Patients Underwent Completion Thyroidectomy Research Articles

6955 A Rare Case of Rapidly Enlarging High Grade Follicular-Derived Carcinoma in a Young Patient - Formerly Known as Insular Thyroid Carcinoma with good response to Radioactive iodine ablation- A New Name, Same Aggressive Features

Abstract Disclosure: R. Abdelmasih: None. N. Prasad: None. N. Shah: None. Introduction: Follicular-derived thyroid carcinomas, formerly known as insular thyroid carcinomas, are an albeit rare but highly lethal thyroid carcinoma subtype with an incidence of 1-10% worldwide. It is known for its aggressive nature and comprises the majority of deaths from non-anaplastic follicular thyroid cancers. Case Presentation: A 30-year-old male presented with 2-year history of progressively enlarging painless right neck mass. Physical exam revealed 6x3 cm right well-circumscribed mobile mass not displacing the trachea. Head and neck CT showed 6.5 cm right thyroid mass with level 2A lymph node. Neck Ultrasound showed a 6.4 cm right thyroid nodule. Fine needle aspiration of the mass showed atypia of undetermined significance. Patient returned to clinic 1 year later with progressively enlarging right neck mass, now associated with dysphagia measuring 10 cm in physical exam deviating the trachea to the left. Repeat CT H&N showed 10 cm right thyroid mass with moderate tracheal deviation and US showed 11 cm right heterogenous thyroid mass with regular margins and negative LNs. Patient underwent right thyroid lobectomy with surgical pathology showed 11.4 cm tumor with vascular invasion and no extrathyroidal extension. Pathology showed high grade follicular-derived Thyroid Carcinoma. Patient underwent completion thyroidectomy with benign pathology followed by radioactive iodine ablation 107.8 mCi I131 with successful targeting of residual thyroid tissue and no evidence of iodine avid distant metastasis. Patient has been followed closely for 2 years now with regular US, thyroglobulin level with recurrence. Discussion: Insular thyroid carcinomas are aggressive malignancies predominantly seen in females within the age of 55-65 though cases of young patients and children have been reported. Patients often present with enlarging goiter, dysphagia, and dyspnea however, metastatic disease to lymph nodes, lung and bone has also been reported as primary presentation in 20% of cases. Per literature review, recurrence and mortality rates have very wide range of 36-83% and 9-75% respectively which could be explained by a variety of prognostic factors including Patient age, tumor size, Macroscopic evident extrathyroidal extension, distant metastasis, or tumor necrosis. Often times insular thyroid carcinomas are mistaken for anaplastic carcinoma and thus fine needle aspiration is a helpful diagnostic tool to differentiate insular carcinoma. Pathology typically demonstrates well-defined insulae of thyroglobulin-filled follicles, necrotic foci, and high random mitotic activity. Treatment includes total thyroidectomy followed by high-dose radiotherapy. We Present this case to shed light on such a rare aggressive entity that requires early detection, belligerent management, and close follow-up for promising outcomes. Presentation: 6/3/2024

5118 When Thyroid Gland Is Not Made Of Thyroid Cells

Abstract Disclosure: A. Bulut: None. L. Ma: None. J.P. Noordzij: None. S.Y. Lee: None. Introduction: Neurofibroma is a type of peripheral nerve tumor that can arise sporadically or be a part of neurofibromatosis type 1 (NF1), a rare genetic disorder. Neurofibromas within the thyroid gland are extremely rare. Here, we present the fifth reported case of primary neurofibroma of thyroid gland. Case: A 60-year-old woman with history of systemic lupus erythematosus and hypertension presented with enlargement of left thyroid gland. She was diagnosed with Graves’ disease 40 years ago, which was treated with right thyroid lobectomy one year after the initial diagnosis. Five years after the surgery, she had recurrence of her symptoms and received radioactive iodine ablation with subsequent hypothyroidism. On presentation to endocrine clinic, she had thyroid ultrasound (US), which showed surgically absent right thyroid lobe and enlarged heterogenous left thyroid lobe measuring 5.1 cm x 3.8 cm x 3.9 cm with scant blood flow without discrete nodules. In interim, patient developed dysphagia and globus sensation. Repeat thyroid US showed enlargement of left lobe to 5.6 cm x 3.7 cm x 4.7 cm. Patient underwent completion thyroidectomy. Surgical pathology showed neurofibroma (S-100+, CD34+ and MSA-) without any thyroid parenchyma. Whole-body scan revealed no other evidence of tumors. Patient was referred for genetic analysis. Discussion: Neurofibromas are benign peripheral nerve system tumors primarily consist of Schwann cells along with other components of perineurium. They can occur as a sporadic lesion which accounts for 90% of solitary neurofibroma cases or be a part of NF1 on rare occasions. NF1 is an autosomal dominant genetic disorder due to germline mutation in NF1 gene located on chromosome 17q11.2, whose manifestations include café-au-lait macules, Lisch nodules, skeletal abnormalities, neurological deficits, and other benign and malignant tumors. Neurofibromas are the hallmarks of NF1. There are only few cases in the literature reported neurofibromas adjacent to or originating from thyroid gland. To the best of our knowledge, there have been only four other cases reporting primary neurofibroma of thyroid gland, one of which developed from thyroid capsule. Our patient most likely has primary neurofibroma of thyroid gland given the lack of syndromic features, however, genetic testing is needed in order to rule out NF1. In conclusion, clinicians should consider neurofibroma in their differential in cases of enlarging thyroid gland or nodules, especially in the presence of other clinical features. Presentation: 6/1/2024

