Treatment of benign nodular thyroid disease

Quantitative Iodine-123 single-photon emission computed tomography/computed tomography for Iodine-131 therapy of an autonomously functioning thyroid nodule

PURPOSE

Autonomously functioning thyroid nodules (AFTNs) are treated with iodine-131 (I-131) therapy, which increases the risk of permanent hypothyroidism; however, the risk can be reduced by separately estimating the accumulated activity for the AFTN and extranodular thyroid tissue (ETT).

METHODS

A quantitative I-123 single-photon emission computed tomography (SPECT)/CT (5 mCi) was performed in one patient with unilateral AFTN and T3 thyrotoxicosis. The I-123 concentrations measured at 24 h were 12.26 µCi/mL and 0.11 µCi/mL in the AFTN and contralateral ETT, respectively. Thus, the I-131 concentrations and radioactive iodine uptake expected at 24 h by 5 mCi of I-131 were 38.59 µCi/mL and 0.31 for the AFTN and 0.34 µCi/mL and 0.007 for the contralateral ETT. The weight was calculated as CT-measured volume multiplied by 1.03.

RESULTS

In the AFTN patient with thyrotoxicosis, we administered 30 mCi of I-131, which would maximize the 24-h I-131 concentration in the AFTN (226.86 µCi/g) and maintain a tolerable concentration in the ETT (1.97 µCi/g). The percentage of I-131 uptake at 48 h post I-131 administration was 62.6%. The patient achieved a euthyroid state at 14 weeks and maintained the state until 2 years post I-131 administration with an AFTN volume reduction of 61.38%.

CONCLUSION

The pre-therapeutic planning of quantitative I-123 SPECT/CT may enable a therapeutic window for I-131 therapy, which directs optimal I-131 activity to effectively treat AFTN while preserving the normal thyroid tissue.

Clinical Characteristics and Predictors Related to the Progression of Multinodular Goiter Causing Tracheal Compression and Deviation: A Report of Two Cases and Review of the Literature

We describe the clinical course of two patients who developed tracheal compression and deviation by multinodular goiter (MNG). Case 1: A 66-year-old woman presented with thyroid swelling. Five years after the initial admission, she was diagnosed with hyperthyroidism by Graves' disease and increased bilateral thyroid lobes compressing the trachea. Thyroglobulin was elevated from 210 to 472 ng/mL. Case 2: A 52-year-old woman presented with thyroid swelling. Five years after the initial admission, the increased right lobe deviated the trachea and compressed the right recurrent laryngeal nerve. Thyroglobulin was elevated from 122 to 392 ng/mL. Two cases and literature review indicated that MNG with >50 mm, solid components, and extension to the mediastinum or paralarynx were risk factors of tracheal compression and deviation. Monitoring thyroglobulin elevation can help predict the clinical course.

Thyrotropin suppression therapy for papillary thyroid carcinoma with a huge recurred neck lymph node

Differentiated thyroid cancer (DTC) originating from thyroid tissue is affected by thyrotropin (TSH). TSH suppression therapy is usually recommended after thyroidectomy in cases of DTC. A 57-year-old woman who harbored a very huge recurred lymph node underwent TSH suppression therapy because of the risk of surgical complications. After TSH suppression, the huge neck lymph node exhibited a response and decreased in size. She had been followed up for 144 months. TSH suppression therapy could be considered as an alternative treatment option in a recurred DTC patient with a high perioperative risk.

Deep Convolutional Neural Networks for Thyroid Tumor Grading using Ultrasound B-mode Images

The performances of deep convolutional neural network (DCNN) modeling and transfer learning (TF) for thyroid tumor grading using ultrasound imaging were evaluated. This retrospective study included input patient data (ultrasound B-mode image sets) assigned to the training group (115 participants) or testing group (28 participants). DCNN (ResNet50) and TF (ResNet50, ResNet101, ResNet152, VGG16, Inception V3, and DenseNet201), which trains a convolutional neural network that has been pre-trained on ImageNet, were used for image classification based on thyroid tumor grade. Supervised training was performed by using the DCNN or TF model to minimize the difference between the output data and clinical grading. The performances of the DCNN and TF models were assessed in the testing dataset with receiver operating characteristic analyses. Results showed that TF based on Resnet50 and VGG16 had better performance than DCNN (ResNet50) in differentiating thyroid tumor with areas under the receiver operating characteristic (AUCs) curve more than 0.8. However, TF based on ResNet101, ResNet152, InceptionV3, and Densenet201 had equal or worse performances than DCNN (ResNet50) in grading thyroid tumor with AUCs less than 0.5. TF based on ResNet50 and VGG16 had a superior performance compared to DCNN (ResNet50) model for grading thyroid tumors based on ultrasound images.

Multivariate evaluation of Thyroid Imaging Reporting and Data System (TI-RADS) in diagnosis malignant thyroid nodule: application to PCA and PLS-DA analysis

OBJECTIVE

To explore the significance of ultrasonic features in differential diagnosis of thyroid nodules via combining the thyroid imaging reporting and data system (TI-RADS) and multivariate statistical analysis.

METHODS

Patients who received surgical treatment and was diagnosed with single thyroid nodule by postoperative pathology and preoperative ultrasound were enrolled in this study. Multivariate analysis was applied to assess the significant ultrasonic features which correlated with identifying benign or malignance and grading the TI-RADS classification of thyroid nodule.

RESULTS

There were significant differences in the nodule size, aspect ratio, internal, echogenicity, boundary, presence or absence of calcifications, calcification type and CDFI between benign and malignant thyroid nodules. Multivariate analysis showed clear-cut distinction both between benign and malignance and among different TI-RADS categories of malignancy nodules. The shape and calcification of the nodule were important factors for distinguish the benign and malignance. Height of the nodule, aspect and calcification was important factors for grading TI-RADS categories of malignancy thyroid nodules.

CONCLUSIONS

Ill-defined boundary, irregular shape and presence of calcification related with highly malignant risk for thyroid nodule. The larger height and aspect and presence of calcification related with higher TI-RADS classification of malignancy thyroid nodule.

