Efficacy and Safety of Radiofrequency Ablation Versus Observation for Nonfunctioning Benign Thyroid Nodules: A Randomized Controlled International Collaborative Trial

BACKGROUND

Percutaneous radiofrequency thermal ablation (RFA) has been reported as an effective tool for the management of benign thyroid nodules (BTN). However, large, randomized controlled trials (RCTs) are lacking.

OBJECTIVE

The aims of this study were to assess the volume reduction of BTN after a single RFA performed using the moving-shot technique and to compare the volume reduction obtained in patients treated in two centers with different experience of the moving-shot technique.

METHOD

This study was an international prospective RCT. It was carried out at the Mauriziano Hospital (Turin, Italy) and the Asan Medical Center (Seoul, Korea). Eighty patients harboring solid, compressive, nonfunctioning BTN (volume 10-20 mL) were enrolled. Twenty patients in each country were treated by RFA using a 18-Gauge internally cooled electrode (group A); 20 nontreated patients in each country were followed as controls (group B).

RESULTS

At six months, BTN volume significantly decreased in group A (15.1±3.1 mL vs. 4.2±2.7 mL; p<0.0001), whereas it remained unchanged in group B (14.4±3.3 mL vs. 15.2±3.5 mL). The baseline volume was larger in the Italian series (16.4±2.5 mL vs. 13.9±3.3 mL, p=0.009). However, at six months, there was no significant difference between the Korean group and the Italian group (3.7±2.9 mL vs. 5.5±2.2 mL). Both cosmetic and compressive symptoms significantly improved (3.6±0.5 vs. 1.7±0.4 and 3.6±1.9 vs. 0.4±0.7, respectively; p<0.001). No side effects occurred.

CONCLUSIONS

RFA was effective in reducing the volume of BTN. The outcome was similar in centers with different experience in the moving-shot technique.

Long-term effect of radioactive iodine on thyroid function and size in patients with solitary autonomously functioning toxic thyroid nodules

OBJECTIVE

To investigate the long-term effects of radioiodine (131I) on thyroid function and size in patients with a solitary toxic thyroid nodule.

DESIGN

Prospective study of patients treated for a solitary autonomous toxic nodule, followed by evaluation of thyroid volume and function.

PATIENTS

Sixty-two consecutive patients followed for a minimum of 12 months (range 12-168, median 60). Seventeen patients received antithyroid drug treatment before 131I.

MEASUREMENTS

Standard thyroid function variables and ultrasonically determined thyroid volume before as well as 0.75, 1.5, 3, 6 and 12 months after treatment, and then once a year were investigated.

RESULTS

131I treatment (3.7 MBq/g thyroid tissue corrected to a 100% 24-h 131I uptake) was given as a single dose in 53 patients; six needed two doses and another three were given 3-5 131I treatments. The median initial dose was 310 MBq (140-666) and the median total dose was 332 MBq (148-1576). In patients receiving one 131I treatment (n = 53) the total thyroid volume decreased significantly from a median of 40 ml (range 19-77) to 24 ml (8-50) within 3 months. This represented a median reduction of 35%. A further significant decrease was seen after 24 months to a total reduction of 45%. In patients given more than one dose the thyroid volume was reduced from a median of 45 ml (19-104) before treatment to 30 ml (14-50) after a follow-up of 60 months (9-132) after the last 131I treatment. Patients without antithyroid pretreatment, receiving one 131I treatment (n = 39) became euthyroid after a median of 1.5 months (0.75-9) after treatment. Seventy-five per cent were euthyroid within 3 months. In patients pretreated with antithyroid drugs and treated with one dose of 131I (n = 14) euthyroidism was achieved after a median of 12 months (0.75-24) after 131I treatment. Hypothyroidism developed in five patients (8%) after a median of 36 months (6-60) after 131I treatment.

CONCLUSION

A cure-rate of 75% within 3 months is seen when treating autonomous solitary toxic thyroid nodules with 131I. The thyroid volume is reduced by 35% within 3 months and 45% after 2 years. Side-effects are few and consist of hypothyroidism in less than 10% with a median follow-up of 5 years. This treatment should be regarded as the standard treatment for this condition until prospective comparisons with surgery and ethanol injection therapy have been performed.

