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Fung MHM, Luk Y, Yuen KKW, Lang BHH. The Two-Year Results of Using Radiofrequency Ablation as a Novel Treatment for Persistent or Relapsed Graves' Disease: A Prospective Study. Thyroid 2024. [PMID: 38836419 DOI: 10.1089/thy.2024.0177] [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] [Indexed: 06/06/2024]
Abstract
Objectives: Graves' disease (GD) is the most common cause of hyperthyroidism. Antithyroid drugs (ATDs) are the first-line treatment, but when discontinued, >50% of patients experience relapses. Conventional definitive treatment options include surgery and radioiodine therapy (RAI), each with its own disadvantages. Radiofrequency ablation (RFA) achieved promising short-term remission rates in a previous pilot study. The current study reports our experience of using RFA to treat relapsed GD in the largest cohort of patients with a longer follow-up period. Methods: This single-arm prospective study recruited consecutive patients aged ≥18 with persistent/relapsed GD requiring ATD from two tertiary endocrine surgery centers. Those with compressive goiter, suspected thyroid malignancy, moderate-to-severe Graves' ophthalmopathy, preference for surgery/RAI, or pregnancy were excluded. Eligible patients received ultrasound-guided RFA to the entire bulk of the thyroid gland. ATDs were discontinued afterward, and thyroid function tests were monitored bimonthly. The primary outcome was the disease remission rate at 24 months follow-up after single-session RFA, defined as being biochemically euthyroid or hypothyroid without ATD. Secondary outcomes were complication rates. Results: Of the 100 patients considered, 30 (30.0%) patients were eligible and received RFA. Most were female patients (93.3%). The median total thyroid volume was 23 mL (15.9-34.5). All completed 24 months follow-up. After single-session RFA, disease remission rates were 60.0% at 12 months and 56.7% at 24 months. Among the 13 patients with relapse after RFA, 9 (69%) required a lower ATD dose than before RFA; 2 received surgery without complications. Total thyroid volume was the only significant factor associated with relapse after RFA (odds ratio 1.054, confidence interval 1.012-1.099, p = 0.012). At 24 months, RFA led to disease remission in 100% of the 9 patients with a total thyroid volume <20 mL and 35% of patients with a total thyroid volume ≥20 mL (p = 0.007). There was no vocal cord palsy, skin burn, hematoma, or thyroid storm after RFA. Conclusions: In a highly selected group of patients with relapsed GD and predominantly small thyroid glands, single-session RFA may achieve disease remission. Smaller total thyroid volume may be a favorable factor associated with disease remission after RFA. The results of this study need to be confirmed with a long-term clinical trial. Clinical Trial Registration: This study is registered at www.clinicaltrial.gov with identifier NCT06418919.
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Affiliation(s)
- Man Him Matrix Fung
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Yan Luk
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Karen K W Yuen
- Division of Anatomical Pathology, Department of Pathology, Queen Mary Hospital, Hong Kong, China
| | - Brian Hung Hin Lang
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, 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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Peng CCH, Lin YJ, Lee SY, Lin SM, Han C, Loh CH, Huang HK, Pearce EN. MACE and Hyperthyroidism Treated With Medication, Radioactive Iodine, or Thyroidectomy. JAMA Netw Open 2024; 7:e240904. [PMID: 38436957 PMCID: PMC10912964 DOI: 10.1001/jamanetworkopen.2024.0904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 01/11/2024] [Indexed: 03/05/2024] Open
Abstract
Importance Excessive thyroid hormones from hyperthyroidism increase cardiovascular risks. Among 3 available treatments for hyperthyroidism, comparisons of long-term outcomes associated with antithyroid drugs (ATDs), radioactive iodine (RAI), and surgery to treat newly diagnosed hyperthyroidism are lacking. Objective To compare risks of major adverse cardiovascular events (MACE) and all-cause mortality among patients with hyperthyroidism treated with ATDs, RAI, or surgery. Design, Setting, and Participants This nationwide cohort study used the Taiwan National Health Insurance Research Database. Patients aged 20 years or older with newly diagnosed hyperthyroidism between 2011 and 2020 were enrolled. Treatment groups were determined within 18 months from diagnosis, with follow-up until the development of MACE, death, or the end date of the database, whichever came first. Data were analyzed from October 2022 through December 2023. Exposures The ATD group received ATDs only. RAI and surgery groups could receive ATDs before treatment. Anyone who underwent thyroid surgery without RAI was classified into the surgery group and vice versa. Main Outcomes and Measures The primary outcomes included MACE (a composite