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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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Javid M, Mirdamadi A, Sheida F, Nayak SS, Borkar R, Hegde R, Javid M, Amirian B, Keivanlou MH, Amini-Salehi E, Hassanipour S. Efficacy of Radiofrequency Ablation in Autonomous Functioning Thyroid Nodules: A Comprehensive Systematic Review and Meta-analysis. Acad Radiol 2024:S1076-6332(24)00383-0. [PMID: 39068094 DOI: 10.1016/j.acra.2024.06.023] [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: 04/18/2024] [Revised: 06/15/2024] [Accepted: 06/17/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Radiofrequency ablation (RFA) is a minimally invasive outpatient procedure that has recently emerged as a treatment option for autonomous functioning thyroid nodules (AFTNs), offering a less invasive alternative to surgery. The objective of this systematic review and meta-analysis is to evaluate the efficacy of RFA for AFTNs. METHOD Global databases of PubMed, Scopus, Embase, Web of Science, and Cochrane Library were systematically searched from 1990 until January 5, 2024, for studies on AFTNs undergoing RFA that presented volume reduction ratio (VRR) for at least one of 1, 3, 6 or 12 months post-operative follow-up with the results presented as means. The primary outcomes were VRR and TSH normalization rate, and the secondary outcomes were the cosmetic score, symptom score, and post-procedure complications. Heterogeneity was assessed by Cochrane and I2 statistics, and a random-effects model was used for meta-analysis. The study protocol was registered on PROSPERO (CRD42024499932). RESULTS A total of 10 eligible studies with a total sample size of 254 were included. The pooled VRR after 1, 3, 6, and 12 months of follow-up post-treatment with RFA was 46.6% (95% CI: 40.3-52.9%), 62% (95% CI: 57.6-66.4%), 67.4% (95% CI:62.3-72.6%), and 77.2% (95% CI: 79.2-81.5%), respectively. The overall rate of TSH normalization was 76.4% (95% CI: 58.1-88.4%). Based on included studies the overall rate of subclinical hypothyroidism as one of the most important side effects of this method was 4% (95% CI: 1.9%-8.1%). CONCLUSION RFA emerges as a promising non-surgical treatment for AFTNs, showing high rates of TSH normalization, tumor size reduction, and improved cosmetic and symptom scores. However, further research is needed to compare RFA with surgical methods and assess long-term outcomes.
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Affiliation(s)
- Mona Javid
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Arian Mirdamadi
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Fateme Sheida
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran; Cancer Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Sandeep Samethadka Nayak
- Division of Hospital Medicine, Department of Internal Medicine, Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut, USAĪ
| | - Rachana Borkar
- Department of Radiology, Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut, USA
| | - Rahul Hegde
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mohammadreza Javid
- Department of Radiology, School of Medicine, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Bita Amirian
- Student Research Committee, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | | | - Ehsan Amini-Salehi
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Soheil Hassanipour
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran.
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Neumann R, Thomann R, Goerres GW. A retrospective study with long term follow-up of Graves' disease patients treated with low activities of 131Iodine. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF... 2024; 68:116-125. [PMID: 36287041 DOI: 10.23736/s1824-4785.22.03468-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Previous studies have shown that application of relatively low 131I-Iodine activities can successfully be used to treat patients with Graves' disease (GD). We assessed treatment outcome in the long-term follow-up of our GD patients and influencing factors. METHODS We evaluated 521 GD patients in this retrospective clinical single-center study. In all patients we performed scintigraphy and thyroid uptake measurement after 4 and 24 hours using 10 MBq 123I and calculated administered activity using Marinellis' formula. Treatment was done according to national regulations. Minimal routine clinical evaluation of all patients was available after 6 weeks and after 3, 6 and 12 months. Success of treatment was defined as euthyroid state or hypothyroidism 6 months after therapy. RESULTS We usually applied relatively low 131I activities. Three hundred seven patients (58.9%) became hypothyroid within 21 years of follow-up. One hundred thirty-nine patients (26.7%) became euthyroid and stayed euthyroid until the end of follow-up. We found a plateau after 7 years of initial therapy with only a few patients becoming hypothyroid after that time and identified 75 patients (14.4%) with persistent hyperthyroidism or recurrence. CONCLUSIONS Treatment with relatively low 131I activities produce favorable responses as shown in previous works. We found a high proportion of patients with long-term euthyroid state. Application of low activities reduces radiation burden of patients and, depending on radiation protection legislation, may lead to shortened hospital stay and reduced costs. Therefore, we feel that application of higher activities to treat GD patients as recommended in several current guidelines should be reconsidered.
