Autonomously Functioning Thyroid Nodules Research Articles

Radiofrequency Ablation of Benign Thyroid Nodules: Initial Clinical Experience in Iran

: Prevalence of thyroid nodules diagnosed by ultrasonography has been reported to be high (about 50%) probably due to iodine deficiency in our region. Most thyroid nodules benign but some require treatment for cosmetic reasons or subjective symptoms. The conventional method of treatment in Iran is surgery. For the first time in Iran, from February 2016, 50 patients with 63 nodules (solid or cystic) were successfully treated by radiofrequency (RF) ablation. The procedure was performed under local anesthesia with no need for hospitalization. At one and three months post-ablation follow ups 40% to 67% reduction in nodule volume was observed. No hormone imbalance or voice changes were seen in none of the patients. Indication of RF ablation includes benign confirmed nodules (at least 2 times Fine needle aspiration or biopsy) neck pain, dysphasia, foreign body sensation, discomfort, cough, cosmetic problems, or thyrotoxicosis in cases of autonomously functioning thyroid nodules (AFTNs). Compared with surgery, RF ablation as a minimally invasive approach provided significantly lower rate of complications regarding thyroid function which well-maintained after procedure also no external scar was formed. Pain and inflammation during the first 3 to 7 days after RF ablation and long term treatment results (1 to 6 months) are of disadvantages. We recommend RF ablation to be considered as possibly the first-line treatment for benign thyroid nodules. Disclosure: Nothing to disclose.

Is TSH necessary for initial assessment of thyroid nodules?

The use of thyrotropin (TSH) in the initial assessment of thyroid nodules is inefficient and leads to unnecessary assessment costs. We compared the total costs of thyroid nodule assessment with or without the use of TSH in the initial assessment. A total of 1808 patients with thyroid nodules received TSH, fine-needle aspiration (FNA) and thyroid scintigraphy (TS) assessment, including 83 autonomously functioning thyroid nodule (AFTN) cases and 1725 non-AFTN cases. The total costs of the TSH strategy and non-TSH strategies were compared. The ratio of single-use costs of FNA to TS (CFNA/TS ) was used as the main outcome measure. Only when 6·03 ≤ CFNA/TS ≤ 27·17, the lowest total costs were associated with using the conventional TSH strategy. When CFNA/TS <6·03 or CFNA/TS >27·17, the lowest costs were found with FNA and TS, respectively. From the perspective of cost economics, in iodine-sufficient areas, we recommend that the decision on the use of TSH for the initial assessment of thyroid nodules should be based on the testing costs of FNA and TS in that medical unit.

Is there still a role for thyroid scintigraphy in the workup of a thyroid nodule in the era of fine needle aspiration cytology and molecular testing?

Thyroid scintigraphy is now rarely used in the work-up of a thyroid nodule except in the presence of a low TSH value. Therefore, autonomously functioning thyroid nodules (AFTNs) with a normal TSH value are diagnosed only in the rare medical centers that continue to use thyroid scan systematically in the presence of a thyroid nodule. In this review, we discuss the prevalence of AFTN with a normal TSH level and the possible consequences of performing fine needle aspiration cytology (FNAC) in an undiagnosed AFTN. We also discuss the risk of malignant AFTN which may be higher than previously stated.

Autonomously Functioning Thyroid Nodules In Patients

This study evaluates the clinical characteristics, workup, treatment, and outcomes of pediatric patients diagnosed with an autonomously functioning thyroid nodule (AFTN) in a large cohort of patients presenting for evaluation of a thyroid nodule. There are few prior studies on AFTN in pediatrics, with limited data on treatment and outcomes. Rates of malignancy in AFTN are perceived as low, but prior studies have varying reports. This is a retrospective chart review of patients less than 21 years of age at Rhode Island Hospital over an 11-year period (2003-2013). We reviewed 354 charts, which yielded 242 patients with a diagnosis of thyroid nodule and 17 patients with AFTN. The prevalence of AFTN in patients presenting with thyroid nodules was 7%. Mean age of patients was 15.8 years at diagnosis, and mean nodule size was 3.3 cm. There was female predominance. Thyroid-stimulating hormone levels were suppressed at diagnosis in 87% of patients. Six patients were treated with surgery, 5 patients with radioactive iodine therapy (RAI), 2 patients with medication, and 1 patient was observed without treatment. Three patients treated with RAI required subsequent treatment for hypothyroidism or continued hyperthyroidism. One patient had papillary thyroid carcinoma based on final surgical pathology. Our study found a higher prevalence of AFTN compared to the reported prevalence in adults. We concur with the new guidelines on management of thyroid nodules in recommending surgery for treatment of AFTN, based on the variability of outcomes after treatment with RAI.

