Cardiomyopathy and thyrotoxicosis: tachycardiomyopathy or thyrotoxic cardiomyopathy?

Ischaemic heart disease is the most common cause of heart failure, but less common causes such as hyperthyroidism should be kept in mind. As a potential reversible cause of cardiomyopathy hyperthyroidism should be excluded in every new patient, young and old, especially in the absence of coronary artery disease. Inspired by an intriguing clinical case we address the question whether hyperthyroidism-related cardiomyopathy is due to tachycardiomyopathy or to thyrotoxic cardiomyopathy.

Outcome of Patients Surgically Treated for Various Forms of Hyperthyroidism with Differentiated Thyroid Cancer: Experience at an Endocrine Center in Italy

PURPOSE

The incidence and aggressiveness of thyroid cancer associated with hyperthyroidism remains a subject of much controversy. The aim of this study was to analyze the frequency of coexisting hyperthyroidism and thyroid cancer, and to determine whether cancer becomes more aggressive with different forms of hyperthyroidism.

METHODS

We retrospectively studied 2,449 patients assessed for hyperthyroidism between 1985 and 2001. All patients with a "cold" nodule on scintigraphy, such as those with Graves' disease and a concomitant solid nodule, underwent fine-needle aspiration biopsy (FNAB). Criteria for surgery were cytological findings indicative of malignancy, goiter with signs of tracheal or esophageal compression, side effects of antithyroid drug therapy, or Graves' disease with multiple relapses after therapy withdrawal or responsiveness to antithyroid drugs.

RESULTS

Thyroid cancer was diagnosed more frequently in patients with Graves' disease (6.5%) than in those with uninodular toxic goiter (UTG) (4.4%) or multinodular toxic goiter (MTG) (3.9%). Lymph node involvement was found in 56% of the patients with Graves' disease, in 23% of those with MTG, and in none of those with UTG. Distant metastases were found in one patient with Graves' disease.

CONCLUSIONS

Cancers associated with Graves' disease seems to be more aggressive than those associated with MTG or UTG. Thus, we suggest that patients with Graves' disease be carefully monitored for the detection of thyroid nodules. Ultrasonography seems to be the best modality to detect such nodules.

Prevalence and risk factors for primary hyperparathyroidism in hyperthyroid patients

BACKGROUND

Coexistence of hyperthyroidism and primary hyperparathyroidism may be more prevalent than previously recognized. We report 13 cases of concomitant occurrence of both diseases to estimate their combined prevalence and its factors.

METHODS

Ninety-six unselected patients admitted for elective hyperthyroidism surgery were retrospectively included. Eighty-three patients were initially seen for hyperthyroidism with normocalcemia (group 1), and 13 patients were initially seen for hyperthyroidism with associated primary hyperparathyroidism (group 2). Patients' characteristics, examinations, and pathology reports were reviewed. Risk factors were identified using a logistic regression model.

RESULTS

The prevalence of concomitant hyperparathyroidism was 13.5%. No patients manifested hypercalcemia in the absence of organic parathyroid disease. Eleven patients had a parathyroid adenoma, and two patients had parathyroid hyperplasia. Group 2 patients were older (median 61 vs 43 years, p = .006). Thyroid-stimulating hormone levels were more depressed in group 2 (median 0.01 vs 0.032 UI/L, p = .034). On multivariate analysis, age was the unique factor significantly different between groups (odds ratio, 1.05; 95% confidence interval, 1.008-1.098; p = .020).

CONCLUSIONS

Hypercalcemia in patients with hyperthyroidism, particularly older patients, should warrant a thorough investigation for concomitant primary hyperparathyroidism that would dictate a combined thyroidectomy and parathyroidectomy.

[Hyperthyroidism surgery: experience of ENT department of hospital center of Thies]

INTRODUCTION

The treatment of hyperthyroidism includes different therapeutics means of which surgery. The objectives of this study were to evaluate the place of the surgery in the treatment of hyperthyroidism and to describes the complications.

PATIENTS AND METHODS

It is a retrospective study on 22 patients treated by thyroidectomy from March 2002 to April 2004. The biological confirmation was systematic. A medical preparation has been done in all the cases. A total thyroidectomy has been done in 13 cases and a subtotal in 9 cases.

RESULTS

The mean age was 37 years. There were 20 women and 2 men. An euthyroidism has obtained after surgery. There complications were: 1/22 temporary palsy of recurrent nerve 1/22 acute hypoparathyroidism 1/22 post-operative death (haematoma)

CONCLUSION

Surgery seems to be a good alternative to antithyroid agents, which are constraining and often ineffective in the long term, and to radioactive iodine who leads to a long follow-up because of induced hypothyroidy. With increasing surgical skill, the risk of recurrent or parathyroid injury is greatly decreased.

Surgical indications for toxic multinodular goitre

The aim of this study was to clarify the surgical indications and the effectiveness of total thyroidectomy in the treatment of toxic multinodular goitre. From January 1998 to May 2004, 70 patients underwent total thyroidectomy in our department because of toxic multinodular goitre. In 46 patients (65.7%) the indications for total thyroidectomy were: 25 compressive goitres, 12 cervico-mediastinal goitres, 2 cases of Pemberton's sign, 5 follicular nodules with cytological atypia, and 2 cases of suspected papillary carcinoma. In 24 patients (34.3%) with failure or intolerance of previous treatment, surgical indications were: 9 persistent and 5 recurrent hyperthyroidism after medical treatment; 6 patients with cardiotoxicity; 3 patients with recurrent disease after percutaneous ethanol injection; 1 patient with antithyroid drug intolerance. The mean postoperative hospital stay was 3.2 days (range: 2-9). Transient hypocalcaemia occurred in 6 patients (8.6%) and transient unilateral recurrent laryngeal nerve injury in another 3 patients (4.2%). None of the patients had permanent hypocalcaemia or permanent recurrent laryngeal nerve injury. All 70 treated patients relieved their symptoms and became biochemically hypothyroid after the operation. Total thyroidectomy results in a rapid, reliable resolution of hyperthyroidism and removal of multinodular goitre, requires no re-treatment, removes any coexisting malignancy, and post-surgical hypothyroidism is simple to treat.