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Affiliation(s)
- Regina Neumann
- Department of Radiology and Nuclear Medicine, GZO Spital Wetzikon, Wetzikon, Switzerland
| | - Robert Thomann
- Center for Metabolic Disease, Buergerspital Solothurn, Solothurn, Switzerland
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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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Kanokwongnuwat W, Penpong N. Prospective study to evaluate radioactive iodine of 20 mCi vs 10-15 mCi in Graves' disease. BMC Endocr Disord 2024; 24:54. [PMID: 38664774 PMCID: PMC11044547 DOI: 10.1186/s12902-024-01588-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/23/2024] [Indexed: 04/29/2024] Open
Abstract
OBJECTIVES To assess whether increasing radioactive iodine dose can increase treatment efficacy in Graves' disease. METHODS A prospective study was conducted, including 106 patients receiving 20 mCi (740 MBq) radioactive iodine (RAI), compared with a retrospective data, including 113 patients receiving 10-15 mCi (370-555 MBq) RAI. Remission and failure rates were evaluated at 6 months post-RAI. Statistical analysis was performed using logistic regression and Kaplan-Meier curves. RESULTS Patients receiving 20 mCi RAI demonstrated a significantly higher remission rate compared to the 10-15 mCi group (82.1% vs 66.4%, p = 0.009). Median time to remission was shorter in the 20 mCI group (3 vs 4 months, p = 0.002). Hypothyroidism at 6 months was more prevalent in the 20 mCi group (67% vs 53%, p = 0.03). Larger thyroid size (> 60 g) was associated with treatment failure (p = 0.02). CONCLUSIONS Higher dosage (20 mCi) RAI showed superior efficacy in achieving remission compared to lower dosages (10-15 mCi) in Graves' disease treatment.
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Affiliation(s)
- Wasit Kanokwongnuwat
- Division of Nuclear Medicine, Department of Radiology, Phrapokklao Hospital, No 38, Leab Neon Road, Mueang, Chanthaburi, 22000, Thailand.
| | - Nawarat Penpong
- Division of Endocrinology, Department of Internal Medicine, Phrapokklao Hospital, No 38, Leab Neon Road, Mueang, Chanthaburi, 22000, Thailand
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Quah NQ, Sobti MM, Wren AM, Scawn R, Kalogianni E, Cleland J, Maenhout A. Radioactive iodine treatment for Graves' hyperthyroidism: incidence of Graves orbitopathy. Nucl Med Commun 2024; 45:103-107. [PMID: 37982569 PMCID: PMC10779450 DOI: 10.1097/mnm.0000000000001791] [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: 09/03/2023] [Accepted: 10/30/2023] [Indexed: 11/21/2023]
Abstract
PURPOSE There are limited recent data on the effect of radioactive iodine (RAI) for Graves' disease on Graves' orbitopathy (GO) development or reactivation. This audit investigates the GO incidence in patients with Graves' disease after RAI treatment, and explores risk factors present, and steroid prophylaxis use. METHODS A retrospective audit of Graves' disease patients treated with RAI over a 5-year period. Data collected: smoking status, thyroid-stimulating hormone receptor antibody (TRAb) status, GO history, Graves' disease duration, eye features pre- and post-treatment, prophylactic corticosteroids, RAI dose given, post-RAI thyroid status, duration until hypothyroid. RESULTS One hundred one patients were included, with a median Graves' disease duration 36 months. 34/101 (33.7%) were active/ex-smokers, 86/101 (85.1%) were TRAb-positive, 11/101 (10.9%) had a GO history; 32 (31.7%) had eye features present. Median RAI dose given was 596MBq. 8/101 (7.9%) patients received prophylactic corticosteroid; 89/101 (88.1%) achieved hypothyroid state in the year after RAI. GO developed in 5/101 (5.0%), of which 4/5 (80%) were de novo in high-risk individuals who did not receive steroids. One was a GO reactivation despite steroids. Two required intravenous steroids with/without orbital radiotherapy, one completed oral steroid taper; the remainder were treated conservatively. CONCLUSION Our cohort had a lower GO incidence in patients with Graves' disease receiving RAI, with majority arising de novo . It is essential that all patients are assessed for Graves orbitopathy risk factors and counselled adequately prior to RAI. The decision to initiate steroids should be undertaken in a multi-disciplinary setting involving endocrinologists and ophthalmologists.
