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Background: Conservative parotidectomy for benign tumours reduces facial nerve palsy, without increasing local recurrence. We report a modified technique of partial parotidectomy and using a novel description of tumour position, explore relationships between tumour position and histological margins, facial nerve palsy and local recurrence., Methods: A prospectively collected single surgeon parotidectomy database was analysed, including tumour location (superficial/deep lobe; central/peripheral) and outcomes. A partial parotidectomy identified the facial nerve and the proximal portion of its branches with a macroscopically clear resection margin. Mean follow up was 5.9 years for pleomorphic adenomas., Results: Three hundred and three patients underwent parotidectomy; 257 (84.8%) were superficial and 46 (15.2%) deep lobe. Tumour position was recorded in 291: 236 (81.1%) were peripheral tumours and 55 (18.9%) central. Histological margin involvement was similar in central and peripheral tumours, both overall and for superficial and deep lobe tumours, but was commoner in central deep lobe tumours, (P = 0.003). Temporary partial facial nerve palsy occurred in 21 (6.9%), with one permanent partial nerve palsy (0.3%). Deep lobe tumours and total parotidectomy were associated with facial nerve palsy (P = 0.01). Facial nerve monitoring reduced the risk of palsy (P < 0.01). Local recurrence of pleomorphic adenomas was uncommon, occurring in 3 (2.0%) of 151 patients., Conclusion: This series confirms the safety and adequacy of more conservative partial parotidectomy for benign tumours, highlighting most tumours are peripheral, but not more prone to histological margin involvement or local recurrence, and with routine intraoperative facial nerve monitoring, is achieved with low facial nerve palsy rates., (© 2024 The Author(s). ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: Thyroid cancer diagnoses have increased over recent decades at a rate much higher than that of any other cancer in Australia. Rural patients are known to have reduced access to healthcare and may have different thyroid cancer presentation rates. This study examined the relationship between thyroid cancer diagnosis and patient rurality., Methods: Data from the Australia and New Zealand Thyroid Cancer Registry from 2017 to 2022 were analyzed, stratifying patient postcodes into rurality groups using the Australian Statistical Geography Standard. The American Thyroid Association (ATA) guidelines were used to stratify risk categories and management to compare treatment adequacy between the groups. Statistical analysis assessed demographic, clinical, and management differences., Results: Among 1766 patients, 70.6% were metropolitan (metro) and 29.4% were non-metropolitan (non-metro). Non-metro patients were older at diagnosis (median 56 vs. 50 years, p < 0.001), presented more frequently with T stage greater than 1 (stage 2-4, 41.9% vs. 34.8%, and p = 0.005), AJCC stage greater than 1 (stage 2-4, 18.5% vs. 14.6%, and p = 0.019), and cancers larger than 4 cm (14.3% vs. 9.9%, p = 0.005). No significant differences in treatment adequacy were observed between the groups for ATA low-risk cancers., Conclusions: Non-metropolitan patients in the registry present with more advanced thyroid cancer, possibly due to differences in healthcare access. Further research should assess long-term survival outcomes and influencing factors. Understanding the impact on patient outcomes and addressing healthcare access barriers can optimize thyroid cancer care across geographic regions in Australia., (© 2024 The Authors. World Journal of Surgery published by John Wiley & Sons Ltd on behalf of International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Purpose: An average parathyroid adenoma (PA) weighs < 1 g. This study aimed to characterise giant PAs ≥ 10 g (GPAs) to facilitate surgical management of primary hyperparathyroidism (PHPT)., Methods: All patients with a GPA confirmed on histology were recruited from the Monash University Endocrine Surgery Unit database. Clinical and demographic data were collected and compared to a group of non-GPA patients., Results: A total of 14 GPAs were identified between 2007 and 2018 out of 863 patients (1.6%) with a single PA excised for PHPT. The GPA patients were compared to a control group of 849 non-GPA patients in the same period with similar mean age (62 ± 16 vs 63 ± 14, P = 0.66) and gender distribution (64% vs 75% female, P = 0.35). Pre-operative calcium (Ca) and parathyroid hormone (PTH) levels were significantly higher in GPA patients (P < 0.001). A higher percentage of GPA patients (79%) had concordant localisation studies (ultrasound and sestamibi) than control patients (59%), (P = 0.13), but they were significantly less likely to undergo MIP (55% vs 82%, P = 0.02). The median GPA weighed 12.5 g (IQR 10.5-24.3). Median serum Ca normalised by day 1 post-operatively, while PTH remained elevated. Both serum Ca and PTH levels were in the normal range at 3 months. All GPA lesions were benign on histopathology., Conclusion: GPAs are rare and display severe clinical and biochemical abnormalities. Despite their large size, concordant pre-operative imaging was not always achieved, and a few patients were suitable for MIP., (© 2022. The Author(s), under exclusive licence to Italian Society of Endocrinology (SIE).)

Background: Current diagnosis and classification of thyroid nodules are susceptible to subjective factors. Despite widespread use of ultrasonography (USG) and fine needle aspiration cytology (FNAC) to assess thyroid nodules, the interpretation of results is nuanced and requires specialist endocrine surgery input. Using readily available pre-operative data, the aims of this study were to develop artificial intelligence (AI) models to classify nodules into likely benign or malignant and to compare the diagnostic performance of the models., Methods: Patients undergoing surgery for thyroid nodules between 2010 and 2020 were recruited from our institution's database into training and testing groups. Demographics, serum TSH level, cytology, ultrasonography features and histopathology data were extracted. The training group USG images were re-reviewed by a study radiologist experienced in thyroid USG, who reported the relevant features and supplemented with data extracted from existing reports to reduce sampling bias. Testing group USG features were extracted solely from existing reports to reflect real-life practice of a non-thyroid specialist. We developed four AI models based on classification algorithms (k-Nearest Neighbour, Support Vector Machine, Decision Tree, Naïve Bayes) and evaluated their diagnostic performance of thyroid malignancy., Results: In the training group (n = 857), 75% were female and 27% of cases were malignant. The testing group (n = 198) consisted of 77% females and 17% malignant cases. Mean age was 54.7 ± 16.2 years for the training group and 50.1 ± 17.4 years for the testing group. Following validation with the testing group, support vector machine classifier was found to perform best in predicting final histopathology with an accuracy of 89%, sensitivity 89%, specificity 83%, F-score 94% and AUROC 0.86., Conclusion: We have developed a first of its kind, pilot AI model that can accurately predict malignancy in thyroid nodules using USG features, FNAC, demographics and serum TSH. There is potential for a model like this to be used as a decision support tool in under-resourced areas as well as by non-thyroid specialists., (© 2022. The Author(s).)