A Rare Presentation of Autonomously Functioning Papillary Thyroid Cancer: Malignancy in Marine-Lenhart Syndrome Nodule.

Objective. Marine-Lenhart Syndrome (MLS) is defined as concomitant occurrence of autonomously functioning thyroid nodule (AFTN) with Graves' disease (GD). Malignancy in a functional nodule is rare. We aimed to present an extremely rare case of papillary thyroid cancer in a MLS nodule with lateral lymph node metastases. Case. A 43-year-old male presented with hyperthyroidism and Graves' ophthalmopathy. On Tc99m pertechnetate scintigraphy, a hyperactive nodule in the left upper thyroid pole was detected and the remaining tissue showed a mildly increased uptake. The ultrasonography demonstrated 15.5 × 13.5 × 12 mm sized hypoechoic nodule in the left upper pole of the thyroid and round lymph nodes on the left side of the neck. Fine needle aspiration biopsy (FNAB) of the nodule and lymph node revealed cytological findings consistent with papillary cancer. Total thyroidectomy with central and left modified radical neck dissection was performed. On pathologic examination, two foci of micropapillary cancer were detected. The skip metastases were present in three lymph nodes on the neck. Conclusion. AFTN can be seen rarely in association with GD. It is not possible to exclude malignancy due to the clinical and imaging findings. In the presence of suspicious clinical and sonographic features, FNAB should be performed.

手術的加療を行った自律性機能性甲状腺結節 (AFTN) の検討

自律性機能性甲状腺結節 (autonomous functioning thyroid nodule : AFTN) は，甲状腺の結節性病変が自律性にホルモンを分泌し甲状腺中毒症を呈する病変である。今回われわれは，2004年から2013年までの間に野口病院でAFTNと診断し手術的加療を行った63例について検討した。手術により甲状腺中毒症は全例是正され，合併症として永続性・一過性反回神経麻痺は認めず，永続性副甲状腺機能低下症を3例 (5％)，一過性副甲状腺機能低下症を4例 (6％) に認めた。組織型は，単発性の機能性結節53例のうち31例 (58％) が濾胞腺腫であり，多発性の機能性結節10例のうち5例 (50％) は腺腫様甲状腺腫であった。また，機能性結節そのものが癌であった症例が3例 (5％) あり，機能性結節そのものは良性であったが癌を合併していた症例が15例 (24％) あった。AFTNの治療としては，手術的加療や131I内用療法が主体となるが，このことを十分ふまえた上で治療方法を選択する必要がある。

Radiofrequency ablation for thyroid nodules: which indications? The first Italian opinion statement.