Prognostic factors of minimally invasive follicular thyroid carcinoma: extensive vascular invasion significantly affects patient prognosis

Follicular thyroid carcinoma (FTC) is divided into two categories: minimally and widely invasive FTC. Generally, the prognosis of minimally invasive FTC is excellent, but patients showing certain characteristics have a dire prognosis. In this study, we investigated the prognostic factors of minimally invasive FTC using a series of 292 patients. On multivariate analysis, extensive (4 or more) vascular invasion, age ≥ 45 years, and tumor size > 4 cm were independent prognostic factors of patient disease-free survival (DFS). Distant metastasis at diagnosis (M1) was the strongest prognostic factor of cause-specific survival (CSS). Extensive vascular invasion and tumor size > 4 cm also independently affected patient carcinoma death. Capsular invasion was not related to patient prognosis. The ten-year DFS rate of patients with extensive vascular invasion was 80%, which was poorer than that of those having tumor size > 4 cm (91%) and aged 45 years or older (90%). These findings suggest that 1) M1 most strongly affects the CSS of patients, and 2) M0 patients with extensive vascular invasion may be candidates for completion total thyroidectomy and radioactive iodine ablation.

Randomized prospective study comparing a single radioiodine dose and a single laser therapy session in autonomously functioning thyroid nodules

OBJECTIVE

To compare the efficacy of interstitial laser photocoagulation (ILP) with radioiodine in hot thyroid nodules.

DESIGN

Thirty consecutive outpatients with subclinical or mild hyperthyroidism and a scintigraphically solitary hot nodule with extraglandular suppression were randomized to either one ILP session or one radioiodine ((131)I) dose.

METHODS

ILP was performed under continuous ultrasound-guidance and with an output power of 2.5-3.5 W. (131)I was given as a single dose based on thyroid volume and a 24-h thyroid (131)I uptake. Thyroid function and nodule volume were evaluated at inclusion and at 1, 3 and 6 months after treatment.

RESULTS

Normalization of serum TSH was achieved in 7 out of 14 patients in the ILP group and in all 15 patients in the (131)I group (P=0.0025). In the ILP group, mean thyroid nodule volume reduction was 44+/-5% (s.e.m.; P<0.001), and in the (131)I group 47+/-8% (P<0.001), within 6 months, without between-group difference (P=0.73). The mean reduction of total thyroid volume was 7+/-5% in the ILP group (P=0.20) and 26+/-8% (P=0.006) in the (131)I group (P=0.06 between-group). Two patients in the (131)I group developed hypothyroidism but no major side effects were seen.

CONCLUSIONS

This first randomized study, comparing ILP with standard therapy, demonstrates that ILP and (131)I therapy approximately halves thyroid nodule volume within 6 months; but in contrast to (131)I, extranodular thyroid volume is unaffected by ILP and no patient developed hypothyroidism. Using the present design, ILP seems inferior to (131)I therapy in normalization of serum TSH. The potential value of ILP as a non-surgical alternative to (131)I needs further investigation.

Nonsurgical approaches to the management of thyroid nodules

Epidemiologic studies have documented substantial increases in the frequency of nodular thyroid disease. This trend is largely due to the increasing detection of nodules by the routine use of sonography in clinical practice. Only a small percentage of the nodules currently being detected will prove to be malignant. The probability of malignancy is similar in nonpalpable and palpable nodules. Fine-needle aspiration cytology has a central role in identifying malignant nodules, which are generally treated with surgery. Most thyroid nodules are cytologically benign and can be managed nonsurgically. Nodules that are completely asymptomatic require follow-up without treatment. Cosmetic problems and/or compression-related symptoms may be indications for surgery. When surgery is contraindicated or refused, several nonsurgical approaches are available. These include levothyroxine therapy, radioiodine treatment, percutaneous ethanol injections, and the new technique of laser photocoagulation. Levothyroxine therapy is the most widely used approach, but its clinical efficacy and safety are controversial. Levothyroxine might, nonetheless, be appropriate in selected cases characterized by low risk for adverse effects and nodule characteristics associated with response to this type of therapy. Radioiodine is the therapy of choice for toxic nodules or for symptomatic nodular goiters when surgery is not possible. Percutaneous ethanol injection should be used, in our opinion, as the first-line therapy only for recurrent symptomatic cystic nodules. Laser therapy should be reserved for selected patients treated in experienced centers only. With these options, clinicians can personalize the management of nodular thyroid disease according to a careful cost-benefit analysis.

Outcome of radioiodine-131 therapy in hyperfunctioning thyroid nodules: a 20 years' retrospective study

OBJECTIVE

To investigate the risk of hypothyroidism after radioiodine (131I) treatment for hyperfunctioning thyroid nodules.

DESIGN

Retrospective analysis of patients treated with 131I for hyperfunctioning thyroid nodules and followed up for a maximum of 20 years.

PATIENTS

A total of 346 patients treated with 131I in the years 1975-95, for a single hyperfunctioning nodule.

MEASUREMENTS

Hypothyroidism was defined as TSH levels > 3.7 mU/l. Kaplan-Meier survival analysis was used to analyse permanence of euthyroidism after 131I. A stepwise Cox proportional hazard model was used to identify factors influencing the progression to hypothyroidism.

