Goiter Size Research Articles

Evaluating of significance of thyroglobulin (Tg) level in blood as a biomarker of iodine deficiency disorders severity in Uzbekistan

Iodine deficiency has serious adverse effects on growth and development of humans, such as mental impairment. It is known, that thyroglobulin level in blood is promising biomarker that can determine iodine deficiency disorders severity in a given region.
 The Aim of study: Evaluating of significance of thyroglobulin level in blood as a biomarker of iodine deficiency disorders severity in Uzbekistan..
 Materials and Methods: We evaluated thyroglobulin level in blood in schoolchildren of Uzbekistan. In this purpose we studied 366 schoolchildren in 8-12 age group, of that 163 boys and 203 girls living in Tashkent city, Fergana, Samarkand, Bukhara, Kashkadarya, Khoresm and Republic of Karakalpakistan. Such parameters as urinary iodine concentration, diffuse goiter plasma TSH, fT4 were analyzed too.
 Results: Diffuse goiter prevalence was 27 % among children, the overall mean thyroglobulin concentration was 12,8 ± 10.4 ng/ml, the overall median urinary iodine concentration (UIC) was 120.27 μg/L indicating iodine sufficiency. Plasma TSH was 2.75 ± 1.69 mIU/l and plasma fТ4 14.48 ± 3,96 pmol/l. Thyroglobulin level depended on goiter size, so that in children without goiter (grade 0) mean thyroglobulin concentration was 11,9 ± 7.9 ng/ml, in children with goiter grade 1 mean thyroglobulin concentration was 14,24 ± 13.5 ng/ml and in children with goiter grade 2 mean thyroglobulin concentration was 18,82±18,3 ng/ml. Overall mean thyroglobulin concentration of goitrous children (grade 1 and 2) was 16,4±10,5 ng/ml.
 Conclusions: Though international studies in school-aged children showed that iodine-sufficient children typically had a median Tg <13 ng/ml, our investigation showed that while study group’s UIC was 120.27 μg/L and overall mean thyroglobulin concentration was 12,8 ± 10.4 ng/ml, that is equal to median thyroglobulin concentration – 11,73 ng/ml, 39% of children in this group still have UIC below 100 μg/L.

Intrauterine death following intraamniotic triiodothyronine and thyroxine therapy for fetal goitrous hypothyroidism associated with polyhydramnios and caused by a thyroglobulin mutation.

In the absence of maternal thyroid disease or iodine deficiency, fetal goitre is rare and usually attributable to dyshormonogenesis, for which genetic ascertainment is not always undertaken in the UK. Mechanical complications include tracheal and oesophageal compression with resultant polyhydramnios, malpresentation at delivery and neonatal respiratory distress. We report an Indian kindred in which the proband (first-born son) had congenital hypothyroidism (CH) without obvious neonatal goitre. His mother’s second pregnancy was complicated by fetal hypothyroid goitre and polyhydramnios, prompting amniotic fluid drainage and intraamniotic therapy (with liothyronine, T3 and levothyroxine, T4). Sadly, intrauterine death occurred at 31 weeks. Genetic studies in the proband demonstrated compound heterozygous novel (c.5178delT, p.A1727Hfs*26) and previously described (c.7123G > A, p.G2375R) thyroglobulin (TG) mutations which are the likely cause of fetal goitre in the deceased sibling. TG mutations rarely cause fetal goitre, and management remains controversial due to the potential complications of intrauterine therapy however an amelioration in goitre size may be achieved with intraamniotic T4, and intraamniotic T3/T4 combination has achieved a favourable outcome in one case. A conservative approach, with surveillance, elective delivery and commencement of levothyroxine neonatally may also be justified, although intubation may be required post delivery for respiratory obstruction. Our observations highlight the lethality which may be associated with fetal goitre. Additionally, although this complication may recur in successive pregnancies, our case highlights the possibility of discordance for fetal goitre in siblings harbouring the same dyshormonogenesis-associated genetic mutations. Genetic ascertainment may facilitate prenatal diagnosis and assist management in familial cases.Learning points:CH due to biallelic, loss-of-function TG mutations is well-described and readily treatable in childhood however mechanical complications from associated fetal goitre may include polyhydramnios, neonatal respiratory compromise and neck hyperextension with dystocia complicating delivery.CH due to TG mutations may manifest with variable phenotypes, even within the same kindred.Treatment options for hypothyroid dyshormogenic fetal goitre in a euthyroid mother include intraamniotic thyroid hormone replacement in cases with polyhydramnios or significant tracheal obstruction. Alternatively, cases may be managed conservatively with radiological surveillance, elective delivery and neonatal levothyroxine treatment, although intubation and ventilation may be required to support neonatal respiratory compromise.Genetic ascertainment in such kindreds may enable prenatal diagnosis and anticipatory planning for antenatal management of further affected offspring.