[Effect of long-term treatment with octreotide-lar in a TSH-secreting pituitary macroadenoma and secondary hyperthyroidism]

A 74 year-old man was admitted to the hospital for heart failure and atrial fibrillation episodes. He had been irregularly treated for hyperthyroidism during the previous 3 years, with poor control. Thyroid function evaluation showed secondary hyperthyroidism, with high free thyroid hormone levels and TSH inappropriately in the high-normal range (4.2 mU/ml), only slightly responsive to TRH-stimulation (6 microU/ml). Alpha-subunits were hyper-responsive to TRH stimulation (+123%). Thyroid autoimmunity tests were negative and ultrasonography evidenced a diffusely enlarged gland. Magnetic resonance (MR) imaging of the pituitary showed a macroadenoma. The patient underwent transphenoidal adenomectomy, and immunohistochemistry confirmed the diagnosis of a TSH-secreting pituitary macroadenoma. A moderate secondary hyperthyroidism was still present and a new MR evidenced residual disease, involving the right cavernous sinus. A (111)In-octreoscan revealed an increased captation in this area. The patient was treated with octreotide-Lar (20 mg/monthly), which normalized FT3, FT4 and TSH levels already after 3 months of therapy. This effect is still maintained at 42 months of treatment. MR imaging showed a reduction in the residual lesion after 18 months (>50% in comparison with postsurgical MR) and a further decrease after 36 months of treatment). This suggests that the antiproliferative effect on the adenomatous cells is progressive and continues over time. This patients did not receive radiotherapy, so this action is entirely due to the medical treatment. No significant side effects developed and the patient's compliance was good. He has not had further arrhythmic episodes.

[Treatment of hyperthyroidisms in Brazzaville Teaching Hospital, Congo]

Between January 1994 and December 2003, a total of 118 patients (MIF = 1/13) with thyrotoxicosis was studied at the endocrine and metabolic diseases unit of the Centre Hospitalier Universitaire de Brazzaville, in Congo. 72 patients (61%) had Graves' hyperthyroidism, 23 (19.6%) had toxic multinodular goitre while the rest had toxic adenoma (7.6%), and thyroiditis (4.2%). The mean age was 26.6 +/- 7.9 years for Graves' cases and 49.4 +/- 9.3 years for toxic multinodular goitre cases. The clinical presentation was similar to other reported series. Thirty-seven patients (31.3%) did not return after the first admission. All patients responded to carbimazole therapy and no major side-effect was recognized. Ten patients (8.5%/) underwent subtotal thyroidectomy, among them one developed hypothyroidism a year later. The result of this study shows that thyrotoxicosis is not a rare condition in Congo.

Thyroid Disorders in Elderly Patients

Thyroid disorders are common in the elderly and are associated with significant morbidity if left untreated. Typical symptoms may be absent and may be erroneously attributed to normal aging or coexisting disease. Physical examination of the thyroid gland may not be helpful, as the gland is often shrunken and difficult to palpate. Usually only myxedema coma requires levothyroxine parenterally; all other forms of hypothyroidism can be treated with oral levothyroxine. Low-dose levothyroxine should be initiated and increased gradually over several months. In unstable elderly patients with hyperthyroidism, antithyroid medication can quickly produce a euthyroid state. Radioactive iodine therapy is more definitive and is well tolerated, effective, and preferred. Surgical thyroid ablation may be necessary in patients who fail to respond to radioactive iodine therapy and in patients with multinodular goiter. If there is a suspicion of malignant disease, early biopsy or fine needle aspiration for cytology should be considered.

[Untreated hyperthyroidism with severe cardiac complication in adolescence--a case study]

A 16-years old boy with poor family circumstances was admitted to hospital due to severe cardiac failure (stagnation in the pulmonary and systemic circulations, ejection fraction: 29%, pericardial fluid, atrial flatter) needing intensive care. Diagnostic tests revealed extreme hyper-function of the thyroid as the underlying cause. After stabilising the cardiac and hormonal states of the patient with medication, subtotal resection of the thyroid was carried out since the poor family circumstances did not make the provision of long-term thyreostatic pharmacotherapy feasible. Cardioversion solved the arrhythmia. The patient was discharged from hospital with stable circulation and normal thyroid functions after 2 months. The authors report the very uncommon complications of an endocrine syndrome with autoimmune origin rarely observed in childhood. They highlight the importance of early diagnosis and the immediate start of adequate therapy for good long-term outcome.

Occurrence of antineutrophil cytoplasmic antibodies and associated vasculitis in patients with hyperthyroidism treated with antithyroid drugs: A long-term followup study

OBJECTIVE

To test whether antineutrophil cytoplasmic antibodies (ANCA) and ANCA-associated vasculitis (AAV) are not only induced during treatment with antithyroid drugs, but can also become evident when medication has been ceased, possibly after years.

METHODS

Patients who visited our hospital for the treatment of hyperthyroidism were included (n = 207). Treatment consisted of antithyroid medications, radioactive iodide, thyroidectomy, or a combination of these treatment options. Patients were retested 3-6 years later to evaluate long-term effects of antithyroid drugs. Patients were tested for the presence of ANCA and, if positive, evaluated for the presence of AAV.