Background: Medullary thyroid cancer (MTC) is rare, with poorer outcomes than differentiated thyroid cancer. We aimed to identify areas for improvement in the pre-operative evaluation of patients with possible MTC in a high-volume endocrine surgery unit in accordance with current practice guidelines. We hypothesised that the selective use of serum calcitonin (sCT) as a biomarker for possible MTC could guide the extent of initial surgical management., Methods: We recruited MTC patients between 2000 and 2020 from the Monash University Endocrine Surgery Unit database. Demographics, tumour characteristics, pre-operative evaluation, operative management, and outcomes were analysed., Results: Of 1454 thyroid cancer patients, 43 (3%) had MTC. Pre-operatively, 36 (84%) patients with MTC confirmed on cytology (28, 65%), elevated sCT (6, 14%) or RET mutation (2, 4%). Of these 36 patients, 31 (86%) had optimal extent of thyroidectomy and lymph node dissection (LND). Five (14%) had less than total thyroidectomy due to nerve injury. Thirty-four patients had compartmental LND. In the 12 (27%) patients with indeterminate or non-diagnostic cytology, 5 had elevated sCT and were managed as above. None of the remaining seven had LND, thus potentially suboptimal surgery., Conclusion: Our findings reflect the rarity of MTC, and the challenges of pre-operative diagnosis. The addition of sCT may improve surgical planning in patients with indeterminate cytology., (© 2022 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Introduction: Informed consent for surgery is a medical and legal requirement, but completing these does not necessarily translate to high patient satisfaction. This patient-reported experience study aimed to examine the surgical consent process, comparing the patients' experience in elective and emergency settings., Methods: Over a 6-mo period, postoperative patients at The Alfred Hospital Breast and Endocrine Surgical Unit were invited to participate in a survey on the surgical consent process - including perceived priorities, information provided and overall experience. Standard statistical techniques were used, with a significant P-value of < 0.05., Results: A total of 412 patients were invited, with 130 (32%) responses. More patients underwent elective surgery (N= 90, 69%) than emergency surgery (N = 40, 31%). Emergency patients were more likely to sign the consent form regardless of its contents (93% versus 39%, P < 0.001) and more likely to be influenced by external pressures (63% versus 1%, P < 0.001). Elective patients were more likely to want to discuss their surgery with a senior surgeon (74% versus 23%, P < 0.001) and more likely to seek advice from external sources (83% versus 10%, P < 0.001). Both groups highly valued the opportunity to ask questions (67% versus 63%, P = 0.65)., Conclusion: This study shows patients have a range of different priorities in preparation for surgery. Therefore, each consent process should be patient-specific, and focus on providing the patient with quality resources that inform decision-making., (Copyright © 2021. Published by Elsevier Inc.)

Background: There are many clinical associations and potential mechanisms of injury resulting in recurrent laryngeal nerve palsy (RLNP) after thyroidectomy. One possible cause of RLNP is focal intralaryngeal compression of the recurrent laryngeal nerve (RLN), which may be associated with the tracheal tube (TT). Therefore, we examined current RLNP rates to investigate potential associations, including intralaryngeal, airway, anaesthetic and anthropometric factors., Methods: We analysed 1003 patients undergoing thyroid surgery at The Alfred from 2010 to 2017, who had anatomically intact RLNs at the conclusion of thyroidectomy. All included patients underwent pre- and post-operative flexible nasendoscopy. The primary outcome was RLNP rate. We analysed potential associated factors including age, sex, operative time, surgical indication, pathology, American Society of Anaesthesiologists Physical Status, Mallampati scores, body mass index, intubation grade, TT size and specimen weight. The independent risk factors were identified by logistic regression analysis., Results: Overall, RLNP occurred in 83 patients (8.3%) of which one was permanent (0.1%). On univariate analysis, RLNP was associated with male sex (P = 0.02), and duration of surgery (P = 0.002). On multivariate analysis, both male sex (P = 0.047) and duration of surgery (P = 0.04) remained significant. Further, factors postulated to cause intralaryngeal compression of the RLN, including TT size, body mass index, intubation grade and Mallampati score, were not significantly associated with RLNP., Conclusion: Our study showed a RLNP rate of 8.3%, and associations with longer operative duration, and male sex. Potential intralaryngeal factors were not identified., (© 2020 Royal Australasian College of Surgeons.)

Background: Indeterminate fine-needle aspiration cytology (FNAC) imposes challenges in the management of thyroid nodules. This study aimed to examine whether preoperative anti-thyroid antibodies (Abs) and TSH are indicators of thyroid malignancy and aggressive behavior in patients with indeterminate FNAC., Methods: This was a retrospective study of thyroidectomy patients from 2008 to 2016. We analyzed Abs and TSH levels, FNAC, and histopathology. Serum antibody levels were categorized as 'Undetectable', 'In-range' if detectable but within normal range, and 'Elevated' if above upper limit of normal. 'Detectable' levels referred to 'In-range' and 'Elevated' combined., Results: There were 531 patients included. Of 402 patients with preoperative FNAC, 104 (25.9%) had indeterminate cytology (Bethesda III-V). Of these, 39 (37.5%) were malignant and 65 (62.5%) benign on histopathology. In the setting of indeterminate FNAC, an increased risk of malignancy was associated with 'Elevated' thyroglobulin antibodies (TgAb) (OR 7.25, 95% CI 1.13-77.15, P = 0.01) and 'Elevated' thyroid peroxidase antibodies (TPOAb) (OR 6.79, 95% CI 1.23-45.88, P = 0.008). Similarly, while still 'In-range', TSH ≥ 1 mIU/L was associated with an increased risk of malignancy (OR 3.23, 95% CI 1.14-9.33, P = 0.01). In all patients with malignancy, the mean tumor size was 8 mm larger in those with TSH ≥ 1 mIU/L (P = 0.03); furthermore, in PTC patients, 'Detectable' TgAb conferred a 4 × risk of lymph node metastasis (95% CI 1.03-13.77, P = 0.02)., Conclusion: In this cohort, in indeterminate FNAC patients, Abs and TSH were associated with an increased risk of malignancy. Additionally, TgAb and TSH were potential markers of aggressive biology. As such, they may be diagnostic and prognostic adjuncts.

Background: Routine preoperative vocal cord (VC) assessment with laryngoscopy in patients undergoing thyroidectomy allows clear documentation of baseline VC function, aids in surgical planning in patients with palsies, and facilitates interpretation of intraoperative neuromonitoring (IONM) findings. We aimed to determine the incidence of preoperative vocal cord palsy (VCP); to evaluate the associated risk factors for preoperative VCP; and to calculate the cost-savings potential of implementing a selective approach. Methods: Patients with a pre-thyroidectomy VC assessment by fiberoptic laryngoscopy were retrospectively recruited from the Monash University Endocrine Surgery Unit database from 2000 to 2018. Cases with preoperative VCP were reviewed for potential contributing factors and compared with a non-palsy cohort. Results: Of the 5987 patients who had preoperative laryngoscopy, VCP was documented in 41 (0.68%) patients. Four clinical parameters were found to be potential indicators of VCP, including: age ( p  < 0.001), nodule ≥3.5 cm recorded on ultrasound imaging ( p  = 0.01), presence of voice symptoms ( p  < 0.001), and previous neck surgery ( p  < 0.001). Malignant cytology ( p  = 0.5) and exposure to head and neck irradiation were not different between the groups. Utilizing these risk factors, 2354 (39%) patients had at least one feature that may raise suspicion for preoperative VCP. By performing preoperative laryngoscopy only on this subset of patients, the potential cost savings exceeds 400 Australian Dollars per patient. Conclusions: Using this large dataset, we have established that a VCP is rare in the absence of a large nodule, hoarseness, or previous neck surgery. Therefore, in the era of IONM, we support a selective approach to preoperative laryngoscopy by using the aforementioned criteria.