5118 When Thyroid Gland is Not Made of Thyroid Cells

Abstract Disclosure: A. Bulut: None. L. Ma: None. J.P. Noordzij: None. S.Y. Lee: None. Introduction: Neurofibroma is a type of peripheral nerve tumor that can arise sporadically or be a part of neurofibromatosis type 1 (NF1), a rare genetic disorder. Neurofibromas within the thyroid gland are extremely rare. Here, we present the fifth reported case of primary neurofibroma of thyroid gland. Case: A 60-year-old woman with history of systemic lupus erythematosus and hypertension presented with enlargement of left thyroid gland. She was diagnosed with Graves’ disease 40 years ago, which was treated with right thyroid lobectomy one year after the initial diagnosis. Five years after the surgery, she had recurrence of her symptoms and received radioactive iodine ablation with subsequent hypothyroidism. On presentation to endocrine clinic, she had thyroid ultrasound (US), which showed surgically absent right thyroid lobe and enlarged heterogenous left thyroid lobe measuring 5.1 cm x 3.8 cm x 3.9 cm with scant blood flow without discrete nodules. In interim, patient developed dysphagia and globus sensation. Repeat thyroid US showed enlargement of left lobe to 5.6 cm x 3.7 cm x 4.7 cm. Patient underwent completion thyroidectomy. Surgical pathology showed neurofibroma (S-100+, CD34+ and MSA-) without any thyroid parenchyma. Whole-body scan revealed no other evidence of tumors. Patient was referred for genetic analysis. Discussion: Neurofibromas are benign peripheral nerve system tumors primarily consist of Schwann cells along with other components of perineurium. They can occur as a sporadic lesion which accounts for 90% of solitary neurofibroma cases or be a part of NF1 on rare occasions. NF1 is an autosomal dominant genetic disorder due to germline mutation in NF1 gene located on chromosome 17q11.2, whose manifestations include café-au-lait macules, Lisch nodules, skeletal abnormalities, neurological deficits, and other benign and malignant tumors. Neurofibromas are the hallmarks of NF1. There are only few cases in the literature reported neurofibromas adjacent to or originating from thyroid gland. To the best of our knowledge, there have been only four other cases reporting primary neurofibroma of thyroid gland, one of which developed from thyroid capsule. Our patient most likely has primary neurofibroma of thyroid gland given the lack of syndromic features, however, genetic testing is needed in order to rule out NF1. In conclusion, clinicians should consider neurofibroma in their differential in cases of enlarging thyroid gland or nodules, especially in the presence of other clinical features. Presentation: 6/1/2024

7914 Staged Treatment with Radioiodine Following Lobectomy in a Case of High Risk Papillary Thyroid Carcinoma

Abstract Disclosure: L. Pathak: None. A. Sharma: None. K. Rao: None. M.G. Jakoby: None. Introduction: Radioiodine ([1]3[1]I ) is usually reserved for patients with differentiated thyroid carcinoma (DTC) who are at high risk of persistence or recurrence after thyroidectomy. We present a case of papillary thyroid carcinoma (PTC) with extrathyroidal extension managed by lobectomy and staged [1]3[1]I ablation of the contralateral lobe and metastases due to comorbidities that made oncologic resection prohibitive. Case Description: A 58-year-old male had a 2.2 cm focus of PTC in the left thyroid lobe that extended into extrathyroidal soft tissue, adjacent trachea, and completely compromised the left recurrent laryngeal nerve. Due to left vocal cord paralysis and subglottic tracheal stenosis, left lobectomy was performed but oncologic resection (total thyroidectomy and tracheal resection) was deferred. The patient underwent recombinant human TSH (rhTSH) stimulated treatment with 30 mCi (1.1 GBq) of [1]3[1]I for right thyroid lobe ablation followed 60 d later by 180 mCi (6.7 GBq) of [1]3[1]I to treat metastases. Response to treatment was incomplete, with unstimulated thyroglobulin level falling from 293.9 to 18.9 ng/mL 1 y after [1]3[1]I and CT of the neck notable for a 2.7 cm left thyroid bed mass with invasion of adjacent trachea and a 1.0 cm right paratracheal mass, both of which exhibited hypermetabolism on PET imaging and yielded cytology consistent with poorly differentiated thyroid carcinoma (PDTC). A cluster of left supraclavicular lymph nodes showed both hypermetabolism on PET and radioiodine uptake on rhTSH scan. This patient is being prepared for surgical resection of the left thyroid bed and right paratracheal tumors and left lateral lymph node dissection. Discussion: Radioiodine lobar ablation is an alternative to completion thyroidectomy in patients with an unexpected diagnosis of DTC after lobectomy, with a recent meta-analysis finding a success rate of 69%. No difference in thyroid cancer recurrence rates was found in nearly 500 matched pairs of patients undergoing completion thyroidectomy or radioiodine lobar ablation. Unfortunately, staged lobar ablation followed by high dose [1]3[1]I was not successful in treating this high-risk PTC patient. Cases of coexisting PTC and PDTC are reported, and [1]3[1]I treatment was unsuccessful at treating PDTC that was not apparent on postsurgical histopathology. This case indicates that surgery is preferable to staged [1]3[1]I treatment of patients with aggressive PTC, especially if there are no comorbidities that make total thyroidectomy a high-risk procedure. Presentation: 6/2/2024

