Bilateral Goiter Research Articles

Thyroid surgery in a context of scarce resources at Saint Martin de Porres Dominican Hospital (Yaounde, Cameroon)

Surgical campaigns for thyroid surgery in low-income environments are very efficient, but there is little literature reporting results. These campaigns are complex due to multiple particularities: highly evolved cases, the need for professionals to travel or an obvious socio-cultural barrier influence towards the surgical act. We describe a surgical campaign in Cameroon to treat patients with goiter and issue some medical and sociocultural recommendations in view of our experience for its implementation with guarantees. An experienced group carried out an 11-day campaign at the Saint Martin de Porres Dominican Hospital, Yaounde, Cameroon. Demographic data, TSH values, surgery and complications after a 12-month follow-up were analyzed. Thirty-eight patients with goiter were selected for the campaign and 32 patients (mean age, 40-years-old; 30 females) were operated. Bilateral goiter, as assessed with echography, was diagnosed in 13 patients (41%). Ten patients (31%) had a WHO grade II goiter (visible with the neck in a normal position). The surgical procedures were 18 unilateral thyroidectomy with isthmectomie, 13 total thyroidectomy, and 1 totalizing thyroidectomy, due to previous unilateral thyroidectomy (cancer recurrence). A pathological study in 13 patients (40%, extra cost 60 €) showed benign multinodular goiter/thyroid nodule (12 patients) and an extensive papillary carcinoma (one patient). Six months postoperatively, 3 patients had a slight dysphonia and one patient had persistent hypocalcemia. Follow-up was completed in all patients, either face to face (75%, 24 patients) or by phone (25%, 8 patients who failed to have a TSH test because of its cost, 23 €). Surgical campaigns to treat thyroid pathology can be carried out with guarantees if a series of important steps are followed: active participation of the patient's environment, thyroid ultrasound by the surgical team to decide which technique, intense awareness about monitoring and hormone replacement therapy, and the participation of local personnel for long-term follow-up.

Clinical application of retrograde thyroidectomy from top to bottom in retrosternal thyroid surgery

Objective:To investigate the value of retrograde thyroidectomy from top to bottom in the operation of retrosternal thyroid surgery. Methods:Retrospective analysis was performed on the cases of retrosternal goiter excised by our surgeons from January 2017 to June 2022,the technical points, feasibility and advantages of the operation were summarized. Results:A total of 15 cases of retrosternal goiter treated by retrograde thyroidectomy were collected, including 5 cases of type Ⅰ retrosternal goiter and 10 cases of type Ⅱ retrosternal goiter.The postoperative pathology was benign. The surgical time is 40-60 minutes for unilateral retrosternal goiter and 70-90 minutes for bilateral goiter. All patients were discharged normally within 7 days after operation, and no operative complications were observed such as bleeding, hoarseness or hypoparathyroidism. Conclusion:This surgical excision method of thyroid is suitable for the type Ⅰ and type Ⅱ retrosternal goiter surgery, which can avoid the difficulties in exposing and separating the the inferior thyroid behind the sternum in conventional surgical method, speed up the operation and reduced the difficulty of operation, and has certain promotion value in clinic.

Large non-functioning substernal parathyroid cyst: A case report and review of the literature.

ObjectivesParathyroid cysts are rare benign lesions of the head and neck that account for less than 1% of cystic neck masses. We present a rare case of a large 6 cm substernal parathyroid cyst.Presentation of caseAn otherwise healthy 65 year-old female presented to the otolaryngology clinic for evaluation of an anterior, midline neck mass. On physical exam, she was noted to have a fullness in the anterior neck extending to the sternal notch. CT demonstrated an enlarged thyroid with a cyst extending to the aortic arch. Initial evaluation suggested a bilateral goiter with substernal extension. The cyst was managed with drainage and observation. After two years of continued growth, the patient underwent a left thyroid lobectomy and mediastinal mass resection via the cervical approach. Final pathology was consistent with a parathyroid cyst.ConclusionsParathyroid cysts are a rare cause of neck mass in an adult, and a 6 cm substernal parathyroid cyst represents an unusual site and size for these cysts. Parathyroid cysts are not often considered on the differential of neck and mediastinal cystic lesions. However, appropriate steps should be taken to ensure a proper diagnosis for any cystic lesion in the neck.

