Surgical intervention in chronic (Hashimoto's) thyroiditis

Role of Total Thyroidectomy in Painful (Symptomatic) Hashimoto's Thyroiditis: Descriptive Study

Hakura Hashimoto described Hashimoto's Thyroiditis (HT) in 1912. In HT, there occurs formation of antibodies against the self (thyroid), which causes enlargement of the thyroid gland as a whole and decreased thyroid hormone levels. Most of the patients with HT are given medical line of management (hypo/hyperthyroidism). The indications for surgical line of management for HT are due to pressure symptoms over the trachea and oesophagus, pain in the thyroid gland and for chance of malignancy. Surgical treatment gives complete relief from pain and pressure symptoms and also prevents the risk of malignancy. To evaluate the outcome and complications of total thyroidectomy in painful (symptomatic) Hashimoto's thyroiditis. It was a Hospital based Descriptive study conducted in tertiary care teaching hospital by ENT Department, Sri Manakula Vinayagar Medical College and Hospital, Pondicherry from Nov 2017 to May 2019. Sample size was 30. All patients with symptomatic (painful) HT was given trail of medical therapy (steroids and NSAIDS), following repeated attempts of failed medical therapy, surgical management (total thyroidectomy) was preferred. Visual Analog Scale (VAS) was used to assess the pain grading pre and post operatively. MS Excel and SPSS trial version 20 software was used to analyze the data. The Wilcoxan Signed Ranked test was used as test of significance to identify the difference between ordinal variables. In this study, all the 30 patients had pain as the predominant symptom. Visual Analog Scale was used to grade the pain in all the patients preoperatively and 2 weeks postoperatively. All the patients had significant reduction in the pain following total thyroidectomy, when compared to pre-operative VAS grading. Total thyroidectomy is the technique of choice in surgical treatment of symptomatic Hashimoto's thyroiditis (pain, tenderness and pressure symptoms) which warrants a radical and definitive control of the disease, without any risk of relapse and without the side effects of medical management. Moreover in longstanding cases of HT, the risk of malignant transformation is prevented due to total thyroidectomy. In experienced hands it assures total relief of compressive and painful symptoms and low incidence of/nil major complications.

The significance of Hashimoto's thyroiditis for postoperative complications of thyroid surgery: a systematic review and meta-analysis

INTRODUCTION

Hashimoto's thyroiditis (HT) is one of the most common immune-mediated diseases. It makes thyroid surgery more complicated and difficult because there may be adhesions between the thyroid gland and surrounding structures. However, it is still controversial whether HT patients carry a high risk for postoperative complications of thyroid surgery. The purpose of this study was to investigate the significance of HT for the postoperative complications of thyroid surgery.

METHODS

A search for studies assessing the postoperative complication risks of HT patients compared with that of patients with benign nodules (BNs) was performed in PubMed, EMBASE and Web of Science. Nine studies (20,118 cases, 1,582 cases of HT and 18,536 cases of BN) were identified, and the data from the relevant outcomes were extracted and analysed.

RESULTS

There were no significant differences between the HT group and BN group in recurrent laryngeal nerve palsy (RLNP) and permanent hypoparathyroidism (PHP). The rate of transient hypocalcaemia (THC) was significantly higher in the HT group (16.85%) than in the BN group (13.20%).

CONCLUSIONS

The meta-analysis showed that HT only increased the risk of the postoperative complication THC compared to BN. Understanding the significance of HT in postoperative hypoparathyroidism after thyroid surgery would help clinicians perform sufficient preoperative (and postoperative) assessments and to optimise surgical planning.

The Role of Surgery in Autoimmune Conditions of the Thyroid

The two most common autoimmune conditions of the thyroid include chronic lymphocytic (Hashimoto's) thyroiditis and Graves' disease. Both conditions can be treated medically, but surgery plays an important role. Hashimoto's thyroiditis and Graves' disease are mediated by autoantibodies that interact directly with the thyroid, creating inflammation and impacting thyroid function. Patients may develop large goiters with compressive symptoms or malignancy requiring surgical intervention. In addition, there are several surgical indications specific to Hashimoto's and Graves' Disease.

