Treatment of Graves' disease: the American way

Change in Practice over Four Decades in the Management of Graves' Disease in Scotland

There is continuing debate on the optimal treatment for Grave's thyrotoxicosis with a resultant variation in clinical practice. The present study aimed to ascertain changes in practice in the treatment of Grave's thyrotoxicosis in Tayside, Scotland, over the past four decades. Methods. The “Scottish automated follow-up register” (SAFUR) was queried to identify all patients treated for Grave's thyrotoxicosis from 1968 to 2007 inclusive. Patients were divided into 4 groups (Groups A to D) according to the decades. Demographic profile, treatment modalities, radioactive iodine (RAI) dose, and recurrence rates were studied and outcomes were compared by χ² test and ANOVA using SPSS v15.0. A p value of < 0.05 was considered significant. Results. Altogether, 3737 patients were diagnosed with Grave's thyrotoxicosis over the 4 decades. Use of RAI has increased from 43.1% in Group A to 68% in Group D (p < 0.001). The dose of RAI has increased (p < 0.001) and there has been a reduction in recurrence rate with higher dose of RAI. Surgical intervention rates decreased from 55.3% to 12.3% (p < 0.001) over time. Conclusions. Analysis of a large dataset of patients with Grave's thyrotoxicosis suggests increasing use of RAI as the preferred first line of treatment. Furthermore, using a single higher dose of RAI and adoption of total thyroidectomy have decreased recurrence rates.

Is subtotal thyroidectomy a cost-effective treatment for Graves disease? A cost-effectiveness analysis of the medical and surgical treatment options

BACKGROUND

The 3 treatment options for Graves disease (GD) are antithyroid drugs (ATDs), radioactive iodine (RAI), and thyroid surgery. We hypothesized that thyroid surgery is cost-effective for Graves disease when compared to RAI or ATD.

METHODS

Cost-effectiveness analysis was performed to compare operative strategies to medical treatment strategies for GD. The decision model, based on a reference case, included treatment outcomes, probabilities, and costs derived from literature review. Outcomes were weighted using quality of life utility factors, yielding quality-adjusted life years (QALYs). The uncertainty of costs, probabilities, and utility estimates in the model were examined by univariate and multivariate sensitivity analysis and Monte Carlo simulation.

RESULTS

The subtotal thyroidectomy strategy produced the greatest QALYs, 25.783, with an incremental cost-effectiveness ratio of $26,602 per QALY, reflecting a gain of 0.091 QALYs at an additional cost of $2416 compared to RAI. Surgery was cost-effective when the initial postoperative euthyroid rate was greater than 49.5% and the total cost was less than $7391. Monte Carlo simulation showed the subtotal thyroidectomy strategy to be optimal in 826 of 1000 cases.

CONCLUSION

This study demonstrates that subtotal thyroidectomy can be a cost-effective treatment for GD. However, a 49.5% initial postoperative euthyroid rate was a necessary condition for cost-effective surgical management of GD.

Functional capacity of the thyroid autograft and heterograft: An experimental study

BACKGROUND

The aim of this study was to investigate the functional capacity of thyroid autografts/heterografts in a guinea pig model.

METHODS

A total of 24 guinea pigs were divided into 4 groups. Group A had only a thyroidectomy incision, and group B had total thyroidectomy. We performed autotransplantation in group C and heterotransplantation in group D. We monitored the guinea pigs for an 8-week period, with weekly measurements of free triiodothyronine (fT3), free thyroxine (fT4), and thyroid-stimulating hormone (TSH). At the final stage, the autografts/heterografts were histologically examined.

RESULTS

In group B, fT3/fT4 showed a gradual decrease; however, an increase of TSH was noted. In groups C and D, fT3/fT4 showed a gradual decrease, followed by a gradual increase until euthyroid levels; an exact opposite was noted for TSH. In histologic examination, there were functional thyroid follicles in all animals of groups C and D.

CONCLUSIONS

The autotransplanted/heterotransplanted guinea pig's thyroid tissue provides adequate thyroid function.

