Nontoxic Multinodular Goiter Research Articles

SUN-517 Postoperative Hypoparathyroidism Treated With Teriparatide In Apatient With Malabsorption Due To Celiac Disease: A Case Report And Literature Review

A 31 year-old female with a past medical history of preeclampsia and non-toxic multinodular goiter causing compressive symptoms underwent total thyroidectomy. A large parathyroid gland was noted and removed during surgery. Hyperparathyroidism was not suspected preoperatively, (preoperative calcium levels were 8.4 mg/dL) and the patient did not have calcium, PTH, or Vitamin D level determination prior to having thyroidectomy. Final pathology showed a 49.5 gm thyroid gland containing multiple benign nodules. Two parathyroid glands were identified. A few hours postoperatively she developed symptomatic hypocalcemia (Ca level 7.8) and required IV calcium supplementation as her calcium levels could not be maintained in the recommended range using oral calcium. Her supplemental therapy requirements reached oral calcium carbonate 7500 mg every 6 hours, IV calcium gluconate at a rate of 750 mg/hr, calcitriol 1 mcg every 6 hours, oral magnesium 800 mg twice daily, and HCTZ 50 mg daily. It was then that teriparatide 20 mcg subcutaneously was initiated twice daily (based on recommendations found in references (1 -2)). With the initiation of teriparatide, she became independent of IV calcium gluconate. At this time the patient disclosed that she had been suffering from diarrhea for the preceding 11 months prior to thyroid surgery. After consultation with GI she underwent biochemical confirmation, colonoscopy and EGD with duodenal biopsies, which demonstrated celiac disease. Colon biopsies showed microscopic colitis. There are limited reports of the use of teriparatide in post operative hypoparathyroidism in adults. Teriparatide was utilized in a study of children with hypoparathyoidism and malabsorption.3 The use of teriparatide after thyroid surgery resulting in either permanent or temporary postoperative hypoparathyroidism reduced hospitalization duration 2 and, in a 2-year prospective study teriparatide was noted to improve quality of life parameters in patients with post surgical hypoparathyroidism.4

SAT-592 Amiodarone-Induced Cure Of Graves' Disease

INTRODUCTION While amiodarone-induced thyrotoxicosis is known to potentially exacerbate latent subclinical hyperthyroidism, we describe a rare case of amiodarone-induced hypothyroidism in a patient with longstanding subclinical hyperthyroidism secondary to Graves disease. CASE The patient is a 66-year-old woman with longstanding subclinical hyperthyroidism due to Graves’ disease and non-toxic multi-nodular goiter. Her mild Graves’ disease was diagnosed nine years back when she presented with hyperthyroidism, negative thyrotropin receptor antibodies (TRAb), and homogenously increased radioactive iodine uptake. The thyroid sonogram and RAI scan had shown bilateral nontoxic nodules, with benign fine needle aspiration cytology. She was intermittently and successfully treated with methimazole 2.5 mg daily, and had no interest in receiving Radioactive Iodine therapy. Her course over the subsequent years was significant for diagnosis of breast cancer treated with lumpectomy and paclitaxel-adriamycin, complicated by the onset of severe congestive heart failure and permanent atrial fibrillation, for which she was started on oral Amiodarone 200mg twice a day. Her serum TSH subsequently increased from baseline 4.53 mcIU/mL (normal 0.73-4.60 mcIU/mL) to 6.04 mIU/L at 6 weeks. Amiodarone dose was tapered to a daily dose and later discontinued because of a prolonged QT on electrocardiogram. Repeat thyroid testing at six months showed a markedly elevated TSH at 66.32 mcIU/mL (normal 0.73-4.60 mcIU/mL) with a serum T4 of less than 0.25 ng/dl (normal 0.58-1.64 ng/dl). TRAb and thyroid peroxidase antibodies remained negative. So with a provisional diagnosis of amiodarone-induced hypothyroidism, methimazole was discontinued and levothyroxine 25 mcg daily started. A follow-up testing one month later showed a TSH of 11.5 mcIU/mL and serum T4 of 0.72 ng/dl. DISCUSSION Amiodarone, through its high iodine content, has been associated with hypothyroidism as well as hyperthyroidism in both normal and dysfunctional thyroid glands. It typically induces thyrotoxicosis in autonomously functioning thyroid glands by stimulating excessive thyroid hormone biosynthesis in response to iodine load, whereas it typically induces hypothyroidism in patients with underlying autoimmune thyroiditis likely because of failure to escape Wolf-Chaikoff effect. Our patient illustrates a very rare and interesting permanent cure of Graves’ disease followed by hypothyroidism after amiodarone exposure.