The Impact of Thyroiditis on Morbidity and Safety in Patients Undergoing Total Thyroidectomy

BACKGROUND

The indications for surgery in thyroiditis vary from compressive symptoms to cosmesis. We analyzed the complications in patients who underwent total thyroidectomy (TT) in goiters associated with thyroiditis.

MATERIALS AND METHODS

This retrospective study was done in an endocrine surgical center over 4 years. A total of 724 patients, who underwent TT for benign thyroid disorders, were included in the study. Patients were divided into two groups based on histopathology into Group A (nonthyroiditis cases) and Group B (thyroiditis cases); Group B is subdivided into Group B1 (nodular goiter with associated thyroiditis) and Group B2 (Hashimoto's thyroiditis). The preoperative parameters analyzed were serum calcium, serum Vitamin D, serum parathyroid hormone (PTH), and vocal cord status. The intraoperative parameters observed were operating time, parathyroid preservation, and autotransplantation and course of recurrent laryngeal nerve (RLN). Postoperative parameters monitored were serum calcium, serum PTH, serum magnesium, signs and symptoms of hypocalcemia, and vocal cord status. Follow-up was done at 6 months with serum calcium, serum PTH, and video laryngoscopy.

RESULTS

Both groups were age and sex matched. All preoperative and intraoperative parameters were comparable among groups. Both transient complications (<6 months) were higher in Group B than A. Transient hypocalcemia was higher in Group B (39.70%) than Group A (24.77%) (P = 0.001). Transient hypocalcemia was higher in Group B1 (36.58%) than Group B2 (44.44%) (P = 0.014). Transient RLN palsy was higher in Group B (9.55%) than Group A (7.52%) (P = 0.040). Transient RLN palsy was higher in Group B1 (8.53%) than Group B2 (11.11%) (P = 0.039). Permanent hypoparathyroidism and permanent RLN palsy were comparable between the Groups A and B and between Groups B1 and B2.

CONCLUSION

The incidences of transient complications are higher in patients with thyroiditis. Careful analysis of surgical indications will avoid unnecessary surgery in thyroiditis cases.

A comparison of lymphocytic thyroiditis with papillary thyroid carcinoma showing suspicious ultrasonographic findings in a background of heterogeneous parenchyma

Purpose:

The aim of this study was to compare ultrasonographic features in patients with lymphocytic thyroiditis (LT) and papillary thyroid carcinoma (PTC) having suspicious thyroid nodule(s) in a background of heterogeneous parenchyma and to determine the clinical and radiological predictors of malignancy.

Methods:

We reviewed the cases of 100 patients who underwent ultrasonography between April 2011 and October 2012, and showed suspicious thyroid nodule(s) in a background of heterogeneous parenchyma. Eight patients who did not undergo ultrasonography-guided fineneedle aspiration cytology (FNAC) and 34 cases of follow-up ultrasonography after initial FNAC were excluded. We compared the benign and malignant nodules in terms of their clinical and radiological factors.

Results:

For the 58 nodules including 31 LTs (53.4%) and 27 PTCs (46.6%), the mean tumor sizes of the two groups were 0.96 cm for LT and 0.97 cm for PTC. A univariate analysis revealed that PTCs were more frequent in patients younger than 45 years and having microcalcifications than was LT. An independent predictor of PTC after adjustment was an age of <45 years.

Conclusion:

LT mimics malignancy in a background of heterogeneous parenchyma on ultrasonography. A young age of <45 years is the most important predictor of malignancy in this condition.