RESULTS

Of 209 patients with hyperthyroidism, 12 patients (6%) were positive for myeloperoxidase- (MPO-), proteinase 3-, or human leukocyte elastase-ANCA. Seventy-seven of 209 patients were retested; 1 patient who had not been treated with antithyroid drugs had developed MPO-ANCA. In 3 of 6 patients previously positive, ANCA could still be detected. The presence of ANCA was highly associated with treatment with antithyroid drugs (odds ratio 11.8 [95% confidence interval 1.5-93.3]). Of 13 patients with a positive ANCA result on enzyme-linked immunosorbent assay, AAV with glomerulonephritis was diagnosed in 4 (31%).

CONCLUSION

The presence of ANCA with or without vasculitis is associated with previous treatment with antithyroid drugs, possibly after years.

[Hyperthyroidism in the elderly]

Hyperthyroidism in elderly patients is not to be under-evaluated, since it is characterized in such age range by particular clinical and prognostic features. Based upon literature survey and their clinical experience, the authors discuss in the present paper clinical, diagnostic and therapeutic problems of hyperthyroidism in geriatric patients.

MATERIAL AND METHOD

In the period between 1978-2003 out of 1804 patients surgically treated for thyroid disease (non neoplastic in 1470 pts.), 180 subjects presented hyperthyroidism (17%). 36 were in geriatric age-range (mean age 76 yr.; 29 females and 7 males). 26 presented a Multinodular Toxic Goiter (72.2%), whereas 9 patients complained of Plummer Adenoma (25%); only 1 patient showed Basedow disease (2.7%).

RESULTS

As far as ASA classification, there were 7 ASA I, 27 ASA II and 2 ASA III. Compression of digestive tract and/or respiratory airway represented a surgical indication in 15 patients (41.6%). 12 (33.4%) were operated due to predominant cardiac symptoms (tachycardia, atrial fibrillation). The remaining 9 patients (25%) were treated for the concomitance of atypical symptoms of hyperthyroidism. We performed 15 total thyroidectomy, 7 "near totally", 8 sub-total, 6 hemithyroidectomy in case of Plummer adenoma. Postoperative mortality was nihil; p.o. morbidity was 5.5% for medical conditions (pneumonia) and surgery-related (1 laryngeal recurrent paralysis and 1 hypoparathyroidism) in 5.5%. Post-operative follow-up, conducted at 6 and 12 months from the operation, showed regression of hyperthyroidism and regression or improvement of all clinical symptoms complained by the patient.

CONCLUSION

Surgical treatment seems to be the only immediate and definitive cure for hyperthyroidism. Geriatric age does not seem to be a surgical contraindication.

Changes in endothelium-dependent arterial dilation before and after subtotal thyroidectomy in subjects with hyperthyroidism

OBJECTIVE

This case-control study was carried out to assess the alteration of endothelium-dependent arterial dilation before and after subtotal thyroidectomy in subjects with hyperthyroidism.

PATIENTS AND METHODS

The study subjects included 12 patients with hyperthyroidism and 39 apparently healthy individuals. We performed a subtotal thyroidectomy on the hyperthyroid patients. The endothelium-dependent arterial dilation was determined with a high-resolution ultrasound method in each patient at the hyperthyroid stage before treatment (stage H), the euthyroid stage induced immediately before surgery (stage E), and the transient hypothyroid stage 1 or 2 months after surgery (stage L).

RESULTS

The flow-mediated arterial dilation decreased significantly from H to E and from E to L (P < 0.001). As compared with H, baseline blood flow decreased markedly at stages E and L (P < 0.001). The flow-mediated arterial dilation and baseline blood flow in the control subjects were very close to those at stage E of the hyperthyroid patients. The absolute change in the flow-mediated arterial dilation showed significant negative correlation with the changes in TSH (r =-0.86, P < 0.001), lipoprotein (a) [Lp(a)] (r =-0.77, P < 0.001) and low density lipoprotein (LDL) (r =-0.79, P < 0.001), and significant positive correlation with changes in fT3 (r =+0.88, P < 0.001). The absolute change in the baseline blood flow showed significant positive correlation with the change in fT3 (r =+0.85, P < 0.001) and significant negative correlation with the change in TSH (r =-0.63, P < 0.01).

CONCLUSION

The endothelium-dependent arterial dilation increases significantly in untreated hyperthyroid patients, and decreases markedly after a subtotal thyroidectomy. Therefore, we conclude that the endothelium is more responsive to reactive hyperaemia in the hyperthyroid than the euthyroid state.

Ultrasound in head and neck surgery: thyroid, parathyroid, and cervical lymph nodes

Ultrasound (US) of the neck is extremely sensitive in detecting thyroid, parathyroid, and cervical lymph node pathology, and is regarded as the most complete and cost-effective imaging method for evaluating the thyroid and parathyroid glands, as well as for the diagnostic evaluation of the cervical lymph node basin. US is widely used in screening high-risk individuals, evaluation of palpable and nonpalpable thyroid nodules, needle guidance for biopsy of nonpalpable and suspicious nodules, and preoperative evaluation of the extent of thyroid neoplasms, as well as in the detection of residual, recurrent, or metastatic thyroid tumors, and in observing nonsurgical cases. It has thus become an important adjunct to the practice of head and neck surgery.

