Efficacy of Thyroid Hormone Suppression for Benign Thyroid Nodules: Meta-Analysis of Randomized Trials

Jiajiejian gel ameliorates thyroid nodules through regulation of thyroid hormones and suppression of the (IL-6, TNF-α, IL-1β)/JAK2/STAT3/VEGF pathway

Background

The high incidence of thyroid nodules and their rapid growth in recent years have become an important issue affecting public health. Traditional Chinese medicine (TCM) external treatments have unique advantages in treating this disease, but the currently available external preparations are relatively few and the therapeutic mechanism is unclear. Jiajiejian gel (JJJG) is a TCM external preparation developed by our team for the thyroid nodule treatment, which has been preliminarily proven to be safe and effective in clinical practice.

Objective

The current study was aimed to elucidate the therapeutic effects and the underlying mechanisms of JJJG on thyroid nodules in rats.

Methods

The contents of paeonol and forsythoside A in JJJG were determined by HPLC. The thyroid nodules rat model was established through oral gavage of 0.1% propylthiouracil (PTU) for 6 weeks and meanwhile the rats were treated with external JJJG (0.26, 0.52, 1.04 g/kg). Subsequently, the therapeutic effect of JJJG was observed by means of ultrasonic examination, morphology observation, organ coefficients determination and histopathological analysis. Mechanismlly, the levels of FT3, FT4 and TSH in serum were measured and transcriptomics methods were used to analyse and screen the key targets and pathways of alleviating thyroid nodules by JJJG. Further, gene and protein expression levels of key factors in the pathways were measured and validated using quantitative real-time PCR, ELISA, western blotting and immunofluorescence, so as to clarify the therapeutic mechanism.

Results

The contents of the paeonol and forsythoside A were 1.160 and 0.608 mg/g, respectively. JJJG reduced thyroid swelling, improved nodular lesions, decreased thyroid coefficients, and inhibited abnormal nodular hyperplasia of follicular epithelial cells. In terms of mechanism, JJJG significantly increased the levels of FT3 and FT4 and decreased TSH level in serum (P < 0.05). Transcriptomics suggested that the (IL-6, TNF-α, IL-1β)/JAK2/STAT3/VEGF pathway may be one of the key mechanisms in the treatment of thyroid nodules by JJJG. Further validation experiments demonstrated that JJJG significantly reduced the mRNA expression and protein content of IL-1β, IL-6 and TNF-α in thyroid tissue, as well as the mRNA expression of JAK2, STAT3 and VEGF and the protein expression of p-JAK2/JAK2, p-STAT3/STAT3 and VEGF (P < 0.05).

Conclusion

This study indicates that JJJG efficiently ameliorates thyroid nodules by regulating the levels of FT3, FT4 and TSH in serum and suppressing (IL-6, TNF-α, IL-1β)/JAK2/STAT3/VEGF pathway in thyroid tissue, providing a potential therapeutic approach for thyroid nodules.

Association between serum TSH concentration and bone mineral density: an umbrella review

INTRODUCTION

The aim of this study was to summarize the results of previous studies, standardize the data, and present new statistical results in order to provide physicians with clinically significant outcomes regarding the association between serum TSH concentration and bone mineral density (BMD).

METHODS

To perform this umbrella review, a systematic search was conducted in which major online medical databases, such as PubMed, Web of Science, Embase, Scopus, Cochrane Library, and Google Scholar, were searched for meta-analyses and systematic reviews regarding the effect of TSH on BMD. Furthermore, all primary studies were screened for statistical analysis.

RESULTS

The statistical outcomes of the present study were based on the data of 75,898 patients. The pooled risk ratio of any kind of fracture in patients with subclinical hyperthyroidism was estimated to be 1.36 (95% CI: 1.18-1.56; p < 0.001). The SMD for BMD in the distal radius in male patients receiving L-thyroxine suppression therapy was estimated to be -0.61 (95% CI: -1.10-(-0.11); p = 0.02). Furthermore, the pooled risk ratio of any fracture in patients receiving L-thyroxine suppression therapy was estimated to be 1.98 (95% CI: 0.98 - 3.98; p = 0.06). In these patients, the BMD may significantly differ from that in non-treated patients. However, the difference depends on the type of bone.

CONCLUSIONS

Our data confirmed that subclinical hyperthyroidism has a detrimental effect on bones, causing decreased BMD. Based on the obtained results, the authors suggest that a reduced TSH serum level itself may be an individual factor associated with decreased BMD and, thus, with a greater risk of bone fracture. Nevertheless, it should be noted that the effects of TSH suppression therapy differ between areas of interest for assessing BMD. Furthermore, the results have shown that this issue may, in specific areas, concern not only postmenopausal women but also male patients. These conclusions should contribute to a careful consideration of the application of TSH suppressive therapy in all patients. Particular attention should be given to patients after DTC, while all the advantages and disadvantages of implementing L-thyroxine therapy should be individually considered.

Sex-specific associations between the developmental alterations in the pituitary-thyroid hormone axis and thyroid nodules in Chinese euthyroid adults: a community-based cross-sectional study

Background

Previous studies have revealed the sex-specific features of pituitary-thyroid hormone (TH) actions and the prevalence of thyroid nodules (TNs) in children and adolescents. However, it was unclear in adults. We aimed to investigate the features of pituitary-TH actions in women and men at different ages, and the associations of thyrotropin (TSH), THs, and central sensitivity to THs indices including the thyroid feedback quantile-based index by FT4 (TFQIFT4) and the thyroid feedback quantile-based index by FT3(TFQIFT3) with of TNs in Chinese euthyroid adults.

Methods

8771 euthyroid adults from the communities in China were involved. Demographic, behavioral, and anthropometric data were gathered through the questionnaires. Ultrasound was performed to evaluate the TNs. TSH and THs levels were measured. The multivariable logistic regression and multivariable ordinal logistic regression were conducted.