Retrosternal goiter in thoracic surgical practice

To evaluate and optimize surgical approaches to the management of retrosternal goiter. A cohort retrospective single-center study included 56 patients aged 68.3±9.8 years with retrosternal goiter who underwent surgery between 2004 and 2019. Right-sided goiter was diagnosed in 16 cases, left-sided goiter in 21 patients, bilateral goiter in 19 patients. Palpable neck mass was found in 17 (30.4%), stridor in 16 (28.6%), thyrotoxicosis in 4 (7.1%) and recurrent laryngeal nerve palsy in 2 (3.6%) cases. X-ray signs of tracheal compression were detected in 43 (76.8%) patients, deviation in 26 (46.4%) patients. Resection through cervical collar incision was performed in 40 (71.4%) patients. Additional sternotomy was required in 11 (19.6%) patients, 1 (1.8%) patient required collar incision and right anterior mediastinotomy. Right-sided posterolateral thoracotomy without collar incision was performed in 1 (1.8%) patient with a suspected mediastinal teratoma. Three patients underwent median sternotomy only because of preoperative diagnosis of teratoma in one and thymoma in two patients. There was no perioperative mortality. Transient vocal changes occurred in 3 (5.4%) patients, recurrent laryngeal nerve palsy in 3 (5.4%), atrial fibrillation in 2 (3.6%), wound complications in 2 (3.6%), left phrenic nerve palsy in 1 (1.8%), transient hypocalcaemia in 1 (1.8%) and persistent hypothyroidism in 1 (1.8%) patient. Hospital-stay ranged from 2 to 12 (5.5±2.0) days. Multinodular goiter was found in 53 (94.6%) patients, diffuse goiter in 1 (1.8%), ectopic thyroid in 1 (1.8%) and oncocytic tumor in 1 (1.8%) patient. One (1.8%) patient underwent simultaneous resection of RSG via a collar incision and right-sided VATS upper lobectomy for primary lung cancer. One (1.8%) patient also underwent simultaneous resection of RSG via collar incision and right-sided VATS subcarinal lymph node biopsy for coexistent lymphoma. Mean vertical length of goiter in the collar incision group was 7.6 cm compared to 10.6 cm in the sternotomy group. Mean weight of specimens was 162.3 g in patients with collar incisions and 312.5 g in the sternotomy group. Sternotomy was required in 14 (25%) patients. Resection of retrosternal goiter is more commonly performed via cervical collar incision with mandatory availability of sternotomy. Radiological measurement of craniocaudal length may predict the need for sternotomy. Surgical outcomes are not affected by surgical approach. Simultaneous thoracic interventions for a coexistent pathology in patients with RSG may be considered. Further research of minimally invasive interventions for RSG resection is required.

Impact of the Italian Society of Anatomic Pathology and Diagnostic Cytology Classification of Thyroid Nodules in the Treatment of Indeterminate Follicular Lesions: Five-Year Results at a Single Center.

Purpose Aim of the study was to assess the impact of the Italian Society of Anatomic Pathology and Diagnostic Cytology (SIAPEC) classification of 2014, on the treatment of indeterminate thyroid lesions (TIR3). Methods We retrospectively analyzed patients undergoing thyroid surgery for TIR3 lesions between 2013 and 2018, at the General Surgery Department of Trieste University Hospital. According to the SIAPEC classification, patients were divided into TIR3A and TIR3B groups. All patients treated before 2014 underwent surgical treatment, and surgical specimens were retrospectively classified after revision of fine-needle aspiration cytology. Starting 2014, TIR3A patients were treated only when symptomatic (i.e., coexistent bilateral thyroid goiter or growing TIR3A nodules), whereas TIR3B patients always received surgical treatment. Hemithyroidectomy (HT) was the procedure of choice. Total thyroidectomy (TT) was performed in case of concurrent bilateral goiter, autoimmune thyroid disease, and/or presence of BRAF and/or RAS mutation. Lastly, we analyzed the malignancy rate in the two groups. Results 29 TIR3A and 90 TIR3B patients were included in the study. HT was performed in 10 TIR3A patients and 37 TIR3B patients, respectively, with need for reoperation in 4 TIR3B (10.8%) patients due to histological findings of follicular thyroid carcinoma >1 cm. The malignancy rates were 17.2% in TIR3A and 31.1% in TIR3B, (p = 0.16). Predictability of malignancy was almost 89% in BRAF mutation and just 47% in RAS mutation. Conclusions The new SIAPEC classification in association with biomolecular markers has improved diagnostic accuracy, patient selection, and clinical management of TIR3 lesions.

Spontaneous primary hypothyroidism in 7 adult cats.

BackgroundNaturally occurring hypothyroidism in adult cats is rare, with only 4 cases reported.ObjectivesTo describe the historical, clinical, laboratory, and scintigraphic features of adult cats with spontaneous hypothyroidism.AnimalsSeven adult cats referred for suspected hypothyroidism.MethodsProspective case series. We collected data on cats’ signalment, clinical signs, results of physical examination, routine laboratory and thyroid hormone testing, and thyroid imaging (thyroid scintigraphy or ultrasound). We subsequently treated cats with levothyroxine and evaluated their response to treatment.ResultsCats ranged from 3.5 to 11 years, with no apparent breed predilection; 6/7 cats were male. Only 2/7 cats were initially tested because of signs of hypothyroidism (hair‐coat changes, lethargy, obesity); others were tested for routine thyroid monitoring or palpable thyroid nodules. Four were azotemic (serum creatinine, 2.2‐3.4 mg/dL). Six of the cats had low serum thyroxine (T4) and free T4 (fT4) concentrations, whereas all 7 cats had high thyroid‐stimulating hormone (TSH) concentrations. In 6/7 cats, thyroid scintigraphy revealed bilateral goiter with intense radionuclide uptake; imaging showed no visible thyroid tissue in the other. After levothyroxine treatment, serum concentrations of T4 and fT4 increased and TSH fell; high serum creatinine normalized in azotemic cats; and repeat imaging showed reduction in goiter size.Conclusions and Clinical ImportancePrimary hypothyroidism develops in adult cats, with a higher prevalence than previously thought. Most cats appear to develop a goitrous form of hypothyroidism associated with thyroid hyperplasia, whereas thyroid atrophy appears to be less common. With levothyroxine replacement, clinical and laboratory abnormalities improve or resolve.

Staged Thyroidectomy: A Single Institution Perspective.

The increasing use of intraoperative neuromonitoring (IONM) in thyroid surgery has revealed the need to develop new strategies for cases in which a loss of signal (LOS) occurs on the first side of a planned total thyroidectomy. This study reviews the experience of the authors in using IONM for planned total thyroidectomy after LOS on the first thyroid lobe. The aims were to estimate the incidence of LOS on the first side of resection and to compare intraoperative strategies applied after this event. Intermittent IONM was performed with stimulation of both the vagal nerve and the recurrent laryngeal nerve (RLN) (V1, R1, R2, V2). Patients underwent pre- and postoperative laryngoscopy. Before surgery, patients were informed that staged thyroidectomy might be required. This study analyzed 803 consecutive thyroid procedures. Of these, V2 LOS (<100 mcV) occurred after first lobe exeresis in 23 (2.8%) procedures. The surgical procedure was stopped in 20 cases (ie, staged thyroidectomy was performed). In three cases with malignancy and severe comorbidity (ASA score 3-4), total bilateral thyroidectomy was performed as planned. No cases of bilateral RLN palsy occurred. Postoperative laryngoscopy confirmed RLN palsy in 21 of the 23 cases. All true positive patients received speech therapy. Patients who had false positive LOS (n = 2) or malignancy (n = 8) and patients who were symptomatic (n = 7) received completion thyroidectomy within 6 months. One patient received radioactive iodine therapy for hyperthyroidism. Two patients received follow up. Neuromonitoring changes the surgical decision-making process in a multidisciplinary manner. A shared decision-making process involving the patient, anesthesiologist, and endocrinologist is suggested. In the case of intraoperative LOS on the first-operated side in a planned total thyroidectomy, the thyroid surgeon essentially has three options for surgery on the contralateral side: 1) Perform staged thyroidectomy. This option is recommended in bilateral goiter, Graves' disease, or low-risk thyroid carcinoma (differentiated or medullary thyroid carcinoma). The aim is to avoid bilateral vocal cord palsy. Two-stage completion surgery is delayed until recovery of ipsilateral nerve function. 2) Perform subtotal resection on the contralateral side ventrally to the RLN plane at a safe distance from the nerve. The aim is to avoid further disease recurrence and revision surgery. 3) Perform total thyroidectomy as planned for advanced thyroid carcinoma (including undifferentiated thyroid carcinoma). The aim is to improve disease control through radioactive iodine therapy, radiation therapy, or target therapy immediately after surgery. 4.