RESULTS

The cumulative incidence of hypothyroidism was 7.6% at 1 year, 28% at 5 years, 46% at 10 years and 60% at 20 years. Age (P < 0.01), 24-th 131I uptake (P < 0.05) and previous treatment with methimazole (MMI, P < 0.1) were associated with a faster progression towards hypothyroidism, while thyroid and nodule size, thyroid status at diagnosis and degree of extranodular thyroid parenchymal suppression had no influence. In hyperthyroid patients with partial parenchymal suppression, however, previous MMI treatment was the most important prognostic factor (P < 0.01).

CONCLUSIONS

After 20 years of follow-up, 60% of patients treated with 131I for a single hyperfunctioning nodule are hypothyroid. Factors increasing the risk of hypothyroidism are age, 131I uptake and MMI pretreatment. The prognostic value of this last factor, however, depends on the degree of suppression of the extranodular thyroid parenchyma at the scan.

Effect of ultrasound-guided interstitial laser photocoagulation on benign solitary solid cold thyroid nodules: one versus three treatments

OBJECTIVE

Interstitial laser photocoagulation (ILP) is a safe and effective procedure when inducing thyroid nodule necrosis. In this prospective randomized study, we evaluated a possible dose-response relationship as well as patient satisfaction.

DESIGN

Thirty euthyroid outpatients with a cytologically benign solitary solid and scintigraphically cold thyroid nodule causing local discomfort were assigned to one session of ILP (ILP-1) (n = 15) or three monthly ILP sessions (ILP-3) (n = 15) and followed for 6 months. ILP was performed under continuous ultrasound (US)--guidance and with an output power of 2.5-3.5 W. Thyroid nodule volume was assessed by US. Pressure and cosmetic complaints were evaluated on a visual analogue scale.

MAIN OUTCOME

In the ILP- 1 group, thyroid nodule volume decreased from 10.1 +/- 4.3 mL (mean +/- standard deviation [SD]) to 5.7 +/- 3.2 mL (p = 0.0004), and in the ILP-3 group from 10.8 +/- 5.5 mL to 4.6 +/- 3.0 mL (p = 0.0005) during follow-up. The overall mean difference between the two groups was 13%, corresponding to an improved mean thyroid nodule volume reduction of 30% (p = 0.03). In both groups subjective symptoms were significantly reduced, and without difference between the two groups (p = 0.7). No major side effects were seen in either group.

CONCLUSION

As a nonsurgical therapeutic option, ILP-1 approximately halves thyroid nodule volume with concomitant symptom relief. There is little incremental effect of additional ILP treatment, which should be limited to patients with large nodules or limited nodule reduction after the first treatment.

Therapy: a new nonsurgical therapy option for benign thyroid nodules?

Despite the increasing implementation of iodization programs, benign nodular thyroid disease will remain a prevalent therapeutic concern for decades. recent research suggests that nonsurgical therapy, including radioactive iodine, radiofrequency thermal ablation and percutaneous laser ablation, might have a role in the treatment of symptomatic patients.

A randomized controlled trial to evaluate the adjuvant effect of lithium on radioiodine treatment of hyperthyroidism

OBJECTIVE

To evaluate the role of lithium (Li) as an adjuvant in radioiodine therapy of hyperthyroidism.

METHODS

A randomized controlled trial was carried out on 350 hyperthyroid patients with a mean follow-up period of 32.3 +/- 9.8 months (range, 12-60 months). The patients were randomized into two groups with 175 patients in each group: (1) radioiodine group (controls)-no lithium was given to these patients at any stage of their treatment and (2) radioiodine and lithium group (Li group)-lithium carbonate, 300 mg three times a day, for 3 weeks starting on the day of radioiodine administration. All patients were made euthyroid with antithyroid drugs prior to radioiodine therapy.

RESULTS

Mean age was 41.8 +/- 11.5 years (range, 18-71) in the control group and 41.8 +/- 12.2 years (range, 19-73) in the Li group. Mean first dose and cumulative dose of (131)I were 229 +/- 85 MBq and 326 +/- 204 MBq in controls and 233 +/- 110 MBq and 344 +/- 281 MBq in the Li group. Average number of radioiodine therapy administered was the same (1.4) in both groups. The cure rate (euthyroid plus hypothyroid) after the first dose of radioiodine in the control and the lithium groups was 68.4% and 68.9%, respectively (p = ns). The overall cure rate at the end of the study was also the same in both groups (96.7% and 96.3%, respectively). Even in patients with a rapidly discharging gland or in patients with a large goiter, no significant statistical difference was observed in radioiodine therapy outcome between the two groups. Ten percent of the patients complained of mild to moderate side effects of lithium.