Mudanças evolutivas no tratamento da doença de Graves com iodo radioativo: 12 anos de experiência em um hospital universitário

OBJETIVO: Avaliar a mudança no perfil e abordagem dos pacientes com doença de Graves submetidos a dose terapêutica de radioiodo. MATERIAIS E MÉTODOS: Avaliamos, retrospectivamente, 226 pacientes portadores de doença de Graves submetidos a dose terapêutica de radioiodo entre janeiro de 1990 e dezembro de 2001. O período de 12 anos foi dividido em três períodos de 4 anos para fins de análise estatística, sendo comparadas variáveis clínicas e laboratoriais nos períodos descritos. RESULTADOS: Constatamos que o número de pacientes encaminhados para a dose terapêutica, assim como o percentual de pacientes do sexo feminino (de 62% para 86%; p = 0,005), tiveram incremento significativo. Houve aumento significativo no percentual de pacientes em uso de metimazol previamente à dose terapêutica (de 9,1% para 35,6%; p = 0,03). A dose média de iodo administrada também teve incremento significativo (de 7,6 mCi para 12,7 mCi; p = 0,000003), com reflexo direto em um maior percentual de pacientes curados (de 55,6% para 83,7%; p = 0,004) um ano pós-dose terapêutica. CONCLUSÃO: A dose terapêutica de radioiodo tem sido um método cada vez mais aceito nos pacientes com doença de Graves e a dose administrada tem sido cada vez maior, no intuito de cura permanente e diminuição das chances de recidiva.

Apoptotic study in Graves disease treated with thyroid arterial embolization

OBJECTIVE

To investigate apoptosis in the thyroid of Graves disease (GD) induced by thyroid arterial embolization.

MATERIALS AND METHODS

Forty one patients with clinically and laboratorily ascertained GD were treated with thyroid arterial embolization and followed up for 3-54 months following embolization. Prior to embolization and at 1, 3, 6, 12 and 36 months following embolization, thyroid autoimmunue antibodies were tested respectively, including thyroid stimulating antibody (TSAb), thyroglobulin antibody (TGAb) and thyroid microsomal antibody (TMAb). Thyroid biopsy was performed under the guidance of computed tomography for immunohistochemistry examination using semi-quantity analysis.

RESULTS

The positive staining of Fas and FasL was mostly in the cytoplasma and cell membrane, the positive expression of Bax was mainly in the cytoplasma, and no positive expression of P53 was detected in the thyroid cells before embolization. After arterial embolziation, the positive cell number and staining degree of these genes were both greater than before embolization.

CONCLUSION

The treatment method of thyroid arterial embolization can effectively enhance the positive expression of pro-apoptotic genes of Fas, FasL, Bax, Bcl-2 and P53 in GD thyroid, thus promoting apoptosis of GD thyroid and helping restore the thyroid size and function to normal conditions.

Long-term immunological study in Graves' disease treated with thyroid arterial embolization

OBJECTIVE

The aim of this study was to investigate long-term immunological changes after the treatment of Graves' disease (GD) with thyroid arterial embolization and the effect of thyroid arterial embolization on the body's immunological functions.

MATERIALS AND METHODS

Forty-one patients with clinically and laboratorily ascertained GD were treated with thyroid arterial embolization and followed up for 3-54 months following embolization. Prior to embolization and at 1, 3, 6, 12, and 36 months following embolization, thyroid autoimmune antibodies were tested respectively, including thyroid stimulating antibody (TSAb), thyrotropin antibody (TRAb), thyroglobulin antibody (TGAb), and thyroid microsomal antibody (TMAb), as well as subgroup lymphocytes of CD16+CD56+, CD19+, CD3+, CD3+CD4+ and CD3+CD8+. The autoimmune status of GD patients prior to embolization and the dynamic changes of the immunological function after embolization were analyzed.

RESULTS

The therapy of thyroid arterial embolization could effectively decrease the activity/titer and positive rate of TRAb and the ratio of CD4+/ CD8+ to normal levels at 6 months following embolization, while the ratio of CD3+CD8+ increased gradually to normal level at 1 year following embolization. In patients with recurrence, TSAb and TRAb remained at a higher level, while the rate of CD3+CD8+ and the ratio of CD4+/CD8+ were not statistically significantly different from those before embolization.

CONCLUSION

Immunological functional disorder exists in GD patients. The treatment method of thyroid arterial embolization can effectively resume the basic immunological function to normal range while patients with recurrence have no significant improvement, suggesting that thyroid arterial embolization has an effective role in adjusting the immunological function.

