels less than 10 pg/mL which shows a positive correlation between intraoperative parathyroid levels and immediate postoperative calcium levels. Conclusion: Intraoperative PTH monitoring may be a quick and effective tool for identifying those patients who are at risk for postoperative hypocalcemia and a useful tool in identifying thyroid cancer patients who will not require postoperative calcium supplementation following total or completion thyroidectomy.

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Original Article

Vijay Kumar, Sanjeev Kumar Tripathi, Jai Prakash, Ashish Dubey, Ranjeet Singh Chauhan, Spandana Jagannath, Sabaretnam Mayilvaganan, Sandeep Kumar Singh

What an Endocrine Surgeon Should Know about Sample Collection and Tissue Preservation

[Year:2023] [Month:July-December] [Volume:18] [Number:2] [Pages:5] [Pages No:53 - 57]

Keywords: Adrenal, Endocrine, Soft tissue tumor, Thyroid cancer

   DOI: 10.5005/jp-journals-10088-11214  |  Open Access |  How to cite  | 

Abstract

One of the challenges that Endocrine Surgeons face is the collection and preservation of tissue samples from patients with endocrine disorders. Different tissue samples are the key essential for the diagnosis and treatment of various endocrine diseases, such as thyroid cancer, adrenal tumors, and parathyroid disorders. However, collecting and preserving tissue samples is a challenge and may hamper the concluding prognosis, onset of the disease, and another parameter of the disease which may mislead the treatment plan of the patients. So, it requires careful planning, preparation, and execution to ensure that the samples are representative of the disease state and suitable for analysis. In this article, we will discuss some of the factors that affect the quality and integrity of tissue samples and provide some tips and best practices for sample collection and preservation.

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ORIGINAL RESEARCH

Raja Suman Datta Aduri, Komal Gupta, Sunil Chumber, Yashwant Rathore, Kamal Kataria

A Pilot Study on Parathyroid Identification, Confirmation, and Autoimplantation from Thyroidectomy Specimen

[Year:2023] [Month:July-December] [Volume:18] [Number:2] [Pages:6] [Pages No:58 - 63]

Keywords: Endocrine surgery, Parathyroidectomy, Thyroidectomy

   DOI: 10.5005/jp-journals-10088-11223  |  Open Access |  How to cite  | 

Abstract

Introduction: Parathyroid identification and preservation are important components of safe thyroid surgery and can significantly reduce the morbidity associated with thyroidectomy. Our study focuses on identifying parathyroid glands by their gross appearance during intraoperative bench dissection of the thyroidectomy specimen with confirmation by histopathological examination (frozen section). Materials and methods: This is a prospective, nonrandomized cohort study conducted from August 2017 to March 2019. Patients with various thyroid disorders undergoing thyroid surgery were included in the study. The excised thyroidectomy specimen was inspected to identify parathyroid glands based on five morphological criteria including location, color, size, presence of a vascular pedicle, and saline floatation test. Confirmation with the frozen section as a gold standard test was performed. Autoimplantation of confirmed parathyroid glands was performed. Results: A total of 41 patients were included. The prevalence of incidental parathyroidectomy (IP) was found to be 9.76% (4 out of 41) [95% confidence interval (CI): 2.72–23.13%] in our study. The sensitivity of the bench dissection of the thyroidectomy specimen was 25% (95% CI: 0.63–80.59%) and the specificity was 94.59% (95% CI: 81.81–99.34%). The positive likelihood ratio was 4.62 (95% CI: 0.53–40.41) and the negative likelihood ratio was 0.79 (95% CI: 0.45–1.40). The positive predictive value was 33.33% (95% CI: 5.41–81.37%), the negative predictive value was 92.11% (95% CI: 86.83–95.38%), and the accuracy was 87.80% (73.80–95.92%). Conclusion: Gross criteria used for identification of parathyroid glands are fairly accurate (87.80%) with high specificity (94.59%) and negative predictive value (92.11%).