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Affiliation(s)
| | | | | | | | - Eleni Kalogianni
- Radiation Protection, King’s College Hospital NHS Foundation Trust
| | - James Cleland
- Department of Nuclear Medicine, Chelsea and Westminster Hospital, London, UK
| | - Annelies Maenhout
- Department of Nuclear Medicine, Chelsea and Westminster Hospital, London, UK
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Alradadi RS, Omar NA, Alhusayni RA, Almokhtar AM, Muhawish SF, Altaleb MM, Tawfiq SA, Alraddadi RM, Almalki RQ. The characteristics of Grave's disease in children and adolescent patients in Al-Madinah Al-Munawwarah: A retrospective chart review. Saudi Med J 2023; 44:284-288. [PMID: 36940965 PMCID: PMC10043888 DOI: 10.15537/smj.2023.44.3.20220501] [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: 10/04/2022] [Accepted: 01/25/2023] [Indexed: 03/23/2023] Open
Abstract
OBJECTIVES To determine the characteristics of Graves' disease in children and adolescents in Medina, the Kingdom of Saudi Arabia, and compare them to those observed in other countries. METHODS This is a retrospective chart review of children and adolescents diagnosed with Graves' disease between January 2010 and May 2021. RESULTS Fifty-eight patients aged 12.02 ± 4.85 years were identified, of which 44 (75.9%) were females. Exophthalmos (63.8%), neck swelling (60.3%), palpitations (46.6%), and tremors (29.3%) were the most common manifestations. Vitiligo (1.72%) and alopecia (1.72%) were the only autoimmune diseases observed in our patients. The median (IQR) value was 0.01 (0.36) (ulU/mL) for thyroid-stimulating hormone (TSH) and 24.89 (29.50) (pmol/L) for FT4. In terms of treatment modalities, 55 (94.8%) received antithyroid medication, 6 (10.3%) underwent thyroidectomy and one patient (1.72%) was treated with radioactive iodine. CONCLUSION In general, Graves' disease is more common in females. Neck swelling, palpitation, and tremors were the main manifestations. Compared with other countries, there was a higher frequency of exophthalmos and a lower frequency of associated autoimmune conditions. The primary treatment was antithyroid drugs; thyroidectomy and radioactive iodine were used less frequently.
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Affiliation(s)
- Rasha S. Alradadi
- From the Department of Pediatric Endocrinology, Taibah University, Al-Medinah Al-Munawarah, Kingdom of Saudi Arabia.
| | - Noura A. Omar
- From the Department of Pediatric Endocrinology, Taibah University, Al-Medinah Al-Munawarah, Kingdom of Saudi Arabia.
| | - Renad A. Alhusayni
- From the Department of Pediatric Endocrinology, Taibah University, Al-Medinah Al-Munawarah, Kingdom of Saudi Arabia.
| | - Amirah M. Almokhtar
- From the Department of Pediatric Endocrinology, Taibah University, Al-Medinah Al-Munawarah, Kingdom of Saudi Arabia.
| | - Shahad F. Muhawish
- From the Department of Pediatric Endocrinology, Taibah University, Al-Medinah Al-Munawarah, Kingdom of Saudi Arabia.
| | - Mawaddah M. Altaleb
- From the Department of Pediatric Endocrinology, Taibah University, Al-Medinah Al-Munawarah, Kingdom of Saudi Arabia.
| | - Sundus A. Tawfiq
- From the Department of Pediatric Endocrinology, Taibah University, Al-Medinah Al-Munawarah, Kingdom of Saudi Arabia.
| | - Reem M. Alraddadi
- From the Department of Pediatric Endocrinology, Taibah University, Al-Medinah Al-Munawarah, Kingdom of Saudi Arabia.
| | - Randa Q. Almalki
- From the Department of Pediatric Endocrinology, Taibah University, Al-Medinah Al-Munawarah, Kingdom of Saudi Arabia.