outcome of acute myocardial infarction, stroke, heart failure, and cardiovascular mortality) and all-cause mortality. Results Among 114 062 patients with newly diagnosed hyperthyroidism (mean [SD] age, 44.1 [13.6] years; 83 505 female [73.2%]), 107 052 patients (93.9%) received ATDs alone, 1238 patients (1.1%) received RAI, and 5772 patients (5.1%) underwent surgery during a mean (SD) follow-up of 4.4 (2.5) years. Patients undergoing surgery had a significantly lower risk of MACE (hazard ratio [HR] = 0.76; 95% CI, 0.59-0.98; P = .04), all-cause mortality (HR = 0.53; 95% CI, 0.41-0.68; P < .001), heart failure (HR = 0.33; 95% CI, 0.18-0.59; P < .001), and cardiovascular mortality (HR = 0.45; 95% CI, 0.26-0.79; P = .005) compared with patients receiving ATDs. Compared with ATDs, RAI was associated with lower MACE risk (HR = 0.45; 95% CI, 0.22-0.93; P = .03). Risks for acute myocardial infarction and stroke did not significantly differ between treatment groups. Conclusions and Relevance In this study, surgery was associated with lower long-term risks of MACE and all-cause mortality, while RAI was associated with a lower MACE risk compared with ATDs.
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Affiliation(s)
- Carol Chiung-Hui Peng
- Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
- Diabetes Technology Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yu-Jie Lin
- Health Information Center, Tzu Chi University, Hualien, Taiwan
| | - Sun Y. Lee
- Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Shu-Man Lin
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Department of Physical Medicine and Rehabilitation, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Cheng Han
- Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
- Department of Clinical Nutrition and Metabolism, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning, China
| | - Ching-Hui Loh
- Diabetes Technology Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Center for Healthy Longevity, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Huei-Kai Huang
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Department of Family Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Elizabeth N. Pearce
- Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
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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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Fung MHM, Lang BHH. Efficacy of single-session radiofrequency ablation (RFA) in rendering euthyroidism for persistent/relapsed Graves' disease, a pilot study. Eur Radiol 2023; 33:6534-6544. [PMID: 37036479 DOI: 10.1007/s00330-023-09620-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 02/22/2023] [Accepted: 02/27/2023] [Indexed: 04/11/2023]
Abstract
OBJECTIVES Graves' disease (GD) is the most common cause of hyperthyroidism. Antithyroid drug (ATD) is often the first-line treatment but > 50% patients suffer a relapse when ATD is discontinued. Surgery or radioiodine remains the current options of definitive treatment in these patients. This pilot study examined the short-term efficacy of single-session thyroid radiofrequency ablation (RFA) as a novel definitive treatment for persistent/relapsed GD. METHODS Consecutive patients with persistent/relapsed GD requiring ATD were considered. Those with a clear surgical indication, either thyroid lobe volume ≥ 20 mL; those who were pregnant or lactating; and those who had any severe medical conditions that would pose extra treatment risks were excluded. Eligible patients received ultrasound-guided RFA of the entire bulk of thyroid gland. Thyroid function tests were monitored bi-monthly. The primary outcome was disease remission rate, defined as a state of biochemical euthyroidism or hypothyroidism without ATD. Secondary outcomes were complication rates. RESULTS Of the 68 patients considered, 15 (22.1%) patients were eligible. Most were females (93.3%). The median age was 37 (IQR 31-48) years old. The disease remission rates were 79.0% at 6 months and 73.3% at 12 months. Among the 4 patients who relapsed after RFA, three required less ATD dose than before RFA. RFA was well-tolerated in the ambulatory setting. There were no vocal cord palsy, skin burn, hematoma, or thyroid storm after RFA. CONCLUSIONS In well-selected patients, single-session RFA of the thyroid gland may be a potential treatment for patients with persistent/relapsed GD. It is a safe and well-tolerated ambulatory procedure. KEY POINTS • Radiofrequency ablation of the thyroid gland is an efficacious treatment for persistent/relapsed Graves' disease in well-selected patients. • Radiofrequency ablation of the thyroid gland for the treatment of persistent/relapsed Graves' disease is a safe and well-tolerated ambulatory procedure. • Radiofrequency ablation of the thyroid gland may be a potential alternative treatment for well-selected patients with persistent/relapsed GD who do not wish to undergo either thyroidectomy or radioactive iodine or continue antithyroid drugs.