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CASE REPORT

Somya Arya, Bharath Shiva, Ashutosh Silodia, Vikram Singh Chauhan, Arun Nayak, Sanjay Kumar Yadav

The Giants of the Dwarf Family: A Contrasting Tale of Two Giant Parathyroid Adenomas

[Year:2023] [Month:July-December] [Volume:18] [Number:2] [Pages:3] [Pages No:64 - 66]

Keywords: Case report, Giant parathyroid, Parathyroid adenoma, Parathyroidectomy, Primary hyperparathyroidism

   DOI: 10.5005/jp-journals-10088-11222  |  Open Access |  How to cite  | 

Abstract

In the following case report, we are reporting two cases of one of the largest parathyroid adenomas in the literature with two contrasting clinical presentations. The initial case is a 42-year-old female who on initial presentation had severe symptomatic primary hyperparathyroidism (PHPT). Her 4D computed tomography (CT) scan revealed a right inferior parathyroid adenoma (7 × 6 cm) reaching up to the arch of the aorta which was excised trans-cervically. The subsequent patient, a 65-year-old female presented with dyspnea on slight exertion. She did not have any symptoms of PHPT and serum calcium was normal. Computed tomography of her neck revealed multinodular goiter with a right inferior parathyroid adenoma extending up to the arch of the aorta and tracheal compression. Total thyroidectomy with right inferior parathyroidectomy was performed addressing an 8 × 7 cm parathyroid adenoma. The combination of giant parathyroid adenomas which are non-functional is extremely rare, and they should always be considered in the differential diagnosis of neck mass evaluation.

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CASE REPORT

M Mohammed Imran, Bharath Shiva, Ashutosh Silodia, Arun Nayak, Sanjay Kumar Yadav

Rare Cause of a Midline Neck Swelling—Congenital Thyroid Teratoma in a 14-month-old Boy: A Case Report and Review of Literature

[Year:2023] [Month:July-December] [Volume:18] [Number:2] [Pages:4] [Pages No:67 - 70]

Keywords: Case report, Congenital neck swelling, Congenital thyroid teratoma, Neck swelling in children, Thyroid teratoma

   DOI: 10.5005/jp-journals-10088-11215  |  Open Access |  How to cite  | 

Abstract

Teratomas are germ cell tumors that are usually diagnosed in newborn babies and infants, but rarely in adults. This tumor normally arises inside the gonad, but it can also occur outside the gonad. About 40% of extragonadal teratomas originate from the sacrococcygeal region, followed by the central nervous system, globe, pharynx, mediastinum, and retroperitoneum. Head and neck teratomas account for 3–6% of all teratomas. We report a case of thyroid teratoma in a 14-month-old baby boy with an emphasis that thyroid teratomas in children should be included in the differential diagnosis of lesions located in the head and neck area.

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CASE REPORT

Jyoti Sharma, Ankita Singh, Kamal Kataria, Rijuta Rajendra Aphale, Devender Singh, Yashwant Singh Rathore, Piyush Ranjan, Sunil Chumber, Amarinder Singh Malhi

Incidentally Diagnosed Thyroid Hemiagenesis with Papillary Thyroid Carcinoma: A Case Report and Literature Review

[Year:2023] [Month:July-December] [Volume:18] [Number:2] [Pages:5] [Pages No:71 - 75]

Keywords: Agenesis, Case report, Papillary carcinoma, Thyroid dysgenesis, Thyroid hemiagenesis, Thyroid nodule, Total thyroidectomy

