Remaining Thyroid Gland Research Articles

Surgical treatment of unilateral nodal goiter with compression syndrome in patients with autoimmune thyroiditis

Background. The problem of choosing the extent of surgeries on the thyroid gland for unilateral nodular goiter with compression syndrome is of concern for surgeons. In such cases, surgical treatment is absolutely indicated, and the possible variants of the extent of the operation are thyroidectomy and hemithyroidectomy. Thyroidectomy allows eliminating the focus of autoimmune aggression in the body, but in such cases, a patient should use thyroxine drugs for life. The purpose was to determine the indications for the choice of the extent of surgery in patients with unilateral nodular goiter and compression syndrome against the background of autoimmune thyroiditis (AIT) and to predict long-term results of surgical treatment. Materials and methods. The long-term outcomes of hemithyroidectomy were analyzed in 101 women aged 23 to 72 years with unilateral nodular goiter on the background of AIT and compression syndrome. We have analyzed the volume of the gland, echostructure variant, blood levels of thyroid-stimulating hormone (TSH), free thyroxine and triiodothyronine, thyroid peroxidase (TPO) antibodies, apoptosis and proliferation indicators before surgery in which treatment results were satisfactory and unsatisfactory. Results. Satisfactory result was revealed is 75 patients (group 1). According to the survey, they had no violations of the thyroid functional state 3 years after hemithyroidectomy, and, according to the ultrasound, in the parenchyma of the remaining lobe of the gland, the signs of AIT present before the surgery did not progress or progressed without hypothyroidism and changed ultrasound picture. The second group (unsatisfactory result) consisted of 26 patients who 3 years after hemithyroidectomy had an increase in the volume of the remaining thyroid gland and the progression of autoimmune process with the development of hypothyroidism on ultrasound. A satisfactory result of hemithyroidectomy in patients with unilateral nodular goiter on the background of AIT with compression syndrome can be expected in cases where at the time of surgery, the volume of the lobe is not more than 12.7 cm3, the echostructure is hypoechoic, heterogeneous and pseudomicronodular, TSH is not more than 2.85 mIU/l, levels of free thyroxine and triiodothyronine are not lower than 16.7 and 5.3 pmol/l, respectively, TPO antibodies are not higher than 137 IU/ml. Conclusions. One of the possible options for surgical treatment of patients with unilateral nodular goiter on the background of AIT with compression syndrome may be hemithyroidectomy in conditions of preserved hormonal function of the gland with moderate processes of proliferation and apoptosis, structural changes in the parenchyma at the level of hypoechoic and heterogeneous, pseudomicronodular echostructural variants. We consider it contraindicated to use hemithyroidectomy in cases of pseudomacronodular and more severe variants of the echostructure of the thyroid parenchyma, regardless of the indicators of hormone-producing function, TPO antibodies, proliferation and apoptosis.

Surgical treatment of unilateral nodular goiter with compression syndrome in patients with autoimmune thyroiditis

Aim — todetermine indications for the choice of the surgery scope in patients with unilateral nodular goiter with compression syndrome against the background of autoimmune thyroiditis (AIