Dr. Pradeep Jacob

INTRODUCTION:
Thyroidectomy is now a less popular therapeutic option for Graves' disease. The frequency of thyroid nodule and the cancer risk of these nodules accompanying Graves' disease are controversial. The outcome of thyroid cancers coexisting with Graves' disease is debated.

STUDY DESIGN:
Designed as retrospective case control study of papillary thyroid cancers associated with Graves' disease and those with euthyroid background. Pathological characteristics and outcome of papillary thyroid cancers in the two groups were compared.

RESULTS:
The tumour characteristics did not differ significantly in the groups. The patients were followed for a mean period of 77.32 months and found significant incidences of disease progression in patients with papillary thyroid cancer associated with Graves' disease (p = 0.034; OR 2.747, CI 1.078-7.004). Disease progression as new distant metastases mostly in skeletal locations was high in this group compared to euthyroid group (p = 0.027; OR 4.121, CI 1.008-15.600). There was higher incidence of cumulative metastatic diseases in papillary thyroid cancer associated with Graves' disease.

CONCLUSION:
Papillary thyroid cancers associated with Graves' disease show aggressive biological behaviour and favoured site of distant metastases was osseous locations. Early diagnosis by routine screening of Graves' disease patients with ultrasound imaging and aspiration studies is recommended.

INTRODUCTION:
Somatic B-type Raf kinase (BRAF) V600E mutation in exon 15 was frequently found in high frequencies associated with papillary thyroid cancer (PTC). The phenotype of these cancers expressed aggressive clinical and pathological features. The present study aimed to assess the prevalence of BRAF V600E mutation among conventional and follicular variants of PTC and its association with aggressive tumor factors and outcome.

STUDY DESIGN:
Patients who were operated and received further treatment for PTC during 2012 were included in the study. BRAF V600E mutation analysis was done by extracting genomic DNA from tumor tissue.

RESULTS:
Of the 59 patients included in the study, 51% harbored BRAF V600E mutation, but the mutation status was not associated with aggressive tumor factors and adverse outcome.

CONCLUSION:
BRAF V600E mutation was not significant predictor of aggressive tumor behavior in conventional and follicular variants of PTC.

INTRODUCTION:
Symptomatic primary hyperparathyroidism (PHPT) is still seen frequently in referral centers all over India. These patients require parathyroidectomy and this study aimed to assess the roll of intraoperative parathyroid hormone (PTH) assay when concordant results of two localization studies were available.

STUDY DESIGN:
We analyzed the case records of patients who underwent parathyroidectomy for PHPT from January 2005 to June 2015.

RESULTS:
Of 143 patients included in the study, technetium 99m methoxyisobutylisonitrate dual phase scintigraphy showed true positive images in 93.7% and high definition ultrasonography in 84.6% of patients. Concordance in localization studies was observed in 121 (84.6%) patients, successful parathyroidectomy was done in 117 (96.7%) patients with concordant localization studies. Intraoperative PTH monitoring showed 97.84% sensitivity and 75% specificity and predicted failure in 2 patients with concordant imaging. However, re-exploration was not successful in these patients.

CONCLUSION:
When concordant result is available between parathyroid scintigraphy and anatomical imaging surgical cure rate is high in trained hands. Re-exploration is unlikely to be successful since these patients require higher imaging.

Chronic inflammatory diseases of the non-lactating breasts cause considerable difficulty in diagnosis and treatment. There is a spectrum of aetiological factors ranging from infection to autoimmune disorders. The disease causes considerable morbidity and psychological distress in relatively young females. The study aimed to analyse the spectrum of chronic disease and to formulate a treatment protocol.

Method: Female patients with histological confirmation of inflammatory disease of the breast in the non-lactational phase were included in the study. The patients were categorized based on histological findings supplemented with immunohistochemical staining with CD3 and CD20 antibodies.