SUN-623 Markedly Elevated Thyroglobulin Levels in a Patient with Papillary Thyroid Carcinoma in the Setting of Hashimoto’s Thyroiditis and Negative Imaging: A Case Report

Background: Despite the high survival rate of differentiated thyroid cancer (DTC), recurrence may occur. After tumor resection, radioactive iodine (RAI) can be considered if necessary, and serum thyroglobulin (Tg) and thyroglobulin antibody (TgAb) levels as well as neck ultrasound (US) are the main tools used for surveillance. Discrepancies between laboratory testing and imaging findings may present. This can occur due to assay interference or less commonly in the setting of Hashimoto’s thyroiditis (HT). We present the case of a patient with low risk DTC and chronic markedly elevated Tg levels in the setting of no evidence of structural disease and a history of HT. Clinical Case: A 72-year-old woman with a history of primary hypothyroidism and non-toxic multinodular goiter underwent left hemithyroidectomy in 2012. Pathology revealed incidentally discovered papillary thyroid microcarcinoma, 0.2 cm with negative margins and negative lymphovascular invasion in a background of chronic lymphocytic thyroiditis. Due to the low risk of recurrence, she did not undergo completion thyroidectomy nor RAI. Post operatively, she was noted to have a serum Tg level of 752 ng/mL (no reference range), TgAb <20 IU/mL (reference range < or =1 IU/mL), with a TSH of 4.3 mIU/L (reference range 0.4-4.5 mIU/L). Since then she has remained with elevated Tg levels ranging from 236 to 786 ng/mL, including Tg levels by liquid chromatography mass spectrometry (LC/MS) and negative TgAb. She did have a thyroid peroxidase antibody measured at > 1000 IU/mL (reference range < 35 IU/mL). Imaging included multiple serial neck US negative for right hemi-thyroid nodules and no suspicious lymph nodes. CT scan of the chest was negative. PET/CT showed FDG uptake in the right thyroid lobe (SUV max 8.6) without any evidence of FDG avid tumor in the rest of the body. She is otherwise clinically stable on levothyroxine therapy to maintain her TSH between 0.5 to 2 mIU/L. Discussion: This patient presents persistently elevated serum Tg levels significantly above what is expected for a patient status post hemithyroidectomy. We suspect the most likely explanation for this finding is her underlying HT causing autoimmune thyroid tissue destruction. Moving forward, we suggest measuring heterophilic antibodies and remeasuring Tg level with serial dilutions to rule out the possibility of assay interference. This case is especially challenging as she has an intact hemi-thyroid, which limits some of the imaging diagnostic modalities available. HT has been shown to result in a diffuse distribution of FDG uptake in the thyroid gland on PET/CT as seen in this case. Conclusion: Even though in most cases with DTC Tg levels serve as a sensitive and reliable tumor marker, in the setting of elevated thyroglobulin levels and no clear structural evidence of disease, it is important to consider other possible etiologies and not only disease recurrence.

Risk of Thyroid Malignancy in Non-Toxic Multi-nodular Goitre: Experience in Rajshahi

