Objective:

Thyroid disease is very common, particularly nodular goiter. Total thyroidectomy is a therapeutic option for both malignant and benign disease. The aim of the study was to evaluate the number of total thyroidectomy surgeries and the rate of benign and malignant histologic exams over the last decade.

Methods:

Hospital discharge records in the Emilia Romagna region (Italy) that reported total thyroidectomy as the principal surgical procedure and included the relative histologic diagnosis were reviewed for the period 2000 to 2010. Mean increment and geometric mean of increments per year were calculated to evaluate differences over the years.

Results:

More than 25,000 patients underwent total thyroidectomy between 2000 and 2010. The total number of thyroidectomies increased over this period, with a mean increment of 7.16% per year. The percentage of malignancies among the total number of thyroidectomies increased from 26.1% (2000) to 39.9% (2010) (mean increment, 1.38% per year). Nontoxic multinodular goiter was the most frequent diagnosis, accounting for 36% of all thyroidectomies.

Conclusions:

Between 2000 and 2010, the proportion of patients thyroidectomized for benign disease progressively decreased, as documented by a lower thyroidectomy/malignancy ratio. Currently, about 60% of thyroid interventions are performed for benign pathology. Improved preoperative diagnostic accuracy and the availability of nonsurgical procedures will presumably further reduce the number of thyroidectomies with benign histologic diagnoses.

Thyroid cancer with concomitant hyperthyroidism is rare. Most foci of malignancy are small and seen postoperatively as incidental findings after surgery for hyperthyroidism. Thyroid masses with clinical features of malignancy and concomitant hyperthyroidism are less-commonly reported. We report two cases of multinodular toxic goitre or Plummer's disease with clinical features of malignancy. Both patients had large multinodular goitres with evidence of metastasis to the manubrium for the first patient and to the lymph node and lungs for the second patient. Both were clinically euthyroid but with free hormone excess and suppressed thyroid stimulating hormone (TSH) on laboratory testing. Both patients received methimazole prior to thyroidectomy. Histopathology revealed follicular variant of papillary cancer with metastasis to the manubrium for the first patient and follicular thyroid cancer with lymph node metastasis for the second. While rare, thyrotoxicosis can occur with malignancy, Plummer's disease may harbour cancer and behave aggressively.

To study hyperthyroidism in long-term iodine sufficiency (IS), as iodine supply affects its occurrence.Prospective descriptive study.In 2003-2005, all referred cases of subclinical (SH) and overt hyperthyroidism (OH) were registered at diagnosis from a population (n = 631 239) in Gothenburg, Sweden.Information on age, gender, smoking, thyroid associated ophthalmopathy (TAO), thyroid hormones and TSH receptor antibodies (TRab) was collected. Incidences were calculated. SH and OH cases with Graves' disease (GD), toxic multinodular goiter (TMNG) and solitary toxic adenoma (STA) were compared. In GD, TRab+ and TRab- cases and patients with (TAO+) and without TAO (TAO-) were compared.The total incidence (n/100 000/year) of hyperthyroidism was 27·6; OH 23·8; SH 3·8; GD 21·4; TMNG 4·3; and STA 1·8. SH was more common among TMNG (40·2%) and STA (45·7%) than in GD (5·9%). SH-GD patients were older, more often smokers and had lower TRab levels than OH-GD patients. FreeT4 and T3 levels in GD were higher than in TMNG and STA. FreeT4, T3 and TRab decreased with age in patients with GD, P < 0·0001. TRab- patients had lower T3 than TRab+ patients, P < 0·001. TRab was positively correlated to FreeT4, P < 0·0001. TAO occurred in 20% of patients with GD. TAO+ patients were younger than TAO- patients. Smokers did not have more TAO.The total incidence of hyperthyroidism was low. GD dominated with an age-related decline of thyroid hormones and TRab levels. The spectrum of hyperthyroidism in this long-term IS area may represent the future situation for countries with shorter history of IS.

Objective:

In cases of multinodular goiter with negative cytological result, reasonable management options include surgical treatment, simple follow up, or more recently, conservative therapies like laser ablation, radiofrequency, or recombinant human TSH-augmented radioiodine (131I). In the case of patients who are eligible for follow up or non-surgical treatments, the possibility that they may be affected by an undiagnosed malignancy [false negative (FN) fine-needle aspiration cytology (FNAC) or by incidental thyroid cancer (ITC)] should be taken into account. The aim of our study was to assess the risk of malignancy in patients known to have presumably benign thyroid disease.

Methods:

Surgical series of patients who underwent total thyroidectomy for benign disease in 2000-2010 from two Italian centers were reviewed. Patients with any pre-operative suspicion of malignancy were excluded.