Results

TFQIFT3 among both genders, except women aged 43 to 59 years, where it increased slightly. Additionally, there was an age-related decline in TFQIFT4 levels in both women and men at ages < 50 and < 53, respectively, but a marked increase after that. Lower TSH levels were significantly associated with a higher prevalence and lower odds of having fewer TNs using multiple nodules as the base category in both men and women (both P for trend < 0.05). Additionally, lower TFQIFT3 and TFQIFT4 levels were significantly associated with a higher prevalence of TNs in women (both P for trend < 0.05), and lower TFQIFT3 levels were significantly associated with a higher prevalence of TNs in men. Both higher TFQIFT3 and TFQIFT4 levels were significantly associated with higher odds of having fewer TNs using multiple nodules as the base category in women. However, the relationships between TFQIFT4 and the prevalence or number of TNs in men were not found.

Conclusions

The trends of THs, TSH, TFQIFT4, and TFQIFT3 at different ages were sex-dependent. Both TFQIFT4 and TFQIFT3 levels were negatively associated with the prevalence and number of TNs in women. The present results may lead to a better understanding of the sex-specific relationships between the development of the pituitary-TH axis and the formation of TNs.

SFE-AFCE-SFMN 2022 Consensus on the management of thyroid nodules : Follow-up: How and how long?

The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians, surgeons, and other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This section deals with the follow-up of thyroid nodules, low-grade tumors and microcarcinomas.

Clinical usefulness of thyroid ultrasonography in patients with primary hypothyroidism

BACKGROUND AND OBJECTIVE

Despite the value of ultrasonography in the detection of chronic thyroiditis (CT) as well as in nodular goitre, it is often only indicated in patients with hypothyroidism if a palpable goitre or a thyroid mass is identified. The objective of the study is to evaluate the clinical usefulness of thyroid ultrasonography in patients with primary hypothyroidism without clinical suspicion of nodular goitre. And more specifically, to analyse its value in the aetiological diagnosis of hypothyroidism, and to evaluate its contribution in the detection and characterisation of coexisting subclinical thyroid nodular disease.

PATIENTS AND METHOD

Prospective cross-sectional observational study of 114 patients with primary hypothyroidism of CT or idiopathic aetiology, without symptoms or cervical palpation suspected of nodular goitre, who underwent a thyroid function test, a serological study of antithyroid antibodies, a thyroid ultrasonound and, when appropriate, a cytological study of the nodules found.

RESULTS

Ultrasonound allowed CT to be recognised as the cause of hypothyroidism in 19% of patients who had a negative serological study, and detected nodules larger than 9mm in 22 patients (16 with antithyroid antibodies). A cytological study was performed in 18 of the cases. Five patients underwent surgery, with carcinoma found in two of them.

CONCLUSIONS

Thyroid ultrasound is useful in the aetiological diagnosis of primary hypothyroidism as well as in the detection of a coexisting, unsuspected, but clinically relevant nodular goitre, so this examination should be indicated in the initial study of patients with primary hypothyroidism.

Safety and Efficacy of Ultrasound-Guided Radiofrequency Ablation for Benign Nonfunctional Thyroid Nodules in Children: A Retrospective Study of 62 Patients with Over Four Years of Follow-Up

Background: Image-guided radiofrequency ablation (RFA) for benign nonfunctional thyroid nodules in adults has been shown to be effective and safe, but few trials address the use of RFA in children. Therefore, this study was designed to assess the efficacy and safety of RFA application to benign nonfunctional thyroid nodules in children. Methods: A retrospective study of RFA for 70 benign nonfunctional thyroid nodules in 62 children with four-year follow-up was conducted. Volume reduction ratio (VRR), technique efficacy, regrowth rate, symptom score, and cosmetic score were calculated to evaluate the efficacy. Complications and side effects were recorded. Logistic regression analysis was performed to identify risk factors, and subgroup analyses were performed. Results: Patients were followed up for at least four years (59.1 ± 10.5 months, range 48-85 months). After RFA treatment, the VRR and technique efficacy rates were highest at the first year^* (77.5% and 91.4%, respectively) but decreased by four years (55.1% and 81.4%, respectively). The symptom score decreased from 4.0 ± 2.1^* to 0.8 ± 1.6 (Z = -6.82, p < 0.001), and the cosmetic score decreased from 3.3 ± 0.7 to 1.3 ± 0.9 (Z = -7.0, p < 0.001).^* The nodule regrowth rate was 22.9%, of which 56.3% of cases represented loss of efficacy. In the cases of loss of efficacy, 66.7% had greater volume than their initial presentation. Patients who received a second RFA treatment due to loss of efficacy lost efficacy again. Bilateral nodules, low vascularity, and low cystic components were independent risk factors correlating with technique efficacy. Bilateral nodules correlated with low VRR, low efficacy rate, and high regrowth rate. Nodules with a higher proportion of cystic components had higher VRR. The overall complication rate was 4.8%. Conclusions: RFA was effective in reducing the volume of benign nonfunctional thyroid nodules in children, providing significant symptomatic relief with a good safety profile during short- and long-term follow-up. RFA is a good minimally invasive treatment modality for selected pediatric patients, and it may not be appropriate for the treatment of bilateral thyroid nodules in children.

Update on the Evaluation of Thyroid Nodules

Thyroid nodules (TN) are prevalent in the general population and represent a common complaint in clinical practice. Most are asymptomatic and are associated with a 7%-15% risk of malignancy (1). Methods: PubMed and Medline were searched for articles with a focus on the epidemiology, diagnosis, and management of TN over the past 5 y. Results: The increase in frequency of imaging has led to a rise in the incidence of incidentally diagnosed TN. The initial evaluation of a TN includes assessing thyroid function, clinical risk factors, and neck imaging. Ultrasound remains the gold standard for assessing TN morphology, and biopsy is the standard method for determining whether a TN is benign. Recently published risk stratification systems using morphologic characteristics on ultrasonography have been effective in reducing the number of unnecessary biopsies. Advances in molecular testing have reduced the number of surgical procedures performed for diagnostic purposes on asymptomatic TN with indeterminate cytology. Scintigraphy is the first-line study for assessing a hyperfunctioning nodule. Many TN can be followed clinically or with serial ultrasound after the initial diagnosis. Surgical intervention is warranted when local symptoms are present, in patients with clinical risk factors, as well as in most situations with malignant cytology. Active surveillance is an option in cases of micropapillary thyroid cancer. Emerging nonsurgical approaches for treating TN include ethanol ablation for TN; sclerotherapy for thyroid cysts; and thermal techniques, such as radiofrequency ablation, laser ablation, microwaves, and high-intensity focused ultrasound. Conclusion: Most TN are benign and can be safely monitored. The indications for biopsy and frequency of imaging should be tailored on the basis of risk stratification. Treatment options should be individualized for each patient's particular situation. Active surveillance should be considered in certain cases of papillary microcarcinoma.

Is Transoral Robotic Surgery the Best Surgical Treatment for Lingual Thyroid?: A Case-Report and Literature Review

OBJECTIVES

To highlight the specific outcomes of the current surgical procedures for lingual thyroid excision, for benign and malignant lesions.

METHODS

We carried out a systematic review of surgical treatments of lingual thyroid, according to the PRISMA method. We conducted our literature search in PubMed and Ovid. Data was collected concerning patient demographics, tumor characteristics, types of surgery performed, and specific intra- and postoperative outcomes of each procedure. Surgical procedures were classified in 4 categories: transcervical approaches, "invasive" transoral approaches (transmandibular and/or tongue splitting), "non-invasive" transoral approaches, and transoral robotic surgery. We detailed the transoral robotic surgical technique through a case report, along with a surgical video.

RESULTS

Of 373 peer-reviewed articles found, 40 provided adequate information on surgical management and outcomes for patients with lingual thyroid. "Non-invasive" transoral approaches and transoral robotic surgeries required significantly fewer tracheostomies than "invasive" transoral and transcervical approaches (P < .001), while there was no statistical difference in the rate of surgical complications between each procedure.

CONCLUSIONS

Transoral robotic surgery appears to be a feasible, effective, and fast solution for lingual thyroid excision, with excellent short- and long-term surgical outcomes.

Diagnosis and Evaluation of Thyroid Nodules-the Clinician's Perspective

Thyroid nodules are a common clinical problem encountered in an endocrine practice. More and more thyroid nodules are now being detected on unrelated imaging studies, leading to an increased diagnosis of low-risk thyroid cancers. There is therefore a greater emphasis on risk assessment based on clinical and sonographic features to avoid morbidity secondary to unnecessary therapy. Molecular diagnostics are also being widely used to further characterize indeterminate nodules. The American Thyroid Association and American College of Radiology-Thyroid Imaging Reporting and Data System guidelines are the most commonly used in clinical practice for risk assessment.

Evaluation and management of thyroid nodules in children

PURPOSE OF REVIEW

The review is focused on new information about the presentation and management of thyroid nodules in children and adolescents.

RECENT FINDINGS

Palpable thyroid nodules are uncommon in children but many children have nodules detected by radiologic imaging. How to evaluate them, when to suspect thyroid cancer, and how best to follow apparently benign nodules has become an area of great interest. The American Thyroid Association recently published treatment guidelines for children with thyroid nodules and cancers but much has been learned since that publication.

SUMMARY

Personal and family history, ultrasound features, and fine needle aspiration cytology are used to determine the risk of cancer in thyroid nodules, which are then managed according to cancer risk.

2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer

BACKGROUND

Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association's (ATA's) guidelines for the management of these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer.

METHODS

The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations for therapeutic interventions. We developed a similarly formatted system to appraise the quality of such studies and resultant recommendations. The guideline panel had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members.

RESULTS

The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, use of molecular markers, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to screening for thyroid cancer, staging and risk assessment, surgical management, radioiodine remnant ablation and therapy, and thyrotropin suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using imaging and serum thyroglobulin, thyroid hormone therapy, management of recurrent and metastatic disease, consideration for clinical trials and targeted therapy, as well as directions for future research.

CONCLUSIONS

We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.

Recombinant human thyrotropin before (131)I therapy in patients with nodular goitre: a meta-analysis of randomized controlled trials

BACKGROUND

Recombinant human thyrotropin (rhTSH) can be used to enhance radioiodine therapy for shrinking multinodular goitre. The aim of this meta-analysis was to compare the effectiveness of rhTSH pretreatment and radioiodine therapy with that of radioiodine alone for treating benign nodular goitre.

METHODS

The PubMed, EMBASE, Cochrane Library, Scopus and ClinicalTrials.gov databases were searched to identify studies published before September 2014. A meta-analysis was performed to calculate the pooled effect size using random-effects models. The primary outcome was the reduction in thyroid volume. Secondary outcomes included thyroid function, extent of tracheal compression, radioactive iodine uptake, incidence of hypothyroidism and other complications.

RESULTS

Nine RCTs including 416 patients were selected. The reductions in thyroid volume were significantly greater in the rhTSH pretreatment groups than those in the radioiodine alone groups at 12 months (weighted mean difference: 14·42%; 95% CI: 4·51-24·34% in high-dose rhTSH vs radioiodine alone; weighted mean difference: 19·66%; 95% CI: 3·67-35·65% in low-dose rhTSH vs radioiodine alone). The incidence of hypothyroidism in the high-dose rhTSH groups was significantly higher than that in the radioiodine alone groups. No significant difference in the incidence of hypothyroidism occurred between the low-dose rhTSH groups and the radioiodine alone groups.

CONCLUSIONS

The overall results indicated that using rhTSH before radioiodine therapy resulted in a greater thyroid volume reduction than radioiodine therapy alone. An increased incidence of hypothyroidism was observed in patients receiving high-dose rhTSH. Low-dose rhTSH before radioiodine therapy is more efficacious than radioiodine therapy alone for treating nontoxic benign thyroid nodules.

Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer

BACKGROUND

Previous guidelines for the management of thyroid nodules and cancers were geared toward adults. Compared with thyroid neoplasms in adults, however, those in the pediatric population exhibit differences in pathophysiology, clinical presentation, and long-term outcomes. Furthermore, therapy that may be recommended for an adult may not be appropriate for a child who is at low risk for death but at higher risk for long-term harm from overly aggressive treatment. For these reasons, unique guidelines for children and adolescents with thyroid tumors are needed.

METHODS

A task force commissioned by the American Thyroid Association (ATA) developed a series of clinically relevant questions pertaining to the management of children with thyroid nodules and differentiated thyroid cancer (DTC). Using an extensive literature search, primarily focused on studies that included subjects ≤18 years of age, the task force identified and reviewed relevant articles through April 2014. Recommendations were made based upon scientific evidence and expert opinion and were graded using a modified schema from the United States Preventive Services Task Force.

RESULTS

These inaugural guidelines provide recommendations for the evaluation and management of thyroid nodules in children and adolescents, including the role and interpretation of ultrasound, fine-needle aspiration cytology, and the management of benign nodules. Recommendations for the evaluation, treatment, and follow-up of children and adolescents with DTC are outlined and include preoperative staging, surgical management, postoperative staging, the role of radioactive iodine therapy, and goals for thyrotropin suppression. Management algorithms are proposed and separate recommendations for papillary and follicular thyroid cancers are provided.

CONCLUSIONS

In response to our charge as an independent task force appointed by the ATA, we developed recommendations based on scientific evidence and expert opinion for the management of thyroid nodules and DTC in children and adolescents. In our opinion, these represent the current optimal care for children and adolescents with these conditions.

Levothyroxine or minimally invasive therapies for benign thyroid nodules

BACKGROUND

Thyroid nodules (TN) are common in the adult population. Some physicians use suppressive levothyroxine (LT4) therapy to achieve a reduction in the number and volume of TN. In addition, minimally invasive treatments, such as percutaneous ethanol injection (PEI) sclerotherapy, laser photocoagulation (LP), and microwave (MW), radiofrequency (RF) and high-intensity focused ultrasound (HIFU) ablation, have been proposed, especially for pressure symptoms and cosmetic complaints, as an alternative to surgery. However, the risk to benefit ratio of all treatments for benign TN is currently unknown.

OBJECTIVES

To assess the effects of LT4 or minimally invasive therapies (PEI, LP, and RF/HIFU/MW ablation) on benign TN.

SEARCH METHODS

We identified studies from computerised searches of The Cochrane Library, MEDLINE, EMBASE and LILACS (all performed up to April 2014). We also searched trial registers, examined reference lists of included randomised controlled trials (RCTs) and systematic reviews, and contacted study authors.

SELECTION CRITERIA

We included studies if they were RCTs of LT4, PEI, LP, RF, HIFU or MW therapy in participants with an established diagnosis of benign TN. We excluded trials investigating the prevention of recurrence of thyroid disease after surgery, irradiation or treatment with radioiodine.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, assessed studies for risk of bias and evaluated overall study quality utilising the GRADE instrument. We assessed the statistical heterogeneity of included studies by visually inspecting forest plots and quantifying the diversity using the I² statistic. We synthesised data using random-effects model meta-analysis or descriptive analysis, as appropriate.

MAIN RESULTS

Thirty-one studies randomised 2952 outpatients to investigate the effects of different therapies on benign TN. Studies on LT4, PEI, LP and RF ablation therapy randomised 2083, 607, 192 and 70 participants, respectively. We found no RCTs of HIFU or MW ablation therapy in benign TN. The duration of treatment varied according to the applied therapies: up to five years for LT4 and one to three PEI ablations, one to three LP sessions and one or two RF sessions. Median follow-up was 12 months for LT4 and six months for minimally invasive therapies. Evidence was of low-to-moderate quality, and risk of performance and detection bias for subjective outcomes was high in most trials.No study evaluated all-cause mortality or health-related quality of life. Only one LT4 study provided some data on the development of thyroid cancer, reporting no abnormal cytological findings. One LP study provided limited information on costs of treatment.LT4 compared with no treatment or placebo was associated with a nodule volume reduction of 50% or more in 16% compared with 10% of participants after 6 to 24 months of follow-up (risk ratio (RR) 1.57 (95% confidence interval (CI) 1.04 to 2.38); P = 0.03; 958 participants; 10 studies; moderate-quality evidence). Pressure symptoms or cosmetic complaints were not investigated in LT4 studies. LT4 therapy was generally well tolerated: three studies provided quantitative data on signs and symptoms of hyperthyroidism, which were observed in 25% of LT4-treated versus 7% of placebo-treated participants at 12 to 18 months of follow-up (269 participants; 3 trials; low-quality evidence).PEI compared with cyst aspiration only was associated with a nodule volume reduction of 50% or more in 83% compared with 44% of participants after 1 to 24 months of follow-up (RR 1.83 (95% CI 1.32 to 2.54); P = 0.0003; 105 participants; 3 studies; low-quality evidence). Improvements in neck compression symptoms after 6 to 12 months of follow-up were seen in 78% of participants receiving PEI versus 38% of those in comparator groups. No reliable summary effect estimate could be established, RR ranged from 1.0 to 3.06 in favour of PEI (370 participants; 3 trials; low-quality evidence). In all trials, participants experienced periprocedural cervical tenderness and light-to-moderate pain usually lasting from minutes to several hours. As a result of the PEI procedure, 26% of participants reported slight-to-moderate pain compared with 12% of those receiving cyst aspiration only (RR 1.78 (95% CI 0.62 to 5.12); P = 0.28; 104 participants; 3 studies; low-quality evidence).One study comparing LP with LT4 showed a nodule volume reduction of 50% or more in favour of LP after 12 months of follow-up in 33% of LP participants versus 0% of LT4 participants, respectively (62 participants; 1 trial; low-quality evidence). A total of 82% of LP-treated versus 0% of untreated participants showed improvements in pressure symptoms after 6 to 12 months of follow-up (RR 26.65 (95% CI 5.47 to 129.72); P < 0.0001; 92 participants; 3 trials; low-quality evidence). Around 20% of LP-treated participants reported light-to-moderate cervical pain lasting 48 hours or more (97 participants; 3 trials; low-quality evidence).One trial with 40 participants, comparing RF with no treatment, resulted in a mean nodule volume reduction of 76% in the RF group compared with 0% of those in the no-treatment group at six months of follow-up (low-quality evidence). These RF-treated participants had fewer pressure symptoms and cosmetic complaints after 12 months of follow-up compared with untreated participants (a 2.8 decrease versus a 1.1 increase on a six-point scale, respectively, with higher values indicating more severe symptoms; low-quality evidence). All participants complained of pain and discomfort during RF, which disappeared when the energy was reduced or turned off (low-quality evidence).