The incidence of thyroid carcinoma in multinodular goiter: retrospective analysis

Thyroid carcinoma (TC) is a relatively rare tumour, but it represents the most frequent form of cancer of the endocrine glands. Epidemiologically ascertained risk factors are ionising radiation, the presence of thyroid adenoma and multinodular goiter (MNG). Multinodularity of goiter should no longer be considered an indicator of probable benign disease. A retrospective analysis was performed on patients operated of MNG at the Unit of Otolaryngology, Sanremo Hospital (Italy) from January 1st 1995 to December 31st 2002, in order to establish the incidence of carcinoma. The results of this retrospective study, demonstrate that in 13.7% of the patients operated for goiter, the presence of a carcinoma was noticed in the definitive histopathologic examination. Such incidence percentage of MNG is in accordance with the data reported in published reports. Thus, the authors conclude that the risk of malignancy in MNG has not to be underestimated, and that a dominant nodule in MNG should be valued as if it were a solitary nodule in an otherwise normal gland.

Advantages and disadvantages of surgical therapy and optimal extent of thyroidectomy for the treatment of hyperthyroidism

Surgery is excellent therapy for hyperthyroidism, with no mortality,and few complications or recurrences. It achieves euthyroidism rapidly and consistently, avoids long-term risks of radioactive iodine and antithyroid medications, provides tissue for histology,renders childbearing immediately possible, and allows absolute titration of thyroid hormone. Advancements such as preoperative preparation and intraoperative parathyroid hormone monitoring have decreased risks greatly and improved outcomes. Hartley-Dunhill procedure is the treatment of choice. Patients should be rendered euthyroid before operation to decrease thyroid vascularity, to improve surgical planes, and to prevent life threatening thyroid storm. Patients must be monitored carefully for hypocalcemia, a potentially serious complication. Patients will require lifelong thyroid hormone replacement. Radioactive iodine ablation should be considered for disease recurrence after surgery.

[Anaesthesia and amiodarone-associated hyperthyroidism]

Amiodarone can induce severe hyperthyroidism that justifies its withdrawal and initiation of antithyroid drugs. Impossibility to stop amiodarone, failure to control hyperthyroidism and unfavourable evolution can lead to thyroidectomy. Cardiac manifestations, persistence of hyperthyroidism and interactions between amiodarone and anaesthetic or haemodynamic drugs may contraindicate anaesthesia. We report nine consecutive cases of amiodarone-associated hyperthyroidism that prompted us to perform thyroidectomy under general anaesthesia. The features and anaesthetic data of patients were noted. The antithyroid medical treatment failed in all patients. After thyroidectomy, evolution was favourable in all nine cases, without any intra or postoperative complication, in spite of the extent of hyperthyroidism and the severity of the associated cardiac problems. Despite potential high risks, thyroidectomy for amiodarone-induced hyperthyroidism does not seem to increase morbidity or mortality and allows a quick return to euthyroidism and reintroduction of amiodarone.

[Hyperthyroidism and coexistent thyroid carcinoma]

The association between thyrotoxicosis and thyroid cancer is a classical, rare and controversial entity. Within their series of eleven such cases the authors dissociate two distinct groups from clinical and pathological viewpoint. The first category is represented by one case of follicular thyroid cancer with clinically and biologically confirmed hyperthyroidism. The second group includes ten patients with thyrotoxicosis (three cases with Graves' disease, four with toxic multinodular goiter and three with toxic adenoma) and associated unsuspected occult or nodular carcinoma. None of these patients had received previous treatment with radioiodine. In all cases the diagnosis was established by pathological examination of the surgical specimen. Surgery is the treatment of choice in these lesions, the presence of carcinoma imposing the extent of operation. Five near total thyroidectomies and three near total lobectomies with ablation of the isthmus was performed in our cases associated with appropriate additional measures: TSH suppression or 131I treatment. Post surgical results were satisfactory without morbidity or mortality. The long-term survey was good (seven cases alive after 5 years).

Thyroid cancer in patients with hyperthyroidism

OBJECTIVE

The coexistence of hyperthyroidism and thyroid cancer is considered a rare event. With the aim of assessing the clinical relevance of this association, we have retrospectively analyzed the incidence of thyroid cancer in 425 hyperthyroid patients seen and treated by surgery in our institutions.

METHODS

Among these hyperthyroid patients, we observed 241 (56.7%) cases of multinodular toxic goiter, 120 (28.3%) of uninodular toxic goiter and 64 (15%) cases of Graves' disease.

RESULTS

Thyroid cancer was diagnosed in 7 (1.65%) hyperthyroid patients. Histological examination revealed the presence of papillary carcinoma in 5 cases and follicular carcinoma in 2 cases. Neoplasia was detected in 4 patients with nodular toxic goiter and in 3 with uninodular toxic goiter. None of the patients with Graves' disease had thyroid cancer. During the follow-up of 74 months (range 4-154), there were no deaths or any recurrences.

CONCLUSION

Although the occurrence of thyroid cancer in hyperthyroid patients is a rare event, the presence of a 'cold' nodule in a hyperfunctioning thyroid should be carefully evaluated to exclude the presence of concurrent malignancy.

The epidemiology, pathology, and management of goitre in Yemen

BACKGROUND

The total goitre rate in Yemen declined by half after the country adopted universal salt iodisation in 1995. We investigated the recent epidemiology, pathology, and management of goitre so as to evaluate changes since the initiation of the salt iodisation programme. We also sought to determine the effect of new diagnostic tools in the preoperative work-up of surgically treated patients.

METHODS

Data were collected from the records of 667 patients with goitre seen in Kuwait University Hospital between 1997 and 2001.