Radioiodine Treatment For Hyperthyroidism In A Patient With Pendred Syndrome

ABSTRACT Objective: To report a case of Pendred syndrome accompanied by hyperthyroidism that was treated with radioiodine. Pendred syndrome is an autosomal recessive disorder characterized by bilateral sensorineural hearing impairment, goiter, and impaired iodide organification. The majority of patients with Pendred syndrome are euthyroid or hypothyroid, and hyperthyroidism is rare. Thus far, there are no reported cases of Pendred syndrome with 131I-treated hyperthyroidism. Methods: A 39-year-old woman with congenital hearing impairment visited our clinic because of easy fatigability and body weight loss. Results: She had a diffuse goiter (estimated thyroid weight, 65 g) and subclinical thyrotoxicosis. 99mTechnetium pertechnetate scintigraphy revealed diffuse thyroidal uptake, but thyroid autoantibodies were absent. Since the therapeutic response to a single 131I dose was poor, the patient underwent a second 131I dose (13 mCi each) for hyperthyroidism. Seven years after the second 131I dose, she was euthy...

Incidental medullary thyroid microcarcinoma revealed by mild increase of preoperative serum calcitonin levels: therapeutic implications

To investigate whether further, diagnostic procedures should be recommended in patients with slight increase of preoperative serum basal calcitonin (bCT) levels in whom surgical treatment can be recommendable. Fourteen consecutive patients with nodular thyroid disease underwent thyroidectomy in our center for suspected medullary thyroid microcarcinoma (MTC) because their serum bCT levels were slightly higher than the upper limit of normal range. Serum bCT was measured by radioimmunoassay, normality range = 0-20 ng/L. Surgical specimens were examined by the same pathologist using histologic and immunohistochemistry techniques. An extensive search for parafollicular C-cell hyperplasia (CCH) and/or microscopic MTC foci was performed. At preoperative ultrasound, a single thyroid nodule was depicted in three patients while a multinodular goiter in 11. The bCT values ranged between 24.4 and 94.6 ng/L, median 42.2 ng/L while the pentagastrin-stimulated CT (sCT) values by pentagastrin test ranged between 61.5 and 1,262 ng/L, median 245.0 ng/L. Total thyroidectomy was performed in 13 patients, and lobectomy in the other one; central node dissection was also performed in eight cases. At histology, MTC was diagnosed in nine patients (64.3 %), showing a median maximum diameter of 6.1 mm (range, 1.5-17 mm); CCH was diagnosed in the other five patients (35.7 %). The pentagastrin stimulation test was obtained in all patients. It is worth noting that a very high increase of sCT >100 ng/mL was observed in 5/9 patients with MTC and in 2/4 patients with HCC, therefore suggesting the absence of a relationship between the entity of response to pentagastrin test with a specific pathology (MTC vs. HCC). In six patients, the MTC was the nodule on which preoperative FNAC had been performed, while in other three patients preoperative FNAC had been performed on a different nodule from the MTC. Based on our experience, in case of the pentagastrin stimulation test with sCT <100 ng/L and a single nodule, the CT assay on FNAC may be useful, subsequently lobectomy with definitive histological diagnosis is recommended. In case of the Pg test with sCT <100 ng/L and bilateral goiter, total thyroidectomy with histological diagnosis is recommended. In this way, as for the surgical procedure, total thyroidectomy is recommended in cases of bilateral goiter, while lobectomy can be offered for cases with single nodes with serum dosage of bCT in the strict follow up. In case of the pentagastrin stimulating test with sCT <100 ng/L and bilateral goiter, total thyroidectomy with histological diagnosis is recommended.

