An assessment of the risk of developing hyperparathyroidism and thyroid disorders subsequent to neck irradiation in middle-aged women

Concomitant thyroid disease and primary hyperparathyroidism in patients undergoing parathyroidectomy or thyroidectomy

BACKGROUND

Thyroid abnormalities have been found intraoperatively during parathyroidectomy and have resulted in concomitant thyroidectomy. The identification of concomitant disease is important prior to primary operation in order to minimize reoperations. This study investigates the incidence of concomitant primary hyperparathyroidism (PHPT) and thyroid nodular disease in patients undergoing thyroidectomy or parathyroidectomy.

METHODS

We performed a retrospective review of prospectively gathered data for 621 patients who underwent thyroidectomy, parathyroidectomy, or both at Tulane Medical Center. Information obtained included initial referral, initial thyroid stimulating hormone (TSH), initial parathyroid hormone (PTH), fine needle aspiration (FNA) results, ultrasound results, type of operation performed, final diagnosis, and final pathology.

RESULTS

Among the 400 patients referred primarily for thyroid disease, 13.50% underwent a thyroidectomy and parathyroidectomy (PTX) simultaneously and 10.75% received a final diagnosis of thyroid and concomitant parathyroid disease. Among the 103 patients referred primarily for parathyroid disease, 26.21% underwent a PTX and thyroidectomy and 24.27% received a final diagnosis of both thyroid and parathyroid disease. Patients referred primarily for parathyroid disease were more likely to receive a final diagnosis of both parathyroid and thyroid disease and were more likely to undergo a combined operation.

CONCLUSIONS

Concomitant thyroid and parathyroid disease occur and preoperative analysis is important to avoid increased complications from reoperations.

An optimal treatment for pediatric Graves' disease is radioiodine

CONTEXT

Antithyroid medications, surgery, and radioactive iodine have been used for more than five decades for the treatment of hyperthyroidism due to Graves' disease in children, adolescents, and adults. Despite the widespread use of these different approaches, controversy still exists relative to the merits of each treatment, especially regarding the use of radioactive iodine.

OBJECTIVE

The objective of the study was to address the risk and benefits of (131)I therapy, as compared with other treatment approaches. POSITION: Long-term, spontaneous remission of Graves' disease occurs in less than 30% of children. Thus, the majority of children with Graves' disease will need definitive, curative therapy. There is little evidence that use of antithyroid medications beyond 1 or 2 yr increases the likelihood of spontaneous, long-term remission. Although the use of antithyroid medications is standard practice, the use of antithyroid medications involves definite risks. When used at sufficient doses, radioactive iodine is an effective cure for Graves' disease and is associated with few acute side effects. Potential long-term adverse side effects, including thyroid cancer and genetic damage, have yet to be observed in individuals treated as children or adolescents with (131)I.

CONCLUSION

Properly administered, radioactive iodine remains an ideal form of treatment for Graves' disease in the pediatric population. Because of the increased risk of thyroid cancer associated with low-dose thyroid irradiation in children, larger, rather than smaller, doses of (131)I should be given.

The treatment of Graves' disease in children

Graves' disease is the most common form of hyperthyroidism in childhood. Current treatment options include antithyroid medications, surgery, and radioactive iodine. Medical therapy is generally associated with long-term remission rates of less than 25% and a small risk of serious adverse reactions that include hepatic failure and bone marrow suppression. Total thyroidectomy is associated with very high cure rates and a small risk of hypoparathyroidism and recurrent laryngeal nerve damage. When radioactive iodine is used at appropriate doses, there is a very high cure rate without increased risks of thyroid cancer or genetic damage. Clinicians caring for the child or adolescent with Graves' disease are thus faced with using medications with potential short-term and long-term toxicity, for a condition in which spontaneous remission occurs in the minority of pediatric patients. Definitive therapy in the form of surgery or radioactive iodine is necessary and unavoidable for the majority of pediatric patients with Graves' disease.