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Veríssimo D, Pereira B, Vinhais J, Ivo C, Martins AC, E Silva JN, Passos D, Lopes L, de Castro JJ, Marcelino M. Long-term follow-up of treatment outcomes in Graves' disease and toxic nodular disease. Endocrine 2024:10.1007/s12020-024-04000-1. [PMID: 39152296 DOI: 10.1007/s12020-024-04000-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 08/07/2024] [Indexed: 08/19/2024]
Abstract
PURPOSE Hyperthyroidism guidelines have not been updated over the past five years, despite numerous data on the subject, and recent studies providing a wide variation in treatment success rates. We aim to compare the effectiveness and safety of treatment modalities in patients with Graves' disease or toxic nodular disease. METHODS Single center retrospective cohort study of Graves' disease and toxic nodular disease patients treated between 1983 and 2023. RESULTS A total of 411 patients were treated for hyperthyroidism, 245 due to Graves' disease and 166 due to or toxic nodular disease, followed for a median of 7 years. In Graves' disease, 90.2% were treated with antithyroid drugs over 250 cycles, achieving 41.7% cumulative remission. Half of all relapses (50.9%) occurred in the first year, 76.3% in the first three years, and 98.3% within nine years. Treatment periods of 12-24 months showed higher remission and lower relapse rates than longer periods. I-131 was used in 103 cycles with 82.5% remission and 7.1% relapse. A total of 29 thyroidectomies resulted in 100% remission, with no relapse. In toxic nodular disease, surgery was the most frequently used treatment (54.5%), followed by I-131 (37.1%). CONCLUSION Our findings support antithyroid drugs as the preferential first-line treatment for Graves' disease, allowing for euthyroidism with minimal adverse effects. Given the propensity for relapse, we suggest a rigorous monitoring, particularly within the first three years. In toxic nodular disease, surgery should be the preferred option, with I-131 being reserved for single adenomas and small goiters.
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Affiliation(s)
- David Veríssimo
- Department of Endocrinology, Portuguese Armed Forces Hospital, Lisboa, Portugal.
| | - Beatriz Pereira
- Department of Endocrinology, Portuguese Armed Forces Hospital, Lisboa, Portugal
| | - Joana Vinhais
- Department of Endocrinology, Portuguese Armed Forces Hospital, Lisboa, Portugal
| | - Catarina Ivo
- Department of Endocrinology, Portuguese Armed Forces Hospital, Lisboa, Portugal
| | - Ana C Martins
- Department of Endocrinology, Portuguese Armed Forces Hospital, Lisboa, Portugal
| | - João N E Silva
- Department of Endocrinology, Portuguese Armed Forces Hospital, Lisboa, Portugal
| | - Dolores Passos
- Department of Endocrinology, Portuguese Armed Forces Hospital, Lisboa, Portugal
| | - Luís Lopes
- Department of Endocrinology, Portuguese Armed Forces Hospital, Lisboa, Portugal
| | - João J de Castro
- Department of Endocrinology, Portuguese Armed Forces Hospital, Lisboa, Portugal
| | - Mafalda Marcelino
- Department of Endocrinology, Portuguese Armed Forces Hospital, Lisboa, Portugal
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He M, Pan L, Li Y, Wang Y, Zhong X, Du Y, Pan T. Clinical factors influencing the success rate of radioiodine treatment for Graves' disease. Diabetes Obes Metab 2024. [PMID: 39021354 DOI: 10.1111/dom.15790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/07/2024] [Accepted: 06/14/2024] [Indexed: 07/20/2024]
Abstract
AIMS To investigate the impact of various clinical factors associated with Graves' disease on the success rate of radioiodine (RAI) therapy for Graves' disease within 3 years, and to determine the optimal range of iodine dosage per unit volume that yields the highest cure rate for Graves' disease within 1 year. MATERIALS AND METHODS This retrospective study included patients diagnosed with Graves' disease who underwent RAI therapy at the Second Affiliated Hospital of Anhui Medical University between October 2012 and October 2022. The cumulative success rate was analysed using the Kaplan-Meier method. Univariate and multivariate Cox proportional hazards regression models were employed to evaluate factors associated with successful treatment of Graves' disease. Outcomes were categorized as either success or failure for all patients. RESULTS Overall, 1994 patients were enrolled in this study, including 594 (29.8%) male and 1399 (70.2%) female patients. The success and failure groups comprised 1645 (82.4%) and 349 patients (17.6%), respectively, after a 3-year follow-up period. Multivariate regression analysis demonstrated that sex, antithyroid drug (ATD) use before RAI therapy, age, thyroid receptor antibody (TRAb) levels, iodine dose, thyroid mass, and early ATD use before RAI therapy were independent influencing factors for Graves' disease cure. CONCLUSIONS We found that female patients and those with TRAbs ≥31.83 IU/L and thyroid mass ≥ 73.42 g had a lower cure rate. Therefore, thyroid size, disease severity, and duration of disease should be comprehensively considered when making treatment decisions and iodine dose selection in clinical practice.
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Affiliation(s)
- Meiwen He
- Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Limeng Pan
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yifan Li
- The Second School of Clinical Medicine, Anhui Medical University, Hefei, China
| | - Yue Wang
- Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xing Zhong
- Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yijun Du
- Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Tianrong Pan
- Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
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Mahmoud HA, Alsanory AABAA, Mostafa HGE, Hassan ER. Factors affecting timing of hypothyroidism following radioactive iodine therapy (RAIT) for patients with Graves' disease: A 12-month observational study. Nucl Med Commun 2024; 45:499-509. [PMID: 38586956 DOI: 10.1097/mnm.0000000000001838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
BACKGROUND This retrospective study analyzed factors influencing hypothyroidism development after radioactive iodine therapy for Graves' disease. PATIENTS AND METHODS Three hundred and three patients with Graves' disease treated with radioactive iodine (RAI) from 2013 to 2022 at two Egyptian hospitals were included. Data collected included demographics, lab values, thyroid imaging, RAI doses, and outcomes. Patients were followed for ≥1 year to assess hypothyroidism onset. RESULTS At the end of 1 year, around 79.5% of the individuals developed hypothyroidism while 12.5% continued to experience hyperthyroidism. The onset of hypothyroidism occurred earlier in those with thyroid volume (≤75.5 cm 3 ), lower thyroid weight (≤84.7 g), thyroid uptake (≤18.8%), and higher RAI dose/volume (≥0.1022 mCi/ml) ( P < 0.001). Additionally, there was a correlation between anti-thyroid peroxidase (anti-TPO) antibodies and faster development of hypothyroidism compared to those who were negative for antibodies (2.9 vs 8.9 months, P = 0.001). When considering factors in analysis it was found that anti-TPO antibodies were the only independent predictor, for developing hypothyroidism (hazard risk 30.47, P < 0.001). Additionally, thyroid volume and uptake independently predicted successful treatment outcomes ( P < 0.05). CONCLUSION Positive anti-TPO antibodies strongly predict hypothyroidism risk after RAI therapy for Graves' disease. Smaller thyroid size, lower uptake, and higher RAI dose/volume correlate with earlier hypothyroidism onset but are less significant predictors than anti-TPO status. Findings can guide RAI therapy personalization to optimize outcomes.
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Affiliation(s)
| | | | | | - Esraa Roshdy Hassan
- Radiotherapy and Nuclear Medicine Department, South Egypt Cancer Institute, Assiut University, El-Fateh, Egypt
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Meling Stokland AE, Austdal M, Nedrebø BG, Carlsen S, Hetland HB, Breivik L, Ueland HO, Watt T, Cramon PK, Løvås K, Husebye ES, Ueland GÅ. Outcomes of Patients With Graves Disease 25 Years After Initiating Antithyroid Drug Therapy. J Clin Endocrinol Metab 2024; 109:827-836. [PMID: 37747433 PMCID: PMC10876387 DOI: 10.1210/clinem/dgad538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Indexed: 09/26/2023]
Abstract
CONTEXT Graves disease (GD) is a leading cause of hyperthyroidism. Detailed investigations and predictors of long-term outcomes are missing. OBJECTIVE This work aimed to investigate the outcomes in GD 25 years after initiating antithyroid drug treatment, including disease course, clinical and biochemical predictors of relapse, and quality of life. METHODS A retrospective follow-up was conducted of GD patients that participated in a randomized trial from 1997 to 2001. Demographic and clinical data were obtained from medical records and questionnaires. Biobank samples were analyzed for inflammatory biomarkers and compared with age- and sex-matched healthy individuals. RESULTS We included 83% (182/218) of the patients from the original study. At the end of follow-up, normal thyroid function was achieved in 34%. The remaining had either active disease (1%), spontaneous hypothyroidism (13%), or had undergone ablative treatment with radioiodine (40%) or thyroidectomy (13%). Age younger than or equal to 40 years, thyroid eye disease (TED), smoking, and elevated levels of interleukin 6 and tumor necrosis factor receptor superfamily member 9 (TNFRS9) increased the risk of relapsing disease (odds ratio 3.22; 2.26; 2.21; 1.99; 2.36). At the end of treatment, CD40 was lower in patients who maintained normal thyroid function (P = .04). At the end of follow-up, 47% had one or more autoimmune diseases, including vitamin B12 deficiency (26%) and rheumatoid arthritis (5%). GD patients who developed hypothyroidism had reduced quality of life. CONCLUSION Careful lifelong monitoring is indicated to detect recurrence, hypothyroidism, and other autoimmune diseases. Long-term ATD treatment emerges as a beneficial first-line treatment option, especially in patients with young age at onset or presence of TED.
