Aim: Recent guidelines have attempted to de-escalate treatment pathways for low-risk papillary thyroid carcinoma (PTC) to reduce long-term morbidities associated with treatment. The literature supporting either hemithyroidectomy or total thyroidectomy for PTC between 1 and 4 cm is conflicting and dependent on the accuracy of clinical staging. We examined the variability between clinical and pathological tumor staging for PTC 1 to 4 cm. Materials and methods: This study is a single center, retrospective cohort study of all patients who underwent surgery for confirmed PTC between 1 and 4 cm, from January 2010 to August 2017. Results: The cohort included 38 patients, of which 20 patients (53%) had no high-risk features on histopathology, and 18 patients (47%) had one or more high-risk feature. Fiftyfive percent of patients had a 5mm or more variance between preoperative and postoperative sizing. Among the patients with no high-risk features, preoperative ultrasound overestimated the size (p = 0.0007) and stage (55% downgraded) when compared to postoperative histopathology reports. 80% of patients that underwent hemithyroidectomy had no high-risk features and avoided completion thyroidectomy. Conclusion: We identified a particular cohort of patients that had no high-risk features on final histopathology that had greater differences in preoperative and postoperative tumor sizes. Overestimation of size and stage of PTC has the potential for the overtreatment of these patients. This study has shown the importance of determining high-risk features and other PTC parameters, such as size and staging. We have highlighted the potential importance of preoperative or intraoperative tumor evaluation in identifying patients who could benefit from conservative surgical approaches. Clinical significance: Identification of papillary thyroid cancer patients without high-risk features either preoperatively or intraoperatively can provide surgeons with a stratified guideline to decide which patients are suitable for conservative surgery compared to total thyroidectomy.

Aim: An incidental thyroid carcinoma (ITC) is a thyroid malignancy that is not clinically or cytologically detected preoperatively. The incidence of ITC is between 10% to 20% in the literature. A study was undertaken to assess the incidence of ITC in patients undergoing total thyroidectomy for benign disease of the thyroid to University Surgical Unit, North Colombo Teaching Hospital (NCTH), Sri Lanka. Materials and methods: Prospective cohort study was undertaken from November, 2002 to October, 2015. Patients with palpable thyroid nodules were assessed with fine needle aspiration cytology (FNAC) and ultrasound scan (USS) to ascertain benign thyroid disease (BTD). Hormone assays were conducted to detect thyroid status. All patients with BTD who underwent total thyroidectomy were included in the study. Histopathological assessments were made by a panel of pathologists. Patients with autoimmune thyroiditis (AIT) were excluded due to the known association with malignancy of the thyroid. Post-thyroidectomy histopathological diagnoses were collected prospectively and patients with ITC were identified. Statistical analysis was done using statistical package for the social sciences (SPSS) software, version 20. Results: Hundred and sixty seven patients (n = 167) who fulfilled the inclusion criteria were analysed (Male–20, female–147, median age = 40.25 year, range 28 year–62 year). ITC was found in 19 patients with an incidence of 11.38%. No significant association was noted with morphology, biochemical status of the thyroid or gender. Conclusion: Incidence of ITC is 11.38% in this cohort. Incidence of ITC being approximately 1:10 emphasizes the need to consider total thyroidectomy in the management of BTD.

Neuroblastoma is an embryonal cancer of the peripheral sympathetic nervous system. It is the most common extracranial tumor of childhood and the third most common tumor overall. Neuroblastoma arises from cells of primordial neural crest. The natural history of this disease is very heterogeneous and extends from spontaneous regression to aggressive metastatic disease. Neuroblastoma in older children is extremely rare and it carries a bad prognosis. We present a case of a 15-year-old boy with unresectable neuroblastoma who was subjected to neoadjuvant chemotherapy which rendered the tumor resectable. The case highlights importance of neoadjuvant therapy in neuroblastomas, need for multimodality involvement and therapeutic challenges faced by phycisians in successfully treating aggressive neuroblastomas.