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Affiliation(s)
- Man Him Matrix Fung
- Department of Surgery, Division of Endocrine Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China
| | - Brian Hung Hin Lang
- Department of Surgery, Division of Endocrine Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China.
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Xu T, Zheng X, Wei T. Preoperative preparation for Graves' disease. Front Endocrinol (Lausanne) 2023; 14:1234056. [PMID: 37680886 PMCID: PMC10482033 DOI: 10.3389/fendo.2023.1234056] [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: 06/03/2023] [Accepted: 08/03/2023] [Indexed: 09/09/2023] Open
Abstract
Thyroidectomy is always regarded as the crucial treatment for Graves' disease, especially in cases of poor efficacy or excessive side effects of antithyroid- drugs and 131I radioiodine therapy. To decrease the incidence of hemorrhage, thyroid storms and other severe complications during the perioperative period, surgeons explore different therapies to prepare for thyroidectomy. We performed a review of preoperative preparation with a focus on the Graves' disease population. Most of the previous schemes are effective, which contributes to the smooth operation of patients, but there is no unified standard for preoperative preparation. This review aims to summarize the preoperative preparation of Graves' disease and the latest developments. Prospective studies with longer follow up-up periods are required to select appropriate preoperative regimens based on personal thyroid statements and to identify target populations of benefit.
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Affiliation(s)
| | | | - Tao Wei
- Division of Thyroid Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 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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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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Issa PP, Hussein M, Omar M, Munshi R, Attia AS, Buti Y, Aboueisha M, Shama M, Toraih E, Kandil E. Cardiovascular Health by Graves' Disease Management Modality - Surgery Versus Radioactive Iodine Versus Antithyroid Medications: A Network Meta-Analysis. J Surg Res 2023; 283:266-273. [PMID: 36423475 DOI: 10.1016/j.jss.2022.10.043] [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: 07/24/2022] [Revised: 10/03/2022] [Accepted: 10/18/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Graves' disease is an autoimmune disorder of the thyroid gland associated with the overproduction of thyroid hormones. Excess secretion of thyroid hormones leads to cardiovascular consequences. Treatment options include antithyroid medications (ATM), radioactive iodine (RAI) ablation, and total thyroidectomy. We examined the cardiovascular outcomes following Graves' disease management modality. METHODS A systematic search was performed up to September 22nd, 2021, using PubMed, EMBASE, and Web of Science databases. We conducted a network meta-analysis analyzing cardiovascular outcomes of interest, including congestive heart failure (CHF), arrhythmia, atrial fibrillation (AF), and hypertension. RESULTS Three studies were included in this analysis totaling 6700 patients with Graves' disease, of which 74% were female. The mean age was 44.34 y. When compared to pretreatment, management options lowered the risk of maintaining arrhythmia 81% with surgery (relative risk [RR] = 0.19; 95% confidence interval [CI] = 0.12 to 0.31), 67% with ATM (RR = 0.33; 95% CI = 0.23 to 0.49), and 50% with RAI (RR = 0.50; 95% CI = 0.13 to 1.95). Risk of maintaining CHF was reduced 80% with surgery (RR = 0.20; 95% CI = 0.08 to 0.49), 41% with ATM (RR = 0.59; 95%CI = 0.52 to 0.67), and only 7% with RAI (RR = 0.93; 95%CI = 0.68 to 1.26). Treatment-ranking analysis found all parameters, including CHF, arrhythmia, AF, and hypertension, to be in favor of surgical treatment over medical treatment and RAI ablation. CONCLUSIONS This is the first network meta-analysis analyzing the cardiovascular outcomes in Graves' disease patients by treatment option. Our study demonstrated that surgery is superior to RAI and medical treatment.