IONM-guided goiter surgery leading to two-stage thyroidectomy—indication and results

Intraoperative neuromonitoring (IONM) in thyroid surgery allows for changing the operative strategy during bilateral procedures to avoid bilateral recurrent laryngeal nerve palsy (RLNP). While this strategy is comprehendible for the surgeon, the question remains, whether it is always necessary. Two thousand five hundred forty-six patients underwent surgery with IONM between January 2008 and October 2010 (4,012 nerves at risk). We performed a retrospective review of all patients after thyroid surgery. In 98 cases, signal loss occurred on the primary side. Of these patients, 64 required bilateral surgery. We proceeded with the contralateral surgery in 24 cases. Forty operations were ended unilaterally. The second operation was performed on 18 patients in total, 16 after confirmation of primarily intact (n = 8) or recovered vocal cord function (n = 8) and twice under persisting dysfunction. Patient satisfaction was evaluated using a five-point scale. We have shown a significant difference (p = 0.017) in the rate of bilateral RLNP when signal loss on the primary side resulted in termination of the procedure compared to continuation. Our evaluation of patient satisfaction did not show a significant difference when comparing the two-stage operation to other procedures. We have shown a significant difference in the rate of bilateral RLNP when comparing termination and continuation of a bilateral procedure after primary IONM signal loss. We strongly recommend a two-stage thyroidectomy after signal loss on the primary side of resection in benign bilateral goiter surgery.

Loss of the nerve monitoring signal during bilateral thyroid surgery

This study aimed to assess current use of recurrent laryngeal nerve monitoring (RLNM) for bilateral thyroid surgery in Germany. It explored the willingness of surgeons to change strategy after loss of signal (LOS) on the first side of resection. Surgical departments in Germany equipped with nerve monitors were asked to complete a structured questionnaire, specifying the number of thyroidectomies done in 2010, and the frequencies of RLNM, vagal stimulation, and electromyographic (EMG) recording before and after thyroidectomy. They were also asked about the surgical plan for bilateral goitre after LOS on the first side of resection. Based on manufacturers' sales data, 1119 (89·1 per cent) of 1256 surgical departments in Germany were equipped with nerve monitors in 2010. A total of 595 departments (53·2 per cent), accounting for approximately 75 per cent of all thyroidectomies in Germany during that year, returned a completed questionnaire. RLNM was used in 91·7-93·5 per cent of thyroidectomies, with the addition of routine vagal stimulation in 49·3 per cent before, and 73·8 per cent after resection. EMG responses to vagal stimulation were recorded in 54·8 per cent before, and 72·5 per cent after resection. Some 93·5 per cent of surgeons changed the resection plan for the other side in bilateral thyroid surgery after LOS had occurred on the first side. RLNM is now the standard of care during thyroidectomy in Germany. After LOS on the first side of resection in bilateral goitre, more than 90 per cent of respondents declared their willingness to change the resection plan for the contralateral side to avoid the risk of bilateral recurrent laryngeal nerve palsy.