Aim: We describe three chromaffin-cell tumors managed during pregnancy as well as systematically review case reports published from 2014 to 2018. Chromaffin-cell tumors are rare catecholamine-producing tumors that can arise from the adrenal medulla, where they are referred to as pheochromocytomas, or from extra-adrenal chromaffin tissue, referred to as paragangliomas. The incidence of chromaffin-cell tumors identified during pregnancy is extremely rare, with an incidence of 0.32 cases per 100,000 pregnancy years. Cases: We describe diagnosis and management during pregnancy of a 25-year-old with a 7.3 cm right pheochromocytoma, a 23-year-old with metastatic paraganglioma and SDHB mutation, and a 28-year-old with MEN2A and a left pheochromocytoma. We performed a systematic review of cases utilizing MEDLINE, EMBASE and Google Scholar with the terms (pheochromocytoma or paraganglioma) and (pregnancy or pregnant) within the timeframe 2014 through 2018 (searched on April 9th, 2018). We found that emergency cesarean section delivery (p < 0.05), maternal heart failure or pulmonary edema (p<0.05) and fetal or neonatal death (p < 0.05) were more common in women with a late or postpartum diagnosis of a chromaffin-cell tumor compared to women with diagnosis during or before pregnancy. Conclusion: Chromaffin-cell tumors are rare during pregnancy. However, morbidity is severe and requires an early diagnosis for the best possible outcomes. Hypertension during pregnancy is the most common presenting symptom of these catecholamineproducing tumors. Severe hypertension, labile hypertension or hypertension before 20 weeks, without proteinuria or lower extremity edema, should raise suspicion for a chromaffin-cell tumor. Management should consist of an experienced multidisciplinary team at a tertiary referral hospital to ensure the best outcomes.

Struma ovarii is a rare form of teratoma that is invariably benign. When neuroendocrine and thyroid tissue both coexist within the ovary, the term strumal carcinoid is often used. The incidence of malignant transformation in this lesion has been rarely described in the literature. Here, we present a case in which the thyroid component metastasized widely throughout the peritoneum.

Aim: In addition to presenting a huge substernal goiter (SSG) reaching the diaphragm, we discuss the diagnosis and treatment of SSGs and bilateral benign multinodular goiters. Background: The presentation of an SSG is usually related to compression of neighboring organs producing symptoms like dyspnoea, dysphonia, and dysphagia. Between 2 to 19% of all goiters are substernal depending on definition. Case description: In the present study we discuss a truly unique case of a huge SSG reaching the diaphragm in a 55-year-old woman. Despite the extension of the goiter, the patient was symptom-free. The patient had a history of subtotal thyroidectomy and radioiodine treatment. The SSG was removed surgically and was characterized as a multinodular goiter on pathological examination. Conclusion: To the best of our knowledge the size, extension, and presentation of the SSG described in this case report is of unprecedented nature. Clinical significance: There is an ongoing discussion about the management of benign bilateral multinodular goiters. With subtotal resection, the risk of nerve injury and hypoparathyroidism decreases, whereas the risk of recurrent disease increases. The present case is an extreme example of recurrent disease but highly relevant when discussing the management of benign bilateral multinodular goiters.

Due to cultural and social pressures, emphasis on cosmesis after thyroidectomy has become an important issue which has led to the emergence of many novel scarless in the neck procedures. However novel procedures have cost issues. Young thyroid surgeons need to be trained in producing an acceptable scar by paying attention to tissue handling and refining techniques of skin closure. As awareness increases patients will demand thyroid surgeons to deal with post thyroidectomy scar. We describe how we deal with the post thyroidectomy scar.

Adrenocorticotropic hormone (ACTH)- independent macronodular adrenal hyperplasia is an infrequent cause of Cushing's syndrome and may be confused with diffuse nodular or bilateral macro nodular hyperplasia (AIMAH) resulting from chronic stimulation by ACTH in Cushing's disease or ectopic ACTH secretion. On Computed tomography (CT) scan adrenal glands can be massively enlarged and bilateral nodules of soft tissue density measuring up to 5 cm distorting normal adrenal glands. Here we have a case of AIMAH in which CT scan revealed massively enlarged bilateral adrenal glands with multiple nodules giving an appearance of ‘bunch of grapes’.