RETROSTERNAL GOITRES: A PRACTICAL CLASSIFICATION.

There is no standard definition for goitres extending below the thoracic inlet and no clear guidelines for pre-operative planning of surgery. The aim of this study is a practical classification of retrosternal goitres (RSG) based on the anatomical , radiological shape and size of the thyroid. Retrospective analysis of all thyroidectomies performed in a referral centre between January 2012 and December 2016. Patients with RSGs had a pre-operative CT scan of neck/thorax. Imaging was reviewed to establish features to predict the difficulty of delivering the goitre through the neck incision and to advise the best surgical approach. 847 thyroidectomies were performed with n=98 involving RSGs. TypeA (n=47) are RSG with a shape of a "cone" or pyramid with the apex pointing down. Cervicotomy is the usual approach. TypeB (n=39) are goitres with a shape of a "pyramid' with the apex pointing up, cervicotomy with ± manubriotomy or sternotomy ± thoracotomy maybe required. TypeC (n=6) are thyroid enlargements in the mediastinum connected by a pedicle with the thyroid in the neck. A cervical approach ± manubriotomy or sternotomy ± thoracotomy is needed. TypeD (n=6) are true intrathoracic or "forgotten" goitres. Sternotomy is indicated for thyroids in the anterior mediastinum though a thoracic approach for those located in the posterior mediastinum might be needed. The shape and size of goitres is important in carefully planning surgery. CT imaging with cross-sectional reconstruction should be analysed before operation. The proposed classification helps treatment planning and allows comparison of outcomes by anatomical complexity.

Volumetric Analysis is Useful for Predicting Use of Sternotomy During Retrosternal Thyroidectomy

Surgical removal is the recommended treatment for retrosternal goitre. This can be successfully achieved through a cervical incision in most cases, however occasionally a thoracic approach is required. Being able to predict the need for sternotomy would improve logistical efficiency, saving time and money, and allow patients to be better informed preoperatively. The aim of this study was to determine whether analysing thyroid volume on preoperative CT scans could help predict the use of sternotomy. To the best of our knowledge this is the first study investigating this. A retrospective study was conducted on 64 patients who underwent thyroidectomy for retrosternal goitre at the Golden Jubilee National Hospital, Scotland, between 2012-2016. Patient demographic information and pathological reports were obtained from databases. Preoperative CT scans were used for volumetric analysis. The total volume, the volume inferior to the level of the sternal notch (intrathoracic volume), and the anteroposterior diameter of the thoracic inlet were measured. An index of relative goitre size was calculated by dividing intrathoracic volume by thoracic inlet diameter. Mann-Whitney U tests and Fisher’s exact tests were used to analyse continuous and categorical variables respectively. Goitres were successfully removed by a cervical incision alone in 55 patients, while thoracic intervention was needed in 9 cases (13.3%). Intrathoracic volume (p=0.0091) and volumetric index (p=0.0033) were significantly larger in those requiring sternotomy. Total volume was not significantly different. All other variables measured were similar in both groups. Our results suggest that assessing intrathoracic volume of goitre is useful in predicting the need for sternotomy. However, it is not able to completely rule out thoracic intervention. The volumetric index is likely to be a better predictor than volume alone.

Serum immunoglobulin G4 levels and Graves' disease phenotype.

We investigated, at diagnosis, the relationship between serum immunoglobulin G4 levels and the main characteristics of Graves' disease: hyperthyroidism severity, goiter size, presence of active Graves' ophthalmopathy, antithyroid antibodies status, and titer. This prospective study included 80 newly diagnosed Graves' disease patients. The main parameters measured at diagnosis: thyroid-stimulating hormone, free thyroxine, free triiodothyronine, total triiodothyronine, thyroglobulin, antithyroid peroxidase antibodies, anti-thyroglobulin antibodies, thyroid-stimulating hormone receptor antibodies, immunoglobulin G4. In Graves' disease patients, serum immunoglobulin G4 levels were higher than in general population (p = 0.028) and higher in men compared to women (p = 0.002). Only one female patient with intense hypoechoic goiter, high anti-thyroglobulin antibody, and antithyroid peroxidase antibody titers had an elevated serum immunoglobulin G4 level at diagnosis. Patients with immunoglobulin G4 levels above the 75th percentile (>237.52 mg/dl, N = 20) were younger at Graves' ophthalmopathy onset (p < 0.001), had higher antithyroid peroxidase antibody (p = 0.01), and anti-thyroglobulin antibody levels (p = 0.006) and required shorter duration of the first methimazole treatment cycle (p = 0.041) than patients with immunoglobulin G4 below the 75th percentile. At diagnosis, patients with immunoglobulin G4 levels above the 90th percentile (>286.28 mg/dl, N = 8) had lower total triiodothyronine values (p = 0.001) than patients with IgG below the 90th percentile. No significant correlations were found between smoking status (p = 0.58), goiter size (p = 0.50), the presence of ophthalmopathy (p = 0.42) or thyroid-stimulating hormone receptor antibody titers (p = 0.45) and the mean value of immunoglobulin G4 levels at diagnosis. Our data suggest that Graves' disease patients with elevated immunoglobulin G4 levels at diagnosis have a phenotype characterized by higher anti-thyroglobulin antibody and antithyroid peroxidase antibody titers, less severe T3 hyperthyroidism, younger age at ophthalmopathy onset and require a shorter duration of the first methimazole treatment cycle.