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Combination of treatments with transoral endoscopic thyroidectomy vestibular approach (TOETVA) for Graves' disease. Sci Rep 2023; 13:2764. [PMID: 36797361 PMCID: PMC9935526 DOI: 10.1038/s41598-023-29885-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/11/2023] [Indexed: 02/18/2023] Open
Abstract
Although the success rates of non-surgical treatments for Graves' disease such as antithyroid medication and radioiodine ablation were good, there were still failure of treatments or intolerance for some patients. Traditional thyroid surgery could treat these patients but result in unaesthetic neck scars. Herein, we report the preliminary results of our combination of treatments with the transoral endoscopic thyroidectomy vestibular approach for Graves' disease. A retrospective review of patients who underwent the transoral endoscopic thyroidectomy vestibular approach for the treatment of different sizes of goiters between January 2019 and December 2020 was performed. The demographic and clinical data of patients were collected. All patients were followed up for > 12 months. Each patient's goiter size was determined using four grades-from 0 to 3. In total, 14 female patients receiving the combination treatment with > 1 year of follow-up and a median (range) age of 35 (20-48) years at surgery were included. There were two, three, four, and five patients with grade 0, 1, 2, and 3 goiters, respectively. The median (range) intraoperative blood loss was higher in grade 3 patients (100 [20-850] mL) than in grade 2 patients (20 [10-200] mL) and grade 1 and 0 patients (both < 10 mL) (p = 0.033). All patients had normal-looking necks with a euthyroid or hypothyroid status within 1 year. There were no complications, including re-operation for bleeding, hypoparathyroidism, vocal cord palsy, or infections. The designed combination treatment with the transoral endoscopic thyroidectomy vestibular approach for Graves' disease provides optimal cosmetic results with a high success rate.
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Lu JY, Chen KH, Shih SR, Wen FY, Wu WC, Chen TC, Hu FC. Predictors of Prolonged Euthyroidism After Radioactive Iodine Treatment for Graves' Disease: A Pilot Study. Endocr Pract 2023; 29:89-96. [PMID: 36396015 DOI: 10.1016/j.eprac.2022.11.005] [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: 07/20/2022] [Revised: 11/06/2022] [Accepted: 11/08/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Patients with Graves' disease who remain hyperthyroid under the treatment of antithyroid drugs (ATD) or cannot tolerate ATD usually receive radioactive iodine (RAI) to control disease activity. This pilot study aimed to identify predictors of prolonged euthyroidism > 12 months after receiving RAI. METHODS Demographic, clinical, and laboratory data from 117 patients receiving RAI were retrospectively collected, including age, gender, body surface area, smoking status, free thyroxine, thyrotropin, thyrotropin binding inhibiting immunoglobulin, microsomal antibody, thyroglobulin antibody, medication history, and thyroid volume. Only 85 patients without missing values were included in statistical analysis. The calculated RAI dose was the estimated thyroid volume × 0.4. The difference and ratio between the actual and calculated RAI doses were examined. A stepwise logistic regression analysis was conducted to identify important predictors of prolonged euthyroidism > 12 months. The cut-off values for discretizing continuous covariates were estimated by fitting generalized additive models. RESULTS Among the 85 patients on RAI, 18 (21.2%) achieved prolonged euthyroidism > 12 months, 38 (44.7%) remained hyperthyroid with decreased ATD doses, but 29 (34.1%) suffered permanent hypothyroidism and needed long-term levothyroxine. Logistic regression analysis revealed that patients with age > 66 years, 33 < age ≤ 66 years, quitting smoking vs nonsmoking or current smoking, 600 < micorsomal antibody ≤ 1729 IU/mL, 47% < thyrotropin binding inhibiting immunoglobulin ≤ 81%, 7 < thyroglobulin antibody ≤ 162 IU/mL, 0.63 < ratio between actual and calculated RAI doses ≤ 1.96, or taking hydroxychloroquine would have a higher chance of reaching prolonged euthyroidism > 12 months after receiving RAI. Its area under the Receiver Operating Characteristic (ROC) curve was 0.932. CONCLUSION Patients with Graves' disease who received an actual RAI dose close to the calculated RAI dose achieved prolonged euthyroidism > 12 months if they also took hydroxychloroquine during RAI treatment.