CONCLUSION

The role of lithium as an adjuvant in radioiodine therapy of hyperthyroidism is insignificant.

Radiofrequency ablation of benign thyroid nodules does not affect thyroid function in patients with previous lobectomy

BACKGROUND

Surgical management of symptomatic benign thyroid nodules in patients with previous lobectomy poses a dilemma for physicians. Radiofrequency (RF) ablation may provide a treatment option that avoids surgery and preserves thyroid function. We evaluated whether RF ablation of benign thyroid nodules affects thyroid function in patients with previous lobectomy.

METHODS

A total of 11 patients with 14 thyroid nodules were enrolled using the following criteria: (i) having a predominantly solid nodule; (ii) reporting pressure symptoms or cosmetic problems; (iii) cytological confirmation of benignancy; (iv) no malignant features detected using ultrasound; (v) serum thyroid hormone and thyrotropin (TSH) levels within normal limits; and (vi) refusal of or ineligibility for surgery. Thyroid function, nodule volumes, and clinical concerns were evaluated before RF ablation and during follow-up after RF ablation.

RESULTS

The mean follow-up duration after RF ablation was 43.7±30.7 months (range=7-92 months). The mean nodule volume was 9.7 mL (0.9-57.6 mL) before the procedure, and was significantly decreased at the last follow-up (p<0.001) with a mean volume reduction rate of 87.2%. The mean symptom score (p=0.003) and cosmetic score (p=0.003) were both significantly decreased at the last follow-up. Levels of TSH, free thyroxine, and triiodothyronine were not significantly different prior to treatment and at the last follow-up (p>0.05), and remained normal in all patients.

CONCLUSIONS

In patients with previous lobectomy, RF ablation should be considered as a first-line treatment for symptomatic benign thyroid nodules to preserve thyroid function.

Radioiodine therapy of thyroid autonomy

Over half a century, treatment of thyroid autonomy with an oral dose of iodine-131 has proven to be effective. The optimum management strategy for the patient is, however, still a matter of debate. The article provides an overview of the pathogenesis of functional autonomy and its clinical relevance. According to the guidelines on both sides of the Atlantic, radioiodine treatment is considered the most comfortable and economical approach to the treatment of the toxic nodular goitre. Some differences in the preparation procedures in the guidelines of the American and the German Society of Nuclear Medicine are discussed with respect to therapy results and the subtypes of thyroid autonomy. The results of studies are summarised concerning changes in thyroid function and thyroid volume after a course of radioiodine treatment. Therapy-related risks, such as immunogenic hypothyroidism or thyroid cancer, are discussed. (131)I treatment of functional autonomy and hyperthyroidism is considered an effective and safe procedure.

Laser, radiofrequency, and ethanol ablation for the management of thyroid nodules

PURPOSE OF REVIEW

The majority of benign thyroid nodules are nearly asymptomatic, remain stable in size, and do not require treatment. However, a minority of patients with growing nodules may complain of local symptoms or have cosmetic concerns, and thus seek surgical consultation.

RECENT FINDINGS

The timely use of ultrasound-guided minimally invasive procedures can change the natural history of benign enlarging thyroid nodules. The procedures produce persistent shrinkage of thyroid nodules and are associated with improvement of local symptoms. Among the various procedures, percutaneous ethanol injection represents the first-line treatment for relapsing thyroid cysts. In solid nonfunctioning nodules, laser and radiofrequency ablation produces a more than 50% reduction in nodular volume that remains persistent over several years. For hyperfunctioning nodules, thermal ablation techniques are not appropriate unless radioactive iodine is contraindicated or not accessible.

SUMMARY

MITs are best suited for the management of medium or large-sized nodules that are sonographically well visualized. Conversely, large nodules or nodular goiters that extend into the chest are difficult to treat. MITs are performed in outpatient clinics, are less expensive, and have a lower risk of complications, compared to surgery, and usually do not induce thyroid dysfunction. However, malignancy should be ruled out with a dedicated ultrasound neck assessment and repeat fine needle aspiration of the lesion before treatment.

Low-energy interstitial laser photocoagulation for treatment of nonfunctioning thyroid nodules: therapeutic outcome in relation to pretreatment and treatment parameters

OBJECTIVE

Interstitial laser photocoagulation (ILP) is a recently proposed therapeutic procedure for the ablation of benign thyroid nodules, which has already proven to be safe and effective. However, results supporting the routine use of ILP are still limited.