Can we predict relapse in Graves' disease? Results from a systematic review and meta-analysis.

Identification of pretreatment risk factors predicting relapse in patients with hyperthyroidism of Graves' disease after stopping anti-thyroid drugs (ATD) is decisive to guide therapeutic options. We performed a systematic search and meta-analysis to study predictors for relapse after stopping ATD in patients with Graves' disease. Based on a pre-specified protocol, we searched PubMed, EMBASE and Cochrane in July 2015 for case-control, controlled and randomized-controlled trials reporting risk factors for relapse after stopping ATD. The primary endpoint was relapse of disease until follow-up. PRISMA and SIGN statements were used for reviewing the data and assessing the quality of included trials. We included 54 trials with a total of 7595 participants. Most trials were small with moderate-to-high risk for bias. Ten trials were assessed only qualitatively (2227 patients), genomic data were reported in 13 trials (2178 patients) and 31 trials (4346 patients) were assessed quantitatively. In total, there were 3696 relapses in 7595 patients (48.7%). By using random-effects meta-analysis, orbitopathy, smoking, thyroid volume measured by sonography, goiter size, fT4, tT3, TRAb and TBII were significantly associated with relapse, whereas male vs female sex, age and initial tT4 level did not show significant associations. This analysis found several risk factors to predict relapse in Graves' disease, which can be combined in a risk score. Prospective studies should evaluate the prognostic accuracy of such a score to guide treatment decisions.

Urinary iodine and thyroid determinants in pregnancy: a follow up study in Sri Lanka

BackgroundIodine deficiency and thyroid dysfunction during pregnancy is associated with number of adverse outcomes that includes mental and physical disabilities creating a huge human and economic burden in later life. Several indicators are used to assess the iodine status of a population: thyroid size by palpation and/or by ultrasonography, urinary iodine excretion and the blood thyroid hormone profile.MethodsThis prospective study was designed to assess the iodine nutrition during the course of pregnancy with reference to urine iodine concentration (UIC) and thyroid determinants among 425 pregnant women from Galle district, Sri Lanka. UIC was estimated in all three trimesters and thyroid functions were assessed in first and third trimesters.ResultsMedian (inter-quartile range IQR) UIC was 170.9 (100.0–261.10) μg/L, 123.80 (73.50–189.50) μg/L and 105.95 (67.00–153.50) μg/L in the first, second and third trimesters respectively (p < 0.001). Median thyroid stimulating hormone (TSH) level in the first trimester was 1.30 (0.80–1.80) µIU/mL. This value significantly increased (p < 0.001) to 1.60 (1.20–2.10) µIU/mL at the 3rd trimester even though it was maintained within the reference range (0.3 – 5.2 µIU/mL). In the assessment of thyroid gland, 67 (16.0 %) women had palpable or visible goitres and 55 (13.1 %) had a goitre that was palpable but not visible. The median thyroid volume of the sample was 5.16 mL (4.30; 6.10 mL) as measured by ultra sound (US) scanning. In multiple regression analysis after controlling for other independent variables (anthropometric, demographic and biochemical parameters); initial body mass index (BMI), goitre size, thyroid volume and parity had significant correlations with the third trimester urinary iodine levels. The thyroid volume accounted for 4.5 % of the urinary iodine variation.ConclusionsEven though iodine status was progressively worsening with the advancement of pregnancy and iodized salt consumption has not met with the increasing demand for iodine, it was not reflected in the serum TSH level. Therefore, it is worthwhile to assess the long term effects of rising TSH levels and inadequate iodine nutrition during pregnancy on the offspring to prevent even mild iodine deficiency.

Pediatric Goiter: Can Thyroid Disorders Be Predicted at Diagnosis and in Follow-Up?