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Affiliation(s)
- Jin-Ying Lu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Kuan-Hua Chen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shyang-Rong Shih
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Center of Anti-Aging and Health Consultation, National Taiwan University Hospital, Taipei, Taiwan
| | - Fang-Yu Wen
- Statistical Consulting Clinic, International-Harvard (I-H) Statistical Consulting Company, Taipei, Taiwan
| | - Wan-Chen Wu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ting-Chu Chen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Fu-Chang Hu
- Statistical Consulting Clinic, International-Harvard (I-H) Statistical Consulting Company, Taipei, Taiwan; Graduate Institute of Clinical Medicine and School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Oueslati I, Salhi S, Yazidi M, Chaker F, Chihaoui M. A case of Hashimoto's thyroiditis following Graves' disease. Clin Case Rep 2022; 10:e6466. [PMID: 36254153 PMCID: PMC9558571 DOI: 10.1002/ccr3.6466] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/28/2022] [Accepted: 09/30/2022] [Indexed: 11/04/2022] Open
Abstract
Graves' disease is characterized by the presence of circulating autoantibodies that stimulate the TSH receptor, inducing hyperthyroidism and goiter. Hashimoto's thyroiditis is an autoimmune disease leading to thyroid tissue destruction by cell and antibody-mediated immune processes. The occurrence of Hashimoto's thyroiditis following Graves' disease has been rarely reported. Its pathogenesis is not clear. Herein, we report the case of a 40-year-old woman who was referred to our department for thyrotoxicosis. Laboratory tests revealed overt hyperthyroidism. Thyroid scintigraphy showed an enlarged gland with diffusely increased tracer uptake, confirming the diagnosis of Graves's disease. The patient was treated with propranolol and thiamazole. Two months later, she received radioactive iodine therapy. Three years and 9 months later, the patient presented with hypothyroidism and very high levels of thyroperoxidase antibodies consistent with the diagnosis of Hashimoto's thyroiditis. She was treated with levothyroxine. The shift from Graves' disease to Hashimoto's thyroiditis was reported in the literature. However, its pathogenesis has not been clearly elucidated.
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Affiliation(s)
- Ibtissem Oueslati
- Department of EndocrinologyLa Rabta University Hospital, University of Tunis‐El Manar, Faculty of MedicineTunisTunisia
| | - Salma Salhi
- Department of EndocrinologyLa Rabta University Hospital, University of Tunis‐El Manar, Faculty of MedicineTunisTunisia
| | - Meriem Yazidi
- Department of EndocrinologyLa Rabta University Hospital, University of Tunis‐El Manar, Faculty of MedicineTunisTunisia
| | - Fatma Chaker
- Department of EndocrinologyLa Rabta University Hospital, University of Tunis‐El Manar, Faculty of MedicineTunisTunisia
| | - Melika Chihaoui
- Department of EndocrinologyLa Rabta University Hospital, University of Tunis‐El Manar, Faculty of MedicineTunisTunisia
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Analysis of the Application Value of Ultrasound Three-Dimensional Speckle Tracking Technology Combined with Thyroid Autoantibodies and Hormones in the Diagnosis and Treatment of Graves' Disease. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:7774283. [PMID: 35845595 PMCID: PMC9279017 DOI: 10.1155/2022/7774283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/24/2022] [Accepted: 06/10/2022] [Indexed: 11/24/2022]
Abstract
Objective The aim of the study is to evaluate the application value of three-dimensional speckle tracking imaging (3D-STI) and combined detection of thyroid autoantibodies and hormones in the diagnosis and treatment of Graves' disease. Methods A total of 60 patients with Graves' disease enrolled in our hospital from February 2020 to February 2021 were included in the experimental group, and 60 healthy patients after a physical examination during the same period were selected as the control group. No intervention was performed on the control group, and the experimental group received conventional Graves' disease treatment. The levels of thyroid autoantibodies and hormones in the two groups before and after the treatment were measured, and the 3D-STI was performed to compare the 3D-STI strain parameters of the research objects. Results A significantly higher level of thyroid autoantibodies in the experimental group than that in the control group before and after the treatment was found (P < 0.001), with a remarkable decline observed after the treatment (P < 0.001). The positive rate of thyroid autoantibodies in the experimental group before the treatment was significantly higher than that in the control group (P < 0.05). After the treatment, the positive rate of TRAb and TPOAb was higher than that of the control group (P < 0.05), and the positive rate of TPOAb was higher than before the treatment. The two groups showed no significant difference in the positive rate of TGAb (P > 0.05). Significant differences were observed in the thyroid hormone levels between the two groups and also between before and after the treatment (P < 0.001). The experimental group garnered significantly higher 3D-STI strain parameters than the control group before the treatment (P < 0.05); after the treatment, the hyperthyroidism of the patients was relieved with a decreased 3D-STI value, but it was still notably higher than the control group (P < 0.05). Remarkably higher positive rates of combined detection before and after the treatment in the experimental group than those in the control group were obtained (P < 0.05). Conclusion The combined detection of 3D-STI and thyroid autoantibodies and hormones ensures a better detection rate of Graves' disease and monitors the treatment effect of patients in real time, which provides a basis for clinical diagnosis and treatment and merits clinical promotion and application.