Surgical management of Graves' disease -10-year prospective trial at a single institution

The extent of thyroidectomy in Graves' disease is still controversial. In our institution, long term euthyroidism without thyroxine replacement therapy has been aimed and, thus, subtotal thyroidectomy has been employed. We prospectively studied whether the surgical outcome was improved by a strategy of leaving smaller thyroid remnants. Between 1989 and 1998, 1897 patients with Graves' disease were treated by subtotal thyroidectomy and their thyroid function could be determined 2 to 3 years after thyroidectomy. The 10-year period was divided into 3 parts, '89-'91 (Period 1, n = 690), '92-'94 (Period 2, n = 587) and '95-'98 (Period 3, n = 620). Different maximum thyroid remnant sizes were prospectively established for each period: up to 7 g left in Period 1, up to 6 g in Period 2 and up to 5 g in Period 3. Thyroid function 2 to 3 years after thyroidectomy and the occurrence of surgical complications were compared among the three groups. The relapse rate for Period 1, Period 2, and Period 3 was 14.1%, 12.6%, and 10.9%, respectively, and the rate of euthyroidism decreased and rate of hypothyroidism increased from period to period. Surgical complications increased in Periods 2 and 3. For preventing relapse, the strategy of reducing the thyroid remnant is effective. Subtotal thyroidectomy leaving 3-4 g remnant tissue is a suitable surgical option for Graves' disease.

Prognostic value of thyrotropin receptor antibodies (TRAb) in Graves' disease: a 120 months prospective study

In most trials, at least 30-60% of patients with Graves' disease treated with antithyroid drugs relapse within 2 years after therapy withdrawal. At present, there are no prognostic parameters available early in treatment to indicate patients likely to achieve long-term remission. Because thyrotropin receptor autoantibodies (TRAb) are specific for Graves' disease, we evaluated the ability of their levels and of their rate of change to predict long-term prognosis. In our study 216 consecutive patients with newly diagnosed Graves' disease started a therapy with methimazole. Patients were treated until they achieved euthyroidism and TRAb were measured at 6-month intervals throughout a follow up of 120 months. Our study demonstrated that at the onset of hyperthyroidism patients' age, sex, fT4 levels and goiter size had no prognostic value in predicting long-term prognosis (respectively p = 0.79; p = 0.98; p = 0.83; p = 0.89). On the contrary, at the time of diagnosis TRAb titer was a good predictor of the final outcome (p<0.001); a titer equal to (or) more than 46.5 UI/L could identify patients who had never achieved long-term remission with a sensitivity of 52% and a specificity of 78%. Also fall rate of TRAb at 6 months of follow up and after therapy withdrawal were useful to predict the final outcome (p<0.001). At 6 months of follow up the time of therapy withdrawal, a decrease of TRAb lower than 52.3% or even its increase could identify patients who had never achieved permanent remission with a sensitivity of 55% and a specificity of 79.1%. No single parameter among TRAb, satisfactory identified a sub-set of patients who achieved long remission. Accordingly to our data, the best result in predicting long term remission is probably given by the presence of at least one of the two features evaluated at 6 months (TRAb titer and/or percentage of TRAb fall rate), with a sensitivity of 63% and specificity of 88%. TRAb titers evaluated both at the onset of hyperthyroidism that at 6 months of therapy or their rate of fall at 6 months and at ATD withdrawal are predictors of outcome. However, the presence of at least one, between titers of TRAb or their rate of fall at six months, resulted to be the best predictor of remission with the higher sensitivity and specificity.

Efeito do propiltiouracil sobre a eficácia da dose terapêutica de iodo radioativo (I-131) no hipertiroidismo por doença de graves

Com objetivo de avaliar a influência das drogas antitiroidianas (AT) sobre a eficácia da dose terapêutica de iodo radioativo (DT), avaliamos retrospectivamente 226 prontuários de pacientes portadores de doença de Graves submetidos à DT no período entre 1990 e 2001: 58 pacientes sem antitiroidiano (AT), 119 em uso de propiltiouracil (PTU) e 49 em uso de metimazol (MMI). O estado funcional tiroidiano 9-12 meses pós-DT dividia os pacientes entre curados e não curados. Níveis elevados de T4 livre, captação de 131I em 24 h tiveram influência negativa sobre a taxa de cura, assim como menor dose de iodo administrada e maior volume do bócio (p< 0,05). O percentual de pacientes curados em uso de PTU previamente à DT foi de 70,2% (84/119), enquanto nos pacientes em uso de MMI foi de 85,7% (42/49), e de 84,5% (49/58) nos pacientes sem AT pré-DT (p= 0,034). Em modelo de regressão multivariado, T4 livre > 4 ng/dl, maior volume do bócio, dose terapêutica < 10 mCi e o uso prévio de PTU tiveram relação com menores taxas de cura. Quando comparado ao grupo sem AT, concluímos que PTU implica em maior risco de falência pós-DT (OR= 3,13), o mesmo não ocorrendo com MMI (OR= 1,28).

Subtotal Thyroidectomy: A Reliable Method to Achieve Euthyroidism in Graves’ Disease. Prognostic Factors

BACKGROUND

Subtotal thyroidectomy is a widely accepted surgical procedure for Graves' disease. The purpose of this work is to evaluate functional long-term results and determine predictive prognostic factors of postoperative thyroid function.