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Affiliation(s)
- Peter P Issa
- School of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Mohammad Hussein
- School of Medicine, Department of Surgery, Tulane University, New Orleans, Louisiana
| | - Mahmoud Omar
- School of Medicine, Department of Surgery, Tulane University, New Orleans, Louisiana
| | - Ruhul Munshi
- School of Medicine, Department of Surgery, Tulane University, New Orleans, Louisiana
| | - Abdallah S Attia
- School of Medicine, Department of Surgery, Tulane University, New Orleans, Louisiana
| | - Yusef Buti
- School of Medicine, Department of Surgery, Tulane University, New Orleans, Louisiana
| | - Mohamed Aboueisha
- School of Medicine, Department of Surgery, Tulane University, New Orleans, Louisiana; Faculty of Medicine, Department of Otolaryngology-Head and Neck Surgery, Suez Canal University, Ismailia, Egypt
| | - Mohamed Shama
- School of Medicine, Department of Surgery, Tulane University, New Orleans, Louisiana
| | - Eman Toraih
- School of Medicine, Department of Surgery, Tulane University, New Orleans, Louisiana; Genetics Unit, Faculty of Medicine, Department of Histology and Cell Biology, Suez Canal University, Ismailia, Egypt
| | - Emad Kandil
- School of Medicine, Department of Surgery, Tulane University, New Orleans, Louisiana.
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Sun H, Tong H, Shen X, Gao H, Kuang J, Chen X, Li Q, Qiu W, Liu Z, Yan J. Outcomes of Surgical Treatment for Graves' Disease: A Single-Center Experience of 216 Cases. J Clin Med 2023; 12:jcm12041308. [PMID: 36835843 PMCID: PMC9968166 DOI: 10.3390/jcm12041308] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 02/01/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND The role of surgery in the treatment of Graves' disease (GD) needs to be revisited. The aims of the present retrospective study were to evaluate the outcomes of the current surgical strategy as a definitive treatment of GD at our center and to explore the clinical association between GD and thyroid cancer. METHODS A patient cohort of 216 cases from 2013 to 2020 was involved in this retrospective study. The data of the clinical characteristics and follow-up results were collected and analyzed. RESULTS There were 182 female and 34 male patients. The mean age was 43.9 ± 15.0 years old. The mean duration of GD reached 72.2 ± 92.7 months. Of the 216 cases, 211 had been treated with antithyroid drugs (ATDs) and hyperthyroidism had been completely controlled in 198 cases. A total (75%) or near-total (23.6%) thyroidectomy was performed. Intraoperative neural monitoring (IONM) was applied to 37 patients. The failure of ATD therapy (52.3%) was the most common surgical indication, followed by suspicion of a malignant nodule (45.8%). A total of 24 (11.1%) patients had hoarseness after the operation and 15 (6.9%) patients had transient vocal cord paralysis; 3 (1.4%) had this problem permanently. No bilateral RLN paralysis occurred. A total of 45 patients had hypoparathyroidism and 42 of them recovered within 6 months. Sex showed a correlation with hypoparathyroidism through a univariate analysis. A total of 2 (0.9%) patients underwent a reoperation because of hematomas. A total of 104 (48.1%) cases were diagnosed as thyroid cancer. In