Non-Toxic multi-nodular goitre is one of the common presentations of various thyroid diseases. A sizable portion of multi-nodular goitre turns into malignancy over time. This cross-sectional study was conducted in RMCH and different clinics of Rajshahi City to determine the incidence and types of various thyroid malignancies in non-toxic multi-nodular goitres. Among the total cases, 43% of the patients were in the age group of 31-40 years and majority (81%) of whom were female. 52% of the patients had a history of thyroid swelling for 1-5 years and 55% of the patients had goitre size ≤ 15 cm2. Sub-total thyroidectomy was the commonest operation performed and all the resected specimens were sent for histopathological examinations, which demonstrates that 13% of the multi-nodular goitres had malignancies with papillary and follicular carcinoma ratio 5:1. This study did not reveal any significant association of malignancies with age and sex and goitre size also not influence the presence of malignancy. However, it was observed that the mean duration of thyroid swelling in patients who developed malignancy was significantly higher (8.6 years) than that of patients who did not experience any malignant change (5.7 years).TAJ 2016; 29(2): 16-20

Benign and Malignant Thyroid Diseases

The thyroid is key to numerous metabolic and homeostatic processes, including thermomodulation, protein synthesis, carbohydrate and lipid metabolism, and adrenergic regulation. A normal thyroid gland weighs 15 to 25 g and is firm, mobile, and smooth to palpation. There are two distinct physiologically active cell types: follicular cells, which synthesize thyroid hormone, and parafollicular or C cells, which produce calcitonin. Surgery is indicated for three broad categories of thyroid disease: (1) a hyperfunctioning gland, (2) an enlarged gland (goiter) causing compressive symptoms, and (3) diagnosing or treating malignancy. These indications may overlap in a patient presenting for surgical consultation. Regardless of the indication, a thorough discussion with the patient about the thyroid disease and other diagnostic or therapeutic options (if any) should be conducted. This reviews contains 3 figures, 13 tables, and 56 references. Key Words: anaplastic thyroid cancer, antithyroid medications, Bethesda classification, follicular thyroid cancer, Graves disease, medullary thyroid cancer, nontoxic multinodular goiter, papillary thyroid cancer, radioactive iodine, toxic nodular goiter

Benign and Malignant Thyroid Diseases

The thyroid is key to numerous metabolic and homeostatic processes, including thermomodulation, protein synthesis, carbohydrate and lipid metabolism, and adrenergic regulation. A normal thyroid gland weighs 15 to 25 g and is firm, mobile, and smooth to palpation. There are two distinct physiologically active cell types: follicular cells, which synthesize thyroid hormone, and parafollicular or C cells, which produce calcitonin. Surgery is indicated for three broad categories of thyroid disease: (1) a hyperfunctioning gland, (2) an enlarged gland (goiter) causing compressive symptoms, and (3) diagnosing or treating malignancy. These indications may overlap in a patient presenting for surgical consultation. Regardless of the indication, a thorough discussion with the patient about the thyroid disease and other diagnostic or therapeutic options (if any) should be conducted. This reviews contains 3 figures, 13 tables, and 56 references. Key Words: anaplastic thyroid cancer, antithyroid medications, Bethesda classification, follicular thyroid cancer, Graves disease, medullary thyroid cancer, nontoxic multinodular goiter, papillary thyroid cancer, radioactive iodine, toxic nodular goiter

Changes in the size of the thyroid in patients with benign non-toxic multinodular goiter after radioactive iodine therapy.

Background: Multinodular goiter (MNG) is regarded as one of the most common causes of hyperthyroidism, particularly in areas of mild-to-moderate iodine deficiency. The present study aims to explore the effects of the radioactive iodine (RAI) therapy on benign non-toxic MNG and evaluate its side effects. Methods: Patients with benign non-toxic MNG entered the study. Ultrasonography was applied to calculate the percentage of the decrease in the size of the thyroid before and six months minimum after the treatment. Chi-square, Mann-Whiteny-U and T-test were done using SPSS v.18.0 (p<0.05). Results: The volumes of the thyroid lobes and nodules decreased significantly due to RAI therapy (p<0.001). The total volume of the thyroid, volume of the right nodule, and volume of the left nodule decreased by 77.8%, 40.7%, and 34.6% respectively. Conclusion: According to the results of the current study, RAI therapy is an effective treatment method although it has short-term side effects. This treatment option is recommended for patients with benign non-toxic MNG, notably those who cannot be a candidate for surgery. This treatment affects the size of the thyroid and its nodules significantly and decreases almost all of the complications.