Functional Thyroid Follicular Cells Differentiation from Human-Induced Pluripotent Stem Cells in Suspension Culture

The replacement of regenerated thyroid follicular cells (TFCs) is a promising therapeutic strategy for patients with hypothyroidism. Here, we have succeeded in inducing functional TFCs from human-induced pluripotent stem cells (iPSCs) in scalable suspension culture. Differentiation of iPSCs with Activin A treatment produced Sox17- and FoxA2-expressing definitive endodermal cells that also expressed thyroid transcription factors Pax8 and Nkx2-1. Further treatment with thyroid-stimulating hormone (TSH) induced TFCs expressing various types of thyroid proteins including TSH receptor, sodium-iodide symporter, thyroglobulin, and thyroid peroxidase. Interestingly, differentiated cells secreted free thyroxine in vitro. These results indicate successful differentiation of human iPSCs to functional TFCs that may enable us to fabricate thyroid tissues for regenerative medicine and disease models.

Internal radiation therapy: a neglected aspect of nuclear medicine in the molecular era

With increasing evidence, internal radiation therapy, also known as brachytherapy, has become a neglected aspect of nuclear medicine in the molecular era. In this paper, recent developments regarding internal radiation therapy, including developments in radioiodine-131 (¹³¹I) and thyroid, radioimmunotherapy (RIT) for non-Hodgkin lymphoma (NHL), and radiopharmaceuticals for bone metastases. Relevant differences and status of their applications in China were mentioned as well. These molecular mediated internal radiation therapies are gaining increasing importance by providing palliative and curative treatments for an increasing number of diseases and becoming one of the important parts of molecular nuclear medicine.

Role of cytological characteristics of benign thyroid nodules on effectiveness of their treatment with levothyroxine

INTRODUCTION

Levothyroxine (LT4) therapy has been used for the treatment of euthyroid nodular goiter, but there are controversial results about its usefulness. We aimed to evaluate the possible role of benign nodules' cytological characteristics in response to LT4 therapy.

MATERIAL AND METHODS

In total, 93 patients with 128 nodules were included in the study; 74 of the nodules were treated with LT4 (group 1), and 54 of them had no medication (group 2). The subgroups consisted of adenomatous nodules, colloid nodules and cystic nodules.

RESULTS

In group 1, mean thyroid volume and mean nodule volume were reduced significantly (p = 0.002 and p = 0.022, respectively) with low-normal level thyrotropin (TSH) suppression (between 0.3 mIU/ml and 1.0 mIU/ml), while there were no significant changes in group 2. When we evaluated changes of the initial and last nodule volumes in cytological subgroups, only colloid nodules in group 1 had significant reduction (p = 0.040) and the others had no significant changes. By omitting the colloid nodules, when the other nodules were revaluated, there were no significant changes in either group.

CONCLUSIONS

On the basis of these results, obtained from a large sample of Anatolian patients, it is possible that LT4 therapy leads to significant reductions of both thyroid volume and nodule size in colloid nodules, but not in other kinds of benign nodules.

Novel DICER1 mutation as cause of multinodular goiter in children

BACKGROUND

The aim of this report was to present a rare case of an adolescent with multinodular goiter (MNG) found to have a DICER1 mutation.

METHODS AND RESULTS

The methodology includes a presentation and discussion of a chart review including endocrine hormone tests, thyroid ultrasound, and genetic testing for DICER1. A 12-year-old girl presented with a diffusely enlarged thyroid gland. Family history revealed an older sister with a history of bilateral ovarian Sertoli-Leydig cell tumors and MNG. Thyroid function tests were normal. Serial thyroid ultrasounds showed enlarging multiple bilateral nodules. Fine-needle aspiration suggested MNG. Genetic testing revealed a novel heterozygous premature termination mutation (c.1525C>T p.R509X) in the DICER1 gene.

CONCLUSIONS

Thyroid nodules are rare in children but carry a higher risk for malignancy. It is essential to inquire about family history and refer for genetic evaluation with a family history of MNG. In patients with DICER1 mutations, tumor surveillance is critical due to the increased risk of multiple tumors, including ovarian tumors and pleuropulmonary blastoma.

Sensitivity of fine-needle biopsy in detecting pediatric differentiated thyroid carcinoma

BACKGROUND

Differentiated thyroid carcinomas (DTC) are uncommon in children. Since the frequency of malignancy is assumed to be high in pediatric symptomatic thyroid nodules, carcinomas should be ruled out reliably. The objective of this study was to assess the sensitivity of fine-needle biopsy (FNB) in diagnosing children with DTC.

PROCEDURE

We retrospectively analyzed 15 years of data from the GPOH-MET registry, a database by the German Society for Pediatric Oncology and Hematology (GPOH) with a focus on malignant endocrine tumors (MET). We reviewed data on pediatric patients with DTC who had undergone FNB. FNB results were classified according to well-established guidelines.

RESULTS

During the study period, 206 children with a histological diagnosis of DTC were entered into the GPOH-MET database. Fifty of those patients aged 3.6-17.3 years (mean, 12.3 years) had undergone FNB preoperatively. Forty-one were diagnosed with papillary thyroid carcinoma (PTC), seven with follicular thyroid carcinoma (FTC), and two had DTC not otherwise specified. Of the first FNB performed on each patient, the cytological specimens were diagnosed as benign in 13 cases, malignant in 14, suspicious in 9, follicular neoplasms in 6, and unsatisfactory in 8. The sensitivity of FNB in detecting DTC was 69.0%.

CONCLUSIONS

Our results reflect the current practice of pediatric thyroid FNB in Germany. In order to improve its usefulness, FNB should always be performed by experienced physicians. Furthermore, a central review of all specimens is necessary to ascertain the validity of the cytological diagnosis and to introduce immunocytological and molecular methods.

Accuracy of ultrasound-guided fine-needle aspiration cytology for diagnosis of carcinoma in patients with multinodular goiter

BACKGROUND

Fine-needle aspiration (FNA) is a useful method for evaluating multinodular goiter; however, its role is still controversial. The aim of this study was to assess the utility of ultrasound-guided thyroid FNA in detecting malignancy in patients with multinodular goiter in Oman.