DESIGN

The aim of the study was to evaluate the efficacy and safety of ILP treatment in benign nonfunctioning thyroid nodules and to establish whether the therapeutic outcome may be predicted by any clinical parameter at baseline. Twenty-three patients with either a solitary nodule or a dominant nodule within a multinodular goiter underwent ILP and were evaluated 1 and 3 months later. In order to assess the efficacy of low-energy ILP, the procedure was performed with an output power of 3 W, delivering a mean energy of 33.4 +/- 12.7 Joule/mL of nodule volume, which is much lower than previously reported.

MAIN OUTCOME

Nodule volume significantly decreased after ILP as assessed after 1 and 3 months (analysis of variance; F = 5.37; p = 0.007). Patients with multinodular goiter showed a greater reduction at 3 months compared with patients bearing a solitary thyroid nodule (38.6 +/- 5.3 vs. 30.9 +/- 6.5%; p < 0.01). Age, sex, ultrasound pattern (isoechogenous/hypoechogenous), pretreatment volume, number of ILP treatments, and total energy delivered did not show any significant correlation with treatment outcome.

CONCLUSIONS

Our results demonstrate that ILP can produce a significant reduction of thyroid nodule volume even when a much lower energy than previously reported is delivered. ILP constitutes a minimally invasive technique, which can be carried out on an outpatient basis and could represent a valid nonsurgical alternative for thyroid nodule management. Dominant nodules within a multinodular goiter appear to be more responsive to ILP compared with solitary thyroid nodules.

Incidence of postradioiodine immunogenic hyperthyroidism/Graves' disease in relation to a temporary increase in thyrotropin receptor antibodies after radioiodine therapy for autonomous thyroid disease

BACKGROUND

The aim of the study was to analyze retrospectively the incidence of postradioiodine immunogenic hyperthyroidism/Graves' disease in relation to a temporary increase in TSH-receptor antibodies without overt hyperthyroidism after radioiodine therapy for autonomous thyroid disease.

PATIENTS AND METHODS

Between May 2000 and May 2003 all patients (n = 1,357) who had undergone radioiodine therapy for autonomous thyroid disease were retrospectively analyzed for development of postradioiodine immunogenic hyperthyroidism. On pretreatment evaluation 565 of 1,357 patients (41.6%) had unifocal autonomous thyroid disease (UFA), 693 of 1,357 patients (51.1%) had multifocal autonomous thyroid disease (MFA), and 99 of 1,357 patients (7.3%) had diffuse thyroid disease (DISS). Free triiodothyronine (FT(3)), free thyroxine (FT(4)), thyrotropin (TSH), and thyroid antibodies were measured. Ultrasound examinations and thyroid scintigraphy were performed before and after radioiodine therapy. A sensitive assay with the human TSH receptor as antigen was chosen for measurement of the TSH receptor antibody and the study was limited to analysis of data obtained since introduction of this assay.

RESULTS

Fifteen of 1,357 patients (1.1%) (UFA, 8/565 = 1.4%; MFA, 6/693 = 0.9%; DISS 1/99 = 1.0%) developed postradioiodine hyperthyroidism between 1 and 13 months after radioiodine therapy with clinically overt hyperthyroidism and an elevation of TSH receptor antibodies. Patients with elevated thyroid peroxidase (TPO) antibodies before radioiodine therapy had an almost 10-fold (6/57 patients =10.5%) higher risk of developing postradioiodine immunogenic hyperthyroidism. Thirteen of 999 patients (1.3%) with antibody measurements after radioiodine therapy (UFA, 2/421 = 0.5%; MFA, 9/494 = 1.8%, DISS, 2/84 = 2.4%) had increased levels of TSH receptor antibodies and, to some extent, TPO antibodies without development of clinically overt hyperthyroidism.

CONCLUSIONS

There is an estimated 1.1% risk of developing postradioiodine immunogenic hyperthyroidism/Graves' disease in patients undergoing radioiodine therapy for autonomous thyroid disease and this increases approximately 10-fold when TPO antibody levels are elevated before radioiodine therapy. Furthermore, there is an estimated 1.3% risk of a temporary increase of TSH receptor antibodies after radioiodine therapy for autonomous thyroid disease without development of clinically overt hyperthyroidism.

Coexistence of malignant struma ovarii and cervical papillary thyroid carcinoma

CONTEXT

Struma ovarii is an uncommon monodermal teratoma in which thyroid tissue is the predominant element. Malignant transformation of struma ovarii is an even rarer occurrence.

CASE PRESENTATION

We describe a 42-year-old woman who underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy for a symptomatic left pelvic mass. Histology revealed malignant struma ovarii with classical papillary thyroid carcinoma expression. Ultrasonography of the cervical neck showed thyroid micronodules and a dominant 1-cm nodule in the left thyroid lobe. As the ovarian tumor was large, the patient underwent a total thyroidectomy with the intention of administering ¹³¹I therapy in an adjuvant setting. Histology of the cervical thyroid gland revealed bilateral multifocal papillary thyroid carcinoma with extrathyroidal extension and perithyroidal lymph node metastasis.