Evaluating the Efficacy and Safety of Robotic Versus Conventional Completion Thyroidectomy: A 10-year Experience.

Robotic thyroidectomy is gaining popularity, yet its role in completion thyroidectomy remains unclear. We aimed to compare robotic vs conventional completion thyroidectomy for thyroid nodules. This retrospective study analyzed patients undergoing completion thyroidectomy from 2010-2020, either by conventional open technique (n = 87) or a robotic remote-access approach (n = 44). Outcomes were compared between groups. A total of 131 patients were included. The robotic cohort was younger (45.3 ± 14.0 vs 55.5 ± 14.5years, P < 0.001) with a lower BMI (25.9 ± 5.5 vs 33.7 ± 7.8kg/m2, P < 0.001). Operative time was longer for robotic procedures (139min vs 99min, P < 0.001). Hospital stay was shorter after robotic surgery, with 25% discharged the same day as compared to 5.7% in the open thyroidectomy cohort (P = 0.006). Overall rates of complication were comparable (P = 0.65). Transient recurrent laryngeal nerve palsy occurred in 4.6% of patients, which was similar between both cohorts (P = 0.66). Robotic completion thyroidectomy appears safe and effective, achieving shorter hospitalization than conventional open approaches despite longer operative times. Appropriate patient selection and surgical technique optimization are key. Larger prospective studies should investigate costs and long-term patient-reported outcomes.

Completion thyroidectomy: A safe option for high-volume surgeons.

The risk of complication in patients undergoing completion thyroidectomy (cT) is mixed. Several studies report increased risk in comparison to total thyroidectomy (TT) and still others reporting a comparatively decreased risk. We compared the rates of complication in patients at our institution undergoing thyroid lobectomy (TL), (TT), and cT by a single high-volume surgeon. We performed a single-institution retrospective cohort study. Patients undergoing TL, TT, or cT by a high-volume surgeon were included. Rates of complication were collected and compared between the three cohorts. A total of 310 patients were included. The overall rate of complication was 4.2%. The complication rates in the TL, TT, and cT cohorts were 1%, 7.1%, and 4.5%, respectively (p = 0.10). Transient hypocalcemia was slightly more common in the TT cohort (6.1%) as opposed to the TL (0%) or cT (0.9%) cohort (p = 0.01). The cohorts also had similar rates of recurrent laryngeal nerve signal loss leading to transient dysphonia (TL: 0% vs. TT: 1% vs. cT: 3.6%, p = 0.10). While rates of complication tended to predictably decrease as approaches became less extensive, there were no significant differences in complication rates among the three surgical approaches when performed by a high-volume surgeon. Considering the low rates of complication overall, patient counseling and preference should be emphasized to provide appropriate and tailored treatment plans.

Propensity Score Matched Outcome Analysis of Lobar Ablation Versus Completion Thyroidectomy in Low-Risk Differentiated Thyroid Cancer Patients: Median Follow-Up of 11 Years.