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Affiliation(s)
- Ann-Elin Meling Stokland
- Department of Endocrinology, Stavanger University Hospital, 4011 Stavanger, Norway
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
| | - Marie Austdal
- Department of Research, Stavanger University Hospital, 4011 Stavanger, Norway
| | | | - Siri Carlsen
- Department of Endocrinology, Stavanger University Hospital, 4011 Stavanger, Norway
| | - Hanne Brit Hetland
- Department of Research, Stavanger University Hospital, 4011 Stavanger, Norway
| | - Lars Breivik
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
| | - Hans Olav Ueland
- Department of Ophthalmology, Haukeland University Hospital, 5021 Bergen, Norway
| | - Torquil Watt
- Department of Endocrinology and Metabolism, Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Per Karkov Cramon
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital Rigshospitalet, 2100 Copenhagen, Denmark
| | - Kristian Løvås
- Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway
| | - Eystein Sverre Husebye
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
- Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway
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Liu X, Wong CKH, Wu T, Chan WWL, Woo YC, Lam CLK, Lang BHH. A comparison of cardiovascular disease, cancer, mortality, and Graves' ophthalmopathy following treatment for hyperthyroidism: A Bayesian network meta-analysis. World J Surg 2024; 48:393-407. [PMID: 38686801 DOI: 10.1002/wjs.12066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 12/18/2023] [Indexed: 05/02/2024]
Abstract
OBJECTIVES This network meta-analysis aimed to evaluate the association of anti-thyroid drugs (ATD), radioactive iodine (RAI), and thyroidectomy with subsequent outcomes in patients with newly-diagnosed hyperthyroidism. METHODS The Ovid Medline, Ovid Embase, and Cochrane Library databases were searched for observational studies and randomized controlled trials. Included studies were published on or before 1st May 2022 involving at least two of the treatments among ATD, RAI, and thyroidectomy for hyperthyroidism. Pairwise comparisons and Bayesian network meta-analysis were used to estimate hazard ratios (HRs) and their credible interval (CrI) of outcomes, including cardiovascular disease (CVD), cancer, overall mortality, and Graves' ophthalmopathy (GO). RESULTS A total of 22 cohort studies with 131,297 hyperthyroidism patients were included. Thyroidectomy was associated with lower risks of mortality and GO than ATD (HR = 0.54, 95% CrI: 0.31, 0.96; HR = 0.31, 95% CrI: 0.12, 0.64) and RAI (HR = 0.62, 95% CrI: 0.41, 0.95; HR = 0.18, 95% CrI: 0.07, 0.35). RAI had a higher risk of GO (HR = 1.70, 95% CrI: 1.02, 2.99) than ATD treatment. CONCLUSIONS This Bayesian network meta-analysis indicated that thyroidectomy was associated with lower risks of mortality and GO in newly-diagnosed hyperthyroid patients compared to ATD and RAI. Relative to ATD, RAI therapy increased the risk of GO.
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Affiliation(s)
- Xiaodong Liu
- Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Carlos K H Wong
- Laboratory of Data Discovery for Health (D24H), Hong Kong SAR, China
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Tingting Wu
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Wendy W L Chan
- Department of Clinical Oncology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yu Cho Woo
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Cindy L K Lam
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Brian H H Lang
- Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
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Wiersinga WM, Poppe KG, Effraimidis G. Hyperthyroidism: aetiology, pathogenesis, diagnosis, management, complications, and prognosis. Lancet Diabetes Endocrinol 2023; 11:282-298. [PMID: 36848916 DOI: 10.1016/s2213-8587(23)00005-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/28/2022] [Accepted: 01/03/2023] [Indexed: 02/26/2023]
Abstract
Hyperthyroidism is a common condition with a global prevalence of 0·2-1·3%. When clinical suspicion of hyperthyroidism arises, it should be confirmed by biochemical tests (eg, low TSH, high free thyroxine [FT4], or high free tri-iodothyonine [FT3]). If hyperthyroidism is confirmed by biochemical tests, a nosological diagnosis should be done to find out which disease is causing the hyperthyroidism. Helpful tools are TSH-receptor antibodies, thyroid peroxidase antibodies, thyroid ultrasonography, and scintigraphy. Hyperthyroidism is mostly caused by Graves' hyperthyroidism (70%) or toxic nodular goitre (16%). Hyperthyroidism can also be caused by subacute granulomatous thyroiditis (3%) and drugs (9%) such as amiodarone, tyrosine kinase inhibitors, and immune checkpoint inhibitors. Disease-specific recommendations are given. Currently, Graves' hyperthyroidism is preferably treated with antithyroid drugs. However, recurrence of hyperthyroidism after a 12-18 month course of antithyroid drugs occurs in approximately 50% of patients. Being younger than 40 years, having FT4 concentrations that are 40 pmol/L or higher, having TSH-binding inhibitory immunoglobulins that are higher than 6 U/L, and having a goitre size that is equivalent to or larger than WHO grade 2 before the start of treatment with antithyroid drugs increase risk of recurrence. Long-term treatment with antithyroid drugs (ie, 5-10 years of treatment) is feasible and associated with fewer recurrences (15%) than short-term treatment (ie, 12-18 months of treatment). Toxic nodular goitre is mostly treated with radioiodine (131I) or thyroidectomy and is rarely treated with radiofrequency ablation. Destructive thyrotoxicosis is usually mild and transient, requiring steroids only in severe cases. Specific attention is given to patients with hyperthyroidism who are pregnant, have COVID-19, or have other complications (eg, atrial fibrillation, thyrotoxic periodic paralysis, and thyroid storm). Hyperthyroidism is associated with increased mortality. Prognosis might be improved by rapid and sustained control of hyperthyroidism. Innovative new treatments are expected for Graves' disease, by targeting B cells or TSH receptors.
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Affiliation(s)
- Wilmar M Wiersinga
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Netherlands
| | - Kris G Poppe
- Endocrine Unit, CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Grigoris Effraimidis
- Department of Endocrinology and Metabolic Diseases, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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7
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Salman MA, Assal MM, Salman A, Elsherbiney M. Outcomes of Radioactive Iodine Versus Surgery for the Treatment of Graves’ Disease: a Systematic Review and Meta-analysis. Indian J Surg 2023. [DOI: 10.1007/s12262-023-03692-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Abstract
Graves’ disease (GD) is a systemic autoimmune disorder mainly affecting the thyroid gland. During GD management, the principal target is to control the hyperthyroid state. There have been three rather similarly effective modalities: medical therapy with antithyroid drugs (ATD), radioactive iodine (RAI), or surgical excision of the thyroid tissue (thyroidectomy). Defining the relative risks and benefits of each of the two potential definitive treatment options (RAI or thyroidectomy) is crucial for creating evidence-based therapy algorithms. This systematic review and meta-analysis aimed to compare the outcomes of these two treatment options. This is a systematic review and meta-analysis that analyzed the studies comparing RAI and thyroidectomy to treat GD. Studies were obtained by searching on Scopus, the Cochrane Central Register of Controlled Trials, and PubMed central database. The surgically treated group showed significantly lower failure rates, non-significantly lower cardiovascular morbidities, non-significantly higher complication rates, and significantly lower mortality rates. The RAI-related complications were mostly the development or worsening of Graves’ ophthalmopathy. This review and meta-analysis comparing surgery and radioactive iodine for the treatment of Grave’s disease from 16 well-conducted trials has shown that although surgery viz., total thyroidectomy was less frequently utilized for the treatment of Grave’s disease, it controlled the symptoms with greater success and without any worsening of Grave’s ophthalmopathy.
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Metwalley KA, Farghaly HS. Graves' Disease in Children: An Update. Clin Med Insights Endocrinol Diabetes 2023; 16:11795514221150615. [PMID: 37151843 PMCID: PMC10161304 DOI: 10.1177/11795514221150615] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/23/2022] [Indexed: 05/09/2023] Open
Abstract
Graves' disease (GD) is the most common cause of hyperthyroidism in children. A common GD symptom is a goiter. The usual biochemical profile in children with GD is a decreased thyroid hormone stimulating hormone (TSH) level and high free thyroxine (FT4) and free triiodothyronine (FT3) concentrations. The presence of thyroid receptor antibodies (TRAb) is the most important specific immunological sign for diagnosing GD. The treatment choices for pediatric GD are anti-thyroid drugs (ATDs), radioiodine, and thyroidectomy, but the risks and benefits of each modality are different. Management recommendations include the first-line use of a prolonged course of ATDs for at least 3 years and potentially 5 years or more. Rituximab and Teprotumumab are new novel alternative medications for the treatment of adult patients with GD and Graves' orbitopathy respectively, but evidence of the efficacy and safety of these drugs in pediatric patients with GD is lacking.
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Affiliation(s)
- Kotb Abbass Metwalley
- Kotb Abbass Metwalley, Pediatric Endocrinology Unit Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut 71111, Egypt.
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Kanokwongnuwat W, Penpong N, Sangsri C. Incidence and treatment outcomes of Graves' disease in Thailand: a single-center retrospective observational study. Thyroid Res 2022; 15:24. [PMID: 36529758 PMCID: PMC9761999 DOI: 10.1186/s13044-022-00142-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 11/09/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Treatment patterns and outcomes of Graves' disease (GD) are variable around the world. However, studies on treatment outcomes of GD from the Asian populations are limited. We aimed to evaluate treatment outcomes of GD in Thailand. METHODS Patients with new diagnoses of GD in a single center between 2014-2018 were retrospectively reviewed. The diagnosis of GD was based on clinical features, which included diffuse goiter, Graves' orbitopathy (GO), pretibial myxedema and acropachy. RESULTS The age-adjusted incidence of GD was 26.57 per 100,000 per year. The study included 355 patients aged 15 years or above with a follow-up period of at least 24 months. Antithyroid drug (ATD) was the most popular first-line treatment modality with 98.7% patients receiving the treatment, followed by radioactive iodine (RAI) treatment in 1.3% patients. The most effective treatment modality was surgery with a remission rate of 100%. ATD had a lowest remission rate of 23.8%. Multivariable Cox regression analysis showed GO (HR 1.76, 95% CI 1.08-2.88) and initial TSH < 0.01 uIU/ml (HR 1.61, 95% CI 1.14-2.28) were significant factors associated with an increased treatment failure rate. CONCLUSION Treatment failure with ATD in patients with GD was frequent in this population. The diagnosis of GD based solely on clinical features may explain the high treatment failure rate in this study. More definitive treatment could be used to prevent relapse and complications of the disease.