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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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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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Alvi AM, Azmat U, Shafiq W, Ali Rasheed AH, Siddiqi AI, Khan S, Ashfaq S, Irfan H, Bashir H, Abu Bakar M, Asghar K. Efficacy of Radioiodine Therapy in Patients With Primary Hyperthyroidism: An Institutional Review From Pakistan. Cureus 2022; 14:e24992. [PMID: 35719786 PMCID: PMC9191269 DOI: 10.7759/cureus.24992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2022] [Indexed: 11/05/2022] Open
Abstract
Background Radioactive iodine (RAI) is the treatment of choice for most patients with primary hyperthyroidism. The most common etiologies of hyperthyroidism are Graves' disease (GD), toxic adenoma (TA), and toxic multinodular goiter (TMNG). A single dose of RAI is usually sufficient to cure hyperthyroidism. The aim of this study was to assess the effectiveness of RAI therapy for patients diagnosed with primary hyperthyroidism. Methods and materials Patients diagnosed with hyperthyroidism who received RAI therapy between 2008 and 2018 were included in the study. The data was acquired from the hospital's electronic medical record system. Following the RAI treatment, a cure was defined as the development of euthyroidism or hypothyroidism after a single fixed-dose without antithyroid medication within one year of RAI therapy. In addition, a simple logistics regression model was used to identify the prognostic factors that may lead to better outcomes. Results A total of 112 patients diagnosed with hyperthyroidism with a mean age of 47 ± 14 were included in this study. The majority of the patients were female, 79 (70.5%). Within one year of RAI therapy, 84 (75%) patients achieved a cure that is either hypothyroid or euthyroid status. RAI dose was higher in responsive patients (18.50 ± 4.10 millicurie [mCi] versus 16.50 ± 4.10 mCi) than in non-responsive patients. The mean RAI doses were 16.05 ± 2.99 mCi in GD, 19.81 ± 4.40 mCi in TMNG, and 20.50 ± 3.30 mCi in TA, with a statistically significant p-value of 0.001. In the univariable logistic regression model, RAI dose was a significant prognostic factor of the responsive group (OR: 1.15, CI [1.01-1.31], p-value 0.03). Conclusion Our data presented that RAI therapy is effective for primary hyperthyroidism. We achieved remission with a single fixed-dose in the majority of patients. Most of our patients were cured within three months of RAI therapy. In addition, the RAI dose was higher in the responsive group as compared to the non-responsive group.
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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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Abstract
Graves disease is an autoimmune disease, with a genetic susceptibility, activated by environmental factors like stress, iodine excess, infections, pregnancy and smoking. It is caused by thyroid stimulating immunoglobulin (TSI) or thyroid stimulating antibody (TSAb) and is the most common cause of hyperthyroidism with an incidence of 21 per 100,000 per year. Treatment of Graves disease includes antithyroid drugs such as methimazole and propylthiouracil, radioactive iodine therapy and thyroidectomy. Methimazole, an antithyroid drug that belongs to the thioamides class, is usually the first line of treatment due to lower risk of hepatotoxicity compared to propylthiouracil. Radioactive iodine therapy is reserved for those patients who do not respond to antithyroid drugs or have contraindication or adverse effects generated by antithyroid drugs, and thyroid surgery is an option in people with thyroid nodular disease with suspected malignancy or large goiters such as predictors of poor response to antithyroid drugs and radioactive iodine therapy. Multiple factors influence the management of patients with Graves disease including patient and physician preferences, access to medical services and patients features such as age, complications and comorbidities.
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Muhammad H, Tehreem A, Russell JO, Tufano RP. Radiofrequency Ablation and Autonomous Functioning Thyroid Nodules: Review of the Current Literature. Laryngoscope 2021; 132:906-914. [PMID: 34375454 DOI: 10.1002/lary.29811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 07/21/2021] [Accepted: 07/25/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Autonomously functioning thyroid nodules (AFTNs) have long been treated with either surgery or radioactive iodine (RAI). Being an invasive procedure, even thyroid lobectomy for this condition is associated with complications such as anesthesia side effects, scarring, iatrogenic hypothyroidism, and injury to other structures. Similarly, RAI is associated with hypothyroidism and may require multiple courses. Therefore, minimally invasive techniques such as radiofrequency ablation (RFA) are being advocated as an alternative treatment for AFTNs. To date, only few studies have been published on this topic and are largely on European and Asian populations. The aim of this review is to assess the efficacy and safety of RFA as a potential alternative for treatment of AFTNs compared to conventional surgery and radioiodine. METHODS/STUDY DESIGN Comprehensive PubMed and Embase searches were performed using the following terms such as (autonomously functioning thyroid nodules and radiofrequency ablation), (radiofrequency ablation and hyperthyroidism), and (radiofrequency ablation and toxic thyroid nodule). Both prospective and retrospective studies were included based on the inclusion and exclusion criteria specified in the text. RESULTS Initially, 57 studies were identified and after excluding 47 studies, finally 10 studies were included in the review. CONCLUSION Although surgery remains the first line treatment for AFTN. However, RFA is a safe option compared to RAI or surgery, especially in patients who are high-risk surgical candidates or have absolute contraindications to RAI. Currently, trials with follow-up greater than or equal to 5 years are warranted. It will aid in formulating a standardized surveillance protocol and also generalize RFA's use for AFTN. Laryngoscope, 2021.