Background: Radioactive iodine lobar ablation (RAILA) of the contralateral thyroid lobe has been suggested as an alternative to completion thyroidectomy in patients of differentiated thyroid cancer (DTC) who underwent initial hemithyroidectomy. However, data on long-term outcomes are scarce. In this study, we intended to describe the long-term outcomes of RAILA versus completion thyroidectomy in a cohort of low-risk DTC patients. Methods: Data of patients with low-risk DTC who underwent initial hemithyroidectomy, and were subsequently treated with either completion thyroidectomy or RAILA between 1996 and 2015, were collected and analyzed. The treatment outcomes included ablation rate, recurrence rate, recurrence-free survival (RFS), and adverse events, and were validated by propensity score matching analysis. Results: Of the 1243 patients (median age: 34 years, range: 5-78) with low-risk DTC, 514 patients underwent upfront RAILA while 729 patients underwent completion thyroidectomy followed by remnant ablation. The ablation rate following the first radioactive iodine (131I) cycle was 75.3% [95% confidence interval (CI) 71.3-78.9] in the RAILA group versus 84.1% [CI 81.2-86.6] in the completion thyroidectomy group (p < 0.001). Over median follow-up of 11.4 years (interquartile range: 8.3-15.8), the recurrence rates between the two groups were not significantly different (1.6% [CI 0.7-3.2] vs. 1.0% [CI 0.4-2.1], respectively, p = 0.343). The product limit estimate of RFS at 10 years was 98.6% [CI 97.6-99.6%] in the RAILA group versus 99.1% [CI 98.3-99.9%] in the completion thyroidectomy group (p = 0.391). The outcomes in 497 matched pairs generated through propensity score analysis were similar. None of the patients in the RAILA group experienced permanent hypocalcemia or recurrent laryngeal nerve palsy, while the corresponding rates in the completion thyroidectomy group were 10/729 (1.4%) (p = 0.006) and 5/729 (0.7%) (p = 0.080), respectively. Radiation thyroiditis was seen in 25/514 (4.9%) patients in the RAILA group versus 3/729 (0.4%) in the completion thyroidectomy group (p < 0.001). Conclusions: Upfront RAILA is seen to be a noninvasive, safe, and effective alternative to surgical completion thyroidectomy in low-risk DTC patients in the absence of macroscopic malignancy in the remaining thyroid lobe.

309 Sonograhic Appearances of Hobnail Thyroid Carcinoma: A Rare Tumour

Abstract Background Hobnail papillary thyroid carcinoma is a rare, recently described papillary thyroid carcinoma variant, with potential for a more aggressive clinical course of disease and poorer prognosis1. The ultrasound features of papillary thyroid carcinoma variants can differ from known traditional features1 and the specific sonographic findings of the hobnail variant itself have not been previously described in the literature. Case report A 53-year-old man presented with a left thyroid mass. The ultrasound features of this mass included a predominantly cystic appearance with mobile internal echoes, vascularised internal septations, and murally based solid material. These ultrasound features were deemed benign by classification standards, which led to the patient being managed with active surveillance and interval imaging. However, the mass grew quickly, and the patient underwent diagnostic hemithyroidectomy which led to hobnail variant papillary thyroid carcinoma being found on pathology. Given that papillary thyroid carcinoma variants can lead to aggressive disease, the patient underwent completion thyroidectomy and level VI lymph node clearance, on multidisciplinary team recommendation. Discussion The ultrasound features of the hobnail variant of papillary thyroid carcinoma have not been previously described in detail in the literature and, in this case, are features that would be deemed benign by classification standards. The rapid growth of the mass is what led to clinical suspicion of malignancy and resulted in diagnosis. Therefore, careful clinical correlation is advised in order to discern this difficult diagnosis and to facilitate appropriate treatment.

Risk of Complications in Patients Undergoing Completion Thyroidectomy after Hemithyroidectomy for Thyroid Nodule with Indeterminate Cytology: An Italian Multicentre Retrospective Study.

Simple SummaryThe increasing use of high-quality imaging techniques together with improved access to healthcare has led to an increase in the detection of thyroid nodules. Fine-needle aspiration cytology (FNAC) is currently considered the most accurate examination for the assessment of thyroid nodular disease. However, in about 25% of cases, FNAC leads to the diagnosis of an indeterminate thyroid nodule, which represents a problem because malignancy, although relatively low (up to 30%), cannot be excluded with certainty. According to the 2015 American Thyroid Association guidelines, patients with thyroid nodular disease with an indeterminate cytology can undergo, based on established factors, a total thyroidectomy or a hemithyroidectomy. However, if an intermediate or high-risk differentiated thyroid carcinoma is detected after the hemithyroidectomy, through histological examination, the above-mentioned guidelines recommend performing a completion thyroidectomy. The main aim of this study was to assess the rate of complications in patients undergoing a completion thyroidectomy after a hemithyroidectomy for a thyroid nodule with an indeterminate cytology.There is still controversy as to whether patients undergoing a completion thyroidectomy after a hemithyroidectomy for a thyroid nodule with an indeterminate cytology have a comparable, increased or decreased risk of complications compared to those submitted to primary thyroid surgery. The main aim of this study was to investigate this topic. Patients undergoing a thyroidectomy for thyroid nodular disease with an indeterminate cytology in four high-volume thyroid surgery centres in Italy, between January 2017 and December 2020, were retrospectively analysed. Based on the surgical procedure performed, four groups were identified: the TT Group (total thyroidectomy), HT Group (hemithyroidectomy), CT Group (completion thyroidectomy) and HT + CT Group (hemithyroidectomy with subsequent completion thyroidectomy). A total of 751 patients were included. As for the initial surgery, 506 (67.38%) patients underwent a total thyroidectomy and 245 (32.62%) a hemithyroidectomy. Among all patients submitted to a hemithyroidectomy, 66 (26.94%) were subsequently submitted to a completion thyroidectomy. No statistically significant difference was found in terms of complications comparing both the TT Group with the HT + CT Group and the HT Group with the CT Group. The risk of complications in patients undergoing a completion thyroidectomy after a hemithyroidectomy for a thyroid nodule with an indeterminate cytology was comparable to that of patients submitted to primary thyroid surgery (both a total thyroidectomy and hemithyroidectomy).

Thyroid lobectomy for low-risk thyroid cancers.

The 2016 American Thyroid Association (ATA) guidelines proposed thyroid lobectomy for low-risk differentiated thyroid cancer (DTC); however, this approach is yet to be widely adopted. The aim of the study was to review our practice over three years following the publication of these guidelines identifying patients who underwent lobectomy-only for low-risk DTC in two regional units in the same multidisciplinary team (MDT). A retrospective review of patients who were operated between January 2016 and December 2018 was carried out. In total, 288 patients undergoing thyroid surgery were included. The preoperative distribution of cytology was: Thy 1 or 2 in 46, THY3a in 57, THY3f in 154, THY4 in 18 and THY5 in 13 patients. Median size of nodules was 26mm (range 1-70mm). DTC was diagnosed in 95 patients (33%). Overall, 39% (n = 37) of patients underwent completion thyroidectomy according to ATA recommendations on size or adverse histological features. The only variable associated with likelihood of completion was tumour size (p < 0.05, OR 1.14). Ten patients were discharged following surgery with no further follow-up as they had T1a/b well-differentiated DTC with no high-risk histological features. Lobectomy-only appears to be the current surgical practice in two-thirds of patients presenting to our regional units with differentiated thyroid carcinoma. In the context of the current drive to reduce the extent of treatment for low-risk thyroid cancer, there is a need for a more homogeneous approach to these patients and for protocols for long-term follow-up after lobectomy-only.

Thyroid lobectomy for low-risk thyroid cancers.

The 2016 American Thyroid Association (ATA) guidelines proposed thyroid lobectomy for low-risk differentiated thyroid cancer (DTC); however, this approach is yet to be widely adopted. The aim of the study was to review our practice over three years following the publication of these guidelines identifying patients who underwent lobectomy-only for low-risk DTC in two regional units in the same multidisciplinary team (MDT). A retrospective review of patients who were operated between January 2016 and December 2018 was carried out. In total, 288 patients undergoing thyroid surgery were included. The preoperative distribution of cytology was: Thy 1 or 2 in 46, THY3a in 57, THY3f in 154, THY4 in 18 and THY5 in 13 patients. Median size of nodules was 26mm (range 1-70mm). DTC was diagnosed in 95 patients (33%). Overall, 39% (n = 37) of patients underwent completion thyroidectomy according to ATA recommendations on size or adverse histological features. The only variable associated with likelihood of completion was tumour size (p < 0.05, OR 1.14). Ten patients were discharged following surgery with no further follow-up as they had T1a/b well-differentiated DTC with no high-risk histological features. Lobectomy-only appears to be the current surgical practice in two-thirds of patients presenting to our regional units with differentiated thyroid carcinoma. In the context of the current drive to reduce the extent of treatment for low-risk thyroid cancer, there is a need for a more homogeneous approach to these patients and for protocols for long-term follow-up after lobectomy-only.

Redo in Thyroid Surgeries

Background: Revision of thyroid surgery is usually technically difficult because of anatomical changes and subsequent fibrosis after the primary surgery especially in the central neck. However, with experience and appropriate preparation, the risk of permanent hypoparathyroidism or recurrent laryngeal nerve injury after revision surgery is reduced. Objective: The aim of the study was to determine the causes of redo in thyroid surgeries, operative difficulties and postoperative complications. Patients and Methods: This prospective randomized controlled study included a total of 60 patients with primary total thyroidectomy and redo surgery, attending at Endocrine Surgery Unit, General Surgery Department, and Mansoura University Hospitals. This study was conducted between February 2018 and January 2019. The included subjects were randomly divided into three main groups: Group 1 (primary total thyroidectomy) consisted of 20 patients underwent total thyroidectomy, Group 2 (early redo surgery) consisted of 20 patients underwent completion thyroidectomy, and Group 3 (late redo surgery) consisted of 20 patients underwent recurrent thyroidectomy. Results: Compared to total thyroidectomy, early and late redo in thyroid surgeries gave better results regarding the recurrence and complications, which occurred in no one case 1 year later. Conclusion: From this study it is shown that total thyroidectomy is advised to be done in all patients with thyroid diseases as there were no recurrence detected and to avoid complications that may be present in redo surgery. To guard against performance of completion thyroidectomy, ultrasound examination and fine needle aspiration cytology (FNAC) should be taken from different sites.

A Tale of Three Cases When Thyroid Cancer Does Not Exist but Metastases Do. A Three-Case Series of Metastatic Follicular Thyroid Carcinoma

Background: Follicular and papillary thyroid carcinomas represent the majority of all malignancies of the thyroid gland. However, follicular thyroid carcinoma (FTC) is much more difficult to diagnose and manage than its papillary counterpart. Among other factors this could be explained by changing diagnostic criteria and by FTC potential for remote distant and often unpredictable metastases sites. Clinical Cases: In our high volume major academic referral center we have encountered three intriguing cases of metastatic FTC with negative surgical thyroid pathology. The first patient is a 61-year-old woman, who at age 50 was diagnosed with 5.4x3.5x4.2 cm left thyroid nodule (TN). FNAB reported hyperplastic nodule versus follicular neoplasm, subsequent surgical pathology report after lobectomy showed hyperplastic nodule. At age 58 she developed a pathological fracture of the 5th thoracic vertebra and pathology report indicated follicular carcinoma of thyroid origin. TG level at this time was 577 ng/ml. Pathology report from completion thyroidectomy again showed nodular hyperplasia, but reexamination of previously resected lobe demonstrated minimally invasive FTC. The second patient is an 83-year-old woman who at age 68 underwent lobectomy for left sided-goiter, pathology report showed benign follicular adenoma. At age 77 she was found to have right-sided skull mass which was determined to be a follicular carcinoma of thyroid origin. Pathology report from completion thyroidectomy was consistent with nodular hyperplasia. At age 82 the patient was noticed to have increased RAI uptake in thyroid bed, sternum, kidneys, and gastroesophageal junction. TG level at this time was 2214 ng/ml. The third patient is a 56-year-old woman initially diagnosed with a 3.5x2.8x2.2cm right TN at age 53. Lobectomy, performed for diagnostic and therapeutic purposes, showed benign follicular adenoma. At age 56 she developed a pathological fracture of the 3rd thoracic vertebra, follicular carcinoma of thyroid origin was shown on pathology report. TG level at this time was 1694 ng/ml. The patient underwent completion thyroidectomy demonstrating multinodular hyperplasia. Conclusion: This case series emphasizes on the pitfalls of follicular neoplasms diagnosis and management. We suggest prolonged clinical and biochemical surveillance of the patients with what appears to be follicular adenoma after lobectomy. Following serum thyroglobulin perhaps represents the most cost-effective surveillance approach of those patients.

Multinodular goitre: a clinicopathological study from Kerala

Background: Multinodular goiter (MNG) occurs due to repeated hyperstimulation of thyroid gland due to iodine deficiency, goitrogens, antithyroid drugs and genetic defects. MNG can have different complications which include treacheal compression, retrosternal extension, malignancy and secondary thyrotoxicosis. The aim of the work was to study the clinical features and histopathology of MN in patients admitted for thyroidectomy in surgical wards of a tertiary care hospital in north Kerala.Methods: A prospective hospital based observational study in the patients in surgical wards of a tertiary care hospital in north Kerala from April 2011 to March 2012. The clinical data of patients who are subjected to thyroidectomy for MNG (clinical and fine needle aspiration cytology diagnosis) were included in this study. Patients undergoing completion thyroidectomy for recurrence or malignancy were excluded from this study.Results: MNG is more common in females. Female to male ratio 24:1 Majority are in the age group of 30-50 years (64%) with a mean age of 41 years. 38% (38 cases) had pressure symptoms in the form of dysphagia or dyspnea. Secondary thyrotoxicosis seen in 17% (17 cases). Fine needle aspiration cytology (FNAC) is not an error-proof investigation in MNG. 14 % of our patients had malignancy inspite of being reported as benign in FNAC. Among the malignancies papillary carcinoma thyroid was found to be most common accounting for 12% of cases (12/100) followed by follicular carcinoma.Conclusions: FNAC is not an error proof investigation in MNG. Incidental thyroid cancer in MNG is about 14 % with papillary carcinoma thyroid being the commonest.

Prevalence and Predictors of Malignancy in Contralateral Thyroid Lobe in Patients Undergoing Completion Thyroidectomy.

(1) To determine prevalence of malignancy in contralateral lobe (CL) in patients undergoing completion thyroidectomy (CT) and to study complications of CT. (2) To analyze clinical, ultrasonography(USG) findings and histopathological features of the tumor in ipsilateral lobe (IL) that could predict malignancy in CL. Retrospective chart review of 40-patients who first underwent hemi-thyroidectomy for fine-needle-aspiration (FNA) diagnosed benign lesions followed by CT between September-2017 and November-2019. Histopathology reports from both surgeries, along with patient characteristics and USGfeatures of initial hemi-thyroid lobe were reviewed. Thirty-two (80%) of the 40 patients were female. Mean age of presentation was 38.2years (Range = 19-61years). Malignancy was found in 22(55%) contralateral-lobes of 40 completion thyroidectomies performed. Multi-focality of tumor in first surgery was only factor with significant association with presence of malignancy in CL (OR = 5.53, 95% CI 1.01-30.35, p = 0.048).In terms of USG-findings, most common suspicious feature in IL was peripheral/rim calcification, with TIRADS ≥ 4 was present in 19 patients but none of features could significantly predict bilateral disease. Three (7.5%) patients developed permanent unilateral recurrent-laryngeal-nerve (RLN) palsy (2-following initial surgery and 1-following CT). Fourteen (35%) patients developed hypoparathyroidism following CT of whom 12 were symptomatic and 4(10%) proceeded to permanent hypoparathyroidism. There were no other major complication following CT. Multifocality in initial hemithyroidectomy specimen was most frequently associated with malignancy in CL. Preoperative TIRADS ≥ 4 of IL may be considered a risk factor for bilateral malignancy. CT may be performed in FNA misdiagnosed thyroid cancers as there is high prevalence(56%) of disease in CL. CT is safe and it eradicates disease in CL.