   DOI: 10.5005/jp-journals-10088-11216  |  Open Access |  How to cite  | 

Abstract

Aim and background: Thyroid hemiagenesis (THA) is a rare congenital condition where one lobe of the thyroid gland fails to develop. Most cases are asymptomatic and require no treatment. However, some cases may develop various morphological, functional, and neoplastic lesions. Case description: We report a case of a 30-year-male who presented with right neck swelling for 3 months, which moved on deglutition. He was clinically euthyroid. Ultrasound neck showed a well-defined TIRADS 3 nodule of ~5 × 3.7 × 2 cm in the right lobe of the thyroid with a significantly small left thyroid lobe. Fine needle aspiration cytology (FNAC) from the nodule was suggestive of papillary carcinoma of the thyroid (PTC) (BETHESDA 6). The patient was planned for total thyroidectomy with central compartment lymph node dissection (CCLND). Intraoperatively, an enlarged 5 × 6 cm right lobe of the thyroid was visualized attached to a small 1.5 × 1.5 cm lobe without its separate neurovascular supply. The final histopathology report was suggestive of a follicular variant of papillary thyroid carcinoma with no gross extrathyroidal extension and a Ki-67 index of 4–5%. The patient is currently on regular follow-up as per the follow-up protocol for PTC. Conclusion: Thyroid hemiagenesis with a follicular variant of papillary carcinoma in the remnant thyroid lobe is a rare entity with only one reported case in the indexed literature. It poses a diagnostic challenge as most cases are asymptomatic, along with challenging management, as there is no standardized protocol for its management, thus necessitating the need for further studies. Clinical significance: The case is a rarity, with only one similar reported case in the indexed literature. There is a higher incidence of the development of carcinoma in these patients but the evidence available is sparse. Due to majority of these cases being asymptomatic, it poses a diagnostic challenge and necessitates the need for development of a standardized protocol for its screening and management.

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CASE REPORT

Ramesh Bhargav Kavuluri, Arun Kumar Mohanty, Biswajit Pusty

Symptomatic Primary Hyperparathyroidism Presenting as Osteitis Fibrosa Cystica in Young Female

[Year:2023] [Month:July-December] [Volume:18] [Number:2] [Pages:3] [Pages No:76 - 78]

Keywords: Case report, Hyperparathyroidism, Osteitis fibrosa cystica, Parathyroid adenoma, Parathyroidectomy, Primary hyperparathyroidism

   DOI: 10.5005/jp-journals-10088-11217  |  Open Access |  How to cite  | 

Abstract

Parathyroid hormone (PTH) plays an important role in calcium and phosphate regulation. A reverse sigmoidal relationship exists between extracellular calcium levels and PTH secretion. Primary hyperparathyroidism is a state of excess production of PTH by abnormal parathyroid glands. Diagnosis requires a high index of suspicion due to its nonspecific symptoms that require a complete evaluation and workup, thus causing a delay in surgical intervention, from the time of index high calcium levels. A 25-year-old female presented with symptoms of pain over her right knee and easy fatiguability. She had abdominal pain and had visited multiple hospitals since 1 year, and no relief in symptoms. Serum calcium levels were elevated to 12.8 mg/dL, Sr PTH 813 pg/mL, and ALP 3386 IU/L. Bone scan and biopsy revealed osteitis fibrosa cystica of Rt femur with brown tumors in the tibia and mandible. Sestamibi scan showed that the right inferior parathyroid increased tracer uptake. Focused parathyroidectomy was done. Sr PTH levels and Sr calcium levels reached normal levels postoperatively and genetic testing was done as the age of presentation was <35 years. Thus, meticulous examination and workup are cornerstones in diagnosing a case of primary hyperparathyroidism in order to prevent delay in treatment and prevent complications.

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CASE REPORT

Pratiksha Pant, Rizhin Sooraj, Ganesh Bhat, Pooja Ramakant

Clinical Enigma of Maxillofacial Tumors: Hyperparathyroidism-related Brown Tumors

[Year:2023] [Month:July-December] [Volume:18] [Number:2] [Pages:4] [Pages No:79 - 82]

Keywords: Brown tumors, Case report, Giant cell tumors, Jaw swelling, Maxillofacial lesion, Primary hyperparathyroidism