Papillary Thyroid Cancer and Hashimoto's Thyroiditis: An Association Less Understood

Hashimoto's thyroiditis (HT), part of the spectrum of autoimmune thyroid diseases is a major cause of thyroid hypofunction worldwide. Papillary thyroid carcinoma (PTC), the most prevalent of all thyroid carcinomas has been associated with HT. Literature on this association are based on preoperative FNA or post thyroidectomy histopathology reports, which are subject to potential biases. Molecular, hormonal and histopathalogical basis of this association has been hypothesized, however a definite causal association has not been proved till date. This review aims to study the basis of this association and clinical features and management of HT concurrent with PTC. There are no distinctive clinical or radiological features that categorically differentiates HT concurrent with PTC from PTC or which can pick up a nodule harboring PTC in setting of HT. Smaller nodule size and radiological features like hypoechogenecity; hyper vascularity and calcification in a clinical setting of hypothyroidism have a higher odds ratio for malignancy and merit further investigations. PTC associated with HT has been seen to be less aggressive with earlier presentation with lesser chances of extra thyroidal extension and lymph nodal metastasis. The management and follow up of PTC in HT is no different from that of PTC alone. The prognosis of PTC concurrent with HT is better compared to age and stage matched PTC in terms of lower recurrence and disease free and overall survival.

Risk of lymph node metastases in multifocal papillary thyroid cancer associated with Hashimoto's thyroiditis

AIMS

The aim of this study was to evaluate the risk factors of lymph nodes metastases (LNM) in patients with papillary thyroid cancer (PTC) and coexisting Hashimoto's thyroiditis (HT).

PATIENTS AND METHODS

This was a retrospective cohort study of patients with PTC and HT who had undergone total thyroidectomy (TT) with central neck dissection (CND) over an 11-year period (between 2002 and 2012). Pathological reports of all eligible patients were reviewed. Multivariable analysis was performed to identify risk factors of LNM.

RESULTS

During the study period, PTC was diagnosed in 130 patients with HT who had undergone TT with CND (F/M ratio = 110:20; median age, 52.4 ± 12.7 years). Multifocal lesions were observed in 28 (21.5 %) patients. LNM were identified in 25 of 28 (89.3 %) patients with multifocal PTC and HT versus 69 of 102 (67.5 %) patients with a solitary focus of PTC and HT (p = 0.023). In multivariable analysis, multifocal disease was identified as an independent risk factor for LNM (odds ratio, 3.99; 95 % confidence interval, 1.12 to 14.15; p = 0.033).

CONCLUSIONS

Multifocal PTC in patients with HT is associated with an increased risk of LNM. Nevertheless, the clinical importance of this finding needs to be validated in well-designed prospective studies.

Hashimoto's thyroiditis: celebrating the centennial through the lens of the Johns Hopkins hospital surgical pathology records

Hashimoto's thyroiditis is now considered the most prevalent autoimmune disease, as well as the most common endocrine disorder. It was initially described in 1912, but only rarely reported until the early 1950s. To celebrate this centennial, we reviewed the surgical pathology archives of the Johns Hopkins hospital for cases of Hashimoto's thyroiditis, spanning the period from May 1889 to October 2012. Approximately 15,000 thyroidectomies were performed at this hospital over 124 years. The first surgical case was reported in 1942, 30 years after the original description. Then, 867 cases of Hashimoto's thyroiditis were seen from 1942 to 2012, representing 6% of all thyroidectomies. Hashimoto's thyroiditis was the sole pathological finding in 462 cases; it accompanied other thyroid pathologies in the remaining 405 cases. The most commonly associated pathology was papillary thyroid cancer, an association that increased significantly during the last two decades. The most common indication for thyroidectomy was a thyroid nodule that was cytologically suspicious for malignancy. Hashimoto's thyroiditis remains a widespread, intriguing, and multifaceted disease of unknown etiology one century after its description. Advances in the understanding of its pathogenesis and preoperative diagnosis will improve recognition and treatment of this disorder, and may one day lead to its prevention.

Surgical Indications for Goiter with Background Hashimoto's Thyroiditis: Institutional Experience