AUTHORS' CONCLUSIONS

No study evaluated all-cause mortality, health-related quality of life or provided systematic data on the development of thyroid cancer. Longest follow-up was five years and median follow-up was 12 months. Nodule volume reductions were achieved by PEI, LP and RF, and to a lesser extent, by LT4. However, the clinical relevance of this outcome measure is doubtful. PEI, LP and RF led to improvements in pressure symptoms and cosmetic complaints. Adverse events such as light-to-moderate periprocedural pain were seen after PEI, LP and RF. Future studies should focus on patient-important outcome measures, especially health-related quality of life, and compare minimally invasive procedures with surgery. RCTs with follow-up periods of several years and good-quality observational studies are needed to provide evidence on the development of thyroid cancer, all-cause mortality and long-term adverse events.

Treatment with thyroid hormone

Thyroid hormone deficiency can have important repercussions. Treatment with thyroid hormone in replacement doses is essential in patients with hypothyroidism. In this review, we critically discuss the thyroid hormone formulations that are available and approaches to correct replacement therapy with thyroid hormone in primary and central hypothyroidism in different periods of life such as pregnancy, birth, infancy, childhood, and adolescence as well as in adult patients, the elderly, and in patients with comorbidities. Despite the frequent and long term use of l-T4, several studies have documented frequent under- and overtreatment during replacement therapy in hypothyroid patients. We assess the factors determining l-T4 requirements (sex, age, gender, menstrual status, body weight, and lean body mass), the major causes of failure to achieve optimal serum TSH levels in undertreated patients (poor patient compliance, timing of l-T4 administration, interferences with absorption, gastrointestinal diseases, and drugs), and the adverse consequences of unintentional TSH suppression in overtreated patients. Opinions differ regarding the treatment of mild thyroid hormone deficiency, and we examine the recent evidence favoring treatment of this condition. New data suggesting that combined therapy with T3 and T4 could be indicated in some patients with hypothyroidism are assessed, and the indications for TSH suppression with l-T4 in patients with euthyroid multinodular goiter and in those with differentiated thyroid cancer are reviewed. Lastly, we address the potential use of thyroid hormones or their analogs in obese patients and in severe cardiac diseases, dyslipidemia, and nonthyroidal illnesses.

Thyroid nodules and differentiated thyroid cancer: update on the Brazilian consensus

Thyroid nodules are frequent findings, especially when sensitive imaging methods are used. Although thyroid cancer is relatively rare, its incidence is increasing, particularly in terms of small tumors, which have an uncertain clinical relevance. Most patients with differentiated thyroid cancer exhibit satisfactory clinical outcomes when treatment is appropriate, and their mortality rate is similar to that of the overall population. However, relapse occurs in a considerable fraction of these patients, and some patients stop responding to conventional treatment and eventually die from their disease. Therefore, the challenge is how to identify the individuals who require more aggressive disease management while sparing the majority of patients from unnecessary treatments and procedures. We have updated the Brazilian Consensus that was published in 2007, emphasizing the diagnostic and therapeutic advances that the participants, representing several Brazilian university centers, consider most relevant in clinical practice. The formulation of the present guidelines was based on the participants' experience and a review of the relevant literature.

Serum TSH and risk of papillary thyroid cancer in nodular thyroid disease

CONTEXT

TSH is the main factor involved in the control of proliferation of thyrocytes. Recently, a strong relationship between serum TSH and risk of thyroid malignancy has been reported.

OBJECTIVES

The aim was to review published papers about the relationship between serum TSH and frequency of differentiated thyroid cancer.

EVIDENCE ACQUISITION

PubMed was used to identify studies focused on the relationship between TSH and differentiated thyroid cancer.

EVIDENCE SYNTHESIS

In patients with nodular thyroid disease, the risk of thyroid malignancy increases with serum TSH, and even within normal ranges, higher TSH values are associated with a higher frequency and more advanced stage of thyroid cancer. The likelihood of papillary thyroid carcinoma is reduced when TSH is lower, as in thyroid autonomy, and increased when TSH is higher, as in thyroid autoimmunity. Treatment with l-thyroxine (LT4), which reduces serum TSH, is associated with significantly lower risk of developing clinically detectable thyroid cancer.

CONCLUSIONS

TSH plays a key role in the development of clinically detectable thyroid cancer, and LT4 treatment reduces the risk of thyroid malignancy in patients with nodular thyroid disease. According to the guidelines of the main scientific societies, LT4 therapy is not currently recommended for the treatment of patients with nodular goiter. Even if the available data are not sufficient to advise LT4 treatment in all patients with nodular goiter with the aim of reducing the risk of papillary thyroid carcinoma, we propose that this indication should be reconsidered, taking into account recent evidence reported in the literature.

Reduction of thyroid nodule volume by levothyroxine and iodine alone and in combination: a randomized, placebo-controlled trial

CONTEXT

Nodular goiter is common worldwide, but there is still debate over the medical treatment.

OBJECTIVE

The objective of the study was the measurement of the effect of a treatment with (nonsuppressive) T(4), iodine, or a combination of both compared with placebo on volume of thyroid nodules and thyroid.