To investigate the prevalence of thyroid dysfunction, autoimmune thyroid disease (AITD), and simple goiter at goiter diagnosis, and to analyze the natural course of simple goiter and predictors for progression to AITD and/or thyroid dysfunction. In total, 939 patients (770 females, 5.0-17.9 years) with goiter were reviewed retrospectively. Anthropometrics, pubertal status, goiter grade, and family history (FH) of thyroid disease were investigated. Simple goiter was defined as euthyroid goiter without pathologic cause, after excluding AITD and isolated nonautoimmune hyperthyrotropinemia (iso-NAHT). At diagnosis, 36.9% of children showed thyroid dysfunction and/or AITD (euthyroid AITD [9.9%], hyper- or hypothyroid AITD [18.4%], iso-NAHT [8.6%]). Risk for subsequent medication was higher in euthyroid AITD than simple goiter (20.4% vs 0.3%, P < .001). Hashimoto thyroiditis (HT) and iso-NAHT developed in 5.2% and 6.6% of patients initially diagnosed with simple goiter during the median 2.0-year follow-up. Compared with the persistent simple goiter group, the HT group had greater FH (54.8% vs 23.6%) and unchanged or increasing goiter size (89.3% vs 71.8%), and the iso-NAHT group had a higher proportion of patients within the upper tertile range of baseline thyrotropin levels (71.8% vs 24.9%) and unchanged or increasing goiter size (86.8% vs 71.8%; all P < .05). Thyroid disorders were detected in one-third of pediatric patients presenting with goiter. The higher risk for thyroid dysfunction needing medication in patients with euthyroid AITD emphasizes the importance of autoantibody evaluation at diagnosis. During simple goiter follow-up, progression to HT or iso-NAHT occurs, especially in patients with FH or persistent goiter.

Management of Graves Disease: A Review.

Graves disease is the most common cause of persistent hyperthyroidism in adults. Approximately 3% of women and 0.5% of men will develop Graves disease during their lifetime. We searched PubMed and the Cochrane database for English-language studies published from June 2000 through October 5, 2015. Thirteen randomized clinical trials, 5 systematic reviews and meta-analyses, and 52 observational studies were included in this review. Patients with Graves disease may be treated with antithyroid drugs, radioactive iodine (RAI), or surgery (near-total thyroidectomy). The optimal approach depends on patient preference, geography, and clinical factors. A 12- to 18-month course of antithyroid drugs may lead to a remission in approximately 50% of patients but can cause potentially significant (albeit rare) adverse reactions, including agranulocytosis and hepatotoxicity. Adverse reactions typically occur within the first 90 days of therapy. Treating Graves disease with RAI and surgery result in gland destruction or removal, necessitating life-long levothyroxine replacement. Use of RAI has also been associated with the development or worsening of thyroid eye disease in approximately 15% to 20% of patients. Surgery is favored in patients with concomitant suspicious or malignant thyroid nodules, coexisting hyperparathyroidism, and in patients with large goiters or moderate to severe thyroid eye disease who cannot be treated using antithyroid drugs. However, surgery is associated with potential complications such as hypoparathyroidism and vocal cord paralysis in a small proportion of patients. In pregnancy, antithyroid drugs are the primary therapy, but some women with Graves disease opt to receive definitive therapy with RAI or surgery prior to becoming pregnant to avoid potential teratogenic effects of antithyroid drugs during pregnancy. Management of Graves disease includes treatment with antithyroid drugs, RAI, or thyroidectomy. The optimal approach depends on patient preference and specific patient clinical features such as age, history of arrhythmia or ischemic heart disease, size of goiter, and severity of thyrotoxicosis. Physicians should be familiar with the advantages and disadvantages of each therapy to best counsel their patients.

Sequential Amniotic Fluid Thyroid Hormone Changes Correlate with Goiter Shrinkage following in utero Thyroxine Therapy

Several isolated reports of fetal goiter treatment have shown limited generalizability of approaches and provide no real guidance for optimal timing, dosages, and treatment strategies. Graves' disease accounts for >60% of these cases. Maternal treatments of hyperthyroidism include antithyroid medications such as methimazole and more commonly propylthiouracil (PTU). Here, our management of a patient with a fetal thyroid goiter from maternal exposure to PTU diagnosed at 23.6 weeks' gestation and the management of other cases allow us propose a general strategy for treatment. Intrauterine therapy with 200 and then 400 μg of levothyroxine (3 weeks apart) showed an 85% reduction in fetal thyroid goiter volume. We collected amniotic fluid samples at the time of treatments and assayed thyroid hormones and associated antibodies which closely reflected the changes in thyroid goiter mass volume. Our observations suggest a weekly or biweekly therapeutic intervention schedule. Utilizing both goiter size as well as a novel approach in using amniotic fluid hormone levels to monitor therapy efficacy might improve the quality of treatments. Only with a standardized approach and collection of amniotic fluid thyroid panels do we have the opportunity to develop the database required to determine the number and timing of treatments needed.