MATERIALS AND METHODS

This was a retrospective study where all patients with multinodular goiter seen at the Sultan Qaboos University Hospital endocrinology clinic in Oman in 2005 were evaluated. The thyroid FNA results were grouped into either malignancy (positive result) or others (negative result). They were compared to those of final histopathological examination in order to calculate the value of the test in diagnosing malignancy. Analyses were evaluated using descriptive statistics.

RESULTS

A total of 272 patients were included in the study. The mean age was 39΁13 years with an age range from 5 to 85 years. The majority of the patients were females (n=236; 87%). The results of thyroid FNA revealed that 6% (n=15) of the patients had malignancies while histopathological results showed that the proportion of subjects with malignancies was 18% (n=49). Out of the 15 cases identified to have malignances by thyroid FNA, only 53% (n=8) of the subjects were confirmed to have malignancy by biopsy. Overall, the results of the tests were poor, revealing a sensitivity of 16%, specificity of 97% and a diagnostic accuracy of 82%, with a positive predictive value of 53% and a negative predictive value of 84%.

CONCLUSION

Thyroid FNA is not a useful test in differentiating multinodular goiter from malignancy, as more than 80% of the malignancies go unnoticed.

Does thyroxine suppression therapy help to rationalize surgery in benign euthyroid nodules?

Background:

Nodular thyroid disease is a common endocrine problem. Most thyroid nodules are benign hyperplastic lesions, but 5–20% may be a true neoplasm. It is important to differentiate a benign from a malignant nodule early as the approach to treatment in the two is radically different. Early institution of medical management in a benign nodule may obviate the need for surgery.

Purpose of the Study:

The present work aims to study the efficacy of thyroxine suppression in the management of benign thyroid nodules.

Materials and Methods:

A prospective study on patients presenting with thyroid nodule was undertaken. The diagnostic work-up included a clinical evaluation, thyroid function tests, thyroid scintigraphy and fine needle aspiration cytology. Based on the investigations, patients were segregated in Group A (toxic nodular goiter), Group B (benign euthyroid nodule) and Group C (malignant nodule). Group A patients were managed with antithyroid drugs and radioiodine and Group C patients were managed surgically. Group B patients were put on thyroxine suppression. Patients who failed to show reduction in size of the nodule at 18 months were treated surgically.

Conclusion:

The response rate of benign euthyroid nodule to thyroxine suppression was 76% in the present study.

Surgical treatment of thyroid diseases in elderly patients

BACKGROUND

We evaluated the safety of thyroid surgery in elderly patients, in whom surgical procedures usually are considered more hazardous than in younger patients.

METHODS

The medical records of all the patients who were aged 70 years or older who had undergone thyroid surgery between January 1998 and June 2008 were reviewed.

RESULTS

A total of 320 patients were included. The preoperative diagnosis was multinodular goiter in 171 cases, toxic goiter in 59 cases, suspicious or indeterminate thyroid nodule in 60 cases, and thyroid carcinoma in 30 patients. Total thyroidectomy was performed in 283 patients, thyroid lobectomy in 15 patients, and a completion thyroidectomy was performed in 22 patients. The final histology showed thyroid cancer in 86 patients and benign disease in 234.

CONCLUSIONS

Thyroid surgery in patients aged 70 years or older is safe and the relatively high rate of thyroid carcinoma and toxic goiter may justify an aggressive approach.

Advances in ultrasound for the diagnosis and management of thyroid cancer

BACKGROUND

Ultrasonography (US) is increasingly being employed by endocrinologists and surgeons in the diagnosis and management of patients with thyroid nodules and thyroid cancer. Recent consensus guidelines from the American Thyroid Association highlight the importance of this modality by recommending that patients with thyroid nodules should undergo further evaluation with cervical US to stratify the risk of malignancy. Likewise, ultrasound is advocated for the preoperative and postoperative diagnosis of cervical lymph node metastases.

SUMMARY

This article will summarize the US characteristics that impart a suspicious appearance on thyroid nodules and cervical lymph nodes as well as those findings that are reassuring. Likewise, the indications for thyroid nodule and lymph node fine-needle aspiration will be reviewed. Finally, this article will briefly discuss adjunctive tools in US such as elastography, percutaneous ethanol ablation, and radiofrequency ablation.

CONCLUSIONS

US may be used to help stratify the risk of malignancy in thyroid nodules and cervical lymph nodes. This tool further aids in the diagnosis of malignancy when used in conjunction with fine-needle aspiration. US plays an important role as both a diagnostic and therapeutic tool in the evaluation of patients with neck masses.

Intratracheal growth of recurrent benign goiter

BACKGROUND

Intratracheal goiter manifestations caused by ectopic thyroid tissue have occasionally been reported. We report a 42-year-old female who had undergone thyroid surgery twice, which had caused unilateral recurrent laryngeal nerve palsy.

SUMMARY

The patient presented with progressive dyspnea. Magnetic resonance imaging showed a recurrent goiter growing through the tracheal wall. She was treated in a multidisciplinary approach; at first she underwent transtracheal laser surgical removal of the intratracheal mass followed by conventional completion thyroidectomy and radioiodine remnant ablation. Thorough histological analysis did not find any signs of malignancy. Currently the patient is disease- and complaint free. As far as we could ascertain, no patient with a recurrent benign goiter growing through the tracheal wall has been reported before.

CONCLUSION

Recurrent benign goiter with intratracheal growth is extremely rare and requires a multidisciplinary approach.