METHODS

Morphological (microscopy), immunohistochemical (Hector Battifora mesothelial cell 1, cytokeratin-19, galectin-3), and molecular (BRAF V600E, RAS, RET-PTC) characteristics and clonality analysis of the cervical thyroid and ovarian tumors were explored to distinguish them as separate malignancies.

RESULTS

The thyroid-type tumors from the cervical gland and ovary were discordant in terms of tissue histology and level of cytokeratin-19 expression. The clinical features and tumor profile results supported the independent existence of these two embryologically related, although topographically distinct, malignancies.

CONCLUSION

Our findings provided support for synchronous, albeit distinct, primary tumors in the ovary and cervical thyroid. "Field cancerization" and early genomic instability may explain multifocality in all thyroid-type tissue. In this regard, patients with malignant struma ovarii should undergo imaging of their thyroid gland for coexisting disease and thyroidectomy recommended for suspected malignancy or in preparation for radioiodine therapy.

Natural history of thyroid nodules in survivors of pediatric Hodgkin lymphoma

BACKGROUND

Survivors of Hodgkin lymphoma and other patients who receive neck irradiation are at increased risk of thyroid cancer. Ultrasonography provides an inexpensive and non-invasive method of thyroid screening, but the clinical significance of thyroid nodules detected by ultrasound screening is uncertain.

PROCEDURE

We reviewed the demographics, clinical characteristics, method of detection, and outcome of patients who developed thyroid nodules after treatment for pediatric Hodgkin lymphoma at our institution. One radiologist reviewed all imaging studies.

RESULTS

Sixty-seven children treated for Hodgkin lymphoma from 1962 to 2001 developed thyroid nodules. The study group represented 9,024 person-years of follow-up after the diagnosis of Hodgkin lymphoma and 581 person-years after diagnosis of a thyroid nodule. A median of 10.5 years (range, 0.2-24.8 years) elapsed between the diagnoses of Hodgkin lymphoma and thyroid nodule(s). All but one patient had received neck irradiation for Hodgkin lymphoma, with a median thyroid radiation dose of 35 Gy (range, 12-45 Gy). Thyroid nodules were found to be malignant in seven patients (10%), at a median of 16.2 years (range, 8.4-23.7 years) after diagnosis of Hodgkin lymphoma. Only one malignancy was found through screening ultrasonography. All patients with thyroid cancer remained disease-free at 0.4-16.2 years of follow-up.

CONCLUSIONS

Thyroid nodules are common in Hodgkin lymphoma survivors treated with neck irradiation, but the majority of these lesions have an indolent clinical course and do not undergo malignant transformation. Only patients with a palpable mass or clinical symptoms need more extensive evaluation, including Doppler-flow ultrasonography and fine-needle aspiration.

Radioiodine and percutaneous ethanol injection in the treatment of large toxic thyroid nodule: a long-term study

Surgery is generally recommended for large thyroid toxic nodules (TTNs). When surgery is not applicable, both radioactive iodine (RAI) and percutaneous ethanol injection (PEI) are alternative treatments. In this retrospective study, the long-term efficacy of nonsurgical treatments was evaluated in 43 patients with TTN, selected on the basis of presence of hyperthyroidism and a fairly large nodule (3- and 4-cm in diameter) completely inhibiting controlateral lobe captation during scintigraphy. Twenty-one patients were treated by RAI (administered dose 670+/-160 MBq; range 555-925) and twenty-two were treated by PEI (6+/-1 sessions; range 5-9). FT4, FT3, thyrotropin (TSH), and nodule volume were assessed before and at fixed intervals after treatment. Median follow-up was 36 months (range, 12-84). Compared to baseline values, with both therapies, serum FT4, FT3, and nodule volume were decreased (p < 0.01) and serum TSH was increased (p < 0.01), after 3 months and during the entire follow-up. Nodule volume reduction percentage was 66.8+/-22.0 and 78.4+/-18.0, in the RAI- and PEI-treated groups, respectively. At the end of follow-up, 34 patients were euthyroid (16 RAI- and 18 PEI-treated). Four RAI-treated patients (19%) showed slightly high TSH levels (4.2-5.3 mU/L), whereas three PEI-treated patients (13.6%) still had suppressed TSH levels, although being clinically asymptomatic. One RAI-treated patient (4.8%) showed overt hypothyroidism during the follow-up period and was then treated with L-thyroxin. One patient (4.6%), who was initially cured by PEI, became newly hyperthyroid during the follow-up period. Both treatments were well-tolerated. In conclusion, both of these nonsurgical treatments are effective and may be chosen also for relatively large TTNs. Specifically, RAI seems to be more effective for treating hyperthyroidism but has minimal sequelae of subclinical or clinical hypothyroidism, while, after PEI treatment the possibility of stable subclinical hyperthyroidism or hyperthyroidism relapse should be taken into account.