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Affiliation(s)
- Wasit Kanokwongnuwat
- grid.415153.70000 0004 0576 179XDivision of Nuclear Medicine, Department of Radiology, Prapokklao Hospital, 38 Leab Neon Road, Muang, Chanthaburi, 22000 Thailand
| | - Nawarat Penpong
- grid.415153.70000 0004 0576 179XDivision of Endocrinology, Department of Medicine, Prapokklao Hospital, Chanthaburi, Thailand
| | - Chaninporn Sangsri
- grid.415153.70000 0004 0576 179XDivision of Head Neck and Breast Surgery, Department of Surgery, Prapokklao Hospital, Chanthaburi, Thailand
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Kim HJ. Long-term management of Graves disease: a narrative review. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2022; 40:12-22. [PMID: 36329661 PMCID: PMC9946914 DOI: 10.12701/jyms.2022.00444] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 08/10/2022] [Indexed: 11/06/2022]
Abstract
Graves disease (GD) is the most common cause of hyperthyroidism, accounting for more than 90% of cases in Korea. Patients with GD are treated with any of the following: antithyroid drugs (ATDs), radioactive iodine (RAI) therapy, or thyroidectomy. Most patients begin treatment with ATDs, and clinical guidelines suggest that the appropriate treatment period is 12 to 18 months. While RAI treatment and surgery manage thyrotoxicosis by destroying or removing thyroid tissue, ATDs control thyrotoxicosis by inhibiting thyroid hormone synthesis and preserving the thyroid gland. Although ATDs efficiently control thyrotoxicosis symptoms, they do not correct the main etiology of GD; therefore, frequent relapses can follow. Recently, a large amount of data has been collected on long-term ATDs for GD, and low-dose methimazole (MMZ) is expected to be a good option for remission. For the long-term management of recurrent GD, it is important to induce remission by evaluating the patient's drug response, stopping ATDs at an appropriate time, and actively switching to surgery or RAI therapy, if indicated. Continuing drug treatment for an extended time is now encouraged in patients with a high possibility of remission with low-dose MMZ. It is also important to pay attention to the quality of life of the patients. This review aimed to summarize the appropriate treatment methods and timing of treatment transition in patients who relapsed several times while receiving treatment for GD.
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Affiliation(s)
- Hyo-Jeong Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Nowon Eulji University Hospital, Eulji University School of Medicine, Seoul, Korea,Corresponding author: Hyo-Jeong Kim, MD, PhD Thyroid-Endocrine Center, Nowon Eulji University Hospital, Annex, 1st floor, 68 Hangeulbiseok-ro, Nowon-gu, Seoul 01830, Korea Tel: +82-2-970-8558 • Fax: +82-2-970-8878 • E-mail:
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Boehm E, Kao YH, Lai J, Wraight PR, Sivaratnam DA. Empiric radioiodine for hyperthyroidism: Outcomes, prescribing patterns, and its place in the modern era of theranostics. Clin Endocrinol (Oxf) 2022; 97:124-129. [PMID: 35508893 DOI: 10.1111/cen.14753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/01/2022] [Accepted: 04/27/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The modern era of radioiodine (I-131) theranostics for metastatic differentiated thyroid cancer requires us to rationalize the role of traditional empiric prescription in nonmalignant thyroid disease. We currently practice empiric I-131 prescription for treatment of hyperthyroidism. This study aims to assess outcomes after treatment of hyperthyroidism by empiric I-131 prescription at our centre, evaluate factors that impact on outcomes and prescribing practice, and gain insight into whether there is a place for theranostically-guided prescription in hyperthyroidism. PATIENTS AND METHODS A retrospective review was undertaken of all patients with Graves' disease, toxic multinodular goitre (MNG) and toxic adenoma treated with I-131 between 2016 and 2021. Associations between clinical or scintigraphic variables and remission (euthyroid or hypothyroid) or persistence of hyperthyroidism at follow-up were performed using standard t test as well as Pearson's product correlation. RESULTS Of 146 patients with a mean follow-up of 13.6 months, 80.8% achieved remission of hyperthyroidism. This was highest in toxic nodules (90.1%), compared with Graves' disease (73.8%) and toxic MNG (75.5%). In patients with Graves' disease, higher administered activity was associated with remission (p = .035). There was a weak inverse correlation between the Tc-99m pertechnetate uptake vs prescribed activity in Graves' disease (r = -0.33; p = .009). Only one patient (0.7%) had an I-131 induced flare of thyrotoxicosis. CONCLUSION Traditional empiric I-131 prescription is a safe and effective treatment of hyperthyroidism and suitable for most patients. However, there may be a role for personalized I-131 prescription by theranostic guidance in selected patients with high thyroid hyperactivity.
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Affiliation(s)
- Emma Boehm
- Department of Nuclear Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Yung Hsiang Kao
- Department of Nuclear Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Jeffrey Lai
- Department of Nuclear Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Paul R Wraight
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Dinesh A Sivaratnam
- Department of Nuclear Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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12
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Hoang TD, Stocker DJ, Chou EL, Burch HB. 2022 Update on Clinical Management of Graves Disease and Thyroid Eye Disease. Endocrinol Metab Clin North Am 2022; 51:287-304. [PMID: 35662442 PMCID: PMC9174594 DOI: 10.1016/j.ecl.2021.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The management of hyperthyroidism and extrathyroidal manifestations of Graves disease remains complex. Considerations that include patient preference, age, comorbidity, pregnancy, tobacco smoking, and social determinants of health must all be weaved into a cohesive management plan. A multidisciplinary team is required to manage all aspects of Graves disease, particularly thyroid eye disease, for which new therapeutic options are now available.
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Affiliation(s)
- Thanh D Hoang
- Division of Diabetes, Endocrinology and Metabolism, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20819, USA; Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Derek J Stocker
- Department of Radiology, Nuclear Medicine Service, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20819, USA; Departments of Internal Medicine, Pathology, and Radiologic Sciences Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Eva L Chou
- Department of Ophthalmology, Oculoplastic Service, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20819, USA; Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Henry B Burch
- Division of Diabetes, Endocrinology and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 6707 Democracy Boulevard, Room 6054, Bethesda, MD 20892-5460, USA; Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.
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13
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Abstract
Thyroid disease affects an estimated 20 million Americans, with 1 in 8 women developing a thyroid disorder during her lifetime. Although most patients with thyroid cancer have a good prognosis and effective treatments for benign thyroid disease are available, disparities exist in thyroid care and result in worse outcomes for racial and ethnic minorities. Inequities in the diagnosis and treatment of thyroid disease are due to the complex interplay of systems-, physician-, and patient-level factors. Thus, innovative strategies that take an ecological approach to addressing racial disparities are needed to achieve equitable care for all patients with thyroid disease.
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Affiliation(s)
- Debbie W Chen
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, 24 Frank Lloyd Wright Drive, PO Box 451, Ann Arbor, MI 48106, USA.
| | - Michael W Yeh
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
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14
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Kim MJ, Cho SW, Kim YA, Choi HS, Park YJ, Park DJ, Cho BY. Clinical Outcomes of Repeated Radioactive Iodine Therapy for Graves' Disease. Endocrinol Metab (Seoul) 2022; 37:524-532. [PMID: 35709827 PMCID: PMC9262691 DOI: 10.3803/enm.2022.1418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/25/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGRUOUND Radioactive iodine (RAI) therapy is a successful therapeutic modality for Graves' disease. However, RAI therapy can fail, and RAI therapy after antithyroid drugs (ATDs) has a lower remission rate. Therefore, many patients require repeated RAI therapy. This study investigated the clinical outcomes of repeated RAI therapy for Graves' disease. METHODS Patients who underwent RAI therapy as second-line therapy after failure of ATD treatment between 2001 and 2015 were reviewed. Remission was defined as hypothyroid or euthyroid status without ATD, and with or without levothyroxine at 12 months after RAI therapy. RESULTS The 1-year remission rate after 2nd RAI therapy (66%, 152/230) is significantly higher than that after 1st RAI therapy (48%, 393/815) or long-term ATD treatment after 1st RAI therapy failure (42%). The clinical response to 2nd RAI therapy was more rapid. The median time intervals from the 2nd RAI therapy to ATD discontinuation (1.3 months) and to the start of levothyroxine replacement (2.5 months) were significantly shorter than those for the 1st RAI therapy. A smaller goiter size, a longer time interval between the 1st and 2nd RAI therapies, and a longer ATD discontinuation period predicted remission after the 2nd RAI therapy. Finally, in 78 patients who failed the 2nd RAI therapy, the mean ATD dosage significantly reduced 5.1 mg over 12 months. CONCLUSION Repeated RAI therapy can be a good therapeutic option, especially in patients with smaller goiters and those who are more responsive to the 1st RAI therapy.
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Affiliation(s)
- Min Joo Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Sun Wook Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Corresponding author: Sun Wook Cho Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: +82-2-2072-4761, Fax: +82-2-762-2292, E-mail:
| | - Ye An Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Veterans Health Service Medical Center, Seoul, Korea
| | - Hoon Sung Choi
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Young Joo Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
| | - Do Joon Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Bo Youn Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Thyroid Center, Chung-Ang University Hospital, Seoul, Korea
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15
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Duan L, Zhang HY, Lv M, Zhang H, Chen Y, Wang T, Li Y, Wu Y, Li J, Li K. Machine learning identifies baseline clinical features that predict early hypothyroidism in patients with Graves' disease after radioiodine therapy. Endocr Connect 2022; 11:e220119. [PMID: 35521803 PMCID: PMC9175589 DOI: 10.1530/ec-22-0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 04/22/2022] [Indexed: 11/08/2022]
Abstract
Background and objective Radioiodine therapy (RAI) is one of the most common treatment solutions for Graves' disease (GD). However, many patients will develop hypothyroidism as early as 6 months after RAI. This study aimed to implement machine learning (ML) algorithms for the early prediction of post-RAI hypothyroidism. Methods Four hundred and seventy-one GD patients who underwent RAI between January 2016 and June 2019 were retrospectively recruited and randomly split into the training set (310 patients) and the validation set (161 patients). These patients were followed for 6 months after RAI. A set of 138 clinical and lab test features from the electronic medical record (EMR) were extracted, and multiple ML algorithms were conducted to identify the features associated with the occurrence of hypothyroidism 6 months after RAI. Results An integrated multivariate model containing patients' age, thyroid mass, 24-h radioactive iodine uptake, serum concentrations of aspartate aminotransferase, thyrotropin-receptor antibodies, thyroid microsomal antibodies, and blood neutrophil count demonstrated an area under the receiver operating curve (AUROC) of 0.72 (95% CI: 0.61-0.85), an F1 score of 0.74, and an MCC score of 0.63 in the training set. The model also performed well in the validation set with an AUROC of 0.74 (95% CI: 0.65-0.83), an F1 score of 0.74, and a MCC of 0.63. A user-friendly nomogram was then established to facilitate the clinical utility. Conclusion The developed multivariate model based on EMR data could be a valuable tool for predicting post-RAI hypothyroidism, allowing them to be treated differently before the therapy. Further study is needed to validate the developed prognostic model at independent sites.