most cases (72.1%), the malignant nodules were microcarcinomas. A total of 38 patients had a central compartment node metastasis. A lateral lymph node metastasis occurred in 10 patients. Thyroid carcinomas were incidentally discovered in the specimens of 7 cases. The patients with concomitant thyroid cancer had a significant difference in body mass index, duration of GD, gland size, thyrotropin receptor antibodies and nodule(s) detected. CONCLUSION Surgical treatments for GD were effective, with a relatively low incidence of complications at this high-volume center. Concomitant thyroid cancer is one of the most important surgical indications for GD patients. Careful ultrasonic screening is necessary to exclude the presence of malignancies and to determine the therapeutic plan.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Jiqi Yan
- Correspondence: ; Tel.: +86-21-6437-0045
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11
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Ze Y, Shao F, Feng X, Shen S, Bi Y, Zhu D, Zhang X. Effect of liver dysfunction on outcome of radioactive iodine therapy for Graves' disease. BMC Endocr Disord 2022; 22:319. [PMID: 36522617 PMCID: PMC9753361 DOI: 10.1186/s12902-022-01242-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022] Open
Abstract
Liver dysfunction is a common complication of Graves' disease (GD) that may be caused by excessive thyroid hormone (TH) or anti-thyroid drugs (ATDs). Radioactive iodine (RAI) therapy is one of the first-line treatments for GD, but it is unclear whether it is safe and effective in patients with liver dysfunction. 510 consecutive patients with GD receiving first RAI were enrolled in the study, and followed up at 3-, 6- and 12-month. Liver dysfunction was recorded in 222 (43.5%) patients. GD patients with liver dysfunction had higher serum levels of free triiodothyronine (FT3) (median 27.6 vs. 20.6 pmol/L, p < 0.001) and free thyroxine (FT4) (median 65.4 vs. 53.5 pmol/L, p < 0.001) levels than those with normal liver function. Binary logistic regression analysis showed that duration of disease (OR = 0.951, 95% CI: 0.992-0.980, p = 0.001) and male gender (OR = 1.106, 95% CI: 1.116-2.384; p = 0.011) were significant differential factors for liver dysfunction. Serum TSH levels were higher in patients with liver dysfunction at all 3 follow-up time points (p = 0.014, 0.008, and 0.025 respectively). FT3 level was lower in patients with liver dysfunction at 3-month follow-up (p = 0.047), but the difference disappeared at 6 and 12 months (p = 0.351 and 0.264 respectively). The rate of euthyroidism or hypothyroidism was higher in patients with liver dysfunction than in those with normal liver function at 3 months (74.5% vs 62.5%; p = 0.005) and 6 months (82.1% vs 69.1%; p = 0.002) after RAI treatment, but the difference did not persist at 12-month follow-up (89.6% vs 83.2%, p = 0.081).There were no statistically significant differences in treatment efficacy (94.48% vs 90.31%, p = 0.142), incidence of early-onset hypothyroidism (87.73% vs 83.67%, p = 0.277), and recurrence rate (4.91% vs 7.14%, p = 0.379) between the 2 groups at 12-month follow-up. In conclusion, the efficacy of RAI was comparable in GD patients with liver dysfunction and those with normal liver function.