Short-stay hospitalisation for benign thyroid surgery: a prospective study

We report our prospective experience of short-stay hospitalisation for benign thyroid surgery. Post-operative outcome, complication rate and duration of hospitalisation were evaluated for 200 similar patients with bilateral multi-nodular goitres treated surgically by total thyroidectomy. All subjects gave written informed consent. A short-stay regimen, with discharge within 24 h of admission, was possible in 92.5 %. Fourteen (7 %) were discharged on the second post-operative day and one on the fourth post-operative day. Causes of the 15 delayed discharges beyond 24 h were 11 hypocalcaemia (5.5 %), 3 haematoma (1.5 %) and 1 dysphonia (0.5 %). All compressive haematoma were treated by urgent reoperation. No mortality occurred. None required tracheostomies. Transient complications were diagnosed in 36 cases: 25 with hypocalcaemia and 11 with recurrent laryngeal nerve injuries. Permanent complications were observed in three patients: two with hypoparathyroidism and one with nerve damage. All patients were carefully counselled about potential thyroid surgery complications and a 24-h emergency-contact number was provided. Short-stay hospitalisation represents safe and cost-saving surgical management for benign thyroid surgery.

Respiratory Syncytial Virus Infection as a Precipitant of Thyroid Storm in a Previously Undiagnosed Case of Graves' Disease in a Prepubertal Girl

Graves' disease is less common in prepubertal than pubertal children, and initial presentation with thyroid storm is rare. We report an 11-year-old prepubertal Hispanic girl who presented with a one-day history of respiratory distress, fever, and dysphagia. She had exophthalmos, a diffuse bilateral goiter and was agitated, tachycardic, and hypertensive. Nasal swab was positive for respiratory syncytial virus (RSV). She was diagnosed with thyroid storm and admitted to the pediatric intensive care unit. While infection is a known precipitant of thyroid storm and RSV is a common pediatric infection, to the best of our knowledge, this is the first reported case of RSV infection apparently precipitating thyroid storm in a prepubertal child.

Indeterminate thyroid nodules: A challenge for the surgical strategy

Because no clinical parameter can establish the final status of a cytologically indeterminate thyroid nodule (ITN) or nodal-metastases in case of malignancy, the initial surgical strategy should define an oncologically adequate procedure with low morbidity. The prognostic relevance of sex, age, tumor sizes, multifocality, thyroid function, and recurrence was analyzed in 156 consecutive patients according to the presence of malignancy and nodal metastases. The accuracy of frozen sections to reveal malignancy was determined. Clinical parameters were compared with regard to their ability to identify malignancy and nodal metastases in an ITN to determine an appropriate initial operative strategy. One hundred and eighteen (75.6%) patients underwent (total) thyroidectomy, 37 (23.7%) patients underwent hemithyroidectomy, and 1 patient underwent isthmus resection. Fifty-five (35.3%) patients showed malignancy. First step lymphadenectomy (lymph node dissection along the recurrent laryngeal nerve before removing the thyroid lobe) was performed in 142 patients documenting 10 nodal metastases. Comparing benign and malignant ITN, no association was found for sex (P = .17), age (P = 1.0), tumor sizes (P = .33, P = .12, P = .19 for < or =30 mm, < or =40 mm, and < or =50 mm, respectively), or thyroid function (P = .26). The determination of malignancy by frozen section showed a sensitivity of 30.9% and a specificity of 100%. No permanent hypoparathyroidism or recurrent laryngeal nerve palsy was observed postoperatively. Because of the failure of available clinical parameters to predict malignancy in cytologically ITN, hemithyroidectomy in unilateral goiter and thyroidectomy in bilateral goiter is recommended. Ipsilateral "first step central neck dissection" on the side of ITN offers the advantages of oncologically adequate resection and staging with a low morbidity, as well as avoids reoperation.

Thyroid cancer (Ca) found during radioguided parathyroidectomy (RP) in hyperparathyroid patients