IGF1 deficiency in newly diagnosed Graves' disease patients.

Thyroid hormones influence the GH/IGF1 axis, but previous studies have reported discrepant results regarding serum IGF1 levels in hyperthyroidism. We have therefore investigated, at diagnosis, the relationship between serum IGF1 levels and the main characteristics of Graves' disease (GD): severity of hyperthyroidism, goiter size, presence of active Graves' ophthalmopathy (GO), antythyroid antibodies status and titer. This cross-sectional study included 98 newly diagnosed hyperthyroid patients with GD who presented consecutively at our clinic. The main measured parameters were: TSH, FT4, FT3, TT3, thyroglobulin,anti-thyroid peroxidase antibodies (TPOAb), anti-thyroglobulin antibodies (ATA), thyrotropin receptor antibodies (TRAb), IGF1. Patients were considered IGF deficient if IGF1 z score was &#8804;-2SD from mean for age. In GD patients, men had higher IGF1 levels (p=0.023) and IGF1 z scores (p=0.013) than women. 18.4% of GD patients were, at diagnosis, IGF1 deficient. Compared to patients without IGF1 deficiency, these patients presented higher thyroglobulin (median=72.55, IQR=116.02 vs median=11.40, IQR=80.74 ng/ml, p=0.002) and FT3 (median=11.30, IQR=7.64 vs median=7.33, IQR=5.72 pg/ml, p=0.027), and lower ATA (median=20, IQR=0 vs median=34.05, IQR=161 iu/ml, p&#60;0.001) levels. Thyroglobulin was independently associated with IGF1 deficiency (AUROC=0.732, 95% CI: 0.620-0.844, p=0.002; cut-off for thyroglobulin=50.40 ng/ml, Se=77.8%, Sp=70%). IGF1 status was not influenced by gender (p=0.084), current smoking (p=0.558), goiter size (p=0.533), active ophthalmopathy (p=0.334), TRAb (p=0.239) or TPOAb status (p=0.367). Nearly one fifth of newly diagnosed GD patients had IGF1 deficiency. IGF1 deficiency was associated with lower ATA titers, higher thyroglobulin levels and more severe FT3 hyperthyroidism at diagnosis.

IMMUNOLOGICAL AND MORPHOLOGICAL PREDICTORS OF CLINICAL HETEROGENEITY OF PATIENTS WITH GRAVES' DISEASE (BASED ON RESEARCH OF THE THYROID GLAND OPERATIONAL MATERIAL)

Very little research is devoted to the study of communication systemic immunological changes and local immunological changes in the tissue of the thyroid in autoimmune thyrophaties. The goal of the research was to establish immunologic and morphologic predictors of clinical course and functional outcomes of Graves’s disease (GD).Material and methods. We examined 45 patients with GD (14 men and 31 women) aged 18–55 years (47.0 (35.0–53.0)) years, matching the following criteria: a verified diagnosis GD, accommodation in Tomsk oblast and the Tomsk not less than 10 years, the patient's consent for the study. The control group included 30 people, with an average age of (45.3 ± 5.6) years and was comparable by age and sex with GD patients. The study included: definition of the standard for GD hormonal and serological profile (free T4, free T3, and TSH, antibodies to TPO, antibodies to the TSH receptor), the cultivation of mononuclear leukocytes in complete culture medium within 24 hours with subsequent determination of interleukins concentrations (IL-2, IL-4, TNF-alpha) in culture medium using enzyme-linked immunosorbent assay, determination of the number of blood cells carrying membrane-bound receptors to IL-2, IL-4, TNF-R1 by flow laser cytometry on cytometer BD FACS Canto tmΙΙ (USA) using labeled monoclonal antibody, the standard postoperative histological examination of thyroid gland tissue samples and immunohistochemical detection in samples of thyroid tissue receptors to IL-2, IL-4, TNF-alpha.Results. On the basis of the received results it is possible to allocate 2 clinical-immunologic and morphologic cluster of autoimmune hyperthyroidism syndrome in patients with clinical diagnosis of GD. The first includes the formation of 1 and 2 histological options GD (minimally expressed monocytes infiltration, lack of oncocytic transformation of thyroid epithelium), with some clinical characteristics (persistent and pronounced hyperthyroidism, the large size of goiter, higher titer of receptor TSH-antibody and smaller TPO-antibody, diffuse nature of the lesion), and the second – is represented by 3d histological option with oncocytic restructuring of follicular epithelium, expressed the monocyte/macrophage infiltration with the TNF-RI expression and clinical patterns, including: the older age group of patients, the smaller size of goiter, the emergence of “pseudo nodes” ultrasound, reflecting the presence of lymphoid follicles-infiltrates, more lenient for hyperthyroidism. Probably, that the 2nd cluster is a combination of “classical GD” with autoimmune thyroiditis, however, a set of clinical and laboratory-instrumental signs led to the fact that these patients were in the group of GD patients.Conclusion. This approach (combining study of indicators of systemic and local tissue-specific autoimmune inflammation) is a promising from the point of view of separate parts coverage in the autoimmune thyroids diseases pathogenesis, approximating researchers to develop immune based therapeutic technologies.