The effects of a custom-made lead collar on dose rates of patients treated with 131I

We studied the effects of a custom-made lead collar on dose rates and hospitalization days of patients treated with high doses (>400 MBq) of radioiodine (131I). Between October 2005 and March 2006, the dose rates of 28 consecutive patients were studied. Dose rates of patients with and without the collar (5.5 mm lead) were measured daily until the rate dropped below the discharge dose rate of 20 microSv-1 h at 1 m. Age, sex, 131I dose, uptake, thyroid disorder, and days of isolated hospitalization were recorded. The difference in mean dose rate with or without the collar was analyzed by t test or Mann-Whitney test, as appropriate. Twenty-eight patients (7 male, 21 female; mean age, 57 y; range, 29-82 y) were analyzed. Nine patients suffered from Graves' disease, 9 from toxic nodular goiter, and 10 from non-toxic nodular goiter. Patients were treated with a mean dose of 1,647 MBq 131I (range, 511-3,276 MBq). The mean anterior dose rates were 28 +/- 12 microSv-1 h at 1 m and 11 +/- 6 microSv-1 h at 1 m without and with the lead collar, respectively (p < 0.001). The mean reduction in dose rate for patients wearing the collar was 61 +/- 13%. The mean hospital stay was 2.6 +/- 1.3 days without the collar vs. 1.2 +/- 0.6 days with the collar (p < 0.001). A custom-made lead collar significantly reduced dose rates and could reduce compulsory hospitalization, especially in toxic- and non-toxic nodular goiter.

Neck masses: evaluation and diagnostic approach

Oral and maxillofacial surgeons frequently deal with patients who present with an unknown neck mass. Formulation of a differential diagnosis is essential and requires that the surgeon bring to bear a host of skills to systematically arrive at a definitive diagnosis and ensure that the correct treatment is rendered. This article highlights some of the skills needed in the workup of neck masses and reviews some of the available techniques that aid in achieving the correct diagnosis.

The odyssey of nontoxic nodular goiter (NTNG) in Greece under suppression therapy, and after improvement of iodine deficiency

BACKGROUND

Nontoxic nodular goiter (NTNG) is common in endemic goiter regions. Thyroxine (T4) is often used to treat NTNG. There is little information regarding T4 treatment in regions that have recently become iodine sufficient. We studied the effect of T4 treatment on thyroid function tests in southwestern Greece (SWG), a recently iodine-sufficient area.

METHODS

We studied 827 residents of SWG (group A) to determine goiter prevalence, thyroid function, and urinary iodine concentration (UIC). Group B: 385 consecutive patients with thyroid dysfunction. Of these, 89 had NTNG and followed for 10 years on T4 treatment, and 296 had hyperthyroidism. Group C: 29 patients with NTNG, treated with triiodothyronine (T3) 50 mug/day and followed for 6 months. Measurements included serum T4 and 24-hour radioactive iodine uptake (RAIU) before and at the end of T3 administration.

RESULTS

The median UIC in group A was 114 microg/L. In group B (89 patients), the incidence of newly diagnosed hyperthyroidism was 5-7% per year with a cumulative percentage of 33% at the 10th year. The initial thyrotropin (TSH) was lower (0.78 +/- 0.51 mIU/L) in those who developed thyrotoxicosis compared to those who remained euthyroid (1.17 +/- 0.74 mIU/L) (p < 0.05). In 296 thyrotoxic patients, the incidence of autoimmune hyperthyroidism and toxic multi-nodular goiter (TMNG) was similar. In group C, 10/29 patients remained euthyroid and the 24-hour RAIU decreased by 49% during T3 treatment. Similarly, serum T4 decreased by 49%. In the remaining patients who developed hyperthyroidism, 24-hour RAIU and T4 were decreased by 19% and 22%, respectively.

CONCLUSIONS

In SWG, a recently iodine-sufficient region, the risk of developing hyperthyroidism in patients with NTNG after administration of 100-150 microg T4 is relatively high in those whose serum TSH before T4 treatment is in the lower normal range. Therefore, T4 treatment should be avoided in these patients.

Thyroid nodules: Does the suspicion for malignancy really justify the increased thyroidectomy rates?

Thyroid nodules are frequently diagnosed today, mainly due to the wide use of neck ultrasonography (US). The majority of these are benign; suspicion for malignancy is an indication for surgery, while benign thyroid nodules may be managed conservatively. There is evidence that a large percentage of patients with thyroid nodules (many diagnosed incidentally) are over-treated. Careful and accurate identification of patients with thyroid nodules highly suspicious for underlying malignancy would allow a more reasonable therapeutic approach and would result in a reduction of the number of unnecessary thyroidectomies. Fine-needle aspiration cytology (FNAC), in conjunction with high-resolution thyroid US, are currently the most accurate and cost-effective diagnostic approach for the evaluation of patients with nodular thyroid disease. Radionuclide thyroid scanning should be used selectively. By increasing the use of FNAC, it is expected that the number of unnecessary thyroidectomies will be further diminished, thereby avoiding over-treatment, without exposing the patients to the risk of under-treatment for a highly curable cancer. However, accurate preoperative diagnosis of thyroid cancer within a thyroid nodule is not always possible and, although the problem of unnecessary surgery can further be diminished, it cannot be completely eliminated.

[Clinical recurrence of multinodular goiter after surgery. A multivariate study on the risk factors]

INTRODUCTION

In multinodular goiter there is no consensus on which is the most adequate surgical technique, since although the techniques with partial resection show lower risk of complications they are associated with a higher risk of recurrences. The objective of this study is to define the risk factors for recurrence of multinodular goiters after surgery in a series with a mean postoperative follow-up higher than 12 years.

PATIENTS AND METHOD

231 multinodular goiters with partial thyroid surgery are analyzed. The recurrence is assessed through clinical exploration, and is confirmed with echography. The variables analyzed are age, sex, family history of thyroid pathology, residence in goitrogenic areas, asymptomatic hyperthyroidism, compression syndromes, intrathoracic extension of goiter, surgeon experience with endocrine surgery, weight of the thyroid, and surgical technique, chi2 test, Student's t test and a logistic regression test are applied.

RESULTS

After a mean postoperative follow-up of 152 +/- 71 months 67 goiters (29%) showed recurrence with a mean time for recurrence of 85 +/- 67 months. Risk factors detected in the multivariate study were youngest age, surgeon's lack of experience in endocrine surgery, and the surgical technique. Forty-six patients (69%) were operated because of recurrence, most of them by surgeons experienced in endocrine surgery. Thyroidectomy was completed in all cases, and two definitive postoperative complications occurred.

CONCLUSIONS

The index of clinical recurrences is high and increases with the progression; primary risk factors are age, surgeon's experience, and surgical technique. The implication is that partial resection techniques should be carried out by surgeons with experience and there should be avoided in young patients.