RESULTS

Females constituted 92.5 % (n=617) of the series. The mean age of all patients was 35.2+/-11.58 years (range, 13 to 90 years). Most patients (93%) came from highland areas with an average altitude of 2000 to 2600 meters above sea level. The average duration since patients noticed swelling until the diagnosis was made was about 4 years. Multinodular bilateral swelling was the most common clinical finding (44.9%), while solitary nodules constituted the least common (17.4%). The most common associated symptom was dyspnoea (20.5%). The most common histopathological finding was nodular and colloid goitre (62.8%), while malignancy accounted for 17.7%. Subtotal thyroidectomy was the most frequent procedure, and the most common postoperative complication was hypocalcaemia.

CONCLUSIONS

Goitre is a national problem in Yemen. The late presentation, which may be important in malignant transformation of the thyroid gland, makes surgery imperative. The salt iodisation programme has been associated with a decrease in the malignancy rate. Yemen is in great need of experienced cytologists and radiologists to increase the efficacy of fine needle aspiration cytology and ultrasonography in the diagnosis of thyroid lesions. Patients need to be educated about the importance of post-operative follow up.

Advances in diagnostic practices affect thyroid cancer incidence in France

OBJECTIVE

To analyse trends in diagnostic practices of thyroid diseases and to relate them to the increase in thyroid cancer incidence in France over time.

DESIGN

From 1980 to 2000, a French retrospective multicentric (three endocrinology and three nuclear medicine centres) study of thyroid diseases was conducted on 20 consecutive unselected patients' records, sampled every 5 years in each centre.

METHODS

Characteristics of the population and diagnosis procedures (thyroid ultrasonography (US), radionuclide scan, cytology and hormonal measurements) were described over time. Changing trends in operated patients and in cancer prevalence were analysed as well as the impact of practices on cancer incidence.

RESULTS

The study included 471 patients (82% female, mean age 46.7, range 9-84 years), referred for nodular thyroid diseases (66.7%) or thyroid dysfunctions (33.3%). A significant increase in US (3 to 84.8%) and cytological practices (4.5 to 23%), and a decrease (89.4 to 49.6%) in radionuclide scan procedures were observed over time. Although the proportion of patients undergoing surgery remained constant (24.8%), the prevalence of cancer increased among operated patients from 12.5 to 37% (P=0.006). In a Cox's proportional hazard model stratified on the clinical characteristics of patients, only the cytological practice, regardless of its results, was significantly associated with the occurrence of cancer: relative risk (RR)=4.4 (95% confidence interval (CI): 1.1-16; P=0.04).

CONCLUSIONS

From 1980 to 2000, a major evolution in clinical practices has led to the increase in thyroid cancer reported in France. Such changes in medical, as well as in surgical and pathological, practices must be taken into account in incidence measurement.

['Hungry bone' syndrome, characterized by prolonged symptomatic hypocalcemia, as a complication of the treatment for hyperthyroidism]

A 22-year-old woman presented with palpitations, agitation, heat intolerance and unintentional weight loss that had started several months before. Pharmacotherapy for hyperthyroidism was prescribed, but a year later thyroidectomy was performed in connection with a lack of treatment compliance. A few hours after the operation the patient developed a tingling sensation and muscle cramp, which were found to be due to severe hypocalcaemia. Although surgery was complicated by hypoparathyroidism, there was an unusually high need for calcium combined with a low calcium excretion in the urine. Such a high need for calcium due to the increased bone reconstruction induced by the hyperthyroidism is referred to as the hungry bone syndrome. One should be particularly alert to this complication in cases of severe, prolonged hyperthyroidism, certainly in the presence of existing or peroperatively induced damage to the parathyroids. In this patient, calcium suppletion led to normalisation of the serum calcium level two weeks postoperatively; she was discharged from the hospital in good condition after 3 weeks.

[Therapeutic specifics in atrial fibrillation in hyperthyroidism. Study of 14 cases]

The aim of this study is to clarify the specificities of atrial fibrillation in hyperthyroidism. It's a retrospective study of 6 years, about 14 patients hospitalized for hyperthyroidism with atrial fibrillation. There were 9 Women and 5 men, 55.7 +/- 11.5 years old. Arryhthmia was discovered especially with palpitation and dyspnea. Cardiac echography diagnosed valvular disease in 83.3% of cases. Cardiovascular complications concerned 5 patients and consisted in cardiac insufficiency and cardiomyopathy in one case. Treatment of hyperthyroid consisted in radio-iodine administered to 7 patients at the dose of 9.8 +/- 3.9 mCi. Two patients had total thyroidectomy. Arryhthmia was treated with propranolol, 98.3 +/- 70 mg daily and anticoagulant treatment was given. From the group of nine hyperthyroid recovered patients, arryhthmia was reduced in 3 cases. In this group, age was higher and arryhthmia history was longer. We conclude that chances to treat arryhthmia associated to hyperthyroid are higher when euthyroidism or even hypothyroidism is rapidly obtained, during of atrial evolution is short and some factors aren't present, like aging, existence of valvular disease or left auricular dilatation.

[Changing trends in the treatment of nodular thyroid disease--own experience]

If the first surgical intervention for benign euthyroid goiter diseased portion is not totally removed one cannot be certain of the long-term behaviour of the remaining tissue. In one third of these patients there may be a recurrence with new nodules developing, functional disorders or even carcinoma may appear in the remnants. Hormonal activity of the removed tissue can be completely substituted for by levothyroxine. That is why some experienced specialists recommend primarily radical surgery even in benign disease, based on their experience with large number of patients. The authors started performing radical excisions in the past three years. A total of 477 operations were performed between 1st January 2000 and 31st December 2002, 45% were radical: lobectomy, near-total thyroidectomy and bilateral lobectomy. Surgery was carried out according to the standardized morphologically adjusted technique (SMART). Results of these operations are compared to conventional procedures performed in the same period. Complication rate was low with no mortality. There was no significant difference between early results of the two groups. About 2% rate of permanent recurrent laryngeal nerve injury a 3% rate of postoperative tetany (hypocalcaemia) in both groups is acceptable. Based on their initial experiences the authors recommend the radical surgical technique for the experienced surgeons.