Result: Out of 50 patients included in the study, 38 patients (76%) were diagnosed as idiopathic granulomatous mastitis (IGM) and 12 (24%) patients as periductal mastitis (PD). The possible aetiology of IGM was localized autoimmunity as evidenced by the infiltration of CD3 positive T lymphocyte. Systemic prednisolone was given for 6 months and 95.6% patients were disease-free after 24months. Out of 15 patients who did not receive prednisolone, only 2 patients were disease-free after 24 months (p = .003).

Conclusion: Idiopathic granulomatous mastitis is an uncommon inflammatory disease of the non-lactating breast. The combination of limited surgical treatment and systemic prednisolone given for 6 months effectively controls the disease as well as prevents recurrence.

Lithium salts are widely used in psychiatric practice and are known to induce thyroid dysfunction. Lithium-induced parathyroid dysfunction is rare. We are reporting a case of hyperparathyroidism in a 28-year-old female patient who was on lithium carbonate for 2 years, when she developed osteopenia and girdle girdle-type muscle weakness. Biochemical parameters showed hyperparathyroidism with shift of calcium creatinine clearance ratio to 0.013, indicating an error in threshold of calcium sensing receptor. The patient eventually required parathyroidectomy and the histology of the gland showed atypical features.

Sir,
Differentiated thyroid cancer may coexist with hyperthyroidism. Cancer cell mass is less functional and appears as cold nodule in thyroid scintigraphy. Cancer cell mass rarely becomes site of excess hormone production. When thyroid cancer cell mass occupies a scintigraphically hot, functionally autonomous thyroid nodule and if thyrotoxicosis is attributable exclusively to this nodule, as shown by clinical and histologic correlation, a toxic thyroid carcinoma is diagnosed.[1] We are reporting case feature which coincides well with the above mentioned diagnosis.

Role of total thyroidectomy in treatment of patients with benign diseases of thyroid gland remains controversial. The hypothesis behind the study is that total thyroidectomy can be performed in all benign thyroid diseases with equal rate of immediate and late complications compared with those of subtotal thyroidectomy. The retrospective case control study was done by reviewing the case records of patients with benign thyroid diseases involving both lobes operated during May, 2002 to September, 2004. The minimum follow-up period was 3 years. Of the 189 patients included in the study 94 underwent total thyroidectomy and 95 patients underwent subtotal thyroidectomy. There was no incidence of permanent recurrent laryngeal nerve paralysis in both groups. Temporary unilateral recurrent laryngeal nerve paralysis occurred in 3 patients (3.2%) in total thyroidectomy group and 1 (1.1%) patient in subtotal thyroidectomy group, which was not statistically significant (p=0.307). Temporary hypocalcaemia was noted in 10 patients of total thyroidectomy group (10.6 %) and 3 patients of subtotal thyroidectomy group (3.2%). Permanent hypocalcaemia was noted in 2 patients each in total thyroidectomy group and subtotal thyroidectomy group (p=0.991). Total thyroidectomy is an acceptable alternative to subtotal thyroidectomy in benign diseases, considering the higher rate of postoperative morbidity in recurrent goitres.

Chronic venous disorders are a major health problem due to their wide prevalence and socio-economic considerations. This book is a comprehensive manual providing state- of- the- art information on the diagnosis and management of these common problems. Till recently venous disorders have been getting secondary attention as compared to their arterial counterpart. However, the last two decades witnessed major technological advancements and therapeutic strategies for these problems. Written with a surgical perspective, this monograph covers the latest developments and recommended procedures in an easy-to-read format guiding the surgeon to prepare a rational treatment plan. Supplemented with numerous figures and illustrations, the chapters update the readers with how to evaluate such patients in their practices, selection criteria for appropriate procedures and how to manage the complications. The book includes basics of venous disorders, primary varicose veins and recurrence after surgery, chronic venous insufficiency, venous ulcers and congenital venous malformations. Detailed coverage of endo-venous procedures such as radio-frequency ablation, laser ablation and foam sclerotherapy are additional essential features of this book. Primarily intended for the practicing general surgeon, this volume is also relevant for residents in general surgery and vascular surgery.