Nodular thyroid disease is a very common finding in clinical practice, discovered by ultrasound (US) in about 50 % of the general population, with higher prevalence in women and in the elderly [1–4]. Whereas therapeutic flowchart is quite established and shared for malignant lesions, multiple options are now available for patients presenting with benign thyroid nodules, ranging from simple clinical and US follow-up to thyroid surgery. The majority of thyroid nodules, benign by fine-needle aspiration, are asymptomatic, stable, or slow-growing over time and require no treatment. Nevertheless, large thyroid nodules may become responsible for pressure symptoms, resulting in neck discomfort, cosmetic complaints, and decreased quality of life. Partial/total thyroid surgery has so far constituted the only therapeutic approach for these. Although surgery is widely available, highly effective, and safe in skilled centers, complications (both temporary and permanent) still occur in 2–10 % of cases [5, 6]. Hypothyroidism is an unavoidable effect after total thyroidectomy, requiring lifelong l-thyroxine replacement therapy. Besides, surgery is expensive and may be not recommended for high-risk patients or refused by others. Radioiodine (131I) therapy has been proven to be effective to treat toxic multinodular goiters and autonomously functioning thyroid nodules (AFTN) [7], although they are usually more radioresistant than toxic diffuse goiters [8]. Radioiodine therapy normalizes thyroid function and significantly reduces thyroid volume. However, hypothyroidism often occurs, in up to 60 % of patients, several years after treatment [9]. Otherwise, radioiodine therapy shows only incomplete, weak effects in nonfunctioning cold thyroid nodules. Pretreatment with recombinant human TSH may improve goiter volume reduction by causing a more homogeneous distribution of radioiodine within the gland, especially increasing the uptake of 131I in scintigraphically relatively cold areas [10]. TSH-suppression therapy withl-thyroxine was widely used to achieve nodule shrinkage and to prevent nodule growth and formation, producing, however, controversial results and exposing patients to heart and bone side effects. Therefore, current guidelines do not recommend its routine use in clinical practice, suggesting its usefulness in some cases only [3, 4]. Over the last two decades, nonsurgical, minimally invasive, US-guided techniques have been proposed for the treatment of thyroid nodules [11–16]. Percutaneous ethanol injection (PEI) is recommended for the treatment of relapsing cysts and dominantly cystic thyroid nodules [17]. Because of the limitations of PEI in the management of solid thyroid nodules, hyperthermic methods (laser ablation and radiofrequency ablation) have been introduced afterward for the treatment of solid, benign thyroid lesions [18], achieving marked nodule size reduction and clinical improvement in nodule-related symptoms, in several series from skilled centers, especially in Korea and Italy. Other nonsurgical therapies, such as high-intensity focused-ultrasound (HIFU), microwaves, cryotherapy, and electroporation, are presently under investigation.

Prevalence of normal TSH value among patients with autonomously functioning thyroid nodule.

International guidelines significantly diverge on the effectiveness of thyroid scintigraphy (TS) in the initial work-up of thyroid nodules. In particular, the role of TS to detect or exclude the presence of autonomously functioning thyroid nodules (AFTN) in patients with normal serum thyrotropin (TSH) is still a matter to debate. Here, we aimed to review the literature on the prevalence of normal TSH value among patients with AFTN and meta-analyse data of the retrieved eligible papers. A comprehensive literature search of studies published from January 2000 to December 2014 on AFTN detected by TS was performed. Records reporting serum TSH values in AFTN were selected. Pooled prevalence of AFTN with normal TSH values was calculated on a per-patient analysis including 95% confidence intervals (95% CI). Eight records including 2761 AFTN were selected for the meta-analysis. Pooled prevalence of AFTN with normal TSH detected by TS was 50% (95% CI: 32-68%). Selection bias in the included studies and heterogeneity among studies were potential limitations of the meta-analysis. Present meta-analysis shows that about one in two patients with AFTN demonstrated by TS has a TSH value within normal references. As a consequence, TSH measurement may not be considered as effective as a single tool to detect or exclude AFTN, and TS remains mandatory.

Follicular thyroid carcinoma in a child presenting as autonomously functioning thyroid nodule