[Organic schizophreniform disorder with pre-existing autoimmune thyroiditis]

We report the case of a 63-year-old patient with sudden onset of an acute syndrome of auditory hallucinations and delusions. Considering the anamnesis, course of the illness, and organopathologic results, we assumed an organic schizophreniform disorder within the scope of pre-existing autoimmune thyroiditis. Under treatment with high-potency neuroleptics, we observed partial regression and, after strumectomy, complete regression of the psychotic symptoms. Apparently, the acute organic schizophreniform disorder was caused by a changed metabolic situation with a transition to hyperthyroidism coinciding with beginning a small dose of antithyroid drugs.

[Toxic multinodular goiter]

OBJECTIVES

We report a series of 70 patients with toxic multinodular goiter (TMNG) and analyze results after surgical removal.

PATIENTS AND METHODS

Over a 15-year period, patients underwent thyroid surgery for TMNG. The large majority, 85.5% were women and mean age was 40 years. All patients had had goiter for more than 5 years. Clinical signs of toxicity were present in all patients, 100% presented tachycardia and palpitations. Nodules were identified at ultrasound in 95% of the patients and at scintigraphy in 90%. Serum T4 was elevated in 40 patients and THS was depressed in all. The chest x-ray revealed a plunging goiter in 10 patients. All patients were given medical treatment prior to surgery for total thyroidectomy in 15 and subtotal thyroidectomy in 55. There were no deaths. Two patients developed hematomas, to suffered injury to the recurrent nerve, and five developed acute hypoparathyroidism. Three cases of thyroid carcinoma were observed.

DISCUSSION

TMNG is an indication for radical treatment, generally surgery. Medical treatment is required in preparation for surgery. Total thyroidectomy is used increasingly, providing a definitive cure of toxic hyperthyroidism and avoiding the risk of recurrence. With increasing surgical skill, the risk of recurrent or parathyroid injury is greatly decreased.

[Paraneoplastic hyperthyroidism in a patient with metastasizing teratocarcinoma and excessively high HCG]

Clinically manifest hyperthyroidism is a rare paraneoplastic syndrome in patients with excessive HCG production due to testicular cancer. A 40-year-old patient with right testicular cancer (teratoma, embryonal cell carcinoma), diffuse pulmonary metastases and high serum HCG levels presented with symptomatic hyperthyroidism. The patient received immediately thyrostatic therapy and 4 cycles of PEI chemotherapy (Cisplatin, Etoposide, Ifosfamide). Thyroid function had returned to normal by the beginning of the second course of chemotherapy. After right orchiectomy and resection of residual pulmonary masses which revealed vital tumor cells, two additional courses of chemotherapy were performed. The patient is well and without evidence of disease 11 months after therapy. All patients with testicular cancer and excessive HCG production should be evaluated for biochemical and clinical signs of hyperthyroidism and treated accordingly with antithyroidal medication and immediate cytoreductive chemotherapy.

Thyrotropin-secreting Pituitary Tumor and Hashimotoʼs Disease: A Novel Association

A 69-year-old man was referred for elevated thyroid hormone levels. He had no symptoms apart from mild hyperhidrosis and heat intolerance with occasional headaches. Past medical history included a right hemithyroidectomy for a multinodular goiter and Hashimoto's disease. At presentation the patient had a firm, slightly enlarged left thyroid lobe. There were no visual abnormalities, and the rest of the physical findings were unremarkable. Laboratory findings included elevated values of free T4, free T3, total T3, thyrotropin-secreting hormone (TSH), antithyroglobulin, and antimicrosomal antibodies. Normal values were found for cortisol, prolactin, testosterone, follicle-stimulating hormone, luteinizing hormone, alpha-subunit, and thyroid-stimulating immunoglobulin. Thyroid 123I scan showed an increased 5-hour uptake of 23% and a 24-hour uptake of 53% with a diffuse uniform enlargement of the left side. TSH level did not increase after a thyrotropin-releasing hormone stimulation test. Serum sex hormone binding globulin was elevated. Magnetic resonance imaging of the pituitary revealed a pituitary macroadenoma with suprasellar extension to the optic chiasm. Histologic examination of the adenoma after transsphenoidal hypophysectomy showed cells that stained positive for TSH. TSH-secreting pituitary adenomas account for 1% of functioning pituitary tumors and are an exceedingly rare cause of hyperthyroidism. To our knowledge, this is the first report of pituitary tumor inducing hyperthyroidism in the setting of Hashimoto's disease. There is a possibility that TSH elevation related to Hashimoto's disease might have contributed to the development of a TSH-secreting pituitary adenoma.

Prevalence of thyroid cancer in hyperthyroidism treated by surgery

The reported prevalence of thyroid cancer with concurrent hyperthyroidism varies from 0.21% to 9.0%. This variability may be due to multiple factors, such as indications for surgery and histopathologic accuracy. However, this condition is not rare and its prevalence has increased in recent surveys, perhaps as a result of more detailed examinations. The aim of this retrospective study was to determine the prevalence of thyroid cancer in hyperthyroid patients at surgery. Forty-five patients, 34 women and 11 men, underwent surgery for hyperthyroidism in our department between 1989 and 2000. Ages ranged from 14 to 67 years. There were 42 cases of Graves' disease, one of functional multinodular goiter, and two of single toxic nodules. Forty-three patients underwent total thyroidectomy and two underwent total lobectomy. Six cases (13.3%) of thyroid cancer were found, two men and four women with ages ranging from 19 to 48 years. Final histologic examination revealed three papillary carcinomas, one follicular carcinoma, one follicular carcinoma combined with clear-cell carcinoma, and one clear-cell carcinoma. Thus, in our department, the prevalence of thyroid cancer in hyperthyroidism treated using surgery was 13.3%. Our study showed that even a single toxic nodule may occur with concurrent thyroid cancer. Careful evaluation of such patients is needed to exclude the presence of associated malignancy and to determine the most appropriate therapeutic plan.