Does Radiofrequency Ablation Induce Neoplastic Changes in Benign Thyroid Nodules: A Preliminary Study

BACKGROUND

To evaluate the clinical feasibility of radiofrequency ablation (RFA) of benign thyroid nodules along with cytomorphological alteration, and any malignant transformation through biopsy.

METHODS

The data were retrospectively collected between April 2008 and June 2013 and core needle biopsy (CNB) was performed on 16 benign thyroid nodules previously treated using RFA. The parameters of the patients were compared, between the time of enrollment and the last follow-up examination, using linear mixed model statistical analysis.

RESULTS

No atypical cells or neoplastic transformation were detected in the undertreated peripheral portion of treated benign nodules on the CNB specimen. RFA altered neither the thyroid capsule nor the thyroid tissue adjacent to the treated area. On histopathological examinations, we observed 81.2% acellular hyalinization, which was the most common finding. After a mean follow-up period of over 5 years, the mean volume of thyroid nodule had decreased to 6.4±4.2 mL, with a reduction rate of 81.3%±5.8% (P<0.0001).

CONCLUSION

RFA is a technically feasible treatment method for benign thyroid nodules, with no carcinogenic effect or tissue damage of the normal thyroid tissue adjacent to the RFA-treated zone.

Beneficial effect of combined aspiration and interstitial laser therapy in patients with benign cystic thyroid nodules: a pilot study

The aim of this study was to evaluate the effect of combined cyst aspiration and ultrasound-guided interstitial laser photocoagulation (ILP) on recurrence rate and the volume of benign cystic thyroid nodules. 10 euthyroid outpatients with a solitary and cytologically benign partially cystic thyroid nodule causing local discomfort were assigned to cyst aspiration followed by ultrasound-guided ILP and followed for 12 months. The ILP was performed under continuous ultrasound-guidance and with an output power of 2.5-3.5 W. The volume of the nodules was assessed by means of ultrasound and determination of the amount of aspirated cyst fluid, thereby calculating the volume of the solid part. Follow-up included ultrasound and determination of thyroid function. Pressure and cosmetic complaints were evaluated on a visual analogue scale. The median initial volume of the cystic nodule decreased from 9.6 ml [6.8;15.5 (quartiles)] to 3.5 ml [2.7;9.0 (quartiles)] (p = 0.0001), and the median cyst volume from 3.0 ml [2.0;6.0 (quartiles)] to 0 ml [0;0.5 (quartiles)] (p = 0.0001) during follow-up. Recurrence of the cystic part was defined as a cyst volume > 1 ml. In eight of 10 patients there was no recurrence of the cystic part. Both pressure symptoms and cosmetic complaints were significantly reduced. The only side effect was mild pain or tenderness for a few days. Our study suggests that complete cyst aspiration and subsequent ultrasound-guided ILP of benign cystic thyroid nodules is a feasible and safe technique, resulting in a significant reduction in the volume of both the solid and the cystic component. A large-scale prospective randomized study is warranted.

Distant, solitary skeletal muscle metastasis in recurrent papillary thyroid carcinoma

BACKGROUND

Papillary thyroid cancer (PTC) is the most common differentiated thyroid carcinoma. Metastases usually occur in regional lymph nodes or to lungs. Distant metastases to skeletal muscle are rare. Here, we report a patient with a solitary metastasis to skeletal muscle.

PATIENT FINDINGS

A 31-year-old woman was found on routine physical examination to have a 1-cm nodule in the right thyroid lobe. The patient underwent endoscopic total thyroidectomy with central cervical lymph node dissection in April 2008. Pathological analysis showed a 1.5 × 0.9 cm PTC in the right thyroid lobe with extension into perithyroidal soft tissue and lymph node involvement (all six central lymph nodes examined were positive). After surgery, she received 100 mCi of radioactive iodine. Subsequently, the patient was found to have a lateral neck recurrence and, therefore, underwent right unilateral modified radical neck dissection followed by additional radioactive iodine ablation. In February 2010, her serum thyroglobulin was 19.4 ng/mL, but the neck ultrasound was negative. However, a fluorodeoxyglucose (FDG) positron emission tomography scan showed focal FDG uptake in the vastus medialis muscle of the right distal femur. A 0.9 × 0.5 cm, well-defined, whitish mass in the vastus medialis muscle was confirmed on histopathology to be metastatic PTC.