Alteration in the serum concentrations of FGF19, FGFR4 and βKlotho in patients with thyroid cancer

IntroductionβKlotho (βKL) is known to act as co-receptor for fibroblast growth factor receptor 4 (FGFR4) which is the main cognate receptor for fibroblast growth factor 19 (FGF19). Dysregulation of this FGF19/FGFR4/βKL signaling axis has been implicated in the pathogenesis of several cancers. However, its role in the pathogenesis of thyroid cancer has not been determined. Materials and methodsThe aim of this study was to assess FGF19, FGFR4 and βKL concentrations in a group of 36 patients with papillary thyroid cancer (PTC), 11 patients with follicular thyroid cancer (FTC), 9 patients with anaplastic thyroid cancer (ATC) and a group of 19 subjects with multinodular nontoxic goiter (MNG). The control group consisted of 20 healthy volunteers. Serum FGF19, FGFR4 and βKL concentrations were measured using specific ELISA methods. ResultsSignificantly lower concentrations of βKL and higher concentrations of FGF19 were found in patients with PTC, FTC and ATC as compared with MNG group and controls. An elevation of FGFR4 serum concentration was observed in all thyroid cancer groups in comparison to MNG group and controls; however, in FTC group it was statistically insignificant. A positive correlation was found between βKL and FGFR4 concentrations in PTC patients. The levels of βKL, FGF19 and FGFR4 did not differ significantly between MNG group and healthy controls. ConclusionsOur results indicate that a disrupted FGF19/FGFR4/βKL signaling pathway may play a role in the development of thyroid cancers. However, further studies are needed to elucidate the molecular mechanism of the neoplastic transition of thyroid epithelial cells.

Development of metabolic syndrome after bilateral total thyroidectomy despite the L-t4 replacement therapy: A prospective study.

The literature about the frequency of metabolic syndrome in patients with multinodular goitre and a new onset of metabolic syndrome after total thyroidectomy is limited. The aim of this study was to investigate the effects of total thyroidectomy and thyroid hormones on a new onset of metabolic syndrome in patients who underwent total thyroidectomy and have received thyroid hormone replacement. Fifty-nine patients who underwent total thyroidectomy for multinodular goitre were included in this prospective study. Patients' height, weight, and waist circumference were measured, and the body mass index was calculated. Peripheral blood samples were obtained preoperatively and at the 12th and 24th month after total thyroidectomy to examine the lipid profile, glucose homeostasis, and thyroid function tests. The lipid profile and blood pressure parameters deteriorated, and the mean body mass index and waist circumference with the metabolic syndrome rates significantly increased at the 12th and 24th months follow-up. Preoperative body mass index (Exp[B] 1.60; p=0.003) was independently associated with metabolic syndrome at the 2nd year after total thyroidectomyin a multivariate regression analysis. The frequency and severity of MetS is high in adult patients with non-toxic multinodular goitre after total thyroidectomy. The frequency of metabolic syndrome increased in patients with a high body mass index after total thyroidectomy.

Therapy for non-toxic multinodular goiter: radioiodine therapy as attractive alternative to surgery

The need for therapy for nodular goiter results from the growth of thyroid nodules over decades and from the possibility of tracheal compression and worsening of respiratory function. Given the high prevalence of non-toxic goiter, the epidemiologically low incidence of clinically apparent thyroid cancer justifies non-surgical strategies. Randomised studies have shown that levothyroxine offers limited therapeutic effects and is inferior to radioiodine therapy regarding goiter shrinkage. When indication for a definitive therapy is given, the choice between resection and radioiodine therapy should consider volume of goiter, severity of clinical symptoms, thyroid uptake, patient's age, co-morbidity, previous resection of goiter, patient's profession and patient's wish. Even in large goiters between 100 and 300 ml radioiodine therapy showed consistent results with goiter size reduction from 35-40% one year and 40-60% two years after radioiodine therapy. Thyroid hormones to prevent recurrence of goiter are not necessary. Recurrent goiters were seldom observed after radioiodine therapy and resulted from initially very large goiters or uptake in dominate nodules or from low (131)I activities. Recombinant human TSH (rhTSH) offers the opportunity to enhance the effect of radioiodine therapy. Observational studies have shown that rhTSH increases low (131)I uptake in case of high alimentary iodine-supply by the factor 4, causes a more homogenous (131)I distribution within the goiter and improves goiter reduction. A phase I study for dose finding is running in the USA. Radioiodine therapy for shrinkage of large non-toxic goiter should not be restricted to elderly patients, or to patients with co-morbidity or high operative risk, but is an attractive alternative to surgery in patients with special professions (singer, teacher, speaker) or with the wish for a non-invasive treatment modality.

Nontoxic Multinodular Goitre and Incidental Thyroid Cancer: What Is the Best Surgical Strategy?—A Retrospective Study of 2032 Patients

Objectives A discussion with regard to the most optimal surgical procedure in nontoxic multinodular goitre (NTMNG). We assessed and compared three main types of operations in 2032 patients with NTMNG. Methods This is a retrospective study of 2032 patients operated on in one center due to NTMNG. The observation period was 48 to 120 months (mean and SD: 87 ± 20). Results The early complications included uni- and bilateral recurrent laryngeal nerve paralysis (URLNP, BRLNP), overt tetany (OT), and postoperative bleeding (POB). We observed after TT, STT, and DO URLNP: 15 (1.73%), 3 (0.64%), and 2 (0.28%), respectively (p < 0.05); BRLNP: 3 (0.34%), 2 (0.43%), and 0 (0.0%), respectively (p = 0.25); OT: 42 (4.84%), 6 (1.29%), and 9 (1.28%), respectively (p < 0.0001); and POB: 11 (1.26%), 4 (0.86%), and 3 (0.42%), respectively (p = 0.209). Persistent complications we observed after TT, STT, and DO are the following: URLNP: 9 (1.03%), 3 (0.64%), and 1 (0.14%), respectively (p = 0.086); BRLNP: 1 (0.11%), 1 (0.21%), and 0 (0.0%), respectively (p = 0.51); and OT: 11 (1.26%), 2 (0.43%), and 2 (0.28%), respectively (p = 0.052). Incidental thyroid cancer (ITC) was recognized after TT, STT, and DO in 18 (2.07%), 21 (4.52%), and 11 (1.56%), respectively (p = 0.039). Recurrent goitre (RG) was observed in 1 (0.11%) after TT, 3 (0.64%) after STT, and 2 (0.28%) after DO (p = 0.234). Conclusions Performing less radical surgery in NTMNG is associated with a significantly lower risk of early and late URLNP and OT. In the case of BRLNP (early and persistent) and POB, no statistically significant differences are seen. The occurrence of ITC is higher following more radical surgeries. Less radical surgery is connected with a higher risk of RG.

Comparative study between Focus harmonic scalpel and conventional hemostasis in open total thyroidectomy

Objective The aim was to compare between Focus harmonic scalpel and conventional hemostasis in open total thyroidectomy regarding operative time, postoperative complications (hypocalcemia and recurrent laryngeal nerve injury), postoperative blood drainage volume, postoperative pain, and hospital stays. Background Thyroidectomy is one of the most common operations, and many studies have been done to improve the technique of thyroidectomy. Therefore, the author conducted this study to determine if Focus harmonic scalpel is effective in thyroidectomy or not. Materials and methods This study is a prospective, comparative, randomized, and descriptive study of 40 patients having nontoxic multinodular goiter. The patients were divided into two groups: group A was subjected to open total thyroidectomy with Focus harmonic scalpel (20 patients), and group B was subjected to open total thyroidectomy with conventional hemostasis (20 patients). Both groups were compared for age, sex, operative time, postoperative complications (hypocalcemia and recurrent laryngeal nerve injury), postoperative blood drainage volume, postoperative pain, and hospital stays. Results Use of Focus harmonic scalpel in open total thyroidectomy leads to shorter operative time, asP value was highly significant; decrease of postoperative blood drainage volume, asP value was significant; decrease of postoperative pain, asP value was highly significant; and shorter postoperative hospital stays, asP value was significant; however, it does not decrease the rate of postoperative complications (hypocalcemia and the Recurrent laryngeal nerve (RLN) injury), asP value was nonsignificant. Conclusion In open total thyroidectomy, the Focus harmonic scalpel is a reliable and safe tool. Its use is more effective than conventional hemostasis. The surgical operative time and the hospital stay are shorter. The postoperative blood drainage volume is reduced; furthermore, the postoperative pain is less. However, the rates of transient hypocalcemia and recurrent laryngeal nerve injury are statistically nonsignificant.