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Affiliation(s)
- Lian Duan
- Department of Nuclear Medicine, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi, China
| | - Han-Yu Zhang
- Changzhi Medical College, Changzhi, Shanxi, China
| | - Min Lv
- Department of Nuclear Medicine, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi, China
| | - Han Zhang
- Changzhi Medical College, Changzhi, Shanxi, China
| | - Yao Chen
- Changzhi Medical College, Changzhi, Shanxi, China
| | - Ting Wang
- Department of Nuclear Medicine, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi, China
| | - Yan Li
- Department of Nuclear Medicine, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi, China
| | - Yan Wu
- Department of Clinical Laboratory, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Junfeng Li
- Department of Radiology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi, China
| | - Kefeng Li
- School of Medicine, University of California, San Diego, California, USA
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16
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Fecca C, Moon J, Posocco D, Zhao H, Dadparvar S. Accuracy of 123I Na Thyroid Imaging in calculating thyroid volume. J Nucl Med Technol 2022; 50:jnmt.121.263395. [PMID: 35610040 DOI: 10.2967/jnmt.121.263395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/22/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: Hyperthyroidism is often managed with radioactive iodine therapy. The dose of 131Iadministered to the patient is determined based on the calculated size of the thyroid gland in gram and 24 hour iodine uptake. Ultrasonography is a validated modality for determination of thyroid volume. Though necessary for assessing degree of 123I uptake, nuclear scintigraphy also allows for the capability of estimating thyroid volume. Here we compare volume measurements calculated based on ultrasonography and nuclear scintigraphy in a cohort of hyperthyroid patients. Methods: This prospective study designed to evaluate 110 consecutive hyperthyroidism patients who were undergoing thyroid ultrasound and 123I scintigraphy. Scintigraphy was performed after oral administration of approximately 11 MBq 123Isodium, and uptakes at 2 and 24 hours were measured. At 24 hours, the patients underwent thyroid scan with a nuclear medicine camera with LEHR (low energy high resolution) collimator next to the patient's chin. Thyroid measurements were calculated via the formula for determining a prolate ellipsoid. The formula was modified for RAIU as it is a planar image. Volumes calculated with these two modalities were subsequently analyzed and compared by linear regression. All patients had undergone ultrasonography with an average three months from nuclear scan. All of our patient 131I dosages were based on the thyroid measurements obtained by thyroid scintigraphy. Results: We included 110 patients (95 females, 15 males) with age range 20-95 years and average age 56 +/- 17.4 years old. Diagnoses included 66 patients with nodular goiter, and 44 patients with Graves' Disease. There was a linear relationship between measurement of thyroid gland weight by two modalities which can be explained in the following formula: log US(g) = 0.841 + 0.649*log NM(g). Conclusion: We have validated that this method has helped obtain more accurate measurements of the thyroid gland by thyroid scintigraphy. Additionally, we have derived conversion factors that convert the estimated thyroid volume calculated from thyroid scintigraphy to the expected ultrasound value.
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Affiliation(s)
| | - Jee Moon
- Temple University Hospital, United States
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17
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Bartalena L, Piantanida E, Gallo D, Ippolito S, Tanda ML. Management of Graves' hyperthyroidism: present and future. Expert Rev Endocrinol Metab 2022; 17:153-166. [PMID: 35287535 DOI: 10.1080/17446651.2022.2052044] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/08/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Graves' disease (GD) is an autoimmune disorder due to loss of tolerance to the thyrotropin receptor (TSHR) and ultimately caused by stimulatory TSHR antibodies (TSHR-Ab). GD may be associated with extrathyroidal manifestations, mainly Graves' orbitopathy. Treatment of GD relies on antithyroid drugs (ATDs), radioactive iodine (RAI), thyroidectomy. The major ATD limitation is the high recurrence rate after treatment. The major drawback of RAI and thyroidectomy is the inevitable development of permanent hypothyroidism. AREAS COVERED Original articles, clinical trials, systematic reviews, meta-analyses from 1980 to 2021 were searched using the following terms: Graves' disease, management of Graves' disease, antithyroid drugs, radioactive iodine, thyroidectomy, Graves' orbitopathy, thyroid-eye disease. EXPERT OPINION ATDs are the first-line treatment worldwide, are overall safe and usually given for 18-24 months, long-term treatment may decrease relapses. RAI is safe, although associated with a low risk of GO progression, particularly in smokers. Thyroidectomy requires skilled and high-volume surgeons. Patients play a central role in the choice of treatment within a shared decision-making process. Results from targeted therapies acting on different steps of the autoimmune process, including iscalimab, ATX-GD-59, rituximab, blocking TSHR-Ab, small molecules acting as antagonists of the TSHR, are preliminary or preclinical, but promising in medium-to-long perspective.
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Affiliation(s)
- Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Eliana Piantanida
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Daniela Gallo
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Silvia Ippolito
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Maria Laura Tanda
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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18
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Role of Thyroid RFA in the Treatment of Autonomously Functioning Thyroid Nodules. Tech Vasc Interv Radiol 2022; 25:100823. [DOI: 10.1016/j.tvir.2022.100823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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19
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Nuclear medicine therapy of thyroid goiter. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00204-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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20
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Outcomes of Graves' Disease Patients Following Antithyroid Drugs, Radioactive Iodine, or Thyroidectomy as the First-line Treatment. Ann Surg 2021; 273:1197-1206. [PMID: 33914484 DOI: 10.1097/sla.0000000000004828] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The long-term outcomes of first-line choice among ATD, RAI, and thyroidectomy for GD patients remain unclear. OBJECTIVE To compare the long-term morbidity, mortality, relapse, and costs of GD patients receiving first-line treatment. METHODS A population-based retrospective cohort of GD patients initiating first-line treatment with ATD, RAI, or thyroidectomy as a first-line primary treatment between 2006 and 2018 from Hong Kong Hospital Authority was analyzed. Risks of all-cause mortality, CVD, AF, psychological disease, diabetes, and hypertension were estimated using Cox proportional hazards regression models. The 10-year healthcare costs, change of comorbidities, and risk of relapse were compared across treatments. RESULTS Over a median follow-up of 90 months with 47,470 person-years, 6385 patients (ATD, 74.93%; RAI, 19.95%; thyroidectomy, 5.12%) who received first-line treatment for GD were analyzed. Compared with ATD group, patients who had undergone surgery had significantly lower risks of all-cause mortality [hazard ratio (HR) = 0.363, 95% confidence interval (CI) = 0.332-0.396], CVD (HR = 0.216, 95% CI = 0.195-0.239), AF (HR = 0.103, 95% CI = 0.085-0.124), psychological disease (HR = 0.279, 95% CI = 0.258-0.301), diabetes (HR = 0.341, 95% CI = 0.305-0.381), and hypertension (HR = 0.673, 95% CI = 0.632-0.718). Meanwhile, RAI group was also associated with decreased risks of all-cause mortality (HR = 0.931, 95% CI = 0.882-0.982), CVD (HR = 0.784, 95% CI = 0.742-0.828), AF (HR = 0.622, 95% CI = 0.578-0.67), and psychological disease (HR = 0.895, 95% CI = 0.855-0.937). The relapse rate was 2.41% in surgery, 75.60% in ATD, and 19.53% in RAI group. The surgery group was observed with a significant lower Charlson Comorbidity Index score than the other 2 groups at the tenth-year follow-up. The mean 10-year cumulative healthcare costs in ATD, RAI, and surgery group was US$23915, US$24260, and US$20202, respectively. CONCLUSIONS GD patients who received surgery as an initial treatment appeared to have lower chances of all-cause mortality, CVD, AF, psychological disease, diabetes, and hypertension in the long-term when compared to those treated with ATD or RAI. The surgery group had the lowest relapse and direct healthcare costs among the 3 treatment modalities. This long-term cohort study suggested surgery may have a larger role to play as an initial treatment for GD patients.
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21
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Abstract
The excess thyroid hormone secretion that characterises Graves' disease (GD) is generated when stimulatory antibodies bind to the thyroid stimulating hormone receptor on the follicular cell of the thyroid gland.This underlying mechanism cannot easily be abolished and the mainstay of Graves' disease (GD) management in the young remains thionamide anti-thyroid drug (ATD). Unfortunately, GD will usually recur after a 2 or 3 year course of ATD, even when the stimulatory antibody titres have fallen. The diagnosis of GD therefore usually signals the start of a lengthy period of out-patient assessments and associated venepuncture. Careful, more protracted administration of ATD may increase the likelihood of longer-term remission and reduce the likelihood of the patient developing ATD side-effects. An understanding of how best to use ATD and an awareness of the less well-known consequences of GD and its' treatment - such as excessive weight-gain and long-term hypothyroidism - are also of fundamental importance.Recent clinical studies have shed light on how best to manage the young patient with GD and the associated new information will help to answer some of the questions posed by the young person and their family at diagnosis. This new knowledge is the focus of this article about ATD therapy in the young.
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Affiliation(s)
- Tim Cheetham
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK. .,Department of Paediatric Endocrinology, Royal Victoria Infirmary, Great North Children's Hospital, Newcastle upon Tyne, NE1 4LP, UK.
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22
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El Kawkgi OM, Ross DS, Stan MN. Comparison of long-term antithyroid drugs versus radioactive iodine or surgery for Graves' disease: A review of the literature. Clin Endocrinol (Oxf) 2021; 95:3-12. [PMID: 33283314 DOI: 10.1111/cen.14374] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/30/2020] [Accepted: 11/18/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The management of Graves' disease (GD) in the US is shifting towards increased use of anti-thyroid drugs (ATD). If patients fail to achieve remission after a standard course of therapy of 12-18 months, long-term treatment with ATD (≥24 months) may be chosen over definitive therapy with radioiodine (RAI) or surgery. Clinicians will need to contrast this strategy to ablative therapies as they help patients in decision making. SUMMARY Review of the literature illustrates that long-term ATD delivers euthyroidism with minimal complications, low financial cost and with an advantageous profile regarding quality of life (QoL) and other biological outcomes. CONCLUSIONS Long-term ATD is a viable alternative to ablative therapies in the management of GD offering advantages across multiple patient centred outcomes. Decision making must factor differences in this approach compared to ablative therapies and ultimately be tailored to individualized patient situations.