Thyroid nodules are uncommon in children (1.5%). However, the incidence of thyroid carcinoma in childhood thyroid nodules (26.4%) is 3-4 folds higher than in adults. Autonomously functioning thyroid nodules (AFTN) or hot nodules account for less than 3% of hyperthyroidism in children and carry a small risk of malignancy (2-5%). The majority of malignant hot nodules are papillary thyroid carcinoma (57.1%) with follicular carcinoma reportedly comprising 36.4% of cases. A search of MEDLINE identified 7 paediatric cases of AFTN harbouring carcinoma. Here we report a child, presenting with hyperthyroidism and subsequently diagnosed with follicular thyroid carcinoma. An 11 year old girl presented with a palpable right sided thyroid nodule and symptoms of hyperthyroidism consisting of tachycardia and anxiety. A thyroid ultrasound showed a solitary, minimally heterogenous nodule on the right, measuring 2.5x1.9x1.6 centimetres. It was hyperechoic to the remainder of thyroid gland and had increased intralesional and perilesional vascularity. A radionuclide scan demonstrated the nodule as hyperfunctioning “hot” nodule with no radiotracer uptake in the rest of thyroid. An ultrasound guided FNAC was performed and features consistent with a follicular neoplasm were identified. She underwent right hemi-thyroidectomy and histopathology was consistent with angioinvasive follicular thyroid carcinoma. No evidence of carcinoma was found in the rest of the thyroid following completion thyroidectomy. Additionally, her head circumference was >98th percentile, a lipoma was present over her sacrum and MRI suggested avascular hamartoma over her right ankle, together raising the possibility of Cowden syndrome. FNAC is warranted in all cases of solid thyroid nodules in children including hot nodules to help define the pathology. If inconclusive, surgical excision of lesion for histopathology should be considered. Familial cancer syndromes, which can include a hamartoma/tumour phenotype such as Cowden syndrome and other PTEN hamartoma/tumour syndromes, DICER1 syndrome and MEN2 are also possible, depending on the type of thyroid malignancy. Written informed consent was obtained from the patient's parent or guardian for publication of this abstract and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.

Follicular Thyroid Cancer with Pulmonary Metastasis Presenting as Toxic Autonomously Functioning Thyroid Nodule

ABSTRACT Objective: We report the case of a patient in whom a toxic autonomously functioning thyroid nodule (AFTN) turned out to be an aggressive follicular carcinoma with pulmonary metastases and subclinical hyperthyroidism. Methods: In this case study, we review the presentation, evaluation, diagnosis, and management of an aggressive follicular carcinoma presenting as an AFTN with hyperthyroidism. We also reviewed potential pitfalls in the diagnosis of this rare presentation of thyroid cancer when following the current standards of care in managing thyroid nodules. Results: An 85-year-old female with atrial fibrillation was seen for an enlarging right thyroid nodule. Biochemical testing revealed subclinical hyperthyroidism. An enlarged, 4.2 × 3.4 × 4.1-cm right thyroid lobe nodule was noted on ultrasound and confirmed to be an AFTN by thyroid scintigraphy. Incidental pulmonary nodules were noted on computed tomography (CT) and found to be fluorodeoxyglucose (FDG)-avid on positron emission tomography (PET). She was treated with total thyroidectomy, and pathologic analysis confirmed the presence of a unifocal follicular thyroid carcinoma (FTC) with lymphovascular invasion. Postoperatively, she was also treated with radioactive iodine and levothyroxine suppressive therapy. Subsequent progression of metastasis ensued, and she died approximately 4 years after diagnosis. Conclusion: Hyperthyroidism resulting from a functioning thyroid tumor is exceedingly rare. Flexibility in the approach to functioning thyroid nodules is essential. Our case demonstrates that thyroid malignancy in an AFTN should be suspected in elderly patients with rapidly growing nodules. Abbreviations: AFTN autonomously functioning thyroid nodule CT computed tomography FDG fluorodeoxyglucose FNA fine needle aspiration FTC follicular thyroid carcinoma 131-I radioactive iodine PET positron emission tomography Tg thyroglobulin TSH thyroid-stimulating hormone

Radiofrequency ablation for autonomously functioning thyroid nodules: a multicenter study.

The purpose of this study is to validate the generalizability of the efficacy and safety of radiofrequency (RF) ablation for treating autonomously functioning thyroid nodules (AFTN) in a large population multicenter study. This study included 44 patients from 5 institutions who refused or were not suitable for surgery or radioiodine therapy. Twenty-three patients were affected by a toxic nodule and 21 by a pretoxic nodule. RF ablation was performed using an 18-gauge, internally cooled electrode. Nodule volume, thyroid function, scintigraphy, symptom/cosmetic scores, and complications were evaluated before treatment and during each follow-up. The mean follow-up period was 19.9±12.6 months. The mean nodule volume was initially 18.5±30.1 mL and significantly decreased after treatment at 1 month (11.8±26.9 mL, p<0.001) and the last month (4.5±9.8 mL, p<0.001). Significant improvement of triiodothyronine, free thyroxine, and thyrotropin was observed at the last follow-up. Regarding scintigraphy, 35 hot nodules became cold or were normal when scanned and 9 decreased uptake, although they remained hot nodules. The mean symptom and cosmetic scores were significantly reduced at the last follow-up. No major complications were encountered. This multicenter study validated the efficacy and safety of RF ablation for treating AFTN; RF ablation can be considered an alternative to surgery or radioiodine therapy.