Effect of maternal iodine supplementation on thyroid function and birth outcome in goiter endemic areas

Objective:The study was undertaken to examine the clinical and endocrine parameters of thyroid in a total of 460 pregnant women belonging to non-goiter areas (group 1; n = 156) and endemic areas without (group 2; n = 154) and with iodine supplementation (group 3; n = 150), and their respective newborns.Methods:Women of group 3 with visible goiter were administered two capsules of iodized oil orally each containing 200 mg of iodine, from weeks 6--8 of pregnancy. Blood samples were obtained from all groups during each trimester, at parturition (umbilical cord blood) and after delivery. Serum triiodothyronine (T3), thyroxine (T4) and thyroid stimulating hormone (TSH) levels were measured by specific enzyme immunoassays.Results:In group 2, serum T4 concentrations were low while T3 and TSH levels were high which showed hypothyroidism in the women of endemic areas. Goiter size decreased in most of the subjects who received a single dose of iodized oil and resulted in increase in serum concentrations of thyroid hormones; whereas, TSH levels decreased. Iodine supplementation also resulted in raised T4 and low TSH levels in the cord blood of neonates. During the course of study, two abortions, three still births and one cretin were reported in group 2; none was reported in group 3; and one still birth was reported in group 1.Conclusions:The oral administration of a single dose of iodized oil is capable of correcting iodine deficiency both clinically and endocrinologically in mothers and neonates. Iodine supplementation has the potential to positively impact the birth weight of newborns.

Thyroid carcinoma with pituitary metastases: 2 case reports and literature review.

We present 2 patients with pituitary metastases from thyroid carcinoma—the first from anaplastic thyroid carcinoma and the second from follicular thyroid carcinoma. The first patient, a 50-year-old lady, presented with 2-week history of hoarseness of voice, dysphagia, dyspnoea, and neck swelling. Imaging revealed metastatic thyroid cancer to lymph nodes and bone. Histology from surgery confirmed anaplastic thyroid cancer. She was found to have pituitary metastases postoperatively when she presented with nonvertiginous dizziness. She subsequently underwent radiotherapy and radioiodine treatment but passed away from complications. The second patient, a 65-year-old lady, presented with loss of appetite and weight with increased goitre size and dyspnoea. Surgery was performed in view of compressive symptoms and histology confirmed follicular thyroid carcinoma. Imaging revealed metastases to bone, lung, and pituitary. She also had panhypopituitarism with hyperprolactinemia and diabetes insipidus. She received radioiodine therapy but eventually passed away from complications.

US not bright but right method of thyroid volume estimation even in large and substernal extended goitres. Comparison of US and three methods of CT thyroid evaluation – prospective study

Ultrasound is nowadays a method of choice for thyroid volume assessment. However, its disadvantage is some inaccuracy, which is said to be higher in huge, especially substernally extended goitres. The aim of the study was to compare the US and CT thyroid volumetric measurements: multi-observers (CT MO) and one-observer (CT OO) to CT planimetry results (CT Pl) in patients with large goitres. The study material comprised 70 thyroid imaging examinations obtained from 35 patients with nontoxic goitres, scanned twice before and after radioiodine treatment. Mean thyroid volume was 88·97 ± 60·21 ml. Thirty-three thyroid scans revealed the extension below the jugular notch (mean of 2·46 cm). Thyroid volume in US, CT MO and CT OO was estimated using the ellipsoid formula. CT Pl was established a reference method. The mean thyroid volume in CT Pl was 88·97 ml (median 80·73, range 11·81 to 315·97). US underestimates thyroid volume by 7·55 ml (7·7%) with a sufficient correlation (R(2) = 0·89) and precision (20·37). CT OO is the closest and CT MO the most distant from CT Pl, with US between them in thyroid volume estimation. The percentage US bias is constant through all range of thyroid volume. There is no difference for percentage bias between US and CT Pl for goitres with (8·67%), and without (6·70%) substernal part. US examination is sufficient for epidemiological studies, radioiodine activity calculation and goitre size assessment in everyday medical practice. Neither initial size of the goitre nor its substernal extension affects US assessment precision.