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Affiliation(s)
- Omar M El Kawkgi
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Douglas S Ross
- Division of Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Marius N Stan
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN, USA
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23
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Lutterman SL, Zwaveling-Soonawala N, Verberne HJ, Verburg FA, van Trotsenburg AP, Mooij CF. The Efficacy and Short- and Long-Term Side Effects of Radioactive Iodine Treatment in Pediatric Graves' Disease: A Systematic Review. Eur Thyroid J 2021; 10:353-363. [PMID: 34540705 PMCID: PMC8406249 DOI: 10.1159/000517174] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/10/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Graves's disease (GD) is the most common cause of hyperthyroidism. Maximal 30% of pediatric GD patients achieve remission with antithyroid drugs. The majority of patients therefore require definitive treatment. Both thyroidectomy and radioactive iodine (RAI) are often used as definitive treatment for GD. However, data on efficacy and short- and long-term side effects of RAI treatment for pediatric GD are relatively scarce. METHODS A systematic review of the literature (PubMed and Embase) was performed to identify studies reporting the efficacy or short- and long-term side effects of RAI treatment in pediatric GD. RESULTS Twenty-three studies evaluating 1,283 children and adolescents treated with RAI for GD were included. The treatment goal of RAI treatment changed over time, from trying to achieve euthyroidism in the past to aiming at complete thyroid destruction and subsequent hypothyroidism in the last 3 decades. The reported efficacy of a first RAI treatment when aiming at hypothyroidism ranged from 42.8 to 97.5%, depending on the activity administered. The efficacy seems to increase with higher RAI activities. When aiming at hypothyroidism, both short- and long-term side effects of treatment are very rare. Long-term side effects were mainly seen in patients in whom treatment aimed at achieving euthyroidism. CONCLUSION RAI is a safe definitive treatment option for pediatric GD when aiming at complete thyroid destruction. When aiming at hypothyroidism, the efficacy of treatment seems to increase with a higher RAI activity. Prospective studies are needed to determine the optimal RAI dosing regimen in pediatric GD.
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Affiliation(s)
- Sarah L. Lutterman
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nitash Zwaveling-Soonawala
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Hein J. Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Frederik A. Verburg
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A.S. Paul van Trotsenburg
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Christiaan F. Mooij
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- *Correspondence to: Christiaan F. Mooij,
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24
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Secular Trends in Ablation Therapy for Graves' Disease: An Analysis of a 15-Year Experience at a Tertiary Hospital in South Korea. J Clin Med 2021; 10:jcm10081629. [PMID: 33921321 PMCID: PMC8069724 DOI: 10.3390/jcm10081629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/05/2021] [Accepted: 04/09/2021] [Indexed: 01/22/2023] Open
Abstract
Ablation therapy, such as radioactive iodine (RAI) therapy or thyroidectomy, is generally used as the second-line treatment for Graves' disease (GD) in Asia. This study investigated changes in the clinical characteristics and outcomes of ablation therapies for GD over 15 years. Patients who underwent ablation therapy between 2001 and 2015 at a single tertiary hospital were included. Among the 10,991 GD patients treated over this 15-year period, 1357 (12.3%) underwent ablation therapy, and the most common reason was intractable GD. The proportion of patients who underwent any type of ablation therapy significantly decreased from 9.0% (2001-2005) to 7.7% (2011-2015). However, the proportion of patients who underwent surgery significantly increased from 1.1% (2001-2005) to 2.4% (2011-2015), and the proportion of patients who received ablation therapy due to suspected thyroid cancer increased from 5% to 13% over time. With a median follow-up duration of 6.2 years, remission was achieved in 86% and 98% of patients in the RAI and surgery groups, respectively, and these rates remained stable over time. In conclusion, although the proportion of patients who underwent ablation therapy for GD decreased during 15 years, the proportion of those who underwent surgery increased in association with the increased rate of suspected thyroid cancers.
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25
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Sjölin G, Byström K, Holmberg M, Törring O, Khamisi S, Calissendorff J, Lantz M, Hallengren B, Filipsson Nyström H, Planck T, Wallin G. Treatment of patients with Graves' disease in Sweden compared to international surveys of an 'index patient'. ENDOCRINOLOGY DIABETES & METABOLISM 2021; 4:e00244. [PMID: 34277969 PMCID: PMC8279596 DOI: 10.1002/edm2.244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/11/2021] [Accepted: 02/06/2021] [Indexed: 01/21/2023]
Abstract
Introduction The treatment strategies for a 42‐year‐old female index patient with moderate Graves’ disease (GD) vary according to several international surveys. The important question whether surveys of treatment preferences in theoretical patient cases also match how real patients are treated has not yet been addressed. Materials and Methods From a Swedish cohort of 1186 GD patients (TT‐12 cohort), 27 women were identified using the same criteria as from the index patient surveys from the European and American Thyroid Associations. This ‘index patient cohort’ was age 40–45, otherwise healthy female, with two children and uncomplicated GD. The applied first‐line treatment of the patients in the index cohort, together with its variations, was compared with the treatment preferences according to international surveys. A comparison with the TT‐12 cohort was also performed. Results In the ‘Index cohort’, 77.8% were treated with antithyroid drugs (ATD), and 22.2% were treated with radioiodine (131I). This preference for ATD is in line with most countries/regions, with the exception of USA and the Middle East/North Africa, where 131I was preferred. The distribution of treatment in the TT‐12 cohort did not significantly differ from the index cohort. ATD was the preferred treatment in male and young (age 19–22) patients, as was RAI in old (age 69–73) patients. The age‐related, but not the gender‐related, cases differed significantly from the entire TT‐12 cohort. Conclusion The treatment choice in an index patient in Sweden seems in line with European practice, where ATD is the preferred first choice. This differs compared to US and North African survey intentions, where 131I is more often used. Age more than gender influences the treatment choice of GD patients. This is, to our best knowledge, the first time an index patient from ‘real life’ has been presented and compared to treatment preferences of international thyroid association surveys.
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Affiliation(s)
- Gabriel Sjölin
- Faculty of Medicine and Health Örebro University Hospital Örebro Sweden
| | - Kristina Byström
- Department of Medicine Örebro University and University Hospital Örebro Sweden
| | - Mats Holmberg
- Institute of Medicine Sahlgrenska Academy University of Gothenburg Göteborg Sweden.,ANOVA, Karolinska University Hospital Stockholm Sweden
| | - Ove Törring
- Institution for Clinical Science and Education Karolinska Institutet Stockholm Sweden
| | - Selwan Khamisi
- Department of Endocrinology Uppsala University Hospital Uppsala Sweden.,Department of Medical Sciences Uppsala University Uppsala Sweden
| | - Jan Calissendorff
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden.,Department of Endocrinology, Metabolism and Diabetes Karolinska University Hospital Stockholm Sweden
| | - Mikael Lantz
- Department of Endocrinology Skåne University Hospital Malmö Sweden.,Department of Clinical Sciences Lund University Lund Sweden
| | - Bengt Hallengren
- Department of Endocrinology Skåne University Hospital Malmö Sweden.,Department of Clinical Sciences Lund University Lund Sweden
| | - Helena Filipsson Nyström
- Institute of Medicine Sahlgrenska Academy University of Gothenburg Göteborg Sweden.,Department of Endocrinology Sahlgrenska University Hospital Göteborg Sweden.,Wallenberg Center for Molecular and Translational Medicine Göteborg Sweden
| | - Tereza Planck
- Department of Endocrinology Skåne University Hospital Malmö Sweden.,Department of Clinical Sciences Lund University Lund Sweden
| | - Göran Wallin
- Faculty of Medicine and Health Örebro University Hospital Örebro Sweden.,Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
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Lane LC, Rankin J, Cheetham T. A survey of the young person's experience of Graves' disease and its management. Clin Endocrinol (Oxf) 2021; 94:330-340. [PMID: 33128233 DOI: 10.1111/cen.14359] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/16/2020] [Accepted: 10/27/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE A suboptimal quality of life (QoL) has been reported in patients with Graves' disease treated in adult life, but long-term QoL in those treated in childhood and adolescence is unclear. We wanted to understand how Graves' disease and its management impact on the physical, psychological and social well-being of young people and their longer-term QoL. DESIGN, PATIENTS AND MEASUREMENTS Two questionnaires were used to assess QoL and patient experience of Graves' disease; PedsQL™ Generic Core Scales and a Graves' disease questionnaire devised for this project. The anonymized questionnaires were sent to young people (<30 years) diagnosed with Graves' disease in childhood and adolescence and managed at a tertiary paediatric endocrine unit in the North of England. Respondent QoL scores were compared with a healthy UK cohort. RESULTS Questionnaires were sent to 51 young people, and 26 responded (51%). Graves' patients reported a lower total QoL score compared with the healthy cohort (p = .003). This was particularly apparent in the psychosocial domain (p = .0016). No patient regretted having definitive treatment (surgery/radioiodine), and all said they would recommend it to others. Half of those who had received definitive treatment still did not feel recovered. There was no difference in the long-term QoL in those who did/did not receive definitive treatment (p = .40). CONCLUSIONS This study highlights short- and long-term impacts on the QoL and general well-being of young people with Graves' disease. There were no regrets regarding the choice of definitive treatment. This information will help inform the counselling of patients and their families.