Lack of association between autonomously functioning thyroid nodules and germline polymorphisms of the thyrotropin receptor and Gαs genes in a mild to moderate iodine-deficient Caucasian population.

Mutations of the thyrotropin receptor (TSHR) and/or Gαs gene have been found in a number of, but not all, autonomously functioning thyroid nodules (AFTNs). Recently, in a 15-year-old girl with a hyperfunctioning papillary thyroid carcinoma, we found two somatic and germline single nucleotide polymorphisms (SNPs): a SNP of the TSHR gene (exon 7, codon 187) and a SNP of Gαs gene (exon 8, codon 185). The same silent SNP of the TSHR gene had been reported in patients with AFTN or familial non-autoimmune hyperthyroidism. No further data about the prevalence of the two SNPs in AFTNs as well as in the general population are available in the literature. To clarify the possible role of these SNPs in predisposing to AFTN. Germline DNA was extracted from blood leukocytes of 115 patients with AFTNs (43 males and 72 females, aged 31-85 years, mean ± SD = 64 ± 13) and 100 sex-matched healthy individuals from the same geographic area, which is marginally iodine deficient. The genotype distribution of the two SNPs was investigated by restriction fragment length polymorphism-polymerase chain reaction. The prevalence of the two SNPs in our study population was low and not different to that found in healthy individuals: 8 % of patients vs. 9 % of controls were heterozygous for the TSHR SNP and 4 % patients vs. 6 % controls were heterozygous for the Gαs SNP. One patient harbored both SNPs. These results suggest that these two SNPs do not confer susceptibility for the development of AFTN.

Autonomous functioning thyroid nodule in a 4 year old male child treated with radioiodine (I-131)

Autonomous functioning thyroid nodule in a 4 year old male child treated with radioiodine (I-131)

TSH measurement is not an appropriate screening test for autonomous functioning thyroid nodules: a retrospective study of 368 patients

Based on the assumption that normal TSH concentration rules out the presence of autonomous functioning thyroid nodules (AFTNs), clinical guidelines on the management of thyroid nodules only recommend a thyroid scan if TSH concentration is subnormal. However, the proportion of AFTN presenting with a normal TSH is unknown. Our objective is therefore to determine the proportion of AFTNs with a normal TSH level to ascertain whether a normal TSH really rules out an AFTN. Retrospective study on 368 patients with an AFTN. Thyroid scans with a diagnosis of AFTN were reviewed retrospectively by one of us (R Moreno-Reyes), blinded to the clinical data. The diagnosis of solitary AFTN was confirmed in 368 patients. Among them, we selected 217 patients based on the absence of another thyroid nodule >10 mm, the absence of medical conditions able to interfere with thyroid function, and the completeness of the data. The proportion of AFTNs with normal TSH was 49%. This proportion increased to 71% in patients for whom thyroid scan was performed in the workup of a thyroid nodule. Our data suggest that serum TSH is not an effective screening tool to diagnose AFTNs. Using 'TSH-only' screening, as recommended by the majority of guidelines, the diagnosis of AFTN would have been missed in 71% of our patients in the workup of a thyroid nodule. Thyroid scan remains the gold standard for detecting AFTN and should be considered before performing fine-needle aspiration cytology (FNAC), as the reliability of FNAC in an unsuspected AFTN remains unclear.