Background: Since the mid-1800s, thyroidectomy has transformed from a procedure associated with high to near-zero mortality. Nonetheless, surgeons must continue to strive to improve patient care. Using historical records and contemporary data, this study compares the practice and outcomes of thyroid surgery at a tertiary institution during two periods, 50 years apart., Methods: 'The Alfred Hospital Clinical Reports' recorded all cases of surgically managed thyroid disease from 1946 to 1959. These historical cases were compared to contemporary thyroidectomy cases at the Alfred Hospital from 2007 to 2016. Cases were compared for surgical indication and post-operative outcomes., Results: There were 746 patients in the historical group (mean age 53 years; 87% female) and 787 patients in the contemporary group (mean age 52 years; 80% female). The most common indication for thyroidectomy in both groups was non-toxic nodular goitre. A greater proportion of the contemporary group were diagnosed with thyroid malignancy (27% vs. 8%; p < 0.001). The contemporary group recorded significantly fewer cases of thyrotoxic crisis (2.1% vs. 0%; p = 0.001), permanent nerve palsy (4.6% vs. 0.4%; p < 0.001) and bilateral nerve palsy (1.2% vs. 0%; p = 0.01). There were no mortalities in the contemporary group, while the historical data recorded three deaths (0.44%)., Conclusions: This study compared thyroid surgery in two cohorts separated by a 50-year period. While it is not surprising that outcomes of thyroidectomy have improved, this study uniquely demonstrates trends of thyroid surgery over time and areas in which further improvements may be made.

Background: The majority of adrenal incidentalomas are benign, although some are large, functional, or malignant and may require surgery. Therefore all require follow-up. This study aimed to determine the pattern of adrenal incidentaloma follow-up in a level 1 trauma center, focusing on the factors that influence whether follow-up is facilitated., Methods: Patients with computed tomography-detected adrenal incidentalomas between January 2010 and September 2015 were included. A keyword search identified case files, which were reviewed for demographic characteristics, managing unit, computed tomography indication and findings, and follow-up arrangements. Statistical analysis was performed using Stata SE Version 14., Results: A total of 38,848 chest and abdominal computed tomographic scans were performed in the study period, revealing 804 patients with adrenal incidentalomas who met inclusion criteria (mean age 65, 58% male). The mean size of adrenal incidentaloma was 23 mm. Follow-up was organized in 30% of cases and was more likely to occur in younger patients (mean age 62 vs 66, P < .001); in larger lesions (mean size 26 mm vs 21 mm, P < .001); if the computed tomographic scan suggested follow-up (P < .001); or if the computed tomography report suggested a diagnosis (P < .001). Follow-up arrangements were most likely to be made by the trauma unit (39%, P = .01)., Conclusion: This study highlights that adrenal incidentalomas follow-up is often overlooked, and that follow-up is influenced by patient, radiologic, and medical provider factors. An adrenal lesion follow-up protocol may improve follow-up rates but requires further analysis., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: There is a common perception that total thyroidectomy causes weight gain beyond expected age-related changes, even when thyroid replacement therapy induces a euthyroid state. The aim of this study was to determine whether patients who underwent total thyroidectomy for a wide spectrum of conditions experienced weight gain following surgery., Methods: We retrospectively studied 107 consecutive total thyroidectomy patients treated between January 2013 and June 2014. Medical records were reviewed to determine underlying pathology, thyroid status, use of antithyroid drugs and preoperative weight. Follow-up data were obtained from 79 patients at least 10 months post-operatively to determine current weight, the type of clinician managing thyroid replacement therapy and patient satisfaction with post-thyroidectomy management., Results: The cohort was 73% female, with a mean age of 55.8 ± 15.7 years and a mean preoperative weight of 78.8 ± 17.5 kg. Commonest pathologies were multinodular goitre, Graves' disease, thyroid cancer and Hashimoto's thyroiditis. Preoperatively, 63.2% of patients were hyperthyroid. Mean weight change at follow-up was a non-significant increase of 0.06 ± 6.9 kg (P = 0.094). Weight change was not significant regardless of preoperative thyroid function status. This study did not demonstrate any significant differences in clinical characteristics (including post-operative thyroid-stimulating hormone) between the group with >2% weight gain and those who did not., Conclusions: This study did not reveal significant weight gain following thyroidectomy for a wide spectrum of pathologies. Specifically, preoperative hyperthyroidism, female gender and use of antithyroid medications do not predict weight gain after thyroid surgery., (© 2018 Royal Australasian College of Surgeons.)

Background: In thyroidectomy, little has been reported on the differential recurrent laryngeal nerve (RLN) palsy rates between the left and right sides. Even less is known about the potential differences causing these differential rates. This study reports the left versus right RLN palsy rates of total thyroidectomy cases in a single institution, relating them to the comparative stiffness of the left and right porcine RLNs. Computed stress modelling was also used to estimate the differential levels of tension within each RLN., Methods: For the comparison of the left and right RLN palsy rates, 1926 cases of total thyroidectomy (between 2007 and 2013) from the Monash University Endocrine Surgery Unit were included. Stiffness of porcine RLNs was experimentally determined by measuring nerve extension against incremental increase in load. Additionally, the tension of intraoperatively stretched RLNs was estimated by computer modelling., Results: The left RLN had a palsy rate of 0.9% (18/1926), which was significantly lower (P = 0.025) than the right RLN palsy rate of 1.8% (34/1926). The left porcine RLN was 22% stiffer than the right RLN (P = 0.004). The stress modelling estimated that at the apex of the artificial RLN genu during anteromedial rotation of the thyroid lobe, the right RLN experiences twice the tension experienced by the left RLN., Conclusion: The stiffer left RLN and the higher tension generated in the right RLN during thyroidectomy may jointly contribute to the higher right RLN palsy rate., (© 2015 Royal Australasian College of Surgeons.)

Background: Recent literature has suggested an association between autoimmune thyroiditis and papillary thyroid cancer. The aims of this study were to evaluate if positive thyroid antibodies are associated with thyroid carcinoma and to examine the role of thyroid antibodies in the management of thyroid nodules., Methods: This is a database study of all patients undergoing thyroidectomy with recorded preoperative thyroid antibodies (autoantibodies to thyroglobulin and/or thyroid peroxidase) levels from 2010 to 2012. We analysed preoperative thyroid antibody levels, fine needle aspiration cytology (FNAC) results, type of thyroid surgery and final histopathology., Results: There were 960 patients who underwent thyroidectomy with recorded preoperative thyroid antibodies. Of 960 patients, 784 had preoperative FNAC of thyroid nodules. Final histopathology showed 758 benign and 202 malignant cases. As expected, there was a strong association between raised thyroid antibodies and lymphocytic thyroiditis on histology (P = 0.0001) (two-sided probability). Overall, positive thyroid antibodies were not found to be a predictor of thyroid carcinoma (P = 0.161) (two-sided probability). However, in patients with benign FNAC, positive thyroid antibodies increased the risk of thyroid malignancy (odds ratio 2.16; 95% confidence interval 1.11 to 4.21, P = 0.027) (two-sided probability)., Conclusion: Patients with positive thyroid antibodies have a greater risk of malignancy in those with benign FNAC. We recommend routine thyroid antibody assessment in addition to FNAC as part of the assessment of thyroid nodules., (© 2013 Royal Australasian College of Surgeons.)