Short- and long-term changes in bone mineral density of the lumbar spine after parathyroidectomy in patients with primary hyperparathyroidism

The aims of this study were (1) to analyze whether correlations exist between lumbar spine (LS) bone mineral density (BMD) and the main preoperative biochemical parameters in a large population of patients with primary hyperparathyroidism (HPT); and (2) to evaluate the LS-BMD changes after parathyroidectomy (PTx) at long-term follow-up. Sixty-two patients (median age 57 years, range 23-82 years) with confirmed primary HPT underwent LS osteodensitometry by dual-energy X-ray absorptiometry with BMD measurements at the L2-L4 region before surgery and at 1 year and 2 years after successful PTx. Three groups of patients were considered: Group A (men, n = 14, 22.6%), Group B (premenopausal women, n = 12, 19.3%), and Group C (postmenopausal women, n = 36, 58.1%). There were no linear correlations (P = NS) among the main biochemical parameters, the age of the patients, and their baseline LS-BMD values that were significantly (P < 0.01) lower in Group C patients. At 2-year follow-up the LS-BMD improved by 13.0%, 11.5%, and 11.7% in Groups A, B, and C, respectively (P = NS). In order to compare groups with the same linear relationship between age and LS-BMD, a subgroup of postmenopausal patients aged < or = 60 years (Group C2) was considered. ANOVA showed that the improvement of the LS-BMD at 1- and 2-year follow-up was higher (P = 0.002) in Group B than in Group C2 patients. The result was confirmed by using the Mann-Whitney U-test (P = 0.0078). Improvement of LS-BMD after successful PTx was significantly (P < 0.01) higher in premenopausal women, suggesting a possible role of estrogen hormone in complete bone remodeling.

Ectopic thyroid

Primary mediastinal ectopic goiters are very rare. We report a case in which an ectopic goiter with blood supply from the thoracic vessels necessitated a transternal approach for removal, resulting in a favorable outcome.

[Surgery for hyperthyroidism on 43 patients]

Treatment of hyperthyroidy uses surgery as well radioactive iodine and antithyroid agents.

OBJECTIVES

The study analyses the modalities of hyperthyroidy surgery, describes its complications and the population undergoing surgical treatment.

POPULATION AND METHODS

It is a retrospective study on 43 patients with hyperthyroidy treated by thyroidectomy from January first 1998 until 31 January 2002.

RESULTS

The mean age is 48 years. The sex ratio showed a predominance of women (with 36 women and 7 men). The most frequent aetiology is Graves' disease and toxic multinodular goiter. Total thyroidectomy is applied to Graves' disease and toxic multinodular goiter while single toxic nodules are treated by loboisthmectomy. Surgery for hyperthyroidy have a low morbidity (1/43 haematoma, 0/43 hypoparathyoidy, 1/43 palsy of recurrent nerve).

CONCLUSIONS

In this conditions, the hyperthyroidy surgery is fast, effective and does not need a heavy follow-up. Surgery seems to be a good alternative to antithyroid agents, which are constraining and often ineffective in the long term, and to radioactive iodine who leads to a long follow-up because of induced hypothyroidy.

[Anesthesia in the surgery of hyperthyroidism at Le Dantec Teaching Hospital]

Authors report a study of 66 patients admitted to the clinic ORL of CHU Le Dantec between 1991 and 2000 for goiter and hyperthyroidism. They evaluate the perioperative management and underline the importance of the medical preparation. The age of patients varied between 15 and 74 years. There were 62 women and 4 men. Fifty three patients presented clinical and biological hyperthyroidism. Thirteen patients had functional hyperthyroidism without clinical signs of thyrotoxicosis. Exophthalmia was present in 20 patients. Twenty one patients have been addressed to the Internal Medicine service for preoperative management of hyperthyroidism. Forty five patients have been operated under general anaesthesia. The medical preparation comprised antithyroid drugs and beta-blockers. We found as complications 3 cases of difficult intubation, 7 cases of peroperative haemorrhage and 1 case of acute thyroid crisis. The anaesthesia for surgery of hyperthyroidism is currently well codified and operative outcome became simple. The medical preparation in case of hyperthyroidism allows to return the patient in euthyroidism and reduces considerably the acute thyroid crisis risk, the most fearsome complication and the most feared of the hyperthyroidism.

Current treatment of nodular goiter with hyperthyroidism (Plummer's disease): surgery versus radioiodine

BACKGROUND

First described 9 decades ago by H. S. Plummer, thyroidectomy and radioiodine remain the 2 therapeutic modalities for toxic nodular goiter. The aim of this study was to determine its optimal treatment.

METHODS

The presentation, operative treatment, pathology, and clinical course of 362 consecutive patients treated at our institution for Plummer's disease from 1990 to 1999 were retrospectively reviewed.