17011 Background: For single parathyroid adenomas diagnosed by Tc-99m sestamibi parathyroid scans (SPS), minimally invasive (MI) RP is the procedure of choice. However, MIRP fails to identify concurrent thyroid pathology which occurs in 40–50% of hyperparathyroid patients (pts). We conducted a prospective study to determine the rates of thyroid pathology with particular attention to thyroid cancer in pts undergoing RP. Methods: Only pts with hypercalcemia and elevated PTH level were included. All surgeries were performed by a single surgeon. Pts were evaluated preoperatively with SPS and thyroid ultrasound (TUS). Pts with a +ve SPS and −ve TUS underwent MIRP. Pts with a +ve TUS underwent fine needle aspiration and bilateral neck exploration with RP regardless of SPS results. Total or partial thyroidectomy was performed as indicated. Results: There were 252 consecutive hyperparathyroid pts. SPS was +ve in 186 (74%) pts, −ve in 58 (23%), and equivocal in 7 (3%). One pt was unable to tolerate SPS. Parathyroid pathologies were as follows: adenoma in 190 (75.4%), hyperplasia in 42 (16.7%), double adenoma in 9 (3.6%), cyst in 1 (0.4%), and parathyroid Ca in 1 (0.4%) of the pts respectively. No parathyroid pathology was identified in 9 (3.6%) pts. Thyroid pathology requiring surgical resection was found in 135 (54%) pts, and included bilateral goiter in 85 (34%), Hashimoto’s in 33 (13%), papillary Ca in 19 (8%), and follicular adenoma in 5 (2%) pts respectively. In 5 pts thyroidectomy was performed due to intrathyroidal adenomas. In 19 pts with papillary Ca, TUS was +ve in 16 (89%) and −ve in 2 (11%) pts. All of these pts were asymptomatic for papillary Ca at their initial presentation. Metastatic disease to lymph nodes was present in 2 (11%) pts at the time of surgery. Conclusions: Preoperative TUS identifies operable thyroid pathology in 54% of our pts, and helped identify asymptomatic papillary Ca which would have gone undetected had these pts undergone MIRP only. Since the prevalence of thyroid pathology is high in hyperparathyroid pts, preoperative TUS may help stratify pts who are ideal candidates for MIRP from those that should undergo bilateral RP along with thyroidectomy. No significant financial relationships to disclose.

Autoantibodies in feline hyperthyroidism

Thyroid autoantibodies have been demonstrated by indirect immunofluorescence in the sera of 10 of 29 (34 per cent) cats with hyperthyroidism. Antinuclear factor, rare in healthy cats, was found in a further four animals. Twenty-eight of the cats had a palpable goitre at first presentation. In 16 cases the goitre was unilateral, while in the others it was bilateral. Lymphocytic infiltration was present in nine of the 27 (33 per cent) thyroids examined histologically. Five of the sera gave a particularly strong reaction for thyroid antibodies. Four of these cases had bilateral goitres and lymphocytic infiltrations were found in four of the five thyroids (P less than 0.05). Twenty-one of the cats were followed up for a mean period of 11 months after operation, during which time three cats developed recurrent hyperthyroidism. Two had bilateral goitres with lymphocytic infiltration and the serum of both was strongly positive for thyroid microsomal antibodies. The third had unilateral goitre with lymphocytic infiltration and serum which was positive for antinuclear factor. In this case, the recurrence involved the lobe which had been previously operated on. Some cases of feline hyperthyroidism may be immunologically mediated and the condition is thus a potential model for some aspects of autoimmune thyrotoxicosis in man.

ASPIRATION CYTOLOGY IN THE DIAGNOSIS OF AUTOIMMUNE THYROIDITIS

We have found aspiration cytology to be a useful and reliable procedure in the diagnosis of autoimmune thyroiditis. This disorder affected more than half of 50 patients who presented with bilateral non-toxic goitre.

Recurrent and persistent hyperthyroidism.

THE writer's earliest years in surgical training and practice were during a period when the classic operation for bilateral goiter was a bilateral, partial resection, then improperly labeled “subtotal.” Perusal of operative records of such cases regularly reveals such estimates as “twothirds of one lobe and five-sixths of the other were removed.” The inadequate results of such a procedure were late in being evaluated, as in the case of gastro-enterostomy or limited resection of the stomach for duodenal ulcer. That the results were far from ideal was shown by the unwillingness of many internists to use the word “cure” to describe the usual sequelae of partial thyroidectomy. Surgeons were still unaccountably influenced by Kocher's earlier dictum that postoperative hypothyroidism should be feared and was to be classed as a complication of thyroidectomy in the same undesirable category as nerve injury or hypoparathyroidism. This attitude was maintained despite the fact that the ability of desiccated thyroid s...