DESIGN

This was a multicenter, randomized, double-blind trial in patients with nodular goiter in Germany [LISA (Levothyroxin und Iodid in der Strumatherapie Als Mono-oder Kombinationstherapie) trial].

SETTING

The study was conducted in outpatient clinics in university hospitals and regional hospitals and private practices.

PARTICIPANTS

One thousand twenty-four consecutively screened and centrally randomized euthyroid patients aged 18-65 yr with one or more thyroid nodules (minimal diameter 10 mm) participated in the study.

INTERVENTION

Intervention included placebo, iodine (I), T(4), or T(4)+I for 1 yr. T(4) doses were adapted for a TSH target range of 0.2-0.8 mU/liter.

OUTCOME MEASURES

The primary end point was percent volume reduction of all nodules measured by ultrasound, and the main secondary end point was a change in goiter volume.

RESULTS

Nodule volume reductions were -17.3% [95% confidence interval (CI) -24.8/-9.0%, P < 0.001] in the T(4)+I group, -7.3% (95% CI -15.0/+1.2%, P = 0.201) in the T(4) group, and -4.0% (95% CI -11.4/+4.2%, P = 0.328) in the I group as compared with placebo. In direct comparison, the T(4)+I therapy was significantly superior to T(4) (P = 0.018) or I (P = 0.003). Thyroid volume reductions were -7.9% (95% CI -11.8/-3.9%, P < 0.001), -5.2% (95% CI -8.7/-1.6%, P = 0.024) and -2.5% (95% CI -6.2/+1.4%, P = 0.207), respectively. The T(4)+I therapy was significantly superior to I (P = 0.034) but not to T(4) (P = 0.190).

CONCLUSION

In a region with a sufficient iodine supply, a 1-yr therapy with a combination of I and T(4) with incomplete suppression of thyrotropin reduced thyroid nodule volume further than either component alone or placebo.

Guidelines of the French society of endocrinology for the management of thyroid nodules

The present document is a follow-up of the clinical practice guidelines of the French Society of Endocrinology, which were established for the use of its members and made available to scientific communities and physicians. Based on a critical analysis of data from the literature, consensuses and guidelines that have already been published internationally, it constitutes an update of the report on the diagnostic management of thyroid nodules that was proposed in France, in 1995, under the auspices of the French National Agency for Medical Evaluation (l'Agence nationale d'évaluation médicale). The current guidelines were deliberated beforehand by a number of physicians that are recognised for their expertise on the subject, coming from the specialities of endocrinology (the French Thyroid Research Group) and surgery (the French Association for Endocrine Surgery), as well as representatives from the fields of biology, ultrasonography, cytology and nuclear medicine. The guidelines were presented and submitted for the opinion of the members of the Society at its annual conference, which was held in Nice from 7-10 October 2009. The amended document was posted on the website of the Society and benefited from additional remarks of its members. The final version that is presented here was not subjected to methodological validation. It does not claim to be universal in its scope and will need to be revised in concert with progress made in technical and developmental concepts. It constitutes a document that the Society deems useful for distribution concerning the management of thyroid nodules, which is current, efficient and cost effective.

Thyroxine suppression therapy for benign, non-functioning solitary thyroid nodules: a quality-effects meta-analysis

Levothyroxine (LT4) suppressive therapy for solitary thyroid nodules is not popularly advocated presently because its clinical efficacy and safety are currently considered controversial. This meta-analysis aims to address efficacy issues by using rigorous methods to arrive at a pooled estimate. On the basis of the analysis, it is estimated that LT4 therapy is clearly associated with up to a two-fold increase in the chance of nodule reduction. This translates to a number needed to treat (NNT) of 6 or a 50% decrease in the risk of cancer given nodule reduction. Keeping this definition of efficacy in mind and a low incidence of adverse events with low level LT4 suppression, such an intervention might be appropriate in patients selected on the basis of a low risk for adverse effects.

The patient with a thyroid nodule

Nodular thyroid disease is common in the United States and throughout the world. Although most thyroid nodules are benign in nature, certain clinical, radiographic, and cytologic features are associated with an increased risk of malignancy. A clear understanding of these risk factors assists in the decision-making process when evaluating a patient with a thyroid nodule. It is this process that ultimately determines whether or not a patient is referred for surgery. This article provides a framework for clinicians to risk-stratify and appropriately manage patients with thyroid nodules.

Benign predominantly solid thyroid nodules: prospective study of efficacy of sonographically guided radiofrequency ablation versus control condition

OBJECTIVE

The purpose of this study was to evaluate the efficacy of radiofrequency ablation of benign predominantly solid thyroid nodules by comparing the findings in treatment and control groups.

SUBJECTS AND METHODS

Thirty patients with normal thyroid function, each with a benign predominantly (> 50%) solid thyroid nodule causing pressure symptoms or cosmetic problems, were assigned to a control group (n = 15) or to a group undergoing a single session of radiofrequency ablation (n = 15). Thyroid nodule volume, thyroid function, pressure symptoms, and cosmetic concerns were evaluated before treatment and during follow-up. Sonographically guided radiofrequency ablation was performed with an internally cooled electrode (1-cm active tip) with an output power of 30-80 W.

RESULTS

The control group had no resolution of symptoms or cosmetic problems. The mean nodule volume increased slightly after 6 months but without statistical significance (p = 0.46). In the radiofrequency ablation group, the mean symptom score (p = 0.001) and cosmetic grade (p = 0.001) improved significantly. Mean nodule volume decreased significantly from 7.5 +/- 4.9 mL (range, 1.7-20.0 mL) to 1.3 +/- 0.8 mL (range, 0.2-2.6 mL) 6 months after radiofrequency ablation (p = 0.001). There were no major complications of ablation.

CONCLUSION

This study confirmed that radiofrequency ablation is effective for reducing nodule volume and relieving nodule-related clinical problems and that an effect due to spontaneous nodule reduction can be excluded owing to the results of the comparison with a similar control group.