Clinical uses of recombinant human thyrotropin

Recombinant human thyroid-stimulating hormone (rhTSH), used to enhance diagnostic radioiodine whole body scanning and thyroglobulin testing, has dramatically altered the management of patients with thyroid cancer. Withdrawal from thyroid hormone suppression therapy and subsequent hypothyroidism is no longer the only safe and effective method for thyroid cancer surveillance. Currently, rhTSH is only approved for the monitoring of low-risk patients with well-differentiated thyroid cancer and radioactive iodine administration, in selected cases. Additional applications of rhTSH include enhancing the sensitivity of positron emission tomography in thyroid cancer, the management of multinodular goiter, and dynamic testing of thyroid reserve. The diagnostic and therapeutic role of rhTSH in these areas is discussed in this review.

L’iode 131 comme traitement des goitres bénins

INTRODUCTION

In order to evaluate the efficacy of 131 Iodine on goitre volume and on thyroid function, we studied a cohort of patients exhibiting a multinodular and toxic or non toxic goitre.

METHODS

This retrospective study was conducted at the Marc Linquette clinic in Lille, in collaboration with the department of nuclear medicine. Thirty-eight patients treated with 131 Iodine were included from 1995 to 2001. Clinical examination and serum analyses including TSH, free T4 and T3, anti-thyroid peroxidase and anti-thyroglobulin antibodies and TSH-receptor antibodies measurements were conducted on inclusion and then at 3, 6, 12 and 72 months. The activity of 131 Iodine corresponded to a standard dose or was calculated according to Marinelli's method. We excluded patients who had not undergone assessment at the above-mentioned time schedules.

RESULTS

The treatment was indicated in 30 patients presenting with a non compressive but toxic goitre, in 5 patients with a toxic compressive goitre and in 3 patients with a compressive but non-toxic goitre. Surgery had been excluded for all these patients because of their age, their cardiac status or because they had refused surgery after failure with prior partial thyroidectomy or medical treatment. Among the toxic goitres, TSH levels were low and T3 and T4 increased in 17 patients. In the 18 others, hyperthyroidism was manifested by an isolated decrease of TSH. The thyroid volume before treatment, assessed in 20 patients, was of 18 to 135 cm3 (mean: 53 cm3). Treatment consisted in administration of radioactivity of 3 to 30 mCi in 30 patients and standard activity of 20 to 25 mCi in 8. Functional efficacy with reduction in hyperthyroidism was noted after 3 months, and corrected in nearly all patients after 1 year, and morphological efficacy, with a mean decrease of 33.5% in the size of the goitres. No supplementary surgery was required, notably for the initially compressed goitres. Immediate and long term tolerance was satisfactory.

CONCLUSION

Metabolic 131Iodine radiotherapy is effective for the functional and morphological treatment of goitres with good tolerance and few side effects. 131 Iodine is a reasonable alternative in cases with absolute or relative contraindication for surgery.

Utility of fine-needle aspiration for diagnosis of carcinoma associated with multinodular goitre

BACKGROUND

Fine-needle aspiration (FNA) is a useful method for evaluating a solitary thyroid nodule; however, this is not an agreed method for a multinodular goitre (MNG). The aim of this study was to assess the utility of preoperative FNA for detecting malignancy in MNG.

PATIENTS AND METHOD

We analysed operated MNGs in which FNA had been performed. Puncture was carried out on the dominant nodule and any other nodules with features suggesting malignancy. The diagnosis was classed as colloid, follicular or Hurthle proliferation, suggestive of malignancy, haematic and inadequate. The thyroid FNA results, grouped into suggestive of malignancy (positive result) and other diagnoses (negative result), were compared to those of the final histological study in order to calculate the value of the test in diagnosing malignancy.

RESULTS

FNA was performed in 432 MNGs, of which 42 (9.7%) were associated with carcinoma. Overall, the results of the test were poor, revealing a sensitivity of 17%, specificity of 96% and diagnostic accuracy of 88%, with a positive predictive value of 32% and negative predictive value of 88%. When the values were recalculated with the exclusion of microcarcinomas--considering their minor clinical importance--there was a slight improvement in the results: the sensitivity increased to 26%, diagnostic accuracy to 93% and negative predictive value to 96%. However, the specificity remained at 96%, and the positive predictive value fell from 32% to 25%. The results of the test improved in multifocal carcinomas.

CONCLUSIONS

Thyroid fine needle aspiration is not useful for differentiating MNG with malignant degeneration from benign MNG, as more than 80% of carcinomas go unnoticed; it provides a sensitivity of 17% for detecting carcinomas, rising to 26% if microcarcinomas are excluded. We therefore suggest that clinical criteria should prevail over FNA.

Radioiodine or surgery for toxic thyroid adenoma: dissecting an important decision. A cost-effectiveness analysis

OBJECTIVE

To examine the cost effectiveness of therapeutic strategies for toxic thyroid adenoma.

DESIGN

Markov state transition decision analytic model.

SETTING

Ambulatory and inpatient.

PATIENTS

Hypothetical cohort of 40- year-old women with toxic thyroid adenomas. Patient age was varied in sensitivity analyses. Data on the prevalence of coincident thyroid cancer, complications, and treatment efficacies were derived from a systematic review of the literature.

INTERVENTIONS

Thyroid lobectomy after a 3 month-course of antithyroid drugs (ATDs), high-dose (<555 MBq) radioactive iodine (RAI), low-dose (>555 MBq) RAI, and lifelong ATDs.

MEASUREMENTS AND MAIN RESULTS

Outcomes were measured in quality-adjusted life years (QALYs). Costs were estimated from the health care system perspective. Future costs and effectiveness were discounted at 3% per year. For a 40- year-old woman, surgery was the most effective, while low-dose RAI was the least costly. The marginal cost-effectiveness of surgery versus low-dose RAI was $13,183 per QALY. Surgery was less costly and more effective than lifelong ATDs. RAI was more effective than surgery if surgical mortality exceeded 0.90% (base-case 0.001%). Surgery provided relatively inexpensive gains (<$50,000 per QALY) in quality-adjusted life expectancy in patients less than 74 years of age.