Introduction: Recurrent laryngeal nerve (RLN) palsy is a devastating complication of thyroidectomy. Although neurapraxia is thought to be the most common cause, the underlying mechanisms are poorly understood. The objectives of this study were to examine the differential palsy rates between the left and right RLNs, and the role of intraoperative nerve swelling as a risk factor of postoperative palsy., Methods: Thyroidectomy data were collected, including demographics, change in RLN diameter, and RLN electromyographic (EMG) reading. Left and right RLNs, as well as bilateral and unilateral subgroup analyses were performed., Results: A total of 5,334 RLNs were at risk in 3,408 thyroidectomies in this study. The overall RLN palsy rate was 1.5%, greater on the right side than the left for bilateral cases (P = .025), and greater on the left side than the right for unilateral cases (P = .007). In a subgroup of 519 RLNs, the diameter and EMG amplitude were measured. The RLN diameter increased by approximately 1.5-fold (P < .001), and corresponded to increased EMG amplitude (P = .01) during the procedure. The diameter of the right RLN was larger than the left RLN, both at the beginning and end of the dissection (P = .001)., Conclusion: The right-left differential rates of post-thyroidectomy RLN palsy seemed to be due in part to differential RLN diameters, with stretch having a more deleterious effect on RLNs with a smaller diameter; also, edema as a result of stretch might be an underlying mechanism for postoperative neurapraxia and palsy. Thyroid surgeons should be aware of the different vulnerabilities of each RLN and develop practices to avoid iatrogenic injury., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To determine the prevalence of thyroglossal tract thyroid tissue on SPECT/CT and to assess the contribution of this tissue to total neck radioactive iodine (RAI) activity in patients given (131) I ablation therapy after total thyroidectomy for thyroid cancer., Patients and Methods: Eighty-three consecutive patients with thyroid cancer treated with total thyroidectomy underwent whole-body planar and SPECT/CT imaging of the neck following initial RAI ablation. On SPECT/CT, thyroglossal tract thyroid tissue was defined as RAI in the anterior neck, superior to the thyroid bed in close proximity to the midline without evidence of localization to lymph nodes. Quantification was performed using region of interest analysis on planar imaging following localization on SPECT/CT. SPECT/CT, and planar images were classified by two reviewers as positive, negative or equivocal with interobserver agreement quantified using a Kappa score. Disagreement was resolved using a third reviewer., Results: Thyroglossal tract thyroid tissue was present in 39/83 (47%; 95%CI: 36-58%) patients on SPECT/CT. In these 39 patients, this tissue contributed to a significant amount of total neck activity (median = 50%; IQR 19-74%). Interobserver agreement for the presence of thyroglossal tract thyroid tissue was substantial on SPECT/CT (Kappa = 0.73) and fair on planar imaging (Kappa = 0.31)., Conclusion: Thyroglossal tract thyroid tissue was present in one half of our study population and contributed to a significant amount of total neck RAI activity. Given the high prevalence of this tissue, our results suggest that total neck RAI activity on planar imaging may not be suitable to assess the completeness of thyroid bed surgery., (© 2014 John Wiley & Sons Ltd.)

Purpose: Fine-needle aspiration cytology (FNAC) assists the diagnosis of thyroid malignancy. A 'suspicious for malignancy' on FNAC creates a management dilemma. The aims of this study were to investigate the malignancy rate for patients with suspicious cytology, and to describe a management approach for those with a suspicious result., Methodology: A retrospective review of prospectively collected data in an endocrine surgery database was undertaken. Patients undergoing thyroidectomy with preoperative FNAC from 1992 to 2012 were analysed., Results: Preoperative FNAC was undertaken in 2,692 patients, and the FNAC result was 'suspicious for malignancy' in 94 (3.5 %) patients. Of these, 53 (56.4 %) were malignant, with the majority 44 (83.0 %) being papillary thyroid cancer. 48 patients went straight to total thyroidectomy, 40 patients had an initial diagnostic hemithyroidectomy, and 1 patient had a diagnostic isthmusectomy. 5 patients required reoperative total thyroidectomy as an initial procedure. Of the 94 suspicious cases, 55 were reported by an unknown, presumably non-expert, thyroid cytopathologist. 38 of these cases were available for review and re-reporting by an experienced cytopathologist. On review, 28 (73.7 %) were reclassified as cytologically malignant, and all of these were confirmed as malignant on subsequent histopathology., Conclusions: Suspicious cytology has a high risk of malignancy. Expert thyroid cytopathology can improve diagnostic accuracy and a preoperative malignant diagnosis should be pursued to enable one-stage surgery where possible.

Background: Successful preoperative diagnosis of a branchial cyst requires a systematic approach. The aim of this study was to evaluate methods of investigation of a lateral neck swelling suspicious for a branchial cyst, and to highlight cases where a less benign cause for the swelling should be suspected and therefore management altered appropriately., Methods: A retrospective case study of 24 patients with presumed branchial cysts managed operatively was undertaken. Demographic, clinical, imaging, cytology and histopathological data were analysed to formulate an approach to the work-up of a lateral neck swelling suspected to be a branchial cyst., Results: All 24 patients presented with a lateral neck mass thought to be a branchial cyst preoperatively underwent preoperative fine-needle aspiration cytology. The overall accuracy of cytology in predicting a benign branchial cyst histopathologically was 83.3% (20 out of 24)., Conclusion: Successful preoperative diagnosis of a branchial cyst requires a combination of imaging and cytology. If there is concern that a lateral neck swelling is not a branchial cyst on clinical, imaging or cytological features, then a full preoperative work-up, including computed tomography scan of the neck and upper aero-digestive tract endoscopy should be performed, prior to an excisional biopsy., (© 2011 The Authors. ANZ Journal of Surgery © 2011 Royal Australasian College of Surgeons.)

Background: Surgical excision has been recommended as a diagnostic test for thyroid nodules ≥ 4 cm, due to the supposedly higher rate of cancer in larger nodules and the higher reported false-negative rates of fine-needle aspiration cytology (FNAC) testing (>10%). The aims of this study are to determine the prevalence of thyroid cancer in nodules ≥ 4 cm, to examine if a relationship between increasing nodule size and malignancy rate was present and to study the accuracy of preoperative FNAC diagnosis., Methods: Retrospective analysis of data from patients with thyroid nodules ≥ 4 cm undergoing surgical resection between 1994 and 2008. Malignancy rates, cytology results and indications for surgery were analysed., Results: A total of 223 patients with thyroid nodules ≥ 4 cm underwent thyroid resection between 1994 and 2008. The overall prevalence of thyroid cancer was 7.2% (95% confidence interval (CI): 4.2-11.4%). The malignancy rate did not vary significantly with increasing nodule size. The sensitivity of FNAC was 93.8% (95% CI: 69.8-99.8%), while the specificity of FNAC was 62.2% (95% CI: 54.9-69.2%). The most common indicator for surgery was compression symptoms. A positive FNAC test was the most significant indicator of underlying malignancy, with a likelihood ratio of 2.5 (95% CI: 2.0-3.1)., Conclusions: Many patients with large thyroid nodules undergo thyroidectomy for symptom relief alone, regardless of their FNAC results. In such patients where other clinical indicators for thyroidectomy are not present, a benign FNAC result can reassure both patient and surgeon that mandatory surgical excision is not needed to exclude malignancy., (© 2011 The Authors. ANZ Journal of Surgery © 2011 Royal Australasian College of Surgeons.)