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Affiliation(s)
- Yuyang Ze
- Department of Endocrinology, Drum Tower Hospital affiliated to Nanjing University Medical School, Branch of National Clinical Research Centre for Metabolic Diseases; Endocrine and Metabolic Disease Medical Center, Drum Tower Hospital affiliated to Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210000, Jiangsu, China
- Department of Endocrinology and Metabolism, the Fifth People's Hospital of Suzhou Wujiang, No. 555, Xinyou Road, Suzhou, 215200, China
| | - Fei Shao
- Department of Endocrinology, Drum Tower Hospital affiliated to Nanjing University Medical School, Branch of National Clinical Research Centre for Metabolic Diseases; Endocrine and Metabolic Disease Medical Center, Drum Tower Hospital affiliated to Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210000, Jiangsu, China
- Department of Endocrinology and Metabolism, Langxi Hospital of Traditional Chinese Medicine, No. 99 Tingzishan Road, Jianping Town, Langxi County, Xuancheng City, 242100, Anhui, China
| | - Xuefeng Feng
- Department of Nuclear Medicine, Drum Tower Hospital affiliated to Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210000, China
| | - Shanmei Shen
- Department of Endocrinology, Drum Tower Hospital affiliated to Nanjing University Medical School, Branch of National Clinical Research Centre for Metabolic Diseases; Endocrine and Metabolic Disease Medical Center, Drum Tower Hospital affiliated to Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210000, Jiangsu, China
| | - Yan Bi
- Department of Endocrinology, Drum Tower Hospital affiliated to Nanjing University Medical School, Branch of National Clinical Research Centre for Metabolic Diseases; Endocrine and Metabolic Disease Medical Center, Drum Tower Hospital affiliated to Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210000, Jiangsu, China
| | - Dalong Zhu
- Department of Endocrinology, Drum Tower Hospital affiliated to Nanjing University Medical School, Branch of National Clinical Research Centre for Metabolic Diseases; Endocrine and Metabolic Disease Medical Center, Drum Tower Hospital affiliated to Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210000, Jiangsu, China.
| | - Xiaowen Zhang
- Department of Endocrinology, Drum Tower Hospital affiliated to Nanjing University Medical School, Branch of National Clinical Research Centre for Metabolic Diseases; Endocrine and Metabolic Disease Medical Center, Drum Tower Hospital affiliated to Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210000, Jiangsu, China.
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Azizi F, Abdi H, Mehran L, Amouzegar A. Appropriate duration of antithyroid drug treatment as a predictor for relapse of Graves' disease: a systematic scoping review. J Endocrinol Invest 2022; 45:1139-1150. [PMID: 35088381 DOI: 10.1007/s40618-021-01730-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/18/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Following the conventional 12-18 month antithyroid drug (ATD) treatment in Graves' disease (GD), 50% of patients experience relapse of hyperthyroidism. OBJECTIVE The aim of this systematic scoping review was critical appraisal of duration of ATD therapy in the last 80 years. METHODS Articles were identified through the search of PubMed from January 1, 1941 to April 30, 2021. All study types were included. Articles were eligible if they reported data on the length of ATD treatment, particularly thyroid hormones and TSH receptor antibodies (TRAb) concentrations and specifically those with data on the remission and/or relapse rates. RESULTS We described major progress regarding the duration of ATD therapy and related outcomes at every 20 years. Articles of 1941-1960 were mainly concerned with determination of favorable treatment, minimal effective dose, side effects and rate of remission after < 12-month ATD therapy. Studies with larger number of patients and longer follow-ups appeared in 1961-1980; higher remission rate after 18-24 months versus 6 months of ATD therapy was reported. Articles of 1981-2000 focused on identification of factors associated with high relapse rates after discontinuation of ATD. In 2001-2021, ATD became the first choice of treatment in many countries. However, 12-18 months of ATD therapy was arbitrarily chosen as the appropriate option. According to recent studies, persistent normalization of TRAb occurs after 5 years of methimazole therapy and ATD treatment of > 60 months could offer a 4-year remission rate of 85%. CONCLUSION Long-term ATD treatment for more than 60 months is safe and effective, has the highest remission rate and cures most patients with GD; hence, it should be considered as the most appropriate duration for ATD therapy in these patients.