Results:

Eighty-four of 970 (8.6%) thyroidectomized patients revealed malignancy at histological exam (5% ITC, and 3.6% FN), with 89.8% of ITC having a diameter less than 10mm and 65.7% of FN having a diameter greater than 30mm. Sixty-seven of patients with thyroid malignancy (79.8%) had stage I disease (AJCC criteria). The risk of FN increases with increasing size of the nodule, while the risk of ITC increases as the size of the nodule decreases.

Conclusions:

The risk of malignancy in presumably benign thyroid disease can not be overlooked The risk of malignancy can be minimized through skilled ultrasound examination and FNAC. Once a patient with multinodular goiter is referred to follow up or non-surgical therapies, careful ultrasound surveillance is mandatory.

The success of I-131 therapy in geriatric patients who were referred to an endocrinology clinic with toxic nodular goiter and who lived in iodine-deficiency regions was studied.Patients older than 60 years who received I-131 therapy were included via retrospective data analyses. Fifty-nine patients between 60 and 82 years of age were enrolled in the study. The patients received an oral capsular form of I-131 (10-25 mCi) and were followed up for 1 year with clinical and laboratory results. Euthyroid or hypothyroid status at the end of the year after treatment was deemed to be a response to treatment.Of the 21 (36%) male and 38 (64%) female patients, 29 (49%) had a solitary toxic nodule and 30 (51%) had toxic multinodular goiter. Twenty-nine (49%) of the patients received propylthiouracil therapy. At the end of the year, 38 (64%) patients were euthyroid, 11 (19%) were hypothyroid, and 10 (17%) were thyrotoxic. Forty-nine (83%) patients who were euthyroid and hypothyroid were considered responders.Geriatric patients with toxic nodular goiter were shown to have a high response rate to I-131 therapy. Thus, we suggest that radioactive iodine treatment should be the first-line treatment in these patients.

Objective:

In the last 6 years, several studies reported a positive association between thyrotropin (TSH) and papillary cancer risk. The rationale is based on stimulatory action exerted by TSH on thyroid cell proliferation and/or progression of a pre-existing papillary carcinoma. To validate this hypothesis, we performed a meta-analysis comparing the incidence of thyroid cancer in 2 groups of patients who underwent surgery for toxic or nontoxic nodular goiter.

Methods:

Using data from 2,150 patients with toxic multinodular goiter (TMNG) and 873 patients with toxic adenoma (TA), the overall incidence of thyroid cancer (and 95% confidence interval [CIs]) was estimated to be 5.9% (3.9 to 8.3) for patients with TMNG and 4.8% (2.5 to 7.9) for patients with TA. Four studies were included in the meta-analysis with a total of 1,964 subjects undergoing thyroidectomy for allegedly benign thyroid disease (520 patients with TMNG or TA and 1,444 for multinodular goiter [MNG] or uninodular goiter [UNG]).

Results:

We did not find any significant differences in the risk of incidental thyroid cancer (ITC) in patients with TMNG versus MNG (odds ratio [OR]: 0.91, 95% CI: 0.47 to 1.77, I2: 62.6%), TA versus uninodular goiter (UNG) (OR: 0.46, 95% CI: 0.12 to 1.79, I2: 12%), and TMNG or TA versus MNG or UNG (pooled analysis) (OR: 0.86, 95% CI: 0.46 to 1.60, I2: 51.5%).

Conclusions:

The results of this meta-analysis did not confirm an association between low TSH values and lower thyroid cancer rate, at least in patients with nodular disease.

ABSTRACT: Sclerostin, a product of a SOST gene, is a protein expressed by osteocytes that inhibits osteoblastic bone formation. Several hormones, including PTH and glucocorticosteroids, have been suggested to be possible regulators of sclerostin production. The influence of thyroid hormones on sclerostin synthesis has not been investigated, so far. The aim of the study was to evaluate sclerostin concentrations in patients before and after treatment of thyrotoxicosis.The study involved 15 patients (4 men), mean age 51.8±15.3 years, mean BMI value - 24.7±3.5, with thyrotoxicosis due to Graves' disease or toxic multinodular goitre. Serum sclerostin was measured by immunoassay at diagnosis of thyrotoxicosis and after 6-10 weeks of treatment with thiamazole. The data were analysed by means of simple descriptive statistics of location and dispersion and Mann-Whitney U test for pairs of results, before and after thiamazole therapy. Association between variables was evaluated with use of Spearman`s correlation coefficient.There was a significant decrease in free T3 (FT3) and free T4 (FT4) concentrations (from 8.74±4.79 pg/ml to 3.54±2.40 pg/ml, and from 4.48±2.21 ng/ml to 1.02±1.07 ng/ml, respectively, p<0.001). This was accompanied by a marked decrease of serum sclerostin levels from 55.46±20.90 pmol/l to 35.73±15.70 pmol/l, p<0.0015). Interestingly, enough, sclerostin levels did not correlate with serum FT3 or FT4 concentrations.Restoration of a euthyroid state in patients with thyrotoxicosis results in a significant decrease in serum sclerostin concentrations. The above mentioned phenomenon may reflect lowering of bone metabolism, but a possible direct influence of thyroid hormones on SOST gene needs to be investigated.