SUN-479 Metastatic Renal Cell Carcinoma (RCC) to the Thyroid: Case Report and Clinical Lesson

Background: Metastatic neoplasms to the thyroid gland are rare and have been observed more in autopsy series than in clinical series. Case: A 71-year old woman presented for thyroid nodule evaluation which was incidentally noted on CT/PET scan. She was diagnosed with renal cell carcinoma (RCC) stage IV (6.4 cm, left nephrectomy) 4 months prior. She had right hemi-thyroidectomy 30 years prior for a benign nodule. She was clinically and biochemically euthyroid with dysphagia and hoarseness in her voice. Thyroid u/s revealed multiple nodules in the left lobe with a dominant 3.6 x 2.9 x 3.6 cm solid, heterogeneous nodule with grade 3 hypervascularity. History positive for 1 cm right renal mass and multiple pulmonary nodules increasing in size thought to be consistent with metastases. The FNA of the dominant nodule was indeterminate, Bethesda III (AUS), GSC suspicious (Affirma, 50% ROM) with negative malignancy classifiers. Patient underwent completion thyroidectomy, and surgical path was consistent multifocal clear cell renal cell carcinoma (CRCC) with the largest focus of 3 cm based on clear cell features and strong positivity for stains: CK OSCAR, RCC, PAX-8 & CD-10. Patient is currently on Pazopanib post thyroid surgery for 18 months, and is stable with no further increase in the size of lung nodules or right renal mass and negative serial PET scans. Clinical lesson: CRCC represents 3-4% of all adult malignancies and 85% of all primary renal tumors. In clinical series, CRCC is the most frequent source of thyroid metastases and represents 12-34% of all secondary thyroid tumors. About 17% of patients with CRCC have metastatic disease at diagnosis. Metastases can be synchronous or metachronous to the primary tumor. Latency from nephrectomy to diagnosis of thyroid mets varies from 2 months-21.9 years. Metastases can be solitary (more common), multiple or diffuse. Radiological findings typically reveal hypoechoic and vascularized mass on ultrasound and cold on thyroid scan. Metastases to thyroid can pose diagnostic problem and be a source of confusion in cytology interpretation. Metastatic CRCC can simulate morphologically primary thyroid neoplasm such as Hurthle cell neoplasm or thyroid carcinomas with clear cell changes. Metastatic carcinoma within the thyroid gland is negative for thyroglobulin, TTF-1, calcitonin unlike primary thyroid cancer. CRCC is usually positive for periodic acid-Schiff and Oil red O, vimentin, and CD10. The mean survival in patients with CRCC who had thyroidectomy alone or with adjuvant treatment was 3 years. Conclusion: Thyroid metastases should be considered in patients with thyroid nodules and positive history of RCC. The preoperative distinction between primary and secondary tumors is difficult. Immunohistochemistry is a useful method for the evaluation of patients with suspected thyroid nodules.

Completion Thyroidectomy for Initially Misdiagnosed Differentiated Thyroid Carcinoma-Study of 51 cases

Introduction: Completion thyroidectomy is the removal of any residual thyroid tissue that remains after a less than total thyroidectomy. This procedure is usually done when the final histopathlogy of the excised ipsilateral thyroid lobe reveals papillary or follicular carcinoma.&#x0D; Objective: A retrospective analysis was done of patients undergoing completion thyroidectomy for thyroid malignancy who had undergone surgery elsewhere for solitary thyroid nodule. The incidence of complications in these patients after re-operation was investigated in this study.&#x0D; Material and Method: Our study included a total 51 patients who had undergone thyroid lobectomy for a solitary nodule as initial surgery in our hospital &amp; elsewhere and were admitted in our hospital for completion thyroidectomy when histopathology revealed malignancy in last 5 years (2014-2018).&#x0D; Result: In this study-51 patients were enrolled; among them 42 were female and 9 male. Their mean age was 33.6 years (range-17-59 years). After initial surgery, the histopathology revealed papillary carcinoma in 45 patients (88.24%), follicular carcinoma in 6 patients (11.76%). Four out of 51 patients had recurrent laryngeal nerve palsy after initial surgery (7.8%). None of the patients had clinical hypocalcaemia after 1st surgery. Parathyroid glands are identified and preserved in all patients during completion thyroidectomy. No patient had additional recurrent laryngeal nerve injury in 2nd surgery. Mean follow-up was one year. Transient hypoparathyroidism occurred in 9.8% patients, but no permanent hypoparathyroidism. Seven patients were lost to follow-up.&#x0D; Conclusion: Completion thyroidectomy is a safe and appropriate procedure for the management of initially misdiagnosed differentiated thyroid carcinoma.&#x0D; TAJ 2019; 32(2): 22-26