Hashimoto's thyroiditis (HT) is usually treated conservatively with thyroxine. Its incidence is higher in Iodine sufficient areas and may require surgery for associated nodularity or complications. A retrospective study on surgically treated HT cases was conducted in a teritiary care teaching hospital in an Iodine sufficient area of Southern India. 34 cases of goiter with associated HT, who underwent thyroidectomy between 2007 and 2010 were analysed for indications of surgery. Minimum follow-up period was 6 months. F:M ratio was 31:3 with mean age of 41.3 years. Goiter was diffuse in 41% and nodular in 59%. 16 (47%) of patients were hypothyroid. Autoimmune association was found in 35%. Commonest surgery done was hemithyroidectomy in 12 (35%) followed by subtotal thyroidectomy in 10 cases. Most frequent indication for surgery was nodular goiter in 12 (35%) followed by associated malignancy, persistent goiter, pressure symptoms and painful thyroiditis. Histopathology showed diffuse HT alone in 12 (35%) and rest of the cases had HT as a component synchronous with other pathologies. Associated pathologies were benign multinodular goiter (6), colloid nodule (6), papillary cancer (5), follicular adenoma (4), cyst (1). Surgery for HT is primarily indicated for associated pathologies like dominant nodule, suspicious or proven malignancy, persistent goiter, painful thyroiditis, pressure symptoms and rarely for HT perse. Rate of surgery for HT associated goiter appears to be higher in Iodine sufficient areas, the cause of which needs to be studied further.

Is thyroidectomy in patients with Hashimoto thyroiditis more risky?

BACKGROUND

Hashimoto thyroiditis (HT) is an organ-specific autoimmune disease characterized by the production of antibodies such as antithyroperoxidase, which leads to the destruction of the thyroid gland and a decrease in normal thyroid function. Thyroidectomy is performed when the patient presents with symptoms or potential neoplastic degeneration occurs; however, surgery can be difficult because of the dense inflammatory process around the thyroid gland. We hypothesized that patients with HT may have a higher rate of complications after thyroid surgery.

METHODS

We identified 1791 consecutive patients who underwent thyroidectomy from May 1994 to December 2009. Patients with HT were compared with those without HT with regard to outcomes with analysis of variance and chi-square test (SPSS, Inc).

RESULTS

Patients with HT were significantly younger and more likely to be female. There was no significant difference between the two groups in the rate of malignancy. However, patients undergoing thyroidectomy with HT had a significantly higher postoperative complication rate. Specifically, the rates of overall, transient, and permanent complications were all increased in HT patients.

CONCLUSION

Patients with HT had a higher rate of complications after thyroidectomy compared with those without HT. Therefore, careful consideration must be taken before pursuing operative treatment in patients with HT including providing adequate informed consent regarding the increased risks of surgery.

Hashimoto's thyroiditis: outcome of surgical resection for patients with thyromegaly and compressive symptoms

BACKGROUND

The purpose of this study was to determine the indications and outcome of surgery in patients with Hashimoto's thyroiditis (HT).

METHODS

All patients who underwent thyroidectomy from 1990 to 2009 with pathologically confirmed HT were identified. Patients whose principle diagnosis was HT were evaluated for symptoms and outcome of thyroidectomy.

RESULTS

Thirty-two (15%) of 216 patients with HT were referred with thyroid enlargement and compressive symptoms; 25 (78%) had an associated nodule and 12 (38%) had retrosternal extension. Symptom resolution occurred in 30 (94%) and improvement occurred in 2 (6%) patients after total thyroidectomy in 21 (66%) and thyroid lobectomy in 11 (34%) patients. The only complication was transient hypocalcemia in 12 (38%) patients. One patient had an incidental thyroid lymphoma.

CONCLUSIONS

HT is a cause for diffuse or nodular goiter that may impinge on vital structures in the neck and thyroidectomy is safe and effective for relief of compressive symptoms.

Should patients with symptomatic Hashimoto's thyroiditis pursue surgery?

BACKGROUND

In this study, patients with Hashimoto's Thyroiditis and significant symptoms were evaluated for improvement or resolution of preoperative symptoms after thyroidectomy. Hashimoto's thyroiditis (HT) is an organ-specific autoimmune disease characterized by production of antibodies such as anti-thyroperoxidase (TPO), which leads to destruction of the thyroid gland and a decrease in normal thyroid function. Thyroidectomy is not generally recommended because the dense inflammatory process that surrounds the thyroid gland can make resection more difficult. However, patients with HT are considered for surgery if they experience persistent symptoms after conservative therapy. We hypothesized that patients with HT and significant compressive and other associated symptoms may benefit from thyroidectomy for palliation.