STUDY DESIGN

This is a retrospective study conducted on 202 patients with Graves' disease undergoing subtotal thyroidectomy during the period 1979-2002. Predictive prognostic factors of final thyroid status were investigated by logistic ordinal regression, and probability of hypothyroidism during the years of follow-up was obtained by the Kaplan-Meier method.

RESULTS

Surgery controlled hyperthyroidism in 196 out of 202 patients (97%). The probability of hypo-, eu-, and hyperthyroidism at 5 years was 62.1%, 35.5%, and 2.4%, respectively. No statistical change in thyroid function occurred in the follow-up after 60 months. Multivariate analysis by a logistic ordinal regression analysis showed that weight of the remnant, age, and gender seemed to influence long-term thyroid function. The higher rates of euthyroidism were obtained when the remnant weight was between 6 and 8 g. No recurrence or persistence of hyperthyroidism occurred with remnant weights under 5 g.

CONCLUSIONS

Subtotal thyroidectomy controlled hyperfunction symptoms in 97% of our patients. Cure (euthyroidism) of Graves' disease patients should be attempted by leaving a thyroid tissue remnant between 6 and 8 g. Even more significant, our results suggest that euthyroidism rates could be improved by leaving a smaller remnant in elderly women and greater remnants in young men.

The cost effectiveness of treatment modalities for thyrotoxicosis in a U.K. center

OBJECTIVE

This study determined the cost effectiveness of treating thyrotoxicosis using thionamide therapy, radioiodine or surgery in the United Kingdom.

DESIGN

One hundred thirty-five patients diagnosed with thyrotoxicosis (62% Graves' disease, 7% nodular disease, 5% thyroiditis, and 27% unknown aetiology) referred in 12 months were offered a fully informed choice of treatment modality. Thirteen patients with transient thyrotoxicosis were subsequently excluded from the analysis. Seventy-four patients (61%) received an 18-month course of thionamide therapy, 43 received radioiodine therapy (35%), and 5 had a thyroidectomy (4%) within the first year of diagnosis as their primary treatment. A successful outcome ("cure") was defined as euthyroidism 12 months after thionamide therapy or euthyroidism or hypothyroidism on thyroxine replacement at 24 months following radioiodine or thyroidectomy. Costs were calculated for outpatient attendances, laboratory tests, and initial and subsequent treatments.

MAIN OUTCOME

In the thionamide group 73% were "cured" at 30 months after initiating treatment compared to 95% in the radioiodine group and 100% treated by thyroidectomy at 24 months. Cost per "cure" was calculated to be 3,763 pounds (5,644 dollars) per patient who received thionamides, 1,375 pounds (2,063 dollars) per patient given radioiodine and 6,551 pounds (9,826 dollars) per patient who underwent thyroidectomy.

CONCLUSION

The most cost-effective primary treatment modality for thyrotoxicosis is radioiodine.

Surgical treatment of Graves' disease in children

Thyroidectomy may be indicated in children with Graves' disease who have adverse reactions to antithyroid drugs or who relapse after antithyroid drug therapy. We investigated the characteristics of childhood Graves' disease from the standpoint of surgical outcome. Between 1989 and 1998, 1897 patients with Graves' disease underwent thyroidectomy and their thyroid function could be evaluated 2 to 3 years after thyroidectomy. The patients were divided into three groups according to age at thyroidectomy: 74 patients were 15 years old or less (children), 345 patients 16 to 20 years of age (adolescents), and 1478 patients 21 years of age or more (adults). The children included higher proportions of patients who had a large goiter (> 100 g), high thyrotropin-binding inhibitory immunoglobulin (TBII) level (> 50%), and small remnant thyroid (< 4 g). At 2 to 3 years after thyroidectomy, the overt recurrence rate of the children, adolescents, and adults was 9.5%, 4.9%, and 5%, respectively. The cumulative recurrence-free rate of the children, adolescents, and adults at 5 years after thyroidectomy was 82%, 90%, and 92%, respectively. Surgical complications were more frequently observed in children. Considering the aggressiveness of childhood Graves' disease, subtotal thyroidectomy with thyroid remnant less than 3 g is the procedure of choice for preventing recurrent hyperthyroidism.