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Affiliation(s)
- Haris Muhammad
- Department of Internal Medicine, Greater Baltimore Medical Center, Towson, Maryland, U.S.A
| | - Aniqa Tehreem
- Department of Internal Medicine, Sinai Hospital, Baltimore, Maryland, U.S.A
| | - Jonathon O Russell
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Ralph P Tufano
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
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Ferris T, Carroll L, Jenner S, Aboagye EO. Use of radioiodine in nuclear medicine-A brief overview. J Labelled Comp Radiopharm 2021; 64:92-108. [PMID: 33091159 DOI: 10.1002/jlcr.3891] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/06/2020] [Accepted: 10/11/2020] [Indexed: 12/15/2022]
Abstract
Radioiodines have a long history in nuclear medicine. Herein, we discuss the production, properties and applications of these versatile iodine-based imaging and theragnostic agents. There are 38 isotopes of iodine (I) including one stable form (127 I). The most common radionuclides used in medical imaging and treatment, including Iodine-123 (123 I), Iodine-124 (124 I), Iodine-125 (125 I) and Iodine-131 (131 I), are discussed in this review.
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Affiliation(s)
- Trevor Ferris
- Department of Chemistry, Molecular Sciences Research Hub, Imperial College London White City Campus, London, UK
| | - Laurence Carroll
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | - Eric O Aboagye
- Comprehensive Cancer Imaging Centre, Department of Surgery and Cancer, Imperial College, Hammersmith Campus, London, UK
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Muhammad H, Santhanam P, Russell JO, Kuo JH. RFA and benign thyroid nodules: Review of the current literature. Laryngoscope Investig Otolaryngol 2021; 6:155-165. [PMID: 33614945 PMCID: PMC7883624 DOI: 10.1002/lio2.517] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/11/2020] [Accepted: 12/26/2020] [Indexed: 12/11/2022] Open
Abstract
Benign thyroid nodules (BTNs) are commonly found in the general population. They are usually asymptomatic and their incidence has increased as a result of wide-spread use of ultrasound. Benign nodules are typically monitored clinically until they increase in size, resulting in compressive symptoms warranting surgery. However, although surgery is generally well-tolerated and of low-risk, it is associated with a small risk for several complications including hypothyroidism, nerve injury, hematoma, injury to other structures and wound infection. Recently, newer image-guided ablation techniques including radiofrequency ablation (RFA) have been introduced. RFA has a similar safety profile when compared to surgery and has shown promising results in challenging surgical candidates. Though several studies have been published in Asian and European countries on the efficacy of RFA, limited data is available on the North American population. The aim of the study is to review the current literature establishing the clinical outcomes and safety of RFA for benign nodules. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Haris Muhammad
- Department of Internal MedicineGreater Baltimore Medical CenterTowsonMarylandUSA
| | - Prasanna Santhanam
- Division of Endocrinology, Diabetes, & Metabolism, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Jonathon O. Russell
- Department of Otolaryngology—Head and Neck SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Jennifer H. Kuo
- Department of Surgery, Section of Endocrine SurgeryColumbia University Medical CenterNew YorkNew YorkUSA
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Kahaly GJ. Management of Graves Thyroidal and Extrathyroidal Disease: An Update. J Clin Endocrinol Metab 2020; 105:5905591. [PMID: 32929476 PMCID: PMC7543578 DOI: 10.1210/clinem/dgaa646] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/11/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT Invited update on the management of systemic autoimmune Graves disease (GD) and associated Graves orbitopathy (GO). EVIDENCE ACQUISITION Guidelines, pertinent original articles, systemic reviews, and meta-analyses. EVIDENCE SYNTHESIS Thyrotropin receptor antibodies (TSH-R-Abs), foremost the stimulatory TSH-R-Abs, are a specific biomarker for GD. Their measurement assists in the differential diagnosis of hyperthyroidism and offers accurate and rapid diagnosis of GD. Thyroid ultrasound is a sensitive imaging tool for GD. Worldwide, thionamides are the favored treatment (12-18 months) of newly diagnosed GD, with methimazole (MMI) as the preferred drug. Patients with persistently high TSH-R-Abs and/or persistent hyperthyroidism at 18 months, or with a relapse after completing a course of MMI, can opt for a definitive therapy with radioactive iodine (RAI) or total thyroidectomy (TX). Continued long-term, low-dose MMI administration is a valuable and safe alternative. Patient choice, both at initial presentation of GD and at recurrence, should be emphasized. Propylthiouracil is preferred to MMI during the first trimester of pregnancy. TX is best performed by a high-volume thyroid surgeon. RAI should be avoided in GD patients with active GO, especially in smokers. Recently, a promising therapy with an anti-insulin-like growth factor-1 monoclonal antibody for patients with active/severe GO was approved by the Food and Drug Administration. COVID-19 infection is a risk factor for poorly controlled hyperthyroidism, which contributes to the infection-related mortality risk. If GO is not severe, systemic steroid treatment should be postponed during COVID-19 while local treatment and preventive measures are offered. CONCLUSIONS A clear trend towards serological diagnosis and medical treatment of GD has emerged.