Background: Hashimoto's thyroiditis (HT) is a chronic autoimmune thyroiditis typically resulting in hypothyroidism. In itself, HT is not an indication for surgery but the co-existence of thyroid nodular disease creates diagnostic and management difficulties. Indications for thyroidectomy include risk of malignancy and pressure symptoms. While fine needle aspirate cytology is effective in the diagnosis of thyroid lesions, in HT there is increased diagnostic uncertainty. This study aimed to document the results of cytology and the rate of malignancy in HT., Methods: Data were analysed for the period 1996–2009. All patients who underwent thyroidectomy and had a formal histological diagnosis of HT were included and compared with a control population who underwent thyroidectomy but did not have HT. In both groups, patient demographics, clinical parameters, cytology findings, operative procedure and final histology were reviewed., Results: One hundred and twelve patients had histologically proven HT, with a significant female preponderance compared with controls (P = 0.002). There were no significant differences between cases and controls for type of procedure or preoperative examination findings. Incidence of hypothyroidism was increased: 17 patients (15.2% versus 1.6%; P < 0.0001), whereas thyrotoxicosis was decreased: four patients (3.6% versus 14.4%; P = 0.002). There was an increased incidence of follicular/indeterminate cytology (35.7% versus 22.1%; P = 0.001). While there was an increased false negative rate in HT, this failed to achieve statistical significance (8.8% versus 2.5%; P = 0.09). Malignancy rates were more prevalent in the setting of HT (23.2% versus 11.4%; P < 0.001)., Conclusions: Given the increased rate of associated malignancy and increased diagnostic uncertainty in patients with HT, we recommend routine preoperative thyroid antibody measurement.

Background: Temporary recurrent laryngeal nerve (RLN) palsy after thyroidectomy is usually due to a neurapraxia. Voice changes after thyroidectomy, in the absence of RLN palsy, are common. We postulated that this is due to edema and consequent increased diameter of the RLN during thyroidectomy. The aim of this study was to document changes in the diameter of the RLN during surgery., Methods: A consecutive series of 110 RLNs was prospectively analyzed in 75 patients. The RLN was measured on identification and removal of the lobe. Electromyogram (EMG) amplitudes were recorded concurrently after neurostimulation. Univariate and multivariate analyses were performed., Results: The mean increase in RLN diameter was 0.71 from 1.95 mm (P < 000.1). Right and left RLNs were similar diameter. On univariate and multivariate analysis, factors predictive of increased RLN diameter were increasing age (P = 0.04) and increased difference in EMG amplitude (P = 0.01). There was a mean increased EMG amplitude of 101 from 493.5 μV (P < 0.001). On univariate and multivariate analyses, factors predictive of increased difference in EMG amplitude were decreasing age (P = 0.01) and increased difference in RLN diameter (P = 0.02). There was a statistically significant positive relationship between increased diameter of RLN and increased EMG amplitude (R(2) = 0.04). The temporary RLN palsy rate was 3%., Conclusions: The small numbers of temporary RLN palsies prevent correlation with increased diameter of RLN. However, this may explain voice changes after thyroidectomy without RLN palsy. The observed increase in RLN diameter is probably due to edema; its cause is unknown. The increased EMG amplitude seen with increasing RLN diameter may reflect increased excitability of ionic channels in neurons.

Background: Malignant melanoma is a common and life-threatening malignancy that often metastasizes to lymph nodes, necessitating lymph node dissections. Dissections aim for regional disease control. Dissections often result in significant morbidity and are associated with local recurrences (LRs) in the surgical field. This study aims to ascertain the LR rate and complication rate in axillary lymph node dissections (ALND) for malignant melanoma. It also aims to identify risk factors for both LR and complications., Methods: This retrospective clinical study involved the analysis of 74 patients who were identified by the Victorian Melanoma Service database as having ALND between 1999 and 2008. Three patients underwent bilateral ALND and three patients underwent reoperative procedures following initial incomplete dissections. Patient demographics and information on the primary tumour was collected using a prospectively kept database and histopathological reports. Operative and post-operative information was obtained through a retrospective review of clinical notes and histopathological reports., Results: Twelve (16%) patients developed LR at a median follow-up time of 9.5 months, and 32 (46%) patients had a post-operative complication. Kaplan–Meier estimates revealed an overall risk of LR to be 24.96% (95% CI: 13.8%–45.1%). Cox regression analysis revealed that having a primary melanoma upon the abdomen statistically significantly increased the risk of LR in the dissected field. (Hazard ratio 3.84; 95% CI: 1.0–15.0; P = 0.048). Twenty-eight (38%) patients died from disseminated disease., Conclusions: ALND is associated with a significant risk of post-operative complications. It can achieve regional disease control, but a significant risk of LR exists. If LR occurs the prognosis is very poor.

Objective: To report a case of corticotropin-independent macronodular adrenal hyperplasia (AIMAH) associated with an insulinoma., Methods: We describe the clinical, radiographic, laboratory, and histopathologic findings of the study patient; review the current protocols for management of AIMAH; and discuss the disease etiology., Results: A 64-year-old woman with multiple intradermal facial nevi experienced intermittent light-headedness, tremor, and confusion and was found to have a venous plasma glucose concentration of 52 mg/dL. Hypoglycemia and hyperinsulinemia after 18 hours of fasting suggested the presence of an insulinoma. Hepatic venous sampling for insulin after selective arterial calcium injection localized the insulinoma to the pancreatic head. The insulinoma was excised, and there was no recurrence over the 5 years the patient was in our care. During the workup for insulinoma, bilateral adrenal masses were incidentally discovered on computed tomography. Twenty-hour urinary free cortisol excretion was elevated and serum corticotropin was suppressed. Overt signs of Cushing syndrome were not present, and subsequent urinary cortisol measurements were within the reference range for several years. After 4 years, Cushing syndrome developed and bilateral adrenalectomy was performed. AIMAH was diagnosed on the basis of histopathologic findings., Conclusions: This appears to be the first reported case of AIMAH associated with an insulinoma. In the absence of other stigmata of multiple endocrine neoplasm type 1 and in the presence of multiple nevi, it may represent a novel endocrine syndrome.

Background:   Lesions of the submandibular gland represent a pleomorphically diverse group in which benign and malignant pathologies are difficult to differentiate from each other. Accurate diagnosis and surgical intervention relies upon clinical presentation, examination and investigations to guide appropriate management. The current series aimed to identify the roles of preoperative cytology and imaging with subsequent histopathology in the management of these lesions., Methods: Between 1998 and 2008, 54 patients of median age 54 years (range 25-94), with a male : female ratio of 1:3.5 were identified, of which, 50 patients underwent 52 excisions of the submandibular gland. Demographic data were recorded. The utility of imaging and cytology were analysed, and the accuracy of cytology correlated with histology., Results: Pathologies of resected specimens were sialadenitis 17 (32%), pleomorphic adenomas nine (17%), calculi eight (15%), lymphoma five (10%), squamous cell carcinoma two (4%), adenoid cystic carcinoma one (2%) and other 10 (20%). Twenty-eight patients (52%) underwent fine-needle aspiration cytology/core biopsies, of which 25 (89%) were correlated with histology. The accuracy, sensitivity and specificity of the fine-needle aspiration cytology correlation with histology were 88.0%, 71.4% and 94.4%, respectively. Overall, the complication rate was 9.6%; involving five temporary nerve palsies of the marginal mandibular branch of the facial nerve, including one temporary lingual nerve palsy., Conclusion: This series demonstrates histological outcomes in patients specific to the submandibular salivary gland. The malignancy rate was low compared to current published literature. The transcervical surgical approach to submandibular gland pathology is a safe and effective method with minimal morbidity when performed by experienced surgeons. No single investigative modality can be solely aligned with diagnosing a specific lesion of the submandibular gland., (© 2010 The Authors. ANZ Journal of Surgery © 2010 Royal Australasian College of Surgeons.)