The association between irisin and muscle metabolism in different thyroid disorders.

Irisin is a new adipo-myokine, encoded by the FNDC5 gene. Currently, there is a discussion regarding the relation between thyroid function and irisin concentration. This prospective study assesses the influence of thyrometabolic changes on serum irisin concentration in association with altered muscle metabolism. This is performed on a large cohort of patients affected by severe hypo- or hyperthyroidism, as well as by the expression of the FNDC5 gene in thyroid tissue affected by different pathologies. The study group comprised 119 patients with newly diagnosed severe hyperthyroidism or hypothyroidism, and a control group of 45 healthy subjects. Body composition, serum irisin concentrations, and thyroid-related hormones, creatine kinase, dystrophin and titin concentrations were evaluated. FNDC5 expression was also analysed in tissue samples from 80 patients with nontoxic multinodular goitre, toxic goitre, Graves' disease and papillary thyroid cancer. Irisin concentration was lower in patients with prolonged hypothyroidism. There was a tendency towards lower dystrophin and titin concentrations in patients with hypothyroidism and hyperthyroidism. Restoration of euthyroidism in patients with hypothyroidism resulted in a decreased muscle mass with an increase in irisin concentrations, while the hyperthyroid group showed an increase in fat mass. Statistically significant overexpression of FNDC5 gene was found in patients with toxic goitre as compared to Graves' disease, papillary thyroid cancer and controls. The presented data support the theory that irisin concentration changes are associated with prolonged hypothyroidism and might primarily constitute the result of prolonged myopathy. These changes are most likely not related to the expression of the FNDC5 gene in the thyroid gland.

Cancer Frequency in Retrosternal Goiter

Retrosternal goiter prevalence is 5 to 40 per cent according to classifications in goiter series. Goiters with mediastinal extension were reported to be related with higher cancer rates. In our study, we aimed to investigate whether cancer incidence increased in retrosternal goiters compared with the cervical ones. Three hundred and ninety consecutive patients, who had surgery because of retrosternal goiter in Istanbul University Medical Faculty Department of General Surgery between 2005 and 2015 were included in the study (Group 1). Control group included 880 patients who had surgery because of nontoxic multinodular goiter in the same period (Group 2). Preoperative ultrasonography (USG) was performed to each patient. Fine-needle aspiration biopsy was performed in suspicious nodules and results were recorded. Carcinomas in histopathological examination were classified as intrathorasic and extrathorasic. Diagnostic rates of USG results were compared with histopathologic cancer results. Papillary carcinoma was diagnosed in 76 patients with retrosternal goiter (19%) and in 200 patients in the control group (22%). No statistically significant difference was detected between groups regarding the tumor rates (P > 0.05). One hundred and forty-four tumoral foci were detected in 76 patients with papillary carcinoma in retrosternal goiter patients. Three hundred and seventy tumoral foci were detected in 200 patients with papillary carcinoma in the control group. In the retrosternal goiter group, 104 carcinoma lesions of 144 papillary carcinomas were intrathorasic (72%). No statistically significant difference was detected between intrathorasic (2.1 ± 1 cm) and extrathorasic regiones (1.9 ± 0.8 cm) regarding the tumor size P > 0.05. When patients with and without cancer in the retrosternal goiter group were compared regarding familial thyroid cancer history, radiation to the neck, and cervical adenopathy, no statistically significant difference was detected. Cancer incidence of retrosternal goiters was not higher than that of the cervical ones. Yet, cancer foci of retrosternal goiters were commonly located in the intrathorasic area and were not detected with USG. Depending on these findings, we suggest that all retrosternal goiters should be surgically treated.

Stimulating TSH receptor autoantibodies immunoassay: analytical evaluation and clinical performance in Graves' disease.