Surgical treatment of hyperthyroidism: a ten-year experience

Hyperthyroidism is treated either by antithyroid drugs, radioiodine (I131) or surgery. In Sweden, surgery is often performed in patients with large goiter or severe hyperthyroidism with infiltrative endocrine ophthalmopathy. To evaluate indications and results of surgical treatment, data from 380 patients operated on for hyperthyroidism at our department during 1986-1995 were analyzed. Twenty-six percent were referred for surgery because of failure of treatment with antithyroid drugs or I131. Ninety-one percent were subjected to subtotal thyroidectomy with a median remnant weight of less than 2 g. In the remaining patients, total thyroidectomy was performed. Transient vocal cord affection occurred in 2.6%, none of which was permanent. Prolonged postoperative hypocalcemia occurred in 3.1%, and permanent hypoparathyroidism in 1%. There was no difference in complication rate between subtotal or total thyroidectomy. In patients with Graves' disease, 5% worsened with regard to ophthalmopathy initially after surgery but later improved. Recurrent disease occurred in 2% of the patients, all of whom had undergone subtotal thyroidectomy. Surgery is not first-line therapy in all patients with hyperthyroidism. However, in experienced hands, surgery is a good therapeutic alternative that can be carried out with no mortality, few complications, and, provided that a minimal remnant is left, very few recurrences.

Management of Graves' disease in Australia

BACKGROUND

Surveys of physicians in Europe, the USA and elsewhere have shown marked international differences in the management of Graves' disease. There are no comparable data on clinical practice in Australia.

AIMS

To examine the current management of Graves' disease by Australian endocrinologists, particularly controversial aspects of management.

METHODS

A questionnaire, modified from previous studies, was sent to members of the Endocrine Society of Australia, asking how they would manage a 43-year-old female with a first episode of Graves' disease. Eight variations on this index case (goitre size, age, sex, severity, recurrent disease) were then introduced. A novel ninth variation, recurrent Graves' disease accompanied by moderate ophthalmopathy, was added.

RESULTS

Responses from 130 endocrinologists who regularly managed Graves' disease in adults were analysed. For the index case, medical treatment with antithyroid drugs was recommended by 81% of respondents and radioiodine by 19%. Most respondents also recommended medical treatment for a patient aged 19 years, a patient with a large goitre, no goitre or severe hyperthyroidism. For an older patient aged 71 years, however, 57% of endocrinologists recommended radioiodine, and the remainder medical treatment. For recurrent Graves' disease after previous medical treatment, 76% of respondents recommended radioiodine, 22% medical treatment and 2% surgery. By contrast, for an identical case accompanied by moderate ophthalmopathy, 54% recommended medical treatment, 27% surgery and only 19% radioiodine.

CONCLUSIONS

Most endocrinologists in Australia recommend medical treatment for a first episode of Graves' disease. Radioiodine is used mainly in older patients and for recurrent disease. In the presence of significant ophthalmopathy, most endocrinologists avoid the use of radioiodine.

Demystifying autoimmune thyroid disease. Which disorders require treatment?

The term "autoimmune thyroid disease" encompasses all of the autoimmune thyroid conditions, including Hashimoto's thyroiditis, Graves' disease, most cases of silent thyroiditis, and postpartum thyroiditis. Extrathyroidal manifestations (e.g., ophthalmopathy, dermopathy) can occur in Graves' disease and, less commonly, Hashimoto's thyroiditis. Spontaneous hypothyroidism is common in patients with Hashimoto's thyroiditis, and when it develops, life-long therapy with levothyroxine is needed. In the United States, most adult patients with Graves' disease are initially or eventually treated with radioiodine thyroid ablation. For transient thyroiditis involving hypothyroidism or hyperthyroidism, short-term or symptomatic therapy is adequate.

Radioactive iodine-associated cytomorphologic alterations in thyroid follicular epithelium: is recognition possible in fine-needle aspiration specimens?

Editor's Note: There is a dilemma in the distinction between radiation effect and neoplasm in patients with thyroid nodules who have been previously treated with (131)I for Graves' disease. The difficulty is to identify the radiation changes and distinguish them from primary thyroid neoplasms. This paper addresses the time response of radiation therapy in the thyroid, as well as distinguishing features between radiation effect and primary carcinomas. Thyrotoxicosis is a condition resulting from presentation to the body's tissues of excessive quantities of thyroid hormones. Graves' disease is the most common cause of thyroid hyperfunction in the United States; this condition can be managed effectively by long-term antithyroid drugs, radioactive iodine ((131)I) therapy, or surgical intervention. The majority of American physicians prescribe (131)I, the most cost-effective therapy, for their patients with thyrotoxicosis. These patients who are closely followed for their existing thyroid pathology may be referred for fine needle aspiration of nodules. This review focuses on (131)I-associated cytologic changes in thyroid follicular epithelium in patients previously treated for underlying hyperthyroidism. Diagn. Cytopathol. 1999;21:207-210.