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Affiliation(s)
- Laura Claire Lane
- Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-upon-Tyne, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, International Centre for Life, Newcastle University, Newcastle-upon-Tyne, UK
| | - Judith Rankin
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Tim Cheetham
- Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-upon-Tyne, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, International Centre for Life, Newcastle University, Newcastle-upon-Tyne, UK
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Sellem A, Elajmi W, Mhamed RB, Oueslati N, Ouertani H, Hammami H. [Role and effectiveness of radioactive-iodine therapy for the treatment of Grave's disease]. Pan Afr Med J 2020; 36:341. [PMID: 33193994 PMCID: PMC7603816 DOI: 10.11604/pamj.2020.36.341.21623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 07/08/2020] [Indexed: 11/11/2022] Open
Abstract
The treatment of Graves' disease is based on three therapies: medical treatment with synthetic antithyroid agents, surgery and radioactive-iodine therapy. The purpose of our study was to study the role and effectiveness of radioactive-iodine therapy for the treatment of Graves' disease. We conducted a retrospective, descriptive study of the epidemiological, clinical, paralclinical and therapeutic features of 54 patients with Graves' disease managed and treated with iodine-131 as well as of their short- and medium-term remission rate. The sex ratio was 0.45. The average age of patients was 38,33 ± 12.7 years. The most common functional signs were weight loss, tremors and palpitations. Mean FT4 was 54,51 ± 19,56 ng/dl (ranging from 8,90 and 100). Mean TSHus was 0,074 ± 0,29 µIU/ml. Synthetic antithyroid drugs were used in 49 patients; 83,67% of cases had persistent hyperthyroidism. Radioactive-iodine therapy was used as first-line therapy in 9,3% of cases and as second-line therapy in 90,7% of cases. Mean activity was 13,29 mCi ± 1,46 ranging from 10 to 15 mCi. The first assessment of hormonal status was performed after an average post-treatment period of 1,91 months; 29 patients (53,7%) achieved remission (eu- or hypo-thyroidism). After a 12 month-follow-up, patients' course was marked by remission in 88,88% of cases (euthyroidism in 14,8% and hypothyroidism in 74% of cases). Radioactive-iodine therapy is an effective treatment for Graves' disease. High radioactive iodine dose provides high remission rate.
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Affiliation(s)
- Ali Sellem
- Service de Médecine Nucléaire, Hôpital Militaire Principal d´Instruction de Tunis, Tunis, Tunisie
| | - Wassim Elajmi
- Service de Médecine Nucléaire, Hôpital Militaire Principal d´Instruction de Tunis, Tunis, Tunisie
| | - Rania Ben Mhamed
- Service d´Endocrinologie, Hôpital Militaire Principal d´Instruction de Tunis, Tunisie
| | - Nesrine Oueslati
- Service de Médecine Nucléaire, Hôpital Militaire Principal d´Instruction de Tunis, Tunis, Tunisie
| | - Haroun Ouertani
- Service d´Oto-Rhino-Laryngologie. Hôpital Militaire Principal d´Instruction de Tunis, Tunisie
| | - Hatem Hammami
- Service de Médecine Nucléaire, Hôpital Militaire Principal d´Instruction de Tunis, Tunis, Tunisie
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Acute Drug-Induced Cholestatic Syndrome in Basedow Graves’ Disease. JOURNAL OF INTERDISCIPLINARY MEDICINE 2020. [DOI: 10.2478/jim-2020-0006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction: Graves’ disease (GD), an autoimmune disorder caused by high levels of auto-antibodies against the thyroid-stimulating hormone receptor, is considered the most common cause of thyrotoxicosis, characterized by features such as goiter, ophthalmopathy and dermopathy. In our country, the administration of antithyroid drugs (ATD) is the first line of treatment in this disease. Side effects are rare but some of them, such as agranulocytosis or liver damage, may become serious.
Case presentation: We report the case of a 20-year-old female patient who was diagnosed with GD after being previously diagnosed with viral hepatitis A. Treatment was initiated with methimazole 30 mg/day, and three weeks later she developed intense hepatic cytolysis and cholestatic syndrome, therefore the ATD was stopped. A suspicion of autoimmune liver disease was raised, and a liver biopsy was performed in order to establish the diagnosis. The next therapeutic option for hyperthyroidism was radioactive iodine (RAI). Three months following RAI, the patient presented severe hypothyroidism, thereupon treatment with levothyroxine was initiated.
Conclusions: Although severe acute liver injury is rare, mild liver dysfunction is quite common in patients with GD. The overproduction of thyroid hormones, or the treatment with ATD through immune mediated processes or drug reactions, represent possible mechanisms responsible for liver damage.
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Hu RT, Liu DS, Li B. Predictive factors for early hypothyroidism following the radioactive iodine therapy in Graves' disease patients. BMC Endocr Disord 2020; 20:76. [PMID: 32471411 PMCID: PMC7260835 DOI: 10.1186/s12902-020-00557-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/21/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Radioactive iodine (RAI) therapy is an important treatment option for Graves' disease (GD), the main side effect of RAI treatment is hypothyroidism, and the factors resulting in hypothyroidism are still controversial. The purpose of this retrospective study was to clarify the possible risk factors of early hypothyroidism after RAI therapy in Graves' disease. METHODS We reviewed 312 GD patients treated with RAI between January 2017 to December 2018, collected the potential risk factors, and analyzed the relationship between these variables and early hypothyroidism. RESULTS After 6 months' follow-up, 218 (69.87%) patients were evaluated as early hypothyroid. Male gender, shorter duration of disease, smaller thyroid weight, lower 2-h radioactive iodine uptake (RAIU), 6-h RAIU, 24-h RAIU and 6/24-h uptake ratio, lower administered dosages were significantly associated with early hypothyroidism. Logistics regression analysis showed that male gender, smaller thyroid weight and lower 6-h RAIU were associated with early hypothyroidism. Multi-factors combined ROC curve analysis suggested that the predictive power of male gender, smaller thyroid weight and lower 6-h RAIU for early hypothyroidism was 0.711. CONCLUSIONS Our results show that RAI is an effective therapy for GD and most of the cured patients became to hypothyroid within 6 months. Male gender, smaller thyroid weight and lower 6-h RAIU are the main risk factors for early hypothyroidism.
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Affiliation(s)
- Rui-Ting Hu
- Department of Traditional Chinese Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China
- Department of Endocrinology, Hospital of Traditional Chinese Medicine of Linyi City, Linyi, 276002, Shandong, China
| | - De-Shan Liu
- Department of Traditional Chinese Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China
| | - Bin Li
- Department of Nuclear Medicine, Linyi People's Hospital, Cheeloo College of Medicine, Shandong University, Linyi, 276000, Shandong, China.
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Ann Surg 2020; 271:e21-e93. [PMID: 32079830 DOI: 10.1097/sla.0000000000003580] [Citation(s) in RCA: 238] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy. BACKGROUND Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US. METHODS The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.
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Yang YT, Chen JF, Tung SC, Kuo MC, Weng SW, Chou CK, Shen FC, Chang CM, Tsai CJ, Taso CF, Wang PW. Long-term outcome and prognostic factors of single-dose Radioiodine Therapy in patients with Graves' disease. J Formos Med Assoc 2020; 119:925-932. [PMID: 32057544 DOI: 10.1016/j.jfma.2020.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/21/2019] [Accepted: 01/21/2020] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND/PURPOSE Few studies exist investigating the effectiveness of radioiodine (RAI) therapy for hyperthyroidism patients in Asia. We herein investigated the real-world efficacy of single-dose RAI therapy in Taiwanese patients with Graves' disease (GD). METHODS This is a retrospective study of 243 patients with GD recorded between 1989 and 2016 in a tertiary referral hospital. Eu- or hypothyroid after RAI therapy were defined as the successful group. Kaplan-Meier curve and cox-regression model were used for analysis of prognostic factors. RESULTS Of the 243 patients, 187 were females, with mean age of 46.9 ± 13.6 years. Most patients (63.8%) did not choose RAI as the first-line therapy. The median dose was 7 mCi, with a mean follow-up period of 107.1 ± 82.8 months. The overall success rate was 70.9%. Univariate analysis revealed calculated- or fixed-dose (P = 0.015), goiter size (P < 0.001), and RAI dose (P = 0.022) were the factors affecting RAI effectiveness, multivariate analysis indicated goiter size was the independent factor. Patients with grade 0-2 goiter had a higher success rate than patients with grade 3 goiter (HR = 2.1, 95%CI = 1.34-3.27, P = 0.001), although the former were treated with lower RAI dose than the latter (7.8 ± 3.2 mCi vs 8.8 ± 3.3 mCi, P = 0.049). However, if the grade 3 goiters became smaller within 3 months of therapy, the success rate was not inferior to grade 0-2 goiter. CONCLUSION In Taiwan, RAI therapy for GD patients reached an overall success rate of 70.9%, with a median dose of 7 mCi. This study identified patients with grade 3 goiter need a more aggressive RAI regimen.
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Affiliation(s)
- Yi-Ting Yang
- Division of Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Jung-Fu Chen
- Division of Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Shih-Chen Tung
- Division of Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Ming-Chun Kuo
- Division of Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Shao-Wen Weng
- Division of Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Chen-Kai Chou
- Division of Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Feng-Chih Shen
- Division of Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Chih-Min Chang
- Division of Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Chia-Jen Tsai
- Division of Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Cheng-Feng Taso
- Division of Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Pei-Wen Wang
- Division of Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC.
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Affiliation(s)
- Carolyn D. Seib
- Department of Surgery, Stanford–Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford University School of Medicine, Stanford, California
- Divisions of General Surgery, Stanford University School of Medicine, Stanford, California
- Division of General Surgery, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
- Address correspondence to: Carolyn D. Seib, MD, MAS, Department of Surgery, Stanford University, 300 Pasteur Drive, H3680, Stanford, CA 94305
| | - Julie Chen
- Divisions of Endocrinology, Gerontology and Metabolism, Stanford University School of Medicine, Stanford, California
| | - Andrei Iagaru
- Divisions of Nuclear Medicine and Molecular Imaging, Stanford University School of Medicine, Stanford, California
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Lane LC, Cheetham T. Graves' disease: developments in first-line antithyroid drugs in the young. Expert Rev Endocrinol Metab 2020; 15:59-69. [PMID: 32133893 DOI: 10.1080/17446651.2020.1735359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 02/24/2020] [Indexed: 10/24/2022]
Abstract
Introduction: First-line treatment for most young people with Graves' disease (GD) will include the administration of a thionamide antithyroid medication (ATD); Carbimazole (CBZ), Methimazole (MMZ), or rarely, propylthiouracil (PTU). GD is a challenge for families and clinicians because the likelihood of remission following a course of ATD is lower in young people when compared to adults, yet the risk of adverse events is higher. An overall consensus regarding the optimal ATD treatment regimen is lacking; how ATD are prescribed, for how long and how the associated risk of adverse events is managed varies between clinicians, units and nations. This partly reflects clinician and family uncertainty regarding outcomes.Areas covered: This review will focus on some of the key articles published in the field of thionamide ATD in children. It will highlight key issues that need to be discussed with families as well as addressing the approach and controversies in the treatment of GD. This article does not reflect a formal systematic review of the literature.Expert opinion: New strategies in areas such as immunomodulation may see the development of new antithyroid drug treatments that, either in isolation or in combination with thionamide therapy, may increase the likelihood of long-term remission.