RESULTS

Three hundred forty-six patients (63 men and 283 women) were treated surgically (181, 53%), with radioiodine (RAI, 157, 45%), or a combination of both (8, 2%). Mean age was 62 years (surgical, 55 years; RAI, 69 years). Nearly half were symptomatic, 51 (15%) with airway or swallowing compromise and 110 (32%) with cardiac complications. The estimated goiter size was larger (60 g or greater) in surgical (72 patients, 38%) than medically treated (45 patients, 29%) patients. RAI treatment dose averaged 28 mCi; 10 patients (6%) required a second treatment, and 8 patients failed treatment and required subsequent thyroidectomy. Types of thyroidectomy included total (29 patients, 16%), near-total (47 patients, 26%), bilateral subtotal (46 patients, 25%), and unilateral (58 patients, 32%). One month after treatment, hyperthyroidism had resolved in 96% of the surgical patients but only 6% of the RAI patients (mean time to resolution, 5.4 months). Only 55 (38%) of the RAI patients' goiters reduced in size. Recurrent laryngeal nerve paralysis and hypoparathyroidism each occurred in 3 (2%) patients.

CONCLUSIONS

Surgical treatment results in rapid, reliable resolution of hyperthyroidism and removal of the nodular goiter with low morbidity and no mortality. RAI is also safe and effective, usually requiring a single dose, but the results are delayed and it usually fails to resolve a goiter.

[Atrial fibrillation and hyperthyroidism: results after thyroidectomy]

Hyperthyroidism patients can develop atrial fibrillation (AF) with a frequency range between 10 and 25%. The Authors consider 256 hyperthyroid patients operated in their Department, from 1985 to 2001. Before and after surgery, thyroid examination, routine blood tests and common diagnostic evaluations were performed. The follow-up has been 12 months and during this period a L-Thyroxine (50-200 mg/die) therapy has been arranged. Before surgery 59 patients (23%) showed an AF associated with palpitations (76%), asthenia (66%), tremors (54%) and dyspnea (43%). The onset of AF was less than 1 months in 18% of cases, less than 3 months in 30% and chronic in remaining 52%. The 87% of patients was already pharmacologically treated. All the patients were treated with anticoagulants, with a INR value between 2 and 3. After the surgery, 47% of patients presented a restoration of the sinusal rhythm, while the 53% showed a stronger therapeutic responsiveness to specific antiarrhythmic therapy. Treatment of FA hyperthyroid patients with FA tends to normalize the function of the thyroid gland (euthyroidism). In our experience the restoring of sinusal rhythm usually develops in patients with 50 years of age (45 +/- 5 years), while in older patients AF tends to be resistant to treatment.

Radioiodine therapy of thyroid autonomy

Over half a century, treatment of thyroid autonomy with an oral dose of iodine-131 has proven to be effective. The optimum management strategy for the patient is, however, still a matter of debate. The article provides an overview of the pathogenesis of functional autonomy and its clinical relevance. According to the guidelines on both sides of the Atlantic, radioiodine treatment is considered the most comfortable and economical approach to the treatment of the toxic nodular goitre. Some differences in the preparation procedures in the guidelines of the American and the German Society of Nuclear Medicine are discussed with respect to therapy results and the subtypes of thyroid autonomy. The results of studies are summarised concerning changes in thyroid function and thyroid volume after a course of radioiodine treatment. Therapy-related risks, such as immunogenic hypothyroidism or thyroid cancer, are discussed. (131)I treatment of functional autonomy and hyperthyroidism is considered an effective and safe procedure.

Feline thyroid surgery

Hyperthyroidism is the most commonly diagnosed endocrine disease in cats. Surgery is a widely available curative therapy for hyperthyroid cats. Because of the multiple metabolic changes associated with hyperthyroidism, surgical management can be challenging. Multiple methods of thyroidectomy and their associated levels of morbidity are reviewed.

[A comparative study of anapriline and carvedilol effectiveness in patients with thyrotoxicosis in pre- and postoperative periods]

Thyrotoxicosis often affects cardiovascular system. Structural-functional condition of the myocardium is essential in the outcome of surgical intervention on the thyroid in thyrotoxicosis and indicates effectiveness of the treatment. A comparative trial studied the effects of beta-blockers (anaprilin and carvedilol) on preoperative condition of left-ventricular (LV) myocardium and late after subtotal resection of the thyroid gland. 27 thyrotoxicosis patients with myocardial remodeling in the form of concentric LV hypertrophy entered the trial. Though in preoperative preparation anapriline is recommended, in postoperative period it is better to use carvedilol as it has a good effect on reverse development of myocardial remodeling and hemodynamics in view of its balanced beta- and alpha-adrenoblocking action.

[Differentiated thyroid gland carcinoma in a scintigraphically hot thyroid nodule: diagnosis and interdisciplinary therapeutic management]

A hyperfunctioning differentiated thyroid carcinoma is a rare occurrence. Nevertheless, this diagnosis must be considered in a scintigraphically hot nodule if there is a clinical or sonographic suggestion of malignancy. The case of a 57-year old patient with hyperthyreosis and a scintigraphically hot thyroid nodule is presented. Further evaluation led to the diagnosis of a differentiated thyroid carcinoma with extensive lymph node and pulmonary metastases (pT2b, pN1b, pM1). The scintigraphically hot nodule corresponded to the primary tumor, whereas scintigraphic detection of the lymph node metastases was only possible postoperatively. Extensive resection of the lymph node metastases was achieved by the intraoperative application of a gamma probe (2nd operation). This allowed sufficient uptake of radioiodine in the pulmonary metastases for their detection and subsequent devitalisation by radioiodine therapy. Complete elimination of all tumour tissue was documented at a control follow-up after six months. Gamma probe-guided surgery may allow for additional removement of non-palpable lymph node metastases. In selected cases this may optimize the surgical results and thereby facilitate the subsequent radioiodine elimination of advanced differentiated thyroid carcinomas.