Thyrotoxicosis is common in the Australian community and is frequently encountered in general practice. Graves disease, toxic multinodular goitre, toxic adenoma and thyroiditis account for most presentations of thyrotoxicosis.This article outlines the clinical presentation and evaluation of a patient with thyrotoxicosis. Management of Graves disease, the most frequent cause of thyrotoxicosis, is discussed in further detail.The classic clinical manifestations of thyrotoxicosis are often easily recognised by general practitioners. However, the presenting symptoms of thyrotoxicosis are varied, with atypical presentations common in the elderly. Following biochemical confirmation of thyrotoxicosis, a radionuclide thyroid scan is the most useful investigation in diagnosing the underlying cause. The selection of treatment differs according to the cause of thyrotoxicosis and the wishes of the individual patient. The preferred treatment for Graves disease is usually antithyroid drug therapy, almost always carbimazole. The primary treatment of a toxic multinodular goitre or toxic adenoma is usually radioactive iodine therapy. Specific therapy is usually not warranted in cases of thyroiditis, however, treatment directed at symptoms may be required. Referral to an endocrinologist is recommended if thyroiditis is unlikely or has been excluded.

Thyroglobulin autoantibodies (TgAb) can develop in patients with subacute thyroiditis (SAT).Comparison of the epitope pattern of TgAb of patients with SAT, Hashimoto's thyroiditis (HT) [autoimmune thyroid disease (AITD)] and non-toxic multinodular goiter (NTMG) (non-AITD).Serum TgAb from 10 patients with SAT, 45 with HT, and 19 with NTMG were evaluated. Serum TgAb binding to Tg was inhibited by 4 recombinant human TgAb-Fab, recognizing Tg epitope regions A, B, C, and D. The ability of single TgAb-Fab to inhibit the binding of serum TgAb to Tg was evaluated in enzymelinked immunosorbent assay.Levels of inhibition were different for all TgAb-Fab in the 3 groups of patients. Inhibition by region A TgAb-Fab in SAT [50.5 (30.3-62.5)%] (median and 25th to 75th percentiles) was similar to HT [49.0 (38.0-69.5)%] and significantly higher than in NTMG [25.0 (14.0-37.0)%]; by region B TgAb-Fab in SAT [0.0 (0.0-12.5)%] was significantly lower than in HT [28.0 (9.5-48.0)%] and similar to NTMG [9.0 (4.8-20.5)%]; by region C TgAb-Fab in SAT [9.5 (0.0-25.8)%] were similar to HT [23.0 (9.5-41)%] and NTMG [6.5 (1.7-21.5)%]; and by region D TgAb-Fab in SAT [0.0 (0.0-8.0)%] were lower than in HT [12.0 (1.0-28.5)%] and similar to NTMG [1.0 (0.0-5.0)%].The epitope pattern of TgAb of SAT is restricted to the A region that is immunodominant in AITD and non-AITD. In the majority of patients with SAT, the autoimmune phenomena represent a non-specific and transient response to the release of thyroid antigens, rather than the expression of thyroid autoimmunity.

Intrathyroid metastases are uncommon in cytology practice. We report a case of metastatic lesion in the thyroid from breast carcinoma which was recognized in a fine-needle aspiration (FNA) biopsy and confirmed by immunohistopathology. In addition, we provide an overview of the literature describing similar cases.The patient was a 54-year old woman with a large, multinodular goiter and bilaterally enlarged lymph nodes in the supraclavicular areas. Fourteen years earlier she had undergone radical mastectomy followed by chemio- and radiotherapy due to a breast carcinoma.FNA of the thyroid nodules showed a metastatic breast carcinoma and was followed by total strumectomy and lymphadenectomy. Histological reassessment of the surgical thyroid specimens as well as the neck lymph nodes revealed multiple breast metastases. This was strongly confirmed by immunohistochemical examinations, which revealed a positive staining for: CKMNF 116, CK7, CEA as well as for ER, PgR and HER2, and a negative staining for: CK20, thyroglobulin, TTF1, calcitonin, and chromogranin.Every new aggregate in the thyroid in patients with even a long-term history of cancer should be considered as potentially metastatic until proved otherwise. FNA could be helpful in the diagnosis of thyroid metastatic lesion, but it should be confirmed by immunohistopathology.