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Affiliation(s)
- Laura C Lane
- Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, UK
- Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-Upon-Tyne, UK
| | - Tim Cheetham
- Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, UK
- Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-Upon-Tyne, UK
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Zarif HA, Alam SS, Baashar A, Alsharif A, Alhilabi M. Comparison Between the Treatment Modalities for Graves' Disease at King Abdulaziz Medical City, Jeddah. Cureus 2020; 12:e6730. [PMID: 32015936 PMCID: PMC6977577 DOI: 10.7759/cureus.6730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Graves' disease is the most common cause of thyrotoxicosis. It can be treated using three different modalities, which include anti-thyroid drugs (ATD), radioactive iodine (RAI), and near-total thyroidectomy. This cohort study aimed to assess the treatment modality preferred at King Abdulaziz Medical City (KAMC) and to compare the treatment options in relation to the prognosis of the disease. Methods A retrospective cohort study was conducted on a total of 100 patients with Graves' disease who were treated and followed up in the endocrine clinics at KAMC between January 2013 and December 2018. Data on age at diagnosis, duration of illness, treatment modality, and response to treatment were extracted from paper and electronic medical files and analyzed. Results A total of 100 patients with Graves' disease were included in this cohort study. The ratio of female:male was 2:1. The median age in years was 32 (16). They were treated with ATD (60%), RAI ablation (40%), and none were treated by surgery. The remission rate was 53.3% for patients treated with ATD and 95% for RAI ablation. Hypothyroidism occurred in 90% of the responders to RAI and in 12% that were treated with ATD. Most of the patients that relapsed underwent RAI as the second line of treatment. Their remission rate was 78.6%. Conclusion ATD was the treatment modality mostly used for Graves' disease in our center. It resulted in a remission rate of 53%, which is higher than reported in national studies. Although the rate of remission post RAI ablation was as high as 95%, most patients developed hypothyroidism.
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Affiliation(s)
- Hawazen A Zarif
- Medicine / Endocrinology, Ministry of the National Guard - Health Affairs, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Sultan S Alam
- Internal Medicine, King Saud Bin Abdulaziz University for Health Sciences / King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
| | - Abdulrahman Baashar
- Internal Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Abdulaziz Alsharif
- Internal Medicine, King Saud Bin Abdulaziz University for Health Sciences / King Abdullah International Medical Research Center / King Abdulaziz Medical City, Jeddah, SAU
| | - Mashael Alhilabi
- Internal Medicine / Endocrinology, King Abdulaziz Medical City / King Abdullah International Medical Research Center, Jeddah, SAU
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Grady EE, Zukotynski K, Greenspan BS. Safety of the Use of Radioactive Iodine in Patients With Hyperthyroidism. JAMA Intern Med 2019; 179:1738-1739. [PMID: 31790528 DOI: 10.1001/jamainternmed.2019.5120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Erin E Grady
- Division of Nuclear Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Katherine Zukotynski
- Departments of Radiology and Medicine, McMaster University, Hamilton, Ontario, Canada
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Sjölin G, Holmberg M, Törring O, Byström K, Khamisi S, de Laval D, Abraham-Nordling M, Calissendorff J, Lantz M, Hallengren B, Filipsson Nyström H, Wallin G. The Long-Term Outcome of Treatment for Graves' Hyperthyroidism. Thyroid 2019; 29:1545-1557. [PMID: 31482765 DOI: 10.1089/thy.2019.0085] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: The treatment efficacy of antithyroid drug (ATD) therapy, radioactive iodine (131I), or surgery for Graves' hyperthyroidism is well described. However, there are a few reports on the long-term total outcome of each treatment modality regarding how many require levothyroxine supplementation, the need of thyroid ablation, or the individual patient's estimation of their recovery. Methods: We conducted a pragmatic trial to determine the effectiveness and adverse outcome in a patient cohort newly diagnosed with Graves' hyperthyroidism between 2003 and 2005 (n = 2430). The patients were invited to participate in a longitudinal study spanning 8 ± 0.9 years (mean ± standard deviation) after diagnosis. We were able to follow 1186 (60%) patients who had been treated with ATD, 131I, or surgery. We determined the mode of treatment, remission rate, recurrence, quality of life, demographic data, comorbidities, and lifestyle factors through questionnaires and a review of the individual's medical history records. Results: At follow-up, the remission rate after first-line treatment choice with ATD was 45.3% (351/774), with 131I therapy 81.5% (324/264), and with surgery 96.3% (52/54). Among those patients who had a second course of ATD, 29.4% achieved remission (vs. the 45.3% after the first course of ATD). The total number of patients who had undergone ablative treatment was 64.3% (763/1186), of whom 23% (278/1186) had received surgery, 43% (505/1186) had received 131I therapy, including 2% (20/1186) who had received both surgery and 131I. Patients who received ATD as first-line treatment and possibly additional ATD had 49.7% risk (385/774) of having undergone ablative treatment at follow-up. Levothyroxine replacement was needed in 23% (81/351) of the initially ATD treated in remission, in 77.3% (204/264) of the 131I treated, and in 96.2% (50/52) of the surgically treated patients. Taken together after 6-10 years, and all treatment considered, normal thyroid hormone status without thyroxine supplementation was only achieved in 35.7% (423/1186) of all patients and in only 40.3% of those initially treated with ATD. The proportion of patients that did not feel fully recovered at follow-up was 25.3%. Conclusion: A patient selecting ATD therapy as the initial approach in the treatment of Graves' hyperthyroidism should be informed that they have only a 50.3% chance of ultimately avoiding ablative treatment and only a 40% chance of eventually being euthyroid without thyroid medication. Surprisingly, 1 in 4 patients did not feel fully recovered after 6-10 years. The treatment for Graves' hyperthyroidism, thus, has unexpected long-term consequences for many patients.
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Affiliation(s)
- Gabriel Sjölin
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mats Holmberg
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
| | - Ove Törring
- Institution for Clinical Science and Education, Karolinska Institutet and Division of Endocrinology, Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden
| | - Kristina Byström
- Department of Medicine, Örebro University and University Hospital, Örebro, Sweden
| | - Selwan Khamisi
- Department of Endocrinology, Uppsala University Hospital, Uppsala, Sweden
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Dorota de Laval
- Department of Medicine, Blekinge Hospital, Karlskrona, Sweden
| | | | - Jan Calissendorff
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Mikael Lantz
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Bengt Hallengren
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Helena Filipsson Nyström
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Göran Wallin
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Baumgarten HD, Bauer AJ, Isaza A, Mostoufi-Moab S, Kazahaya K, Adzick NS. Surgical management of pediatric thyroid disease: Complication rates after thyroidectomy at the Children's Hospital of Philadelphia high-volume Pediatric Thyroid Center. J Pediatr Surg 2019; 54:1969-1975. [PMID: 30902456 DOI: 10.1016/j.jpedsurg.2019.02.009] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/29/2018] [Accepted: 02/03/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Recent studies suggest improved outcomes for children undergoing thyroidectomy at high-volume pediatric surgery centers. We present outcomes after thyroid surgery at a single center and advocate for referral to high-volume centers for multidisciplinary management of these children. METHODS Medical records were reviewed for all pediatric patients undergoing thyroid surgery at a single institution from 2009 through 2017. Routine recurrent laryngeal nerve and parathyroid hormone monitoring was used. Lymph node dissections were performed in appropriately selected cancer patients. Data collection focused on pathologic diagnosis, surgical technique, and surgical complications, including postoperative hematoma, neurapraxia, permanent nerve damage, hypocalcemia, and transient and permanent hypoparathyroidism. RESULTS From 2009 through 2017, 464 patients underwent thyroid surgery. Median age of the cohort was 15 years (range 2-24). Thirty-three percent were diagnosed with benign nodules (n=151), 36% with papillary or follicular thyroid cancer (n=168), 27% with Graves' disease (n=124), 3% with medullary thyroid cancer (n=14), and 1.5% underwent prophylactic thyroidectomy for MEN2a (n=7). Six patients required return to the OR for hematoma evacuation including 5 patients after surgery for Graves' disease (RR 8.7, 95% CI 1.06-71.85). In sixteen cases, concern about neurapraxia resulted in laryngoscopy, revealing eleven patients with vocal cord paresis. Two of these patients demonstrated a persistent deficit at 6 months postoperatively (0.4%). Thirty-seven percent of patients had transient hypoparathyroidism (n=137), and two patients had persistent hypoparathyroidism 6 months after total thyroidectomy (0.6%). There was no significant difference in either hypocalcemia or hypoparathyroidism after total thyroidectomy based on age or diagnosis. CONCLUSIONS Characterizing outcomes for pediatric patients based on diagnosis will assist in preoperative counseling for patients and their families. This high-volume center reports low complication rates after pediatric thyroid surgery, highlighting that referral to high-volume centers should be considered for children and adolescents with thyroid disease requiring surgery. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Heron D Baumgarten
- Department of Surgery, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Andrew J Bauer
- Department of Pediatrics, and the Pediatric Thyroid Center, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Amber Isaza
- Department of Pediatrics, and the Pediatric Thyroid Center, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sogol Mostoufi-Moab
- Department of Pediatrics, and the Pediatric Thyroid Center, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ken Kazahaya
- Department of Surgery, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - N Scott Adzick
- Department of Surgery, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
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Jia X, Guo K, Gao R, Yu Y, Yang A. Radiosensitivity-related postirradiation hypothyroidism in Graves' disease patients. Hormones (Athens) 2019; 18:267-272. [PMID: 31446546 DOI: 10.1007/s42000-019-00123-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 07/10/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE The cumulative incidence of hypothyroidism, in 131I-treated patients with hyperthyroidism caused by Graves' disease, has been gradually increasing each year. Meanwhile, the role of the genes that control radiation sensitivity (GCRS) involved in 131I therapy is yet to be defined. The main purpose of the present study is to find GCRS that could indicate hypothyroidism in Graves' disease patients treated with 131I. METHODS Thyroid tissue was collected from 59 patients who were diagnosed with Graves' disease. GCRS (including Bcl-2, NF-κB, Survivin, Ku-70, Tob1, EGFR, Egr-1, TP-53, BRCA-1, and ATM) mRNA levels were analyzed with qRT-PCR before radioiodine therapy. Patients were followed up and then grouped by end-point outcomes. The association of the variation of target genes with susceptibility to hypothyroidism was analyzed. RESULTS Altogether 44 patients were enrolled, including 11 men and 33 women with an average age of 44.79 ± 12.94 years. Based on their clinical outcomes after at least 2-year follow-up, 59% (26/44) patients were evaluated as hypothyroid, while the remaining 41% (18/44) patients were non-hypothyroid, including 18% (8/44) with persistent hyperthyroidism. The hypothyroid group showed significantly lower Ku-70 mRNA expression levels than the non-hypothyroid group (p = 0.022), whereas no significance was detected regarding other target genes (p > 0.1). Multivariate analysis showed that Ku-70 was significantly correlated with hypothyroidism after 131I treatment (p = 0.033). CONCLUSIONS The opposing changes in mRNA expression levels of Ku-70 in patients with hypothyroidism indicate its potential as a prognostic marker for hypothyroidism induced by 131I treatment.