Background: Diagnosis of thyroid malignancy relies on clinical assessment, imaging and fine-needle aspiration cytology 'FNAC' of thyroid nodules. The purpose of this study was to evaluate how effective synoptically reported FNAC is in clinical practice in diagnosing thyroid cancer. We also examined the effectiveness of using preoperative FNAC results to plan the type of operation for treating thyroid cancer., Method: A retrospective case series of all patients undergoing thyroid surgery from 1993 to 2008 was analysed. All data were collected prospectively and recorded in a dedicated endocrine surgery database. Data analysed included age, sex, preoperative FNAC result, type of surgery, final histology and complications. Cytology was reported based on a five-tiered classification system., Results: There were 1373 patients in total and 125 patients with a final diagnosis of thyroid cancer. Female to male ratio was 3:1. Cytology reported as 'malignant' was confirmed as thyroid cancer in 100% of the cases. Of the patients, 47% with 'suspicious' cytology report and 14% with 'follicular/indeterminate' cytology report had a final diagnosis of cancer. Thyroid cancer subtypes were 90 patients with papillary thyroid cancer 'PTC', 24 with follicular 'FTC', eight with medullary 'MTC' and two with anaplastic cancer. Cytology was suggestive of cancer in 89% of the patients with PTC >10 mm, 75% with FTC and 88% with MTC. Transient hypocalcaemia was the commonest complication occurring in 7.2%. There were no cases of permanent hypoparathyroidism. Recurrent laryngeal nerve neuropraxia occurred in 2.4% with a permanent palsy occurring in 0.8%. There were three cancer-related deaths., Conclusions: Preoperative synoptically reported FNAC is effective when used in diagnosing and planning surgery for thyroid cancer., (© 2010 The Authors. ANZ Journal of Surgery © 2010 Royal Australasian College of Surgeons.)

Background: Avoiding recurrent laryngeal nerve (RLN) injury is aided by a precise anatomical understanding of the RLN before entry into the larynx where it is at greatest risk., Methods: A literature review and study of 977 RLNs at operation have been used to describe the last 2 cm of the anatomical course of the extralaryngeal RLN., Results: The tertiary branches of the inferior thyroid artery pass in a superficial vascular fascial layer anterolateral to the RLN. The tubercle of Zuckerkandl and the superior parathyroid glands lie within this superficial vascular fascial covering layer. The RLN lies on a deeper layer of more fibrous tissue, the ligament of Berry. In all 977 RLNs, the RLN was sandwiched between an anterolateral vascular layer and a medial layer, the ligament of Berry., Conclusions: The site of greatest risk during thyroidectomy to the RLN is in the 2-cm course of the extralaryngeal nerve above the trunk of the inferior thyroid artery where tension forms an artificial genu of the nerve. Once the superficial vascular fascial and Berry's ligament layers are released, the nerve falls back into the tracheoesophageal groove and adopts a serpiginous appearance, indicating completeness of the dissection of the lobe from the lateral trachea and division of the ligament of Berry.

Objective: To report a case of Cushing syndrome due to apparently sporadic primary pigmented nodular adrenal disease in a young woman., Methods: We describe the clinical, biochemical, radiologic, and histologic findings of Cushing syndrome due to the rare condition of primary pigmented nodular adrenal disease., Results: A 30-year-old woman presented with a 2-year history of worsening itch without rash over her shoulders and arms and weight gain, particularly around the abdomen and face. Careful questioning did not elicit any history of exogenous glucocorticoid use (systemic or topical), including hydrocortisone. On examination, the patient had a slightly rounded and plethoric face, a small buffalo hump, central adiposity, and thin skin with a few small striae on her inner thighs. No features of the Carney complex were observed. Investigations showed hypercortisolism with suppressed corticotropin and normal adrenal imaging despite documentation of enlarged adrenal glands at removal. High-dose dexamethasone administration was followed by a decrease in urinary free cortisol excretion rather than a paradoxical rise as previously reported in primary pigmented nodular adrenal disease. No mutations were detected in the PRKAR1A gene., Conclusions: Primary pigmented nodular adrenal disease should be suspected in patients with corticotropin-independent Cushing syndrome who have normal adrenal imaging. The role of genetic testing in apparently sporadic cases is not established, but cumulative experience may be helpful in defining the frequency of PRKAR1A mutations.

Objective: To investigate the incidence, time to onset, and risk factors for the development of hypothyroidism after hemithyroidectomy., Background: The incidence and risk factors for hypothyroidism in patients undergoing partial thyroid surgery remains unclear. Hypothyroidism is an under appreciated sequel of hemithyroidectomy. The early recognition of this postoperative complication may prevent symptoms of hypothyroidism and recurrent thyroid disease., Methods: We conducted a retrospective review of all patients undergoing hemithyroidectomy from August 1992 to June 2006 by a single surgeon. Patients were analyzed for age, sex, family history of thyroid disease, thyroid antibody levels, pre- and postoperative thyroid stimulating hormone (TSH), histologic diagnosis, weight of resected tissue, histologic evidence of thyroiditis, and lag time to diagnosis of hypothyroidism. chi or Fisher exact test or Student t test were performed., Results: Hypothyroidism was diagnosed in 10.9% of 294 patients. The mean time to diagnosis was 8.2 +/- 10.9 months. The mean thyroxine dose was 69.4 +/- 31.6 micrograms. Patients with postoperative hypothyroidism had a higher incidence of a high-normal preoperative TSH level (TSH: 2.5-4.0 mIU/L, 18.8% vs. 3.8%; P < 0.01), thyroiditis on histology (46.8% vs. 11.8%; P < 0.01) and elevated thyroid antibodies levels (47.8% vs. 11.5%; P < 0.01). Age, gender, family history of thyroid disease, thyroid pathology, and weight of resected tissue were not significant risk factors for hypothyroidism., Conclusions: An incidence of 10.9% is higher than anticipated and all patients should have postoperative thyroid function assessment. However, a high-normal preoperative TSH, elevated thyroid antibody levels, and the presence of thyroiditis on histology are indications for close monitoring.