CONCLUSIONS

For most patients less than 60 years of age, surgery is an effective strategy with a reasonable cost. However, for any given patient, surgical mortality, therapeutic costs and preference must be considered in choosing an appropriate therapy.

Subclinical hyperthyroidism: to treat or not to treat?

Subclinical hyperthyroidism may be defined as the presence of free thyroxine and tri-iodothyronine levels within the reference range and a reduced serum thyroid stimulating hormone (TSH) level. In this review the prevalence of low TSH in the population and health consequences of subclinical hyperthyroidism, for example, effects on heart and bone mass, are discussed. Guidelines for treatment are given, based on expert opinion.

Management of thyroid nodules: a clinicopathological, evidence-based approach

Management of thyroid nodules is one of the most controversial issues in thyroidology. Different approaches derive from geographical variation in presentation, inadequate or incomplete clinical diagnosis, lack of prospective controlled studies and, frequently, the different cultural backgrounds of physicians. This review aims to offer a practical approach to the management of nodular thyroid disorders, considering the way in which the pathophysiology of the disease provides clues to the correct clinical diagnosis and therapy.

Total thyroidectomy for clinically benign disease of the thyroid gland

Background

The role of total thyroidectomy in the treatment of patients with benign thyroid disease remains controversial. However, this procedure may be appropriate when both thyroid lobes are involved and when the risk of recurrence is significant. This study is a review of a 15-year experience of total thyroidectomy for benign disease.

Methods

Between 1988 and 2002, 834 patients underwent total thyroidectomy for clinically benign disease at the Sydney Head and Neck Cancer Institute, Royal Prince Alfred Hospital. There were 128 men and 706 women with a mean age of 52 (range 16–91) years. Indications for surgery were euthyroid multinodular goitre (MNG), toxic MNG and Graves' disease in 730 (87·5 per cent), 57 (6·8 per cent) and 47 (5·6 per cent) respectively. A total of 74 patients had previously undergone partial thyroidectomy.

Results

The incidence of temporary recurrent laryngeal nerve palsy was 2·3 per cent and that of temporary hypoparathyroidism 14·4 per cent. Permanent recurrent laryngeal nerve palsy occurred in 1·1 per cent, and 2·4 per cent of patients had permanent hypoparathyroidism. Neither the initial clinical diagnosis nor a history of previous treatment significantly influenced the rate of complications. The incidence of malignancy, other than incidental microscopic papillary carcinoma, was 4·6 per cent.

Conclusion

Total thyroidectomy has an important role in the management of patients with benign disease when both lobes of the thyroid gland are involved. This approach avoids disease recurrence and the increased risk of morbidity associated with secondary operation.

Risk factors for malignancy in multinodular goitres

BACKGROUND

Multinodular goitre (MNG) is quite often associated with thyroid carcinoma, but the risk factors for malignancy are not well known. The aim is to analyse patients with thyroid carcinoma associated with MNG to determine the clinical risk factors for malignancy.

METHOD

From a series of 672 MNGs we analysed a subgroup of 59 patients presenting with an associated thyroid carcinoma. The variables analysed were age, sex, family history, cervical radiation therapy, residence in areas of endemic goitre, prior thyroid surgery, time of evolution, asymptomatic status, hyperthyroidism, compressive syndromes, intrathoracic prolongation, goitre consistency and cervical adenopathies. These were compared to MNGs not developing malignancy using the Chi-squared test, Student's t test and a logistic regression test.

RESULTS

Of the 59 cases, 37 corresponded to a microcarcinoma (< or =1 cm). The most common histological type was papillary (n=48), followed by follicular (n=6). In 20 cases the carcinoma was multifocal, and capsular involvement was noted in 16 patients, lymph node involvement in five and vascular involvement in another five. The multivariate analysis confirmed the following as independent variables associated with the presence of carcinoma: family history of thyroid pathology (RR=1.6), history of cervical radiation therapy (RR=1.8), recurrent goitre (RR=2.1) and presence of adenopathies on physical exploration (RR=1.6).

CONCLUSION

The risk factors for carcinoma associated with MNG are family history of thyroid pathology, personal history of cervical radiation therapy, prior surgery and presence of cervical adenopathies.

Administration of a single dose of recombinant human thyrotrophin enhances the efficacy of radioiodine treatment of large compressive multinodular goitres

OBJECTIVE

Patients with very large multinodular goitres, frequently found among elderly people, often suffering from cardiovascular or other disabling disorders, may be considered as unsuitable for surgery. We have evaluated the feasibility of relatively high-dose 131I therapy in such patients. As subclinical or clinical hyperthyroidism is commonly found in these patients, associated with a low radioiodine (RAI) uptake at 24 h, we pretreated a group of patients with a single intramuscular injection of recombinant human TSH (rhTSH 0.45 mg) in order to increase the uptake of the therapeutic dose of RAI.

DESIGN AND PATIENTS

Forty-one patients with large, long-standing multinodular goitres, were recruited for this study. After a careful and detailed clinical and laboratory evaluation, 34 patients (28 women, six men) were included and randomly assigned to group 1 (control, n = 17, 15 women, two men, age 63.1 +/- 11.2 years) receiving only RAI. Patients in group 2 (n = 17, 13 women, four men, age 63.6 +/- 12.3 years) received the therapeutic dose of RAI, having been pretreated (24 h) with 0.45 mg of rhTSH. Both groups of patients were submitted to a low iodine diet, 4-6 months before RAI treatment, while seven thyrotoxic patients also received methimazole (40 mg/day) until they reached euthyroidism. Ultrasonographic studies were performed for all patients and fine-needle aspiration biopsy (FNAB) were performed on one or two nodules before RAI treatment. RAI was given as a single oral dose to the hospitalized isolated patients. Blood samples for thyroid function tests and serum thyroglobulin (Tg) were collected daily during the first week following RAI treatment, and at 1, 3, 6, 9 and 12 months thereafter.

MEASUREMENTS

Goitre volume was estimated by computed tomography scan. Thyroid function tests (total T3, free T4, TSH and serum Tg) were assayed with commercial kits. Urinary excretion of iodine was assayed by the Sandell-Kolthoff method.