Background Thyroid-stimulating hormone (TSH) receptor (TSHR) autoantibodies (TRAbs) are a heterogeneous group of antibodies (Abs) with different functionalities. Among all TRAbs, only the stimulating ones (S-TRAbs) are considered as the pathogenetic marker of Graves' disease (GD). To date, the methods available for TRAbs testing are based on immunoassays (IMAs) which detect total serum TRAbs or bioassays which are not suitable in clinical practice, even though they discern Abs functionality. The aim of our work was to evaluate the analytical and clinical performance of a very recent IMA (Immulite TSI method), supposed to test only the serum concentration of S-TRAbs, in comparison with a current method for total TRAbs (Roche/Elecsys IMA). Methods We evaluated serum samples of 145 subjects: 46 with untreated (GD), 36 with chronic autoimmune thyroiditis, 3 with atrophic thyroiditis, 10 with multinodular non-toxic goiter and 50 healthy subjects. Results The method showed an optimal analytical sensitivity and high precision levels (LoB: 0.04 UI/L, LoD:0.07 UI/L, LoQ:0.14 UI/L, intra-assay CV: 4.2-5.9%, inter-assay: 4.5-7.2%). By receiver operating characteristics curve analysis, we obtained a value of 0.57 (sensitivity: 98.0%, specificity: 99.9%) as the best cut-off to distinguish GD, apart from four cases. Passing Bablok regression and Bland Altman analysis pointed out a good correlation and agreement with Roche method (R2 = 0.98, slope = 1.03, bias = -2.70). Conclusions The new method presents very promising analytical characteristics and could be adopted in clinical practice for GD diagnosis. Moreover, the test allows to accurately detect very low values of analyte with a further clinical utility in detecting earlier possible relapses.

Ten-Year Follow-Up of a Randomized Clinical Trial of Total Thyroidectomy Versus Dunhill Operation Versus Bilateral Subtotal Thyroidectomy for Multinodular Non-toxic Goiter

BackgroundThe aim of this study was to validate in a 10-year follow-up the initial outcomes of various thyroid resection methods for multinodular non-toxic goiter (MNG) reported in World J Surg 2010;34:1203–13.Materials and methodsSix hundred consenting patients with MNG were randomized to three groups of 200 patients each: total thyroidectomy (TT), Dunhill operation (DO), bilateral subtotal thyroidectomy (BST). Obligatory follow-up period of 60 months was extended up to 120 months for all the consenting patients. The primary outcome measure was the prevalence of recurrent goiter and need for revision thyroid surgery. The secondary outcome measure was the cumulative postoperative and post-revision morbidity rate.ResultsThe primary outcomes were twice as inferior at 10 years when compared to 5-year results for DO and BST, but not for TT. Recurrent goiter was found at 10 years in 1 (0.6%) TT versus 15 (8.6%) DO versus 39 (22.4%) BST (p < 0.001), and revision thyroidectomy was necessary in 1 (0.6%) TT versus 5 (2.8%) DO versus 14 (8.0%) BST patients (p < 0.001). Any permanent morbidity at 10 years was present in 5 (2.8%) TT patients following initial surgery versus 7 (4.0%) DO and 10 (5.7%) BST patients following initial and revision thyroidectomy (nonsignificant differences). At 10 years, 23 (11.5%) TT versus 25 (12.5%) DO versus 26 (13.0%) BST patients were lost to follow-up.ConclusionsTotal thyroidectomy can be considered the preferred surgical approach for patients with MNG, as it abolishes the risk of goiter recurrence and need for future revision thyroidectomy when compared to more limited thyroid resections, whereas the prevalence of permanent morbidity is not increased at experienced hands.Registration number:NCT00946894 (http://www.clinicaltrials.gov).

How does total/near-total thyroidectomy compare with subtotal for the treatment of multinodular non-toxic goiter in adults?

How does total/near-total thyroidectomy compare with subtotal for the treatment of multinodular non-toxic goiter in adults?