Time to reconsider nonsurgical therapy of benign non-toxic multinodular goitre: focus on recombinant human TSH augmented radioiodine therapy

The treatment of benign multinodular goitre (MNG) is controversial, but surgery is recommended in large compressive goitres. While some patients decline surgery others may have contraindications due to comorbidity, since MNG is prevalent in the elderly. Therefore, non-surgical treatment alternatives are needed. Until recently, levothyroxine therapy was the preferred non-surgical alternative, but due to low efficacy and potential side-effects, it is not recommended for routine use in recent international guidelines. Conventional radioiodine ((131)I) therapy has been used for two decades as an effective and safe alternative to surgery in the treatment of symptomatic non-toxic MNG. Since much higher activities of (131)I are employed when treating non-toxic rather than toxic MNG, there has been reluctance in many countries to use this treatment modality. Frequently, the (131)I -uptake in a non-toxic MNG is low, which makes (131)I therapy less feasible. Another challenge is the negative correlation between the initial goitre size and goitre volume reduction (GVR). With its ability to more than double the thyroid (131)I-uptake, recombinant human TSH (rhTSH) increases the absorbed radiation dose and thus enhances the GVR by 35-56% at the expense of up to fivefold higher rate of permanent hypothyroidism. An alternative strategy is to reduce the administered (131)I-activity with a factor corresponding to the rhTSH induced increase in (131)I-uptake. Hereby, the extrathyroidal irradiation can be reduced without compromising efficacy. Thus, although in its infancy, and still experimental, rhTSH-augmented (131)I therapy may profoundly alter the non-surgical treatment of benign non-toxic MNG.

The majority of Danish nontoxic goitre patients are ineligible for Levothyroxine suppressive therapy

OBJECTIVE

Levothyroxine suppressive therapy (LT4-therapy), aimed at shrinking thyroid nodules is controversial. Despite evidence of limited effect and long-term side-effects, questionnaire surveys indicate widespread use. Our aim was to determine, in consecutive nontoxic goitre patients, the proportion ineligible for LT4-therapy. Exclusion criteria were set up in agreement with recent guidelines.

SETTING

Secondary/tertiary referral centre at University Clinic.

SUBJECTS AND METHODS

During 1997-2001, 822 patients were referred to our endocrine unit on suspicion of nontoxic goitre. Patients were evaluated clinically including fine needle aspiration biopsy, thyroid scintigraphy and ultrasound. Seven-hundred and forty-five patients (627 women and 118 men; median age 47 years, range 11-90) were potential candidates for LT4-therapy. Based on guidelines we defined conditions where LT4-therapy is contraindicated. Exclusion criteria included (1) Serum TSH < 1.0 mIU/l, (2) Post-menopausal status, or males older than 60 years, (3) Thyroid volume above 100 ml, (4) Intrathoracic goitre, (5) Clinical suspicion of malignancy, (6) Dominant thyroid cyst, (7) Nondiagnostic FNA, (8) Previous ineffective LT4-therapy, (9) Elevated serum calcitonin, (10) Osteoporosis or cardiovascular disease.

RESULTS

Of patients 84% were ineligible for LT4-therapy. In diffuse goitre (n = 35) 63%, in uninodular goitre (n = 320) 77% and in multinodular goitre (n = 390) 91% were ineligible. Main ineligibility reasons were a low serum TSH, post-menopausal status, a large goitre or clinical suspicion of malignancy.

CONCLUSION

The vast majority of consecutive Danish nontoxic goitre patients (84%) were ineligible for LT4-therapy. Due to low efficacy and potential long-term adverse effects on the skeleton and cardiovascular system we strongly advocate against LT4-therapy for nontoxic goitre.

Evaluation of meta-analyses in the otolaryngological literature

OBJECTIVE: To evaluate the quality of meta-analyses written on otolaryngological topics and define areas that can be improved upon in future studies.

DATA SOURCES: MEDLINE (PubMed) and EMBASE databases were searched. The Cochrane database of systematic reviews was excluded, because these meta-analyses have already been critically evaluated and found to be of high quality.

REVIEW METHODS: A systematic review of otolaryngological meta-analyses published between 1997 and 2006 (10 years) was performed in duplicate and independently by two authors. The search included 16 common otolaryngological terms. Inclusion criteria were meta-analytic methodology, otolaryngological topic, and at least one author from a department of otolaryngology. Fifty-one articles fulfilled eligibility criteria. In duplicate and independently, two reviewers assessed the quality of eligible metaanalyses using a validated 10-item index called the Overview Quality Assessment Questionnaire. Using the methods of Spearman, correlation coefficients are reported for associations examined between covariates and the Overall Score Quality.

RESULTS: The majority of studies had methodologic flaws (mean score 3.9, scale of 1-7). Variables predicting higher-quality meta-analyses were publication in journals with higher impact factors ( P = 0.0007) and authors who previously published metaanalyses ( P = 0.0001). Using and reporting about a validity assessment tool needs to be improved upon in future studies.

CONCLUSION: The quality of meta-analyses on otolaryngological topics is moderate. Future meta-analyses can be improved upon by following evidence-based guidelines for the reporting of metaanalyses, which include the use of a validity assessment tool, and consulting with an author familiar with meta-analysis methodology.

Thyroxine therapy in euthyroid patients does not affect body composition or muscular function

OBJECTIVE

The main objective of the study was to evaluate the effects of small increments in thyroxine (T4) levels following levothyroxine (L-T4) administration on the body composition of women patients. The secondary objective was to assess the effect of the therapy on energy expenditure and muscular function.

METHODS

The prospective, randomized study consisted of a 12-month follow-up of 37 women with thyroid nodules. The patients were divided into two groups for comparison, one treated with L-T4 (20 women) and the other untreated (17 women). L-T4 dose was individually adjusted to obtain a serum thyroid-stimulating hormone in the lower portion of the normal range. Multiple tests, including bioelectrical impedance analysis, dual-energy X-ray absorptiometry, air displacement plethysmography, measurement of waist circumference, and skinfold anthropometry, were used to investigate the muscular, fat, and water compartments; energy expenditure and muscular function were assessed by cycle ergometry.