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Affiliation(s)
- F Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Aerabi St, Daneshjoo Blv, Velenjak, P.O. Box 19395-4763, Tehran, Iran
| | - H Abdi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Aerabi St, Daneshjoo Blv, Velenjak, P.O. Box 19395-4763, Tehran, Iran
| | - L Mehran
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Aerabi St, Daneshjoo Blv, Velenjak, P.O. Box 19395-4763, Tehran, Iran
| | - A Amouzegar
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Aerabi St, Daneshjoo Blv, Velenjak, P.O. Box 19395-4763, Tehran, Iran.
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Best Left to the Experts: Proficiency and Experience are Key for Safety in Remote-Access Thyroidectomy for Graves' Disease. World J Surg 2022; 46:1114-1115. [PMID: 35230507 PMCID: PMC8971150 DOI: 10.1007/s00268-022-06496-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 11/03/2022]
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Liu X, Wong CKH, Chan WWL, Tang EHM, Woo YC, Liu SYW, Lam CLK, Lang BHH. OUP accepted manuscript. BJS Open 2022; 6:6640505. [PMID: 35822337 PMCID: PMC9277064 DOI: 10.1093/bjsopen/zrac079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background The relationship between good early control of thyroid hormone levels after thyroidectomy for Graves’ disease (GD) and subsequent risks of mortality and morbidities is not well known. The aim of this study was to examine the association between thyroid hormone levels within a short interval after surgery and long-term mortality and morbidity risks from a population-based database. Methods Patients with GD who underwent complete/total thyroidectomy between 2006 and 2018 were selected from the Hong Kong Hospital Authority clinical management system. All patients were classified into three groups (euthyroidism, hypothyroidism, and hyperthyroidism) according to their thyroid hormone levels at 6, 12, and 24 months after surgery. Cox proportional hazards models were performed to compare the risks of all-cause mortality, cardiovascular disease (CVD), Graves’ ophthalmopathy, and cancer. Results Over a median follow-up of 68 months with 5709 person-years, 949 patients were included for analysis (euthyroidism, n = 540; hypothyroidism, n = 282; and hyperthyroidism, n = 127). The hypothyroidism group had an increased risk of CVD (HR = 4.20, 95 per cent c.i. 2.37 to 7.44, P < 0.001) and the hyperthyroidism group had an increased risk of cancer (HR = 2.14, 95 per cent c.i. 1.55 to 2.97, P < 0.001) compared with the euthyroidism group. Compared with patients obtaining euthyroidism both at 6 months and 12 months, the risk of cancer increased in patients who achieved euthyroidism at 6 months but had an abnormal thyroid status at 12 months (HR = 2.33, 95 per cent c.i. 1.51 to 3.61, P < 0.001) and in those who had abnormal thyroid status at 6 months but achieved euthyroidism at 12 months (HR = 2.52, 95 per cent c.i. 1.60 to 3.97, P < 0.001). Conclusions This study showed a higher risk of CVD in postsurgical hypothyroidism and a higher risk of cancer in hyperthyroidism compared with achieving euthyroidism early after thyroidectomy. Patients who were euthyroid at 6 months and 12 months had better outcomes than those achieving euthyroidism only at 6 months or 12 months. Attaining biochemical euthyroidism early after thyroidectomy should become a priority.
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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, People's Republic of China
| | - Carlos K H Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People's Republic of 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, People's Republic of China
- Laboratory of Data Discovery for Health, Hong Kong Science Park, New Territories, Hong Kong SAR, People's Republic of 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, People's Republic of China
| | - Eric H M Tang
- 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, People's Republic of 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, People's Republic of China
| | - Shirley Y W Liu
- Division of Endocrine Surgery, Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of 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, People's Republic of China
| | - Brian H H Lang
- Correspondence to: Brian H. H. Lang, Division of Endocrine Surgery, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 102 Pokfulam Road, Hong Kong SAR, People's Republic of China (e-mail: )
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