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Affiliation(s)
- Xi Jia
- Department of Nuclear Medicine, First Affiliated Hospital, Medical School of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, 710061, Shaanxi, China
| | - Kun Guo
- Department of Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Rui Gao
- Department of Nuclear Medicine, First Affiliated Hospital, Medical School of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, 710061, Shaanxi, China
| | - Yan Yu
- Department of Public Health, Medical College of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, People's Republic of China
| | - Aimin Yang
- Department of Nuclear Medicine, First Affiliated Hospital, Medical School of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, 710061, Shaanxi, China.
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Bobanga ID, McHenry CR. Treatment of patients with Graves' disease and the appropriate extent of thyroidectomy. Best Pract Res Clin Endocrinol Metab 2019; 33:101319. [PMID: 31530446 DOI: 10.1016/j.beem.2019.101319] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Graves' disease is an autoimmune disorder caused by thyroid stimulating auto-antibodies directed against the thyrotropin receptor on thyroid follicular cells. It is the most common cause of hyperthyroidism and is associated with cardiovascular, ophthalmologic and other systemic manifestations. Three treatment options are available for Graves' disease: anti-thyroid drugs, radioactive iodine and thyroidectomy. While thyroidectomy is the least common option used for treatment of Graves' disease, it is preferentially indicated for patients with a large goiter causing compressive symptoms, suspicious or malignant thyroid nodules or significant ophthalmopathy. The best operation for Graves' disease has been a matter of debate. The standard operation was a subtotal thyroidectomy for much of the twentieth century, however, over the past 20 years total thyroidectomy has been increasingly performed. Herein, we provide a historical perspective and review the current literature, including randomized controlled trials, systematic reviews and meta-analyses and conclude that total thyroidectomy is the preferred option for the surgical treatment of Graves' disease, with a nearly 0% recurrence rate, predictable postoperative hypothyroidism and a low complication rate comparable to subtotal thyroidectomy when performed by high-volume thyroid surgeons.
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Affiliation(s)
- Iuliana D Bobanga
- Case Western Reserve University School of Medicine, Portage Medical Arts Building, 6847 N. Chestnut St, Suite 330, Ravenna, OH 44266, USA; Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Christopher R McHenry
- Case Western Reserve University School of Medicine, Department of Surgery, MetroHealth Medical Center, H-918, 2500 MetroHealth Drive, Cleveland, OH 44109-1998, USA.
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Fu H, Cheng L, Jin Y, Chen L. Thyrotoxicosis with concomitant thyroid cancer. Endocr Relat Cancer 2019; 26:R395-R413. [PMID: 31026810 DOI: 10.1530/erc-19-0129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 04/26/2019] [Indexed: 12/26/2022]
Abstract
Thyrotoxicosis with concomitant thyroid cancer is rare and poorly recognized, which may result in delayed diagnosis, inappropriate treatment and even poor prognosis. To provide a comprehensive guidance for clinicians, the etiology, pathogenesis, diagnosis and treatment of this challenging setting were systematically reviewed. According to literatures available, the etiologies of thyrotoxicosis with concomitant thyroid cancer were categorized into Graves' disease with concurrent differentiated thyroid cancer (DTC) or medullary thyroid cancer, Marine-Lenhart Syndrome with coexisting DTC, Plummer's disease with concomitant DTC, amiodarone-induced thyrotoxicosis with concomitant DTC, central hyperthyroidism with coexisting DTC, hyperfunctioning metastases of DTC and others. The underlying causal mechanisms linking thyrotoxicosis and thyroid cancer were elucidated. Medical history, biochemical assessments, radioiodine uptake, anatomic and metabolic imaging and ultrasonography-guided fine-needle aspiration combined with pathological examinations were found to be critical for precise diagnosis. Surgery remains a mainstay in both tumor elimination and control of thyrotoxicosis, while anti-thyroid drugs, beta-blockers, 131I, glucocorticoids, plasmapheresis, somatostatin analogs, dopamine agonists, radiation therapy, chemotherapy and tyrosine kinase inhibitors should also be appropriately utilized as needed.
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Affiliation(s)
- Hao Fu
- Department of Nuclear Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, People's Republic of China
| | - Lin Cheng
- Department of Nuclear Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, People's Republic of China
| | - Yuchen Jin
- Department of Nuclear Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, People's Republic of China
| | - Libo Chen
- Department of Nuclear Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, People's Republic of China
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Sharma A, Stan MN. Thyrotoxicosis: Diagnosis and Management. Mayo Clin Proc 2019; 94:1048-1064. [PMID: 30922695 DOI: 10.1016/j.mayocp.2018.10.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 09/25/2018] [Accepted: 10/22/2018] [Indexed: 12/20/2022]
Abstract
Thyrotoxicosis is the clinical manifestation of excess thyroid hormone action at the tissue level due to inappropriately high circulating thyroid hormone concentrations. Hyperthyroidism, a subset of thyrotoxicosis, refers specifically to excess thyroid hormone synthesis and secretion by the thyroid gland. We performed a review of the literature on these topics utilizing published data in PubMed and MEDLINE. In this review, we discuss the more common etiologies of thyrotoxicosis, focusing on the current approach to diagnosis and management, new trends in those directions, and potential upcoming changes in the field.
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Affiliation(s)
- Anu Sharma
- Division of Endocrinology, Metabolism and Diabetes, University of Utah School of Medicine, Salt Lake City, UT
| | - Marius N Stan
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN.
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Cipolla C, Graceffa G, Calamia S, Fiorentino E, Pantuso G, Vieni S, Latteri M. The value of total thyroidectomy as the definitive treatment for Graves' disease: A single centre experience of 594 cases. J Clin Transl Endocrinol 2019; 16:100183. [PMID: 30815364 PMCID: PMC6377402 DOI: 10.1016/j.jcte.2019.100183] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/30/2019] [Accepted: 02/07/2019] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Thyroidectomy is the preferred approach as the definitive treatment for Graves' disease. The outcomes for total thyroidectomy in a large series of 594 patients, who were observed in the last decade, will be presented in this study. METHODS The study concerned a retrospective review of 594 patients, undergoing a total thyroidectomy for Graves' disease. The incidence of complications and outcomes on hyperthyroidism and correlated symptoms resolution were also evaluated. RESULTS The mean age of the patients was of 44.7 ± 12.7 years and 456 patients (76.7%) were females. The mean gland weight was 67.3 ± 10.8 g (range: 20-350 g) and, in 397 patients (66.8%), the gland weighed >40 g. The mean operative time was 125 ± 23.1 min (range: 65-212 min). Temporary and permanent hypocalcaemia developed in 241 (40.6%) and 3 patients (0.5%), respectively. Temporary and permanent recurrent laryngeal nerve palsy were recorded in 31 (5.2%) and 1 patients (0.16%) respectively. No patient developed a thyroid storm. On multivariate analysis, patient age ≤50 years (Odds ratio: 1; 95% Confidence Interval: 0.843-0.901) and thyroid weight >40 g (Odds ratio: 1; 95%, Confidence Interval: 0.852-0.974), were mainly associated with the occurrence of complications. CONCLUSION This high-volume surgeon experience demonstrates that total thyroidectomy is a safe and effective treatment for Graves' disease. It is associated with a very low incidence rate of post-operative complications, most of which are transitory; therefore, it offers a rapid and definitive control of hyperthyroidism and its related symptoms.
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Affiliation(s)
- Calogero Cipolla
- University of Palermo, Department of Surgical Oncological and Oral Sciences, Division of General and Oncological Surgery, Palermo, Italy
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Davis JR, Dackiw AP, Holt SA, Nwariaku FE, Oltmann SC. Rapid Relief: Thyroidectomy is a Quicker Cure than Radioactive Iodine Ablation (RAI) in Patients with Hyperthyroidism. World J Surg 2018; 43:812-817. [PMID: 30483883 DOI: 10.1007/s00268-018-4864-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Hypothyroidism and its associated factors after radioactive iodine therapy among patients with hyperthyroidism in the Northeast Coast State of Malaysia. J Taibah Univ Med Sci 2018; 13:432-437. [PMID: 31435358 PMCID: PMC6694960 DOI: 10.1016/j.jtumed.2018.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 06/06/2018] [Accepted: 06/10/2018] [Indexed: 11/23/2022] Open
Abstract
Objectives The aim of this study was to determine the incidence of hypothyroidism and its associated factors within one-year post radioactive iodine (RAI) therapy. Methods A retrospective study was conducted among patients with hyperthyroidism who received RAI therapy at Nuclear Medicine Clinic, Hospital Universiti Sains Malaysia (HUSM), Kelantan. Data regarding patients’ demographics, gender, aetiology of hyperthyroidism, presence of autoantibodies, dose of RAI used and usage of antithyroid drug post RAI therapy were included in the analysis. Results Of a total of 167 screened patients, 137 subjects were eligible for this study. The incidence of hypothyroidism within one year of RAI therapy was 32.9%. Women were found to be less likely to develop hypothyroidism post RAI therapy (adjusted odds ratio, 0.406; 95% confidence interval: 0.181–0.908; p = 0.028). The usage of antithyroid drug post RAI was significantly associated with a lower incidence of hypothyroidism post RAI therapy (adjusted odds ratio, 0.188; 95% confidence interval: 0.081–0.438; p<0.001). Conclusion This study showed a high incidence of hypothyroidism within one-year post RAI therapy. Gender and usage of antithyroid drug post RAI therapy are significantly associated with the development of hypothyroidism.
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