RESULTS

There were no significant differences in body composition, heart rate, energy metabolism, or muscular function between the group of women treated with L-T4 and the untreated group.

CONCLUSION

The controlled increase of circulating T4 does not appear to modify the body composition or muscular function in women patients.

Differences between endocrinologists and endocrine surgeons in management of the solitary thyroid nodule

BACKGROUND

It is not known whether management of the solitary thyroid nodule differs between endocrinologists and endocrine surgeons.

METHODS

A questionnaire containing a hypothetical case (a 42-year-old euthyroid woman with a 2-x-3-cm solitary thyroid nodule) and 13 clinical variations was sent to endocrinologists and endocrine surgeons in Australia.

RESULTS

The response rate was 51%, including 122 endocrinologists and 48 endocrine surgeons. For the index case, serum thyroid-stimulating hormone (TSH), fine needle aspiration biopsy (FNAB) and ultrasonography were widely used by both groups, but thyroid antibody tests and scintigraphy were ordered more commonly by endocrinologists. In the setting of benign cytology, treatment differed significantly between specialties for the index case (endocrinologists: no treatment 78%, surgery 11%, thyroxine 11%; surgeons: no treatment 73%, surgery 25%, thyroxine 2%; P = 0.032). Treatment recommendations also differed significantly for 12 of the 13 clinical variations. In particular, for a patient with a suppressed serum TSH concentration, a majority of endocrinologists recommended radioiodine treatment, whereas surgeons favoured surgery (endocrinologists: radioiodine 53%, surgery 22%, no treatment 25%; surgeons: surgery 60%, radioiodine 11%, no treatment 27%; P < 0.001). For most of the variations, a higher proportion of surgeons than endocrinologists recommended surgical treatment. Comparison with previous surveys of European Thyroid Association and American Thyroid Association members (predominantly endocrinologists) demonstrated considerable international differences in management.

CONCLUSION

There are clinically significant differences between Australian endocrinologists and endocrine surgeons in management of the solitary thyroid nodule, and international differences in management of this disorder.

Treatment of benign cold thyroid nodules: a randomized clinical trial of percutaneous laser ablation versus levothyroxine therapy or follow-up

AIM OF THE STUDY

To compare clinical and ultrasound (US) changes induced in cold thyroid nodules by US-guided percutaneous laser ablation (PLA) versus follow-up or levothyroxine (LT4) suppressive therapy.

METHODS

62 patients randomly assigned to a single PLA (Group 1), LT4 (Group 2), or follow-up (Group 3). Entry criteria: euthyroid patients with a solid thyroid nodule >5 mL and benign cytological findings.

TREATMENT

Group 1: PLA was performed with a 1.064 mum neodymium yttrium-aluminum-garnet laser with output power of 3 W for 10 minutes; Group 2: the LT4 dose was adjusted to induce thyrotropin suppression; Group 3: no treatment.

RESULTS

In Group 1 a significant nodule reduction was found 6 and 12 months after PLA (delta volume: -42.7 +/- 13.6%; p = 0.001). A reduction >50% was found in 33.3% of cases. In Group 2 a nonsignificant nodule shrinkage was observed. A nonsignificant volume increase was observed in Group 3. Improvement of local symptoms was registered in 81.2% of patients in Group 1 vs. 13.3% in Group 2 and 0.0% in Group 3 ( p = 0.001). No complications were noted.

CONCLUSIONS

A single PLA induced significant volume reduction and improvement of local symptoms. PLA was more effective than LT4. Follow-up was associated with nodule growth and progression of local symptoms. PLA should be considered a potential mini-invasive alternative to surgery in symptomatic patients with benign cold thyroid nodules.

Factors related to the recurrence of thyroid nodules after surgery for benign radiation-related nodules

OBJECTIVE

Benign thyroid nodules are increased by radiation exposure and recurrences are common. The goal of this study was to determine the factors related to recurrence of nodular disease and the efficacy of thyroid hormone therapy in reducing them.

DESIGN, SETTING, AND SUBJECTS

The study population was drawn from a cohort of 4296 people treated before the age of 16 with conventional external radiation for benign conditions of the head and neck between 1939 and the early 1960s. The study group consisted of 632 subjects who had benign nodules removed surgically. At the discretion of their physicians, 426 subjects were treated with thyroid hormone after surgery, 198 were not, and in 8 subjects, thyroid hormone treatment status was unknown.

MAIN OUTCOMES

There were 129 (20.4%) subjects who developed new nodules during follow-up. Women had a greater risk of recurrent nodules than men (27.5% vs. 13.5%) and the rate of recurrence correlated inversely with the extent of surgery. The group who took thyroid hormone had a lower recurrence rate than the untreated group (14.2% vs. 34.2%). The risk of recurrence was reduced to 0.69 (0.47-1.01) in thyroid hormone-treated subjects, regardless of extent of surgery, and to 0.66 (0.46-0.97) when only the subjects with less than 75% of their thyroid removed were considered.

CONCLUSION

Thyroid hormone therapy reduced recurrences in this irradiated cohort. It should be recommended to all patients with irradiated thyroids and previous thyroid surgery.

Progress in the preoperative diagnosis of thyroid nodules: managing uncertainties and the ultimate role for molecular investigation

The preoperative evaluation of thyroid nodules currently relies on a clinical assessment of risk factors and an algorithm based on imprecise tests. With serum TSH, thyroid ultrasound and fine-needle aspiration (FNA) with or without ultrasound guide, accounting for the routine initial evaluation, indeterminate aspirates remain the major obstacle for confidently advising patients whether to have surgery or not. Recent clinical guidelines have attempted to settle various controversies but many inherent errors of clinical testing result in delayed diagnosis and unnecessary surgery. A better solution may ultimately involve the use of molecular markers of thyroid carcinogenesis but further research is still needed regarding the basic biology of thyroid cancer.