METHODS

We identified 1791 patients who underwent thyroidectomy from May 1994 to December 2009. Of those 1791 patients, 311 were diagnosed with HT. Of these 311 patients, 133 had 170 significant preoperative symptoms, and served as our sample population. Patients were subjectively evaluated for improvement or relief of symptoms postoperatively.

RESULTS

The mean age of the group was 46 ± 1 y, and 90% were female. Patients underwent lobectomy (33%), subtotal thyroidectomy (6%), or total thyroidectomy (61%). The overall rate of symptomatic improvement for HT patients was 90% after thyroidectomy. The most frequent preoperative symptom was compression, and >93% of patients experienced relief. In addition, we found high rates of improvement for HT patients with other preoperative symptoms including voice problems (77%), hormone imbalance (84%), and other (90%).

CONCLUSION

The overwhelming majority of HT patients with significant symptoms appear to benefit from thyroidectomy. Therefore, HT patients should consider pursuing surgery for palliation if they suffer from persistent symptoms after conservative therapy.

Profile of Hashimoto's Thyroiditis in Sri Lankans: Is There an Increased Risk of Ancillary Pathologies in Hashimoto's Thyroiditis?

Hashimoto's thyroiditis has been reported to be associated with many neoplastic and nonneoplastic thyroid pathologies. This retrospective study aims to determine the demographic profile of Hashimoto's thyroiditis in Sri Lankans, document ancillary pathologies in Hashimoto's thyroiditis, and determine whether there is an increased risk of occurrence of malignancies, benign neoplasms, and nonneoplastic benign lesions in Hashimoto's thyroiditis by comparing with thyroids showing multinodular goiters, follicular adenomas, and colloid nodules. The mean age of Hashimoto's thyroiditis is 43.3 years with the majority in the 41 to 60 year age group and a female to male ratio of 10.3 : 1. This study revealed a statistically significant increase of thyroid malignancies in association with Hashimoto's thyroiditis. The association of Papillary carcinoma, Non-Hodgkin's lymphoma, and Hurthle cell adenoma with Hashimoto's thyroiditis was statistically significant.

Total thyroidectomy for the treatment of Hashimoto's thyroiditis coexisting with papillary thyroid carcinoma

The coexistence of Hashimoto's thyroiditis (HT) and papillary thyroid carcinoma (PTC) is controversial. This study was conducted to evaluate the correlation between HT and PTC and to identify predictive factors for the coexistence of PTC and HT. A total of 922 patients underwent surgery for thyroid disorders between January 2001 and August 2005. In all, 199 patients had been diagnosed with PTC, 37 of whom had coexistent HT; in 689 patients, benign thyroid disease had been diagnosed. Patients' age and sex, as well as histopathology, tumor size, nodal involvement status, multicentricity, presence of metastasis, and serum thyroglobulin levels, were retrospectively reviewed. A significant correlation was observed between HT and PTC, although no statistical significance was noted between PTC and HT type (nodular or diffuse). Most patients with PTC+HT were female and younger (<40 y old) than those with PTC only. The rate of occult tumor in patients with PTC+HT was higher than that in patients with PTC alone. Data indicate the coexistence of PTC and HT and suggest that PTC may develop even in cases of diffuse HT. Total thyroidectomy is the surgical procedure of choice, especially in young, female patients with HT.

Role of fine needle aspiration cytology in thyroiditis

Fine needle aspiration (FNA) of thyroid is a cost-effective, simple, diagnostic tool in the initial screening of patients with thyroid lesions. Its role in a minimally enlarged thyroid in a symptomatic patient suspected of thyroid dysfunction is now well known. It plays an important role in the medical management of all nonpalpable/minimally enlarged thyroid (goiter) in patients suspect for thyroid pathology and/or in combination with thyroid-stimulating hormone, T3 and T4 levels by diagnosing early cases of thyroiditis. FNA may be of assistance in the early detection of subclinical hypothyroidism, which is of utmost importance in pregnant women, and further makes possible the availability of baseline values for future reference. With the implementation of this protocol of FNA thyroid with/without imaging, we affirm that the practice of cytology has differed in different geographic areas and from country to country, depending on economy and availability of infrastructure.