Ca2 +-binding protein expression in primary human thyrocytes

We recently identified several Ca2+-binding proteins (CaBP) from the S100 and annexin family to be regulated by TSH in FRTL-5 cells. Here, we study the regulation of S100A4, S100A6 and ANXA2 in primary human thyrocytes (PHT) derived from surrounding tissues (ST), cold benign thyroid nodules (CTN) and autonomously functioning thyroid nodules (AFTN). We investigated the expression and regulation of CaBP and the effect of their expression on Ca2+ and TSHR signaling. We used an approach that accounts for the potential of an individual PHT culture to proliferate or to express thyroid differentiation features by assessing the expression of FOS and TPO. We found a strong correlation between the regulation of CaBP and the proliferation-associated transcription factor gene FOS. PKA and MEK1/2 were regulators of ANXA2 expression, while PI3-K and triiodothyronine were additionally involved in S100 regulation. The modulated expression of CaBP was reflected by changes in ATP-elicited Ca2+ signaling in PHT. S100A4 increased the ratio of subsequent Ca2+ responses and showed a Ca2+ buffering effect, while ANXA2 affected the first Ca2+ response to ATP. Overexpression of S100A4 led to a reduced activation of NFAT by TSH. Using S100A4 E33Q, D63N, F72Q and Y75K mutants we found that the effects of S100A4 expression on Ca2+ signaling are mediated by protein interaction. We present evidence that TSH has the ability to fine-tune Ca2+ signals through the regulation of CaBP expression. This represents a novel putative cross-regulating mechanism in thyrocytes that could affect thyrocyte signaling and physiology.

Autonomous Functioning Thyroid Nodules and 131I in Diagnosis and Therapy After 50 Years of Experience

Autonomous functioning thyroid nodules (AFTN), defined as "hot nodules" at thyroid scan, are often cured by radioiodine treatment. The aim of our study was to investigate the long-term outcome in patients treated with an 131I calculated dose, to identify a possible "size-tailored" dose, and to simplify follow-up procedures. Retrospective analysis was carried out on 1402 cases, covering a period of 50 years, of AFTN treated with an 131I calculated dose. Our study focused on nodular size and mean administered dose. Concordance between thyroid scan and serum TSH levels at 3-6 months from treatment was considered. A single 131I dose was effective for the vast majority of patients (93%). The outcome was influenced by nodular size. On the basis of the Italian dose limit for outpatient treatment, our population was divided into subgroups according to administered doses (more or less than 16 mCi) and nodular dimensions: no differences in outcome were observed for each class of nodule size. A dose ≤10 mCi was effective on the smaller nodules (50.1% of our population). The agreement between TSH and scan after treatment was 90.3% at 3 months and 94.5% at 6 months. 131I therapy with a calculated dose is an effective treatment of AFTN. If a fixed dose is chosen, 16 mCi is often resolutive and for nodules <3 cm a dose of 10 mCi can suffice. Nodules >5 cm are eligible for surgery. TSH is the only parameter required to evaluate the outcome.

Increased expression of pro-angiogenic factors and vascularization in thyroid hyperfunctioning adenomas with and without TSH receptor activating mutations

Autonomously functioning thyroid nodules (AFTN) are known to receive an increased blood influx necessary to sustain their high rate of growth and hormone production. Here, we investigated the expression of hematic and lymphatic vases in a series of 20 AFTN compared with the contralateral non-tumor tissues of the same patients, and the transcript levels of proteins involved in the control of vascular proliferation, including the vascular endothelial growth factor (VEGF) and platelet-derived growth factors (PDGF) and their receptors and the endothelial nitric oxide synthase (eNOS). In parallel, the expression of the differentiation markers sodium/iodide symporter (NIS), thyroperoxidase (TPO), thyroglobulin (Tg), and TSH receptor (TSHR) was also investigated. The data were further analyzed comparing subgroups of tumors with or without mutations in the TSHR gene. Analysis by means of CD31 and D2-40 immunostaining showed in AFTN an increased number of hematic, but not lymphatic, vessels in parallel with an enhanced proliferation rate shown by increased Ki67 staining. Quantitative RT-PCR analysis revealed an increase of VEGF, VEGFR1 and 2, PDGF-A, PDGF-B, and eNOS expression in tumor versus normal tissues. Also, higher transcript levels of NIS, TPO, and Tg were detected. Comparison of the two subgroups of samples revealed only few differences in the expression of the genes examined. In conclusion, these data demonstrate an increased expression of angiogenesis-related factors associated with an enhanced proliferation of hematic, but not lymphatic, vessels in AFTNs. In this context, the presence of TSHR mutations may only slightly influence the expression of pro-angiogenic growth factors.