SUMMARY

Here, we report an adult woman who presented with a thyroid nodule that was noted to be PTC on histopathology after total thyroidectomy. Almost 2 years later, she was noted to have had focal FDG uptake consistent in the region of the right femur. A solitary metastasis of PTC in the right vastus medialis muscle was resected. A MEDLINE (Medical Literature Analysis and Retrieval System Online) search showed that this is only the third report of PTC with a distant, solitary skeletal muscle metastasis.

CONCLUSIONS

Distant skeletal metastasis in PTC is very rare. Until the availability of FDG to detect skeletal metastasis of PTC, they may have been more difficult to discern.

F-18-FDG-PET in a patient with Hashimoto's thyroiditis and MALT lymphoma recurrence of the thyroid

We report on the case of a 86-year-old male patient with a rapidly growing nodule within the right lobe of the thyroid gland, which after hemithyroidectomy, turned out to be a mucosa-associated lymphoid tissue (MALT) lymphoma of the thyroid gland. In addition, Hashimoto's thyroiditis was reported in the thyroid tissue adjacent to the MALT lymphoma. During follow-up a second nodule emerged within the left lobe and, because of evidence of MALT lymphoma recurrence, F-18-FDG-PET was performed. F-18-FDG-PET imaged a clearly increased accumulation within the whole left lobe and isthmus. Thus, no differences in the degree of hypermetabolism could be imaged between the nodule and the adjacent thyroid tissue. To our knowledge, this is the first report about F-18-FDG-PET in a patient with MALT lymphoma of the thyroid. Literature search revealed only a few cases of MALT lymphomas in locations other than the thyroid gland that were studied with F-18-FDG-PET. In no case was F-18 FDG accumulation seen in the MALT lesions. However, clear F-18 FDG accumulation was reported in some patients with Hashimoto's thyroiditis. It is concluded that the intensive F-18-FDG accumulation within the whole left lobe and isthmus of the presented case was due to the coexisting Hashimoto's thyroiditis. Consequently, F-18-FDG-PET imaging does not seem to be indicated in a patient with MALT lymphoma and known Hashimoto's thyroiditis in order to evaluate the status of the MALT lymphoma.

Is it useful to routinely biopsy hot nodules in iodine deficient areas?

Incidence of nodular thyroid disease as well as that of functioning thyroid nodules (FTN) increases dramatically in iodine deficient (ID) areas. Cancer is extremely rare in FTN; thus, some do not routinely biopsy and treat them with radioactive iodine (RAI) straight away or follow-up. The outcome of 296 patients followed or treated at our institution for solitary or multiple FTN were retrospectively evaluated. Hospital records of 224 female, 72 male patients, with a mean +/- SD age of 54.9 +/- 12.4 yr and followed for 22 (0-156) months were examined. 175 patients had solitary, 121 had multiple hot or warm nodules. 230 (77.7%) of the patients received RAI treatment. 402 fine needle aspiration biopsies (FNABs) were performed on 260 patients and on 343 FTN (381 benign and 21 suspicious diagnoses). Eleven of the patients were operated for suspicious FNAB results and 10 were followed-up. Only one nodule turned out to be malignant. Malignancy is extremely rare in functioning thyroid nodules (0.34%) and some of malignant cases could be predicted by their suspicious clinical features. Routine practice of treating FTN with RAI therapy is reasonable in clinically low-risk patients. FNAB is reserved for cases with suspicious clinical features, resulting in fewer surgeries and reduced cost.

Autonomously functioning thyroid nodule treated with radioactive iodine and later diagnosed as papillary thyroid cancer

The malignancy risk is low in hot thyroid nodules verified by scintigraphy. We present a rare case of papillary carcinoma, initially treated as an autonomous hot nodule. Case report. A 36-year old male patient with a hot thyroid nodule and subclinical hyperthyroidism was treated with 10mCi 131 I. On admission, both 99mTc and 131 I thyroid scintigraphic imaging revealed a hot nodule at the right lobe accompanied by lower uptake in the remaining thyroid tissue. After treatment, there was a progressive increase in the nodule size; a fine needle aspiration biopsy was thus performed which showed findings compatible with papillary thyroid cancer. The patient was referred to our department for further management. Total thyroidectomy with right central neck dissection was performed. The pathologic examination showed that the whole nodule (1.5 cm diameter) was a columnary type papillary thyroid cancer.

CONCLUSION

In the case of a small-sized toxic thyroid nodule, the possibility of malignancy cannot be totally ruled out. Suspicious hot nodules should be cytologically evaluated before radioactive iodine treatment to determine the existing malignancy risk. Fine needle aspiration biopsy should be performed in all hot thyroid nodules that increase in size after radioactive iodine treatment.