Radioactive iodine therapy for goitrous Hashimoto's thyroiditis

CONTEXT

Hashimoto's thyroiditis is an autoimmune disease that can produce marked clinical symptoms when patients have large diffuse goiters.

DESIGN

This retrospective cohort study was designed to evaluate whether radioactive iodine (RAI) is effective for Hashimoto's thyroiditis with a large goiter. Starting in November 1999, 13 Hashimoto's patients with large goiters, whose thyroiditis was refractory to TSH suppression therapy with thyroid hormone administration [two men and 11 women with a mean age of 61.2 +/- 8.9 yr (50-79 yr)], were recruited for the present study. The duration of symptomatic goiter before undergoing RAI was 12.0 +/- 7.9 yr (4-33 yr). Thirteen millicuries of 131I was administered two to six times, at an interval of 1-6 months on an outpatient basis. Thyroid weight was measured ultrasonographically, or by computed tomography if ultrasound was not possible due to the large size of the goiter.

RESULTS

RAI was administered an average of 4.7 +/- 1.4 times (two to six times), with a total dose of 59.8 +/- 17.3 mCi (25.0-78.0 mCi). The observation period was 47.9 +/- 13.4 months (26-66 months) after the first RAI. The average weight of the thyroid gland was 125.3 +/- 57.7 g (42.9-269.4 g) before the first RAI, decreasing significantly to 49.7 +/- 25.8 g (18.3-93.3 g) after the last RAI (P < 0.001, paired Student's t test). The percent reduction from baseline was 58.7 +/- 14.2% (35.7-84.0%). None of the patients showed an increase in goiter size or complained of a pressure sensation after any of the RAI treatments.

CONCLUSION

RAI is effective in Hashimoto's thyroiditis with a large goiter.

Hypothyroidism presenting as a hot pertechnetate nodule

The authors report an uncommon finding of hot nodule on Tc-99m sodium pertechnetate thyroid scan in three patients with hypothyroidism. Data indicate that hypothyroidism is secondary to Hashimoto's disease (HD). There was a concordant aspect on I-131 scan in two; a nodular discrepancy (cold nodule with I-131) was associated with the highest microsomal antibodies titer. The findings of thyroid scan and ultrasonographic findings indicate that hot nodules may be observed either on initial or advanced stages of HD. Color flow Doppler sonography, showed an absence of internal increase of vascularization. These data suggest that the observed hot nodules correspond to localized hyperplasia of the less diseased portions secondary to chronic stimulation by TSH.

Surgical therapy in Hashimoto's thyroiditis

Hashimoto's thyroiditis (HT) is usually considered to be manageable by levothyroxine (L-T4) administration, which can reduce the thyroid volume and supplement the lack of hormone. However, we sometimes encounter a huge goiter that has not shrunk in response to L-T4 therapy. These goiters continue to produce symptoms of compression and an unsightly appearance. Here we discuss the surgical indication and procedure for HT. Thirteen patients with clinically diagnosed Hashimoto's thyroiditis involving a huge diffuse goiter that produced pressure symptoms or nodular lesions were treated with surgery. The gender, age distribution, total dose and period of L-T4 administration prior to the operation, and clinical symptoms caused by the large goiter were evaluated in each case. The titer of antibodies was extremely elevated in 8 HT patients with a diffusely enlarged goiter. The total period of L-T4 medication ranged from 6 to 25 years. A subtotal thyroidectomy in which a small amount of thyroid was left in the posterior area of the bilateral lobes was performed in the 8 cases of diffusely enlarged goiter. Pressure symptoms and the unsightly appearance caused by the goiter were relieved by the surgery in all cases. No surgical complications developed. In conclusion, the surgery is an effective therapy for HT patients who have persistent compression symptoms and/or an unsightly neck appearance due to a large goiter despite long-term L-T4 treatment.