Objective: This study aimed to establish the prevalence of extralaryngeal bifurcation of the recurrent laryngeal nerve (RLN) and investigate the location of the motor fibers to the intrinsic muscles of the larynx within the branches of the RLN., Summary of Background Data: Recognition of extralaryngeal branching of the RLN is important, because inadvertent division of a branch may lead to significant vocal cord palsy despite the operator believing the nerve was preserved., Methods: Prospective operative data on branching of the RLN were collected in 579 patients undergoing thyroidectomy or open parathyroidectomy over a 3 year period and nerve integrity monitoring was utilized to document the position of the motor fibers of the last 176 RLNs. Adduction of the vocal cords was detected by the electromyography-endotracheal tube and abduction by finger palpation of muscle contraction in the posterior cricoarytenoid., Results: A total of 838 RLN were studied (right--432, left--406). Bifurcations occurred on the right in 111 (25.7%) and left 93 (22.9%). Bilateral bifurcation occurred in 23 (8.9%) of bilaterally dissected nerves. Overall 176 RLNs in 118 patients were assessed by the nerve integrity monitoring. Of these 41 (23.3%) were bifid RLN. In all 41 (100%) cases of bifid RLN, motor fibers for both adduction and abduction of the vocal cords were located exclusively in the anterior branches of RLN, and none in the posterior branches., Conclusion: Extralaryngeal bifurcation of RLN is a common anatomical variant. The motor fibers of RLN are located in the anterior branch, for both adduction and abduction. Great care is therefore required following the presumed identification of the RLN to ensure there is no unidentified anterior branch.

The Objective Structured Clinical Assessment (OSCA) was introduced by the Royal Australasian College of Surgeons in 1990. Over the last 5 years important changes have been made to the format of the examination to improve the processes of the examination overall and its reliability and validity. Competency scores have been introduced to comprise 25% of the score for each station to allow an additional judgement by the examiner of clinical competence beyond the structure objective marking scale. The examination has changed to a purely clinical examination with an increase in stations from 12 to 16 and deletion of the written component. The name has progressively changed from OSCA to Objective Structured Clinical Examination to Clinical Examination. The roles of the clinical committee have been refined and a database of station questions has been developed. This enables a blueprint matrix of clinical skills and specialty classifications to ensure a broad representation of stations on each examination. The database also allows information to be collected about the performance of stations and statistical analysis has shown the current clinical exam to have an overall reliability of approximately 0.7, which is a good level of reliability. Progressively stations with low correlation are being reduced and reproducibility across multiple centres is being assessed. In the 18 years since this examination was introduced multiple changes have refined the processes, reliability and validity of the examination.

Heuristics describe the multiple small steps required for successful surgery, which are often taken for granted, enabling key manoeuvres, their correct order and their timely performance. Successful hemithyroidectomy is dependent on correct siting of the incision; tension to allow elevation of sub-platysmal flaps without damaging anterior jugular veins; strap muscle division with preservation of the ansa cervicalis; recognition of the importance of the sub-sternothyroid plane; superior mobility of the thyroid lobe, involving freeing the superior strap muscle layer and dissection of the pyramidal lobe; division of the isthmus to assist anteromedial mobility; dissection of the lateral thyroid space to free the posterior 'v' lip of the superior pole; medial to lateral dissection of the avascular cricothyroid space with preservation of the external laryngeal nerve, prior to ligation of the superior thyroid vessels; anteromedial rotation of the thyroid lobe with elevation of any retrosternal component; capsular dissection of the inferior pole with preservation of vascularity of the inferior parathyroid gland; dissection of the thyroid lobe off the recurrent laryngeal nerve, especially above the inferior thyroid artery in the region of greatest risk to the nerve, the region of the ligament of Berry; preservation of a vascularized superior parathyroid gland; capsular dissection, creating windows between vessels enabling their precise control, thereby minimizing haemorrhage. This paper aims to emphasize these heuristic components of thyroidectomy.

Background: Soft tissue sarcomas (STS) are rare. More often than not, the possibility of STS is not considered preoperatively and the lesions are enucleated. Enucleation (excisional biopsy) is inappropriate for sarcomas as it compromises the planning of definitive surgery and radiotherapy. Incisional biopsy has been regarded as the biopsy of choice by some, but it has a high rate of wound complications. The aims of the study were (i) to assess the current accuracy of core biopsy in the diagnosis of STS; (ii) to assess whether preoperative core biopsy facilitates the surgical management of soft tissue tumours; and (iii) to evaluate whether there has been an increase in the use of core biopsy before referral., Methods: Patients with soft tissue tumours managed by a surgeon with a special interest in soft STS from 1994 to 2007 were reviewed from data collected in a database prospectively. The accuracy of core biopsy in the diagnosis of soft tissue tumours and planning of definitive surgery were assessed., Results: Ninety-four patients with 98 lesions were reviewed. Sixty-eight lesions had core biopsy. The overall sensitivity of core biopsy in diagnosing soft tissue tumours was 83.6%. It has a sensitivity of 91.3% and specificity of 100% for malignant STS. For patients who had core biopsy, 95% had one-stage surgery; those who had no core biopsy, only 45% had one-stage surgery (P value <0.001)., Conclusions: Core biopsy is accurate in the diagnosis of soft tissue tumours. It is safe and does not have the complications of open biopsy. It enables most patients to have one-stage surgery.

Background: The aim of this study was to assess the value of fine-needle aspiration cytology (FNAC) as a preoperative evaluation for parotid tumours., Methods: Prospectively collected data on 77 patients, collected on a parotid database, were retrospectively analysed. Preoperative investigations were carried out and cytology, histopathology and clinical outcomes were evaluated., Results: The most common histopathology was benign lesions (89.6%), including pleomorphic adenoma (55.8%) and Warthin's tumour (11.7%). Melanoma (3.9%) and lymphoma (2.6%) were the commonest malignancies. Preoperative investigations included FNAC in 72 of the 77 patients (93.5%). FNAC had a sensitivity and specificity for benign tumours of 92.3 and 75%, respectively. FNAC for malignant tumours had a sensitivity of 75% and specificity of 93.8%. FNAC accurately diagnosed cell type in 85.9% of specimens for benign lesions, but only 50% for malignancy. Complications included wound infections (10.4%), salivary fistulas (6.5%) and temporary partial facial palsies in six patients (7.8%)., Conclusion: We conclude FNAC assists in preoperative assessment and surgical planning for parotidectomy. This confirms the usefulness of FNAC as a preoperative assessment of parotid masses.

Thyroid nodules are common, with up to 8% of the adult population having palpable nodules. With the use of ultrasound, up to 10 times more nodules are likely to be detected. Increasing numbers of nodules are being detected serendipitously because of the rising use of imaging to investigate unrelated conditions. The primary aim in investigating a thyroid nodule is to exclude the possibility of malignancy, which occurs in about 5% of nodules. This begins with a thorough history, including previous exposure to radiation and any family history of thyroid cancer or other endocrine diseases. Clinical examination of the neck should focus on the thyroid nodule and the gland itself, but also the presence of any cervical lymphadenopathy. Biochemical assessment of the thyroid needs to be followed by thyroid ultrasound, which may demonstrate features that are associated with a higher chance of the nodule being malignant. Fine-needle aspiration biopsy is crucial in the investigation of a thyroid nodule. It provides highly accurate cytologic information about the nodule from which a definitive management plan can be formulated. The challenge remains in the management of nodules that fall under the "indeterminate" category. These may be subject to more surgical intervention than is required because histological examination is the only way in which a malignancy can be excluded. Surgery followed by radioactive iodine ablation is the mainstay of treatment for differentiated thyroid cancers, and the majority of patients can expect high cure rates.