Methimazole-Induced Goitrogenesis in an Adult Patient With the Syndrome of Resistance to Thyroid Hormone.

Patients with the syndrome of resistance to thyroid hormone (RTH) have clinical (tachycardia and anxiety) and biochemical (elevated thyroid hormones level) features of hyperthyroidism. Based on previous reports in pediatric patients with the RTH, antithyroid treatment in these patients is not indicated. Clinical and biochemical sequel of antithyroid therapy in an adult patient with RTH was not previously reported. A 63-year-old African American female with history of RTH was treated with a therapy consisting of methimazole 15 mg daily and atenolol. Methimazole treatment resulted in reduction in thyroid hormone level while the patient’s TSH increased with a peak of 24.88 mIU/L. Having achieved biochemical euthyroidism, the patient developed thyroid gland enlargement associated with progressive symptoms of dysphagia and dyspnea. Examination demonstrated globally enlarged firm thyroid gland with areas of nodularity in both lobes. A computed tomography of the neck showed enlarged thyroid gland with extension around bilateral sternocleidomastoid muscles and compression onto the trachea. Methimazole therapy was discontinued and patient was treated just on atenolol. Over 12 months following discontinuation of methimazole, the patient experienced marked clinical and radiographic improvement of the goiter size associated with TSH reduction to 1.26 mIU/L and modest free thyroxine increase as expected in RTH. It seems appealing to treat patients with the RTH with antithyroid medications. However, in these patients decrease in thyroid hormone levels will stimulate TSH production, which can, in turn, predispose to goiter formation. Our report supports prior observations in children with RTH that treatment with methimazole is not indicated in adult patients with RTH.

Surgical Management of Retrosternal Goitre: Experience of a Moroccan Center

Introduction and objectivesThis was a retrospective study reviewing 93 cases of retrosternal goitre (RG) operated in our department, with the aim of describing epidemiological and clinical data and discussing the surgical challenges of RG. Patients and methodsFrom January 2004 to December 2012, 35 men and 58 women presenting with RG had surgery. Eighty-nine cases (95.7%) underwent cervicotomy, and a sternotomy was mandatory in 4 cases (4.3%). Laryngoscopy was performed in all cases. A second preoperative laryngoscopy by a senior was mandatory for patients with hoarseness or dyspnea even if the initial laryngeal exam was normal. ResultsA cervical mass was noted in 81 cases (87.1%), dyspnea in 17 cases (18.3%), dysphagia in 2 cases (2.1%), hoarseness in 7 cases (7.5%), partial vena cava syndrome in 2 cases and recurrent goitre was noted in 2 cases (2.1%) after previous thyroid resection. Mediastinal extension was on the left side in 47 cases (50.5%), on the right side in 29 cases (31.2%) and bilateral in 17 cases (18.3%).A total thyroidectomy was performed in 86 cases (92.5%) and a unilateral isthmo-lobectomy was performed in 7 cases (7.5%). Mean goitre size was 9.3cm. Postoperative complications were present in 9 cases (9.7%), 3 cases with hypoparathyroidism (3.2%) and 4 cases (4.3%) of recurrent nerve injury. There was no postoperative death. The histological study objectified 88 cases of multiheteronodular goitre, 4 cases of Basedow thyroid, and 1 case of thyroid carcinoma (papillary carcinoma). ConclusionOur experience confirms that cervicotomy often allows removing goitre with a mediastinal extension. However, intraoperative enlargement may be necessary, with increased operating time, hospital stay and morbidity.

Tratamiento quirúrgico del bocio retroesternal: experiencia en un centro de Marruecos