Successful outcome after surgical management in two cases of the "painful variant" of Hashimoto's thyroiditis

OBJECTIVE

To describe two cases of the rare "painful variant" of Hashimoto's thyroiditis (HT) that were refractory to medical management and in which surgical intervention provided the definitive treatment.

METHODS

We thoroughly review the clinical history as well as the laboratory, imaging, and surgical pathology data in these cases, and follow-up of the clinical response over time is provided. The relevant literature is also discussed.

RESULTS

A 56-year-old woman, who had remotely undergone a left hemithyroidectomy and had been diagnosed with HT, sought further assessment because of neck pain and edema. Treatment with corticosteroids was partially successful but led to the development of Cushing's syndrome. A 32-year-old man had pain and swelling of the thyroid and was diagnosed with HT shortly thereafter. Levothyroxine treatment was unsuccessful. Both patients underwent thyroidectomy. Chronic lymphocytic thyroiditis (HT) with a variable degree of fibrosis was found on assessment of pathology specimens. The patients remained asymptomatic after the surgical procedure and did not require any further anti-inflammatory therapy.

CONCLUSION

In selected cases, surgical treatment may become necessary for effective and permanent control of symptoms and local signs in painful HT. Access to experienced endocrine surgeons is important in order to avoid postoperative complications because the thyroid gland may be small or fibrosed in this rare variant of HT.

Incidence of neoplasia in Hashimoto's thyroiditis: a fine-needle aspiration study

There is a recognized association between Hashimoto's thyroiditis (HT) and thyroid neoplasms. We reviewed fine-needle aspirations (FNAs) from 90 patients with HT to assess the contribution of this procedure. For seven patients, FNA showed HT and follicular neoplasm (n = 6) or HT and papillary carcinoma (n = 1). Eighteen patients underwent thyroid resection. Three patients had follicular adenomas which were not detected by FNA, one patient had papillary carcinoma confirmed, and six patients with follicular neoplasm by FNA were negative for tumor. Thus, 4% of our patients had confirmed neoplasms, an incidence lower than usually reported. One reason for the lower rate of neoplasia in our series was misinterpretation of follicular neoplasia in the background of HT. The cytologic changes in the hyperplastic follicular and metaplastic oncocytic epithelium are similar to those seen in follicular neoplasm. Our study suggests that these processes may be indistinguishable, and thus, in the presence of HT, the diagnosis of follicular neoplasm probably should not be rendered.

Hashimoto's thyroiditis presenting with severe pressure symptoms--a case report

A extremely rare case of Hashimoto's thyroiditis presenting with pressure symptoms is described herein. A 50 year old Japanese woman was referred to our department with swelling of the anterior neck, facial edema and recent heavy snoring. Oto-rhinolaryngological examinations revealed no movement of the bilateral vocal cords, severe laryngeal edema and diffuse edema of the tongue and pharynx. These findings had apparently been induced by compression of the bilateral recurrent nerves and internal jugular veins by an enlarged thyroid gland. The results of thyroid function and autoimmune tests were compatible with a diagnosis of Hashimoto's disease and thus, total thyroidectomy with a tracheostomy was performed uneventfully. The resected specimen weighed 168 grams and was confirmed histologically to be Hashimoto's disease. Following her operation, all the above symptoms disappeared and 4 months later, the patient is well and asymptomatic.

Histologic infiltrating pattern of gastric microcarcinoma by means of serial sections

Two hundred eighty serial histologic sections, 5 micron thick, were made of a very small gastric carcinoma with submucosal invasion in order to assess the initial infiltrating pattern into the submucosa, as well as the growth therefrom. The small carcinoma infiltrated into the submucosa through four independent small channels, 0.02 to 0.05 mm2 in size, despite its small spread (3 mm in diameter) on the mucosal layer. Each small channel always was accompanied by the small blood vessels penetrating the lamina muscularis. The size of carcinoma in submucosa grew further to reach 3 to 10 times small infiltrating sites of lamina muscularis mucosa. The growth pattern of the carcinoma in the submucosa, therefore, seemed to be an "expanded balloon." Moreover, a small but distinct vascular invasion could be demonstrated within the balloon, suggesting a possible vascular metastasis.