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Affiliation(s)
- George J Kahaly
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
- Correspondence and Reprint Requests: George J. Kahaly, MD, PhD, JGU Medical Center, Mainz 55101, Germany. E-mail:
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Giant toxic multinodular goiter with dyspnea: A case report. Int J Surg Case Rep 2020; 73:190-195. [PMID: 32693233 PMCID: PMC7533637 DOI: 10.1016/j.ijscr.2020.07.017] [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: 05/21/2020] [Revised: 07/12/2020] [Accepted: 07/12/2020] [Indexed: 11/21/2022] Open
Abstract
This case report mainly focus on a case of 47-year old female with multinodular goiter. Fine Needle Aspiration Cytology needs to be done from the suspicious nodule. Toxic MNG is most effectively treated by total thyroidectomy, which achieves complete diminution from symptoms. Surgery for huge goiter is challenging particularly on difficult intubation, altered anatomy, supraglottic edema and adhesions.
Introduction Toxic multinodular goiter (MNG) involves an enlarged thyroid gland, is a common cause of hyperthyroidism and when it is accompanied by obstructive symptoms such as dyspnea, it carries an indication for surgery. Case presentation We present a case of 47-year old female with multinodular goiter with a rapid increase in size within 2 years. She also reported palpitation, breathlessness on exertion, tachycardia and hand tremor. Computed tomography scan of the neck shows a gross enlargement of thyroid gland across both sides of the neck. The fine needle aspiration cytology and final histopathological examination were suggestive of MNG with adenomatous nodules and toxic changes respectively. A total thyroidectomy was performed and the gland was dissected successfully. Discussion Toxic MNG is most effectively treated by total thyroidectomy, which achieves complete diminution from symptoms. Conclusion Surgery for huge goiter is challenging and one should be careful about difficult intubation, altered anatomy and adhesions to the surrounding structures. Recognizing and treating this kind of cases are important, as they constitute a preventable cause of mortality if timely diagnosed and treated.
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Abstract
Whether or not Graves' hyperthyroidism can be really cured, depends on the definition of "cure." If eradication of thyroid hormone excess suffices for the label "cure," then all patients can be cured because total thyroidectomy or high doses of ¹³¹I will abolish hyperthyroidism albeit at the expense of creating another disease (hypothyroidism) requiring lifelong medication with levothyroxine. I would not call this a "cure," which I would like to define as a state with stable thyroid stimulating hormone (TSH), free thyroxine, and triiodothyronine serum concentrations in the normal range in the absence of any thyroid medication. Surgery and radioiodine are unlikely to result in so-defined cures, as their preferable aim as stated in guidelines is to cause permanent hypothyroidism. Discontinuation of antithyroid drugs is followed by 50% recurrences within 4 years; before starting therapy the risk of recurrences can be estimated with the Graves' Recurrent Events After Therapy (GREAT) score. At 20-year follow-up about 62% had developed recurrent hyperthyroidism, 8% had subclinical hypothyroidism, and 3% overt hypothyroidism related to TSH receptor blocking antibodies and thyroid peroxidase antibodies. Only 27% was in remission, and might be considered cured. If the definition of "cure" would also include the disappearance of thyroid antibodies in serum, the proportion of cured patients would become even lower.
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Affiliation(s)
- Wilmar M Wiersinga
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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