Introduction and objectivesThis was a retrospective study reviewing 93 cases of retrosternal goitre (RG) operated in our department, with the aim of describing epidemiological and clinical data and discussing the surgical challenges of RG. Patients and methodsFrom January 2004 to December 2012, 35 men and 58 women presenting with RG had surgery. Eighty-nine cases (95.7%) underwent cervicotomy, and a sternotomy was mandatory in 4 cases (4.3%). Laryngoscopy was performed in all cases. A second preoperative laryngoscopy by a senior was mandatory for patients with hoarseness or dyspnea even if the initial laryngeal exam was normal. ResultsA cervical mass was noted in 81 cases (87.1%), dyspnea in 17 cases (18.3%), dysphagia in 2 cases (2.1%), hoarseness in 7 cases (7.5%), partial vena cava syndrome in 2 cases and recurrent goitre was noted in 2 cases (2.1%) after previous thyroid resection. Mediastinal extension was on the left side in 47 cases (50.5%), on the right side in 29 cases (31.2%) and bilateral in 17 cases (18.3%).A total thyroidectomy was performed in 86 cases (92.5%) and a unilateral isthmo-lobectomy was performed in 7 cases (7.5%). Mean goitre size was 9.3 cm. Postoperative complications were present in 9 cases (9.7%), 3 cases with hypoparathyroidism (3.2%) and 4 cases (4.3%) of recurrent nerve injury. There was no postoperative death. The histological study objectified 88 cases of multiheteronodular goitre, 4 cases of Basedow thyroid, and 1 case of thyroid carcinoma (papillary carcinoma). ConclusionOur experience confirms that cervicotomy often allows removing goitre with a mediastinal extension. However, intraoperative enlargement may be necessary, with increased operating time, hospital stay and morbidity.

Evaluación del estado nutricional de los escolares de una zona endémica de bocio

El bocio endémico puede determinar retardo en el desarrollo mental y físico de la población infantil; pero como los factores etiopatogénicos son múltiples y no se circunscriben sólo a la deficiencia de iodo, se ha considerado necesario establecer si existe correlación entre el bocio y el retardo de los índices pondo-estaturales en la población escolar de una zona con alta prevalencia de bocio. Para evaluar el estado nutricional de los escolares de la zona endémica de bocio de Urubamba (Cusco), se ha utilizado los indicadores talla/edad (T/E) , peso/edad (PIE), pesoltalla (P/T) en 3517 escolares de ambos sexos, de 6 a 17 años de edad. El tamaño de la tiroides y el estado nutricional fueron determinados de acuerdo a los criterios recomendados por la OMS y se ha tomado como patrón de referencia a los preconizados por el Centro Nacional de Estadística para la Salud de los Estados Unidos (NCSH). En el indicador TIE se encontró una prevalencia de retardo de talla para la edad en un 49%, que fluctuó entre un 44% en Urubamba a 64% en Maras. La prevalencia de deficiencia para el indicador PIE fue de 35%, variando entre 20% en Urubamba a 47% en Ollantaytambo. La prevalencia de deficiencia para el indicador P/T se encontró en 12% y varió entre 20% en Chinchero a 9% en Huayllabamba. Según la clasificación de Waterloo el 46% presentó desnutrición crónica, 7% desnutrición aguda y 5% desnutrición aguda crónica. No se encontró correlación entre la presencia de bocio y desnutrición crónica, lo cual sugiere que esta última debe estar relacionada con otros factores que se debe investigar (An Fac Med UNMSM " Epoca 1989; 1 (1-2): 27-30).

Przydatność oznaczania stężenia PTH w popłuczynach z igły do biopsji aspiracyjnej cienkoigłowej w identyfikowaniu patologicznych przytarczyc — analiza czynników wpływających na skuteczność tej metody

The aim of this investigation was to assess the usefulness of the measurement of PTH concentration in the material obtained during FNAB (PTH-FNAB) in the identification of pathological parathyroids in patients with frequently coexisting thyroid abnormalities (nodular goitre, chronic thyroiditis, previous thyroidectomy). Additionally, the influence of the size of goitre, parathyroid localisation and size on the results of PTH-FNAB measurement was examined. Fifty patients with primary hyperparathyroidism and sonographically detected focal lesion that was suggestive of parathyroid gland were included in this study. PTH-FNAB results were correlated with the outcome of routine cytological examination and biochemical indices of hyperparathyroidism, SPECT-CT (33 patients) and histopathological examination (20 patients). Positive PTH-FNAB was observed in 80% of patients, and in more than 70% of persons with non-diagnostic smears or smears 'contaminated' with thyroid follicular cells. In the group of operated patients, sensitivity of PTH-FNAB (95.0%) was higher than SPECTCT (64.3%, p < 0.05). Presence of nodular goitre and/or chronic thyroiditis exerts a two times stronger negative effect on percentage of negative results of SPECT-CT than of PTH-FNAB. On the other hand, lower frequency of positive PTH-FNAB but not SPECT-CT was observed when the thickness of the thyroid was ≥ 20 mm (50% v. 87.5%, p < 0.05) and when the thickness of a lesion suspected of parathyroid pathology was ≤ 5 mm (66.7% v. 93.3%, p < 0.05). In patients with thyroid abnormalities, PTH-FNAB measurements show advantages over routine biopsy and SPECT-CT in the identification of typically located pathological parathyroids.