   DOI: 10.5005/jp-journals-10088-11218  |  Open Access |  How to cite  | 

Abstract

A young adolescent female presented with swelling over the right jaw for the past 4 months. The biopsy showed a giant cell tumor of the mandible and was planned for excision with free fibular graft placement for coverage but blood investigations showed markedly elevated calcium levels (13.92 mg/dL; normal: 8.6–10.3 mg/dL), and the patient was referred to the Endocrine Surgery Department for further management. High-resolution ultrasonography (HR-USG) of the neck showed a well-defined hypoechoic lesion (9.5 × 8.9 × 28.7 mm) below the right thyroid lobe suggestive of a parathyroid adenoma, which was concordant with a99mTc-Sestamibi (MIBI) scan. The second patient was a young adult female in her early 30s with swelling in the jaw for 3.5 years with a history of fractures following trivial trauma. The patient was evaluated with a biopsy suggestive of a brown tumor. Biochemical investigations showed markedly raised serum calcium levels (13.41 mg/dL). High-resolution ultrasonography demonstrated a left superior parathyroid adenoma with a concordant MIBI scan. Both the patients underwent focused parathyroidectomy and had a considerable reduction in the size of the swelling at the 6-month follow-up. The jaw lesions were determined to be brown tumors of hyperparathyroidism (BTH), which are non-neoplastic, reactive tissue responses associated with primary hyperparathyroidism (PHPT). Distinguishing BTH from other giant cell-containing lesions and malignancies is crucial. It is often misdiagnosed, emphasizing the importance of considering PHPT in patients with unusual bone lesions. While these tumors often regress spontaneously with the correction of hypercalcemia and PHPT, surgical removal may be considered in cases with specific indications such as large tumor size, risk of pathological fractures, compression symptoms, or slow regression. Careful evaluation and diagnosis are essential to avoid unnecessary surgical procedures. These cases highlight the challenging diagnosis of BTH associated with PHPT in patients initially presenting with jaw lesions.

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CASE REPORT

Meghana V Shetty, Asiya Zehra, Pooja Ramakant, Preeti Agrawal, Kul Ranjan Singh, Anand Mishra

The Master Masquerader: A Case Series on Adrenal Teratoma

[Year:2023] [Month:July-December] [Volume:18] [Number:2] [Pages:3] [Pages No:83 - 85]

Keywords: Adrenal, Adrenocortical cancer, Case report, Endocrine surgery, Heterogenous adrenal mass, Retroperitoneal tumors, Teratoma

   DOI: 10.5005/jp-journals-10088-11226  |  Open Access |  How to cite  | 

Abstract

Adrenal teratoma is a rare entity that often resembles other adrenal pathology in imaging studies and intraoperatively. A high degree of suspicion, as well as knowledge about imaging characteristics of teratoma, is essential to make a diagnosis.

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VIEWPOINT

Kamal Kataria, Richa Garg, Vikram Saini, Pritam Yadav, Shahid Dar, Preetham Chiramshetty, Sugandha Agarwal, Kanika Sachdeva, Rajendra Meena

Is Lactation Really a Contraindication or an Unjustified Worry for Milk Fistula in Patients Undergoing Endoscopic Thyroidectomy via Breast Approach

[Year:2023] [Month:July-December] [Volume:18] [Number:2] [Pages:2] [Pages No:86 - 87]

Keywords: Endoscopic thyroidectomy, Lactation, Milk fistula

   DOI: 10.5005/jp-journals-10088-11225  |  Open Access |  How to cite  | 

Abstract

Endoscopic thyroidectomy either by ipsilateral axillo-breast approach (IABA) or bilateral axillo-breast approach (BABA) has gained popularity as a minimally invasive technique, offering high cosmetic satisfaction and noninferiority to conventional thyroidectomy. In literature, lactation has been considered a relative contraindication of endoscopic thyroidectomy via breast approach due to fear of milk fistula formation. Milk fistula, an abnormal connection between a lactiferous duct and the skin, is a complication of radiologic and surgical procedures performed on the lactating breast. While the incidence of milk fistula remains relatively low, its impact on postoperative recovery, patient discomfort, and potential for infection necessitates proactive measures. Hence, a question arises whether lactation should be considered a contraindication for this approach of thyroidectomy. In our setup, We performed six cases of endoscopic thyroidectomy via breast approach in lactating females. Our study cohort had lactating females during 7–12 months of lactation and patients were followed up for a period of 3 months. None of them developed a milk fistula. The lower incidence reported in our study even after periareolar incision may arise from the fact that the plane of dissection was in subcutaneous space, thereby minimum alteration of breast anatomy was done. Although our experience is small but with this experience, endoscopic thyroidectomy seems a safe and feasible option. Larger evidence can be generated once we start using breast approaches in lactating female for endoscopic thyroidectomy.

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