RESULTS

After the RAI therapeutic dose, serum thyroid function tests were carried out daily for the first week and then on a monthly basis (1, 3, 6, 9 and 12 months). Serum TSH levels rose to a peak level of 45.9 +/- 19.1 mU/l (24 h) in group 2 returning to normal at 72 h. Free T4 serum concentrations rose significantly to 59.35 +/- 21.61 pmol/l at 48 h (in group 2) returning to normal at 7 days. Similarly, serum TT3 also peaked above normal levels only in group 2 (6.12 +/- 1.89 nmol/l) at 24 h. Serum Tg increased in both groups (significantly higher in group 2) and remained elevated during the following 12 months. Both groups had a significant reduction in goitre volume at 12 months (group 2: 57.8%vs. group 1: 39.7%, P < 0.05). Hypothyroidism was detected after RAI treatment, respectively, in 21.4% (group 1) and 64.7% (group 2), of the patients at 12 months.

CONCLUSIONS

Our results indicate that the use of hTSH increased the efficacy of the RAI therapeutic dose. This was basically due to an increased uptake of the radionuclide (as a consequence of the higher serum TSH levels) and a more extensive distribution of 131I within the nodules of the multinodular goitre. A more intense radiation effect was reflected in there being a higher output of serum Tg and thyroid hormones (group 2). As a consequence this group had a significantly higher reduction of the goitre volume. Also incidence of hypothyroidism post-RAI was significantly higher in group 2. We concluded that pretreatment with rhTSH in elderly patients with large multinodular goitres increases the uptake of the RAI therapeutic dose, thereby significantly reducing the multinodular goitre volume and relieving the compressive symptoms with relatively few side-effects.

Percutaneous ultrasound-guided radiofrequency heat ablation for treatment of hyperthyroidism in cats

OBJECTIVE

To determine efficacy and safety of percutaneous radiofrequency heat ablation for treatment of hyperthyroidism in cats.

DESIGN

Prospective study.

ANIMALS

9 cats.

PROCEDURE

Hyperthyroidism was diagnosed via clinical signs and high serum total (TT4) and free thyroxine (fT4) concentrations. One or 2 hyperfunctional cervical thyroid nodules were detected by use of scintigraphy and ultrasonography. If cats had 1 abnormal thyroid lobe, heat ablation was performed on that lobe; if cats had 2 abnormal lobes, heat ablation was applied to the larger lobe. Overall, heat ablation was performed 14 times in the 9 cats. Clinical signs and serum TT4, fT4, and calcium concentrations were monitored daily for 2 days after the procedure, weekly for the first month, and then monthly. Laryngeal function was evaluated and cervical ultrasonography and thyroid scintigraphy were also performed. Monitoring continued for as long as 9 months after heat ablation if a cat became euthyroid or until an owner chose an alternative treatment because of recurrence of hyperthyroidism.

RESULTS

Serum TT4 and fT4 concentrations transiently decreased after all 14 heat ablation procedures (< or = reference range after 10 of 14 treatments) within 2 days after the procedure. Cats were euthyroid for 0 to 18 months (mean, 4 months). Hyperthyroidism recurred in all cats. Adverse effects included transient Horner's syndrome (2 cats) and laryngeal paralysis without clinical signs (1 cat).

CONCLUSIONS AND CLINICAL RELEVANCE

Percutaneous heat ablation as a treatment for hyperthyroidism in cats is effective transiently but not permanently.

Injeção percutânea de etanol no tratamento de nódulos tiroidianos sólidos, císticos e autônomos

A injeção percutânea de etanol (IPE) guiada por ultra-som tem sido utilizada para o tratamento de nódulos tiroidianos autônomos, sólidos e císticos. Apresentamos nossa experiência em 50 pacientes tratados, sendo 26 portadores de nódulos sólidos, 17 de nódulos císticos e 7 de nódulos autônomos (NA). Avaliamos os pacientes 1 semana, 1 mês, 3 meses, 6 meses e 1 ano após a IPE. Após 1 ano, os nódulos sólidos reduziram a 74% do volume inicial, os císticos diminuíram 92% sem apresentar recidivas. Um ano após o tratamento dos nódulos autônomos, 5 pacientes estavam em eutiroidismo clínico e laboratorial e 2 em eutiroidismo mas com TSH subnormal. Não houve recorrência da tirotoxicose e a redução nodular foi de 66%. O procedimento foi bem tolerado por todos. Os resultados confirmam que a IPE é uma boa alternativa terapêutica para redução dos nódulos tiroidianos císticos e sólidos e no tratamento dos nódulos autônomos.

Differences between endocrine surgeons and endocrinologists in the management of non-toxic multinodular goitre

BACKGROUND

It is not known whether the management of multinodular goitre differs between endocrinologists and endocrine surgeons.

METHODS

A questionnaire containing a hypothetical case (a 42-year-old euthyroid woman with a 50-80-g multinodular goitre) and 11 variations on the case was sent to endocrinologists and endocrine surgeons in Australia.

RESULTS

The response rate was 55 per cent, including 45 endocrine surgeons and 127 endocrinologists. For the index case, serum thyroid-stimulating hormone (TSH), fine-needle aspiration biopsy and ultrasonography were widely used by both groups. Thyroid antibodies and scintigraphy were ordered by a greater proportion of endocrinologists than surgeons, and computed tomography more frequently by surgeons than endocrinologists. Treatment recommendations differed significantly between specialties for the index case (endocrinologists: no treatment 65 per cent, thyroxine 22 per cent, surgery 10 per cent, radioiodine 3 per cent; surgeons: no treatment 67 per cent, thyroxine 2 per cent, surgery 31 per cent; P < 0.001) and for seven of the variations. In particular, for a patient with suppressed TSH, most endocrinologists (60 per cent) recommended radioiodine treatment, whereas there was no consensus among surgeons (surgery 40 per cent, no treatment 36 per cent, radioiodine 21 per cent). For a patient with a partly intrathoracic goitre, most surgeons (88 per cent) recommended surgery, whereas there was no consensus among endocrinologists (surgery 45 per cent, no treatment 34 per cent, thyroxine treatment 13 per cent, radioiodine 8 per cent).