Elevated Concentrations of SERPINE2/Protease Nexin-1 and Secretory Leukocyte Protease Inhibitor in the Serum of Patients with Papillary Thyroid Cancer

Introduction. SERPINE2 and secretory leukocyte protease inhibitor (SLPI) are proteins with anticoagulant properties which could promote solid tumor growth. However, their role in the pathogenesis of thyroid cancer has not been determined. Materials and Methods. The aim of this study was to assess serum SERPINE2 and SLPI concentrations in a group of 36 patients with papillary thyroid cancer (PTC) and a group of 19 subjects with multinodular nontoxic goiter (MNG). The control group (CG) consisted of 20 healthy volunteers. Blood samples were collected one day before surgery. Serum SERPINE2 and SLPI concentrations were measured using specific ELISA methods. Results. Significantly higher concentrations of SERPINE2 and SLPI were found in patients with PTC as compared with MNG and controls. Positive correlation was found between SERPINE2 and SLPI concentrations in PTC patients. The levels of SERPINE2 and SLPI did not differ significantly between MNG and healthy controls. Conclusions. Our results indicate that SERPINE2 and SLPI play a significant role in the development of papillary thyroid cancer and imply that the evaluation of serum concentrations of both anticoagulant molecules may be considered as additional marker for the differentiation of malignancies during the preoperative diagnosis of patients with thyroid gland tumors.

Metastatic Neuroendocrine Tumor in the Thyroid: Report of an Incidental Diagnosis

Secondary tumors of the thyroid are quite rare with an estimated prevalence of &lt; 1%. Herein, we describe the incidental discovery of metastatic small cell lung cancer in a non-toxic multinodular goiter. A 57-year-old lady has had a non-toxic multinodular goiter for over 10 years. She has had two thyroid fine needle aspirations (FNAs) in the past, which were reported benign. As the goiter was increasing in size and causing compression, she underwent a total thyroidectomy. Pathology revealed multi-centric high grade carcinoma with small cell/neuroendocrine features with the largest focus being 1.1 cm. Calcitonin staining was negative. Further imaging revealed a 68 × 37 × 51 mm soft tissue mediastinal mass and an 18 × 10 mm left upper lobe pulmonary nodule. She was then initiated on chemotherapy and radiation therapy for extensive stage small cell cancer of the lung. After two cycles of chemotherapy, restaging chest computed tomography (CT) showed interval improvement in lung masses. This rare presentation of small cell lung cancer with multi-centric metastasis to the thyroid highlights the need to obtain nodule directed FNAs, as the two non-directed FNAs done prior to surgery were benign. It also points out to clinicians that rapidly growing goiters are a cause for concern, and should be evaluated, even if patients are not symptomatic. J Endocrinol Metab. 2017;7(6):190-193 doi: https://doi.org/10.14740/jem468w

Metastatic Neuroendocrine Tumor in the Thyroid: Report of an Incidental Diagnosis

Secondary tumors of the thyroid are quite rare with an estimated prevalence of < 1%. Herein, we describe the incidental discovery of metastatic small cell lung cancer in a non-toxic multinodular goiter. A 57-year-old lady has had a non-toxic multinodular goiter for over 10 years. She has had two thyroid fine needle aspirations (FNAs) in the past, which were reported benign. As the goiter was increasing in size and causing compression, she underwent a total thyroidectomy. Pathology revealed multi-centric high grade carcinoma with small cell/neuroendocrine features with the largest focus being 1.1 cm. Calcitonin staining was negative. Further imaging revealed a 68 × 37 × 51 mm soft tissue mediastinal mass and an 18 × 10 mm left upper lobe pulmonary nodule. She was then initiated on chemotherapy and radiation therapy for extensive stage small cell cancer of the lung. After two cycles of chemotherapy, restaging chest computed tomography (CT) showed interval improvement in lung masses. This rare presentation of small cell lung cancer with multi-centric metastasis to the thyroid highlights the need to obtain nodule directed FNAs, as the two non-directed FNAs done prior to surgery were benign. It also points out to clinicians that rapidly growing goiters are a cause for concern, and should be evaluated, even if patients are not symptomatic. J Endocrinol Metab. 2017;7(6):190-193 doi: https://doi.org/10.14740/jem468w