Thyroid scintigraphy: an old tool is still the gold standard for an effective diagnosis of autonomously functioning thyroid nodules.

Patients with autonomously functioning thyroid nodules (AFTN) may not have an abnormal TSH value, particularly in iodine-deficient areas. To verify the accuracy of TSH as screening test in detecting AFTN and to evaluate ultrasonographic features of thyroid nodules which have resulted autonomously functioning at thyroid scintigraphy (TS). Seventy-eight patients with nodular goiter, no marker of autoimmunity and at least one AFTN at TS were selected and divided in: Group 1 (no.=25) with TSH>0.35 IU/l, and Group 2 (no.=53) with TSH≤0.35 IU/l. In Group1 the mean nodule diameter was 19.8±9.4 mm; 12 nodules were isoechoic, 2 hyperechoic, and 11 hypoechoic. Vascular pattern was type I in 4, type II in 6 and type III in 15 nodules. In Group 2 the mean nodule diameter was 28.6±14.2 mm; 27 nodules were isoechoic, 9 hyperechoic and 17 hypoechoic. Vascular pattern was type I in 14, type II in 15 and type III in 24 nodules. In our study TSH alone was not able to identify AFTN in 32% of the patients. All hot nodules predominantly showed an isoechoic pattern with peri-intranodular vascularization; however, the presence of this pattern was not statistically significant. Moreover, we noticed a weak inverse correlation between the diameter of AFTN and TSH level. In conclusion, TS is the most sensitive tool to detect AFTN, allowing a precocious diagnosis even in the presence of a normal TSH value.

Autonomous functioning thyroid nodule successfully treated with radioiodine in a 3 and a half-year-old boy

Hyperthyroidism is rare in paediatric age group, the most common cause being Graves' disease. Very few cases of autonomous functioning thyroid nodule (AFTN) as a cause of paediatric hyperthyroidism have been reported. We herein report a case of AFTN in a 3 and a half-year-old boy who had become symptomatic with a swelling in the neck and hypermetabolic features at the age of 8 months. He was successfully treated with 131I radioablation, which rendered him euthyroid.

Association of Autonomously Functioning Thyroid Nodules with Hashimoto's Thyroiditis: Study on A Large Series of Patients

Autonomously functioning thyroid nodules (AFTNs) associated with Hashimoto's thyroiditis (HT) are rarely reported. This study evaluates the magnitude of such association, elaborating the clinical and biochemical characteristics of HT and AFTN. We reviewed the records of our patients with thyroid nodules, including serum TSH, free T4 and T3, Tg-Ab, TPO-Ab, ultrasonography, Tc-99m Sodium Pertechnetate scintigraphy (performed in overt or subclinical hyperthyroid patients). HT patients with coexisting AFTN(s) (group A) were compared with patients with AFTNs alone (group B, n=267). 80 patients (65 women and 15 men; F:M ratio 4.3:1; age 57±15 years) had AFTN(s) and coexisting HT. Except 9 patients who were under methimazole, all had suppressed (<0.01 mU/L) or low (<0.4 mU/L) TSH; 17/71 (24%) had increased FT4 and/or FT3. Subclinical hyperthyroidism prevailed over frank hyperthyroidism in group A (76 vs. 24%), but not in group B (56 vs. 44%) ( P=0.005). Group A patients had lower serum FT3 (∼0.6 pmol/L or 9%) and FT4 (∼0.9 pmol/L or 4%) as compared to group B. The maximum diameter of the AFTN(s) was 8% smaller in group A as compared with group B, thus matching the said difference in FT3. A positive correlation between nodule size and age was found only in group B ( P=0.015). Even if difference in the size of nodules between groups A and B does not reach statistical significance, the chronic intrathyroid lymphocytic infiltration of HT may decrease the tendency of the AFTNs to grow and diminish their degree of functioning.