Background: Fine-needle aspiration cytology (FNAC) is integral to the diagnosis and management of patients with thyroid nodules. We introduced synoptic cytology reporting for thyroid nodules in 2004. The aim of this study was to examine the effect of synoptic cytology reporting in our institution., Methods: A comparative study of two 2-year periods (1 August 2002 to 1 August 2004 and 2 August 2004 to 2 August 2006) before and after the introduction of synoptic reporting was conducted from a prospectively collected database of patients presented with thyroid nodules. The only change during these periods was the format of FNAC reporting. We used the same radiological practice and cytopathology service throughout the study period. All patients are still being followed up., Results: There were a total of 660 patients. Of these, 376 were operated and 284 non-operated. The female to male ratio was 7:1. Comparing the two periods, the overall FNAC sensitivities were 60% versus 79.1%; specificities, 83.7% versus 79.4%; accuracy, 76% versus 79.3%; false-positive result, 16.3% versus 20.6% and false-negative result, 40% versus 20.9%. The non-diagnostic rates were 7.4% versus 3.15%. FNAC prompted surgery in 66.7% versus 100% in carcinoma and 56.4% versus 73.6% in adenoma. A benign FNAC prompted surgery in 15% versus 19.8% of cases. There was no thyroid cancer detected in the current follow up., Conclusions: Synoptic cytology reporting has resulted in an overall improvement in all measures of the tests. It is a simple and effective tool to use. Synoptic cytology reporting is therefore recommended for all endocrine surgical units.

Background: Lipomatous tumours comprise a range of diagnoses. There are controversies regarding the histopathological diagnosis, nomenclature, diagnostic method, surgical management, roles of radiotherapy and the risk of metastasis, local recurrence and dedifferentiation. This study describes our experience with such tumours., Methods: Retrospective review of 224 soft tissue tumours from the Senior Author's (J. W. S.) database identified 28 patients with deep lipomatous tumours. Clinical features and outcomes were studied with median follow up of 1.5 years., Results: Eleven deep lipomas, six deep atypical lipomas, four well-differentiated (lipoma-like) liposarcomas, three well-differentiated liposarcomas and four liposarcomas were studied. Preoperative diagnosis was established by image-guided core biopsy in 20 patients, excisional biopsy in 6, incisional biopsy in 1 and fine-needle aspiration in 1. All patients diagnosed with deep lipoma and deep atypical lipoma underwent marginal excision. The median size of the excised tumour was 11 cm. Recurrence occurred in three deep atypical lipomas and one liposarcoma. Dedifferentiation occurred in one deep atypical lipoma, which transformed into a liposarcoma. None had metastasis or died of metastatic malignancy., Conclusion: Large deep lipomatous tumours are uncommon and although they do not tend to metastasize, they not infrequently recur locally. Hence their local treatment to prevent local recurrence is important. Key aspects in achieving a complete, but marginal resection of the deep atypical lipoma and the well-differentiated lipoma-like liposarcoma is accurate preoperative diagnosis with core biopsy and accurate imaging to assess deep unsuspected extensions of the tumour.

Background: Total thyroidectomy is the preferred operation for multinodular goitre, Graves' disease and thyroid cancer. This study reviewed prospectively collected data on a personal consecutive series of 336 total thyroidectomies to assess whether results reported in world centres of excellence could also be achieved elsewhere., Methods: Between 1991 and 2004, 336 total thyroidectomies (85% over the last 6 years) of median age 53 years (13-86 years) and male : female ratio of 1:4.3 were undertaken for multinodular goitre 232 (69%), Graves' disease 26 (7.7%), thyroid cancer 60 (17.9%) and other benign conditions 17 (5.4%). Thirty-nine patients had 2-stage procedures. No patient required median sternotomy. Parathyroid autotransplantation was carried out in 43 (12.8%)., Results: Permanent unilateral recurrent laryngeal nerve palsy occurred in 0.3% and permanent hypoparathyroidism in 1.8%. Significant temporary hypocalcaemia occurred in 13.4%. Non-significant temporary hypocalcaemia occurred in 23.8%, resulting in an overall rate of hypocalcaemia of 38.9% for the total series. Hypocalcaemia was more common after 1-stage compared with 2-stage surgeries (P < 0.001). Temporary hypocalcaemia was commoner after surgery for Graves' disease than surgery for other conditions. The rate of postoperative haemorrhage was 0.9% and wound infection, 1.5%. There was no postoperative mortality., Conclusion: Total thyroidectomy removes the disease process completely, lowers local recurrence rates and avoids the substantial risks of reoperative surgery. Total thyroidectomy is safe and can be carried out with low complication rates that are equal to world centres of excellence.

Extralaryngeal bifurcation and trifurcation of the recurrent laryngeal nerve (RLN) is not well described in anatomical texts. This significant anatomical variation is important because prevention of vocal cord paralysis requires preservation of all branches of the RLN. The aim of this study was to examine the prevalence of extralaryngeal bifurcation of the RLN seen during thyroid/parathyroid surgeries. All patients undergoing total thyroidectomy, hemithyroidectomy and parathyroidectomy (excluding all minimally invasive procedures) carried out by a single endocrine surgeon from November 2003 to December 2004 were included. Operative data obtained prospectively included the location of the nerve, number of branches and the distance in millimetres from the inferior border of the cricothyroid to the point of bifurcation. A total of 213 (right = 114, left = 99) RLN in 137 patients were studied. Seventy-seven (36%) nerves bifurcated or trifurcated before entry into the larynx. Bifurcations were more common on the right (43%) than on the left (28%) (P = 0.05). Trifurcations were seen in eight nerves, seven on the right and one on the left (P = 0.05). Bilaterally branched RLN were observed in 14 (18%) of 77 patients undergoing a bilateral procedure. One non-RLN was identified on the right. The median distance from the cricothyroid to the point of division was 18 mm on the right and 13 mm on the left. Extralaryngeal division of the RLN is a common anatomical variant occurring more frequently on the right. Unseen branches of the RLN are at risk of injury during surgery. Therefore, great care is required following presumed identification of the RLN to ensure that there are no other unidentified branches.

Background: Retrosternal goitre was defined as any thyroid enlargement identified below the thoracic inlet at operation, with the patient's neck held in extension. The aim of this study was to determine the characteristics of the patients, the goitres, the surgery and its morbidity (including tracheomalacia, recurrent laryngeal nerve palsy and hypocalcaemia) and the incidence of malignancy in order to establish guidelines for managing patients with a retrosternal goitre., Methods: Data were collected prospectively on all thyroidectomies carried out by a single surgeon over 14 years. Patients underwent appropriate preoperative assessment and thyroidectomy was carried out using a standardized capsular dissection technique. There were 199 cases of retrosternal extension., Results: Retrosternal extension was significantly more common on the left side than on the right side (ratio 3:2, P < 0.05). Most patients (83.4%) had significant symptoms that were relieved by surgery. Of the 199 thyroidectomies, none required a sternal split. The rate of malignancy was low (2.5%). Postoperative morbidity was 30%, the majority being asymptomatic temporary hypocalcaemia. There were no patients with permanent recurrent laryngeal nerve palsies or permanent hypoparathyroidism. There was one case of tracheomalacia. There was no death., Conclusion: Retrosternal goitre is a frequently symptomatic condition, with a low but definite rate of malignancy. Surgery is usually possible through a cervical incision and with an acceptable risk of significant morbidity. Thyroidectomy should be recommended as the treatment of choice.