Outcome of Thyroid Surgeries at Patan Hospital

Objective: To assess the outcome of thyroid surgeries at Patan HospitalMaterials and Methods: It is a retrospective study of in-patient records of patients undergoing thyroid surgeries for various indications from April 2013 to January 2015 at Patan Hospital, Lalitpur.Results: During the period of 21 months, 75 patients underwent thyroid surgeries. Majority of patients underwent hemithyroidectomy (35) followed by total thyroidectomy (28), subtotal thyroidectomy (7) and completion thyroidectomy (5). Out of 28 patients undergoing total thyroidectomy (TT), 11 underwent central compartment clearance (CCC), 5 underwent CCC and lateral neck dissection. Among 5 patients undergoing completion thyroidectomy, CCC was performed in all cases and in one patient lateral neck dissection was also performed. A total of 13 patients developed unilateral recurrent laryngeal nerve palsy (RLN), among them 5 had permanent palsy. Tracheostomy had to be done in immediate postoperative period for stridor following total thyroidectomy (TT) in one case. Temporary hypocalcaemia was observed in 10 (10/28) cases following TT, out of which 8 had undergone CCC. Permanent hypocalcaemia was observed in 7 (7/28) cases following TT out of which 3 had undergone CCC. Chylous leak occurred in one of the patient undergoing left level II-IV neck dissection which was managed conservatively. None of the patient had to be transfused postoperatively.Conclusion: Complications to thyroid surgery are not uncommon. Visualization of recurrent laryngeal nerve alone in our context is adequate in experienced hands. Identification of parathyroid during thyroidectomy is recommended to avoid hypocalcaemia. Meticulous dissection can reduce the complications.Nepalese Journal of ENT Head and Neck Surgery, Vol. 6, No. 1, 2015

Completion Thyroidectomy for Differentiated Thyroid Cancers: Predicting Contralateral Disease

About 12% of the Indian population present with a thyroid nodule to the surgeon, who is then faced with a clinical dilemma if the fine needle aspiration cytology (FNAC) is inconclusive or indeterminate, and the ultrasonogram of the neck is also not contributory. The extent of surgery and the need for a second surgery always weighs on the mind of the surgeon and the patient. We attempt, in our study, to identify a few pathological features in a hemithyroidectomy specimen which would predict the occurrence of malignancy in the opposite lobe. To determine the pathologic predictors of malignancy in the contralateral thyroid lobe, in patients of differentiated thyroid cancer (DTC) who underwent hemithyroidectomy. A retrospective review of the case records of all patients who underwent thyroid surgery in our Institute between January 2010 and December 2014 was undertaken. Various pathologic parameters were analyzed with respect to their predictive power regarding the occurrence of malignancy in the opposite lobe. Three hundred eighty-nine patients underwent thyroid surgery during the above period, of which 91 patients underwent completion thyroidectomy, as they were found to have malignancy in the hemithyroidectomy specimen. The effect of age, gender, and tumor size on bilaterality could not be established statistically. Other variables such as perithyroidal spread and perineural invasion also did not demonstrate statistical significance. Multifocality of the tumor in the hemithyroidectomy specimen, lymphovascular invasion, and capsular invasion were the pathologically significant factors determining the presence of malignancy in the contralateral lobe. Multifocality, lymphovascular invasion, and capsular invasion can be used as additional markers to decide on performing a completion thyroidectomy in a patient of differentiated thyroid cancer.

Single-incision endoscopic thyroidectomy for papillary thyroid cancer: A pilot study

BackgroundRecently, we have reported single incision endoscopic thyroidectomy using an axillary approach with gas inflation (SIET) in cases with benign thyroid tumors to reduce post-operative pain and invasiveness of the conventional endoscopic thyroidectomy. The aim of this study was to present our experiences with SIET for papillary thyroid cancer (PTC). MethodsPatients who were diagnosed with histologically papillary thyroid carcinoma (≤1 cm) with single, unilateral, and intra-thyroidal lesion and without clinical lymph node metastasis were included. We analyzed clinico-pathological characteristics, surgical outcomes, and oncologic adequacy of the SIET procedure. ResultsBetween January 2011 and July 2012, a total of 75 patients underwent hemi-thyroidectomy with ipsilateral central lymph node dissection via SIET. The mean tumor size was 0.5 cm and 4.1 ± 2.43 central lymph nodes were removed. Of the patients, 98.3% were satisfied with their surgical wound post-operatively and no critical post-operative complications occurred during the study, except for one case of post-operative bleeding. There was one case of disease recurrence, which occurred in the contra-lateral cervical lymph node region 6 months after SIET. This patient underwent completion thyroidectomy with selective neck dissection. ConclusionThe SIET is a safe and acceptable procedure for PTC with a reduced dissection field, less post-operative pain, and more cosmetic satisfaction than conventional endoscopic thyroid surgery.