CONCLUSION

There are clinically significant differences between endocrine surgeons and endocrinologists in the management of multinodular goitre.

Utility of recombinant human thyrotropin for augmentation of radioiodine uptake and treatment of nontoxic and toxic multinodular goiters

OBJECTIVE

To report our results in treating 16 patients with low radioiodine uptake (RAIU) multinodular goiter who had obstructive symptoms or suppressed thyroid-stimulating hormone (TSH or thyrotropin), indicating mild hyperthyroidism.

METHODS

Six patients were treated with 0.3 mg of recombinant human thyrotropin (rhTSH) followed by 30 mCi of (131)I 72 hours later. Ten patients were treated with 0.9 mg of rhTSH followed by 30 mCi of (131)I 24 hours later.

RESULTS

Of the 16 treated patients, all 10 with compressive symptoms and both patients with weight loss had remission or improvement, as did 1 of 2 patients with atrial fibrillation. All patients with suppressed TSH had a return to normal levels or became hypothyroid. During the next 3 to 7 months, estimated gland size reduction was 30 to 40%. Three of the 6 patients who received 0.3 mg of rhTSH and 6 of the 10 patients who received 0.9 mg of rhTSH, in conjunction with (131)I therapy, ultimately had TSH levels indicative of hypothyroidism. Mild radiation thyroiditis developed in only one patient, and no other side effects occurred.

CONCLUSION

The 0.3-mg dose of rhTSH seemed to be as efficacious as the 0.9-mg dose. The greater than fourfold increase in RAIU at 72 hours after administration of rhTSH in our study is more than twofold higher than the 24-hour RAIU results previously reported in normal subjects and in patients with multinodular goiter. These findings have implications for future expanded studies and alternative dosing regimens in treating patients with both multinodular goiter and subclinical hyperthyroidism.

Frozen section in a cytological diagnosis of thyroid follicular neoplasm

OBJECTIVE/HYPOTHESIS

Fine-needle aspiration biopsy is the most accurate diagnostic test for thyroid nodules, its only limitation being the diagnosis of follicular neoplasm that does not distinguish between benign and malignant follicular lesions.

STUDY DESIGN

To determine the utility of intraoperative frozen-section analysis in cases of a cytological diagnosis of follicular neoplasm, a retrospective review of 66 patients with a solitary thyroid nodule and follicular neoplasm who underwent thyroid surgery was carried out.

METHODS

Fine-needle aspiration was classified following the Papanicolaou Society of Cytopathology Classification, and frozen section was defined as malignant or "deferred." If a malignant diagnosis was made by frozen-section analysis, a total thyroidectomy was carried out. The extension of thyroid surgery in the deferred cases was based on the definitive histological diagnosis.

RESULTS

Sixty-four cases were classified as deferred, and two as suspect for malignancy. Among the 64 deferred cases, 15 were malignant in the final pathological findings, and 49 were benign. The two suspect cases were papillary carcinoma. Frozen-section analysis classified 2 of 17 (11.7%) cases as follicular variant of papillary carcinoma that could not be diagnosed by cytological study. However, these two cases had a strong clinical evidence of malignancy.

CONCLUSION

The routine use of frozen-section analysis is useless in cases of cytological diagnosis of follicular neoplasm on fine-needle aspiration biopsy, because of the low probability of achieving the diagnosis of follicular carcinoma and the inability to provide additional information apart from the clinical and the cytological data.

Management of simple nodular goiter: current status and future perspectives

The simple nodular goiter, the etiology of which is multifactorial, encompasses the spectrum from the incidental asymptomatic small solitary nodule to the large intrathoracic goiter, causing pressure symptoms as well as cosmetic complaints. Its management is still the cause of considerable controversy. The mainstay in the diagnostic evaluation is related to functional and morphological characterization with serum TSH and (some kind of) imaging. Because malignancy is just as common in patients with a multinodular goiter as patients with a solitary nodule, we support the increasing use of fine-needle aspiration biopsy (cytology). Most patients need no treatment after malignancy is ruled out. In case of cosmetic or pressure symptoms, the choice in multinodular goiter stands between surgery, which is still the first choice, and radioiodine if uptake is adequate. In addition to surgery, the solitary nodule, whether hot or cold, can be treated with percutaneous ethanol injection therapy. If hot, radioiodine is the therapy of choice. Randomized studies are scarce, and the side effects of nonsurgical therapy are coming into focus. Therefore, the use of the optimum option in the individual patient cannot at present be based on evidence. However, we are of the view that levothyroxine, although widely used, should no longer be recommended routinely for this condition. Within a few years, the introduction of recombinant human TSH and laser therapy may profoundly alter the nonsurgical treatment of simple nodular goiter.

Minimal access thyroid surgery: is it feasible, is it appropriate?

BACKGROUND

Reports of minimal access thyroid surgery (MATS) using various techniques have recently appeared. This study examined the feasibility of MATS using either a lateral 'focused' or endoscopically assisted approach.

METHODS

The study group comprised all patients undergoing minimally invasive parathyroidectomy (MIP) during the period May 1998 to April 2002 in whom a concomitant thyroid procedure was undertaken. All procedures were performed either through a 2-cm lateral cervical incision (n = 19) or endoscopically (n = 7).

RESULTS

Twenty-six patients underwent thyroid surgery, consisting of either local excision of a thyroid nodule (n = 25) or hemi-thyroidectomy (n = 1). In 13 patients the nodule was incidentally discovered, in four patients removal of the parathyroid necessitated partial thyroidectomy, and in nine patients the lesion identified by preoperative parathyroid localization proved to be a thyroid nodule. There were no permanent complications in the study group. Two patients required drainage of a haematoma. The final pathology of all 26 cases revealed benign nodular thyroid disease.

CONCLUSION

Thyroid surgery can safely be performed as a minimally invasive procedure. Minimal access thyroid surgery is therefore a feasible option for selected patients. The question remains to be answered as to whether this surgical approach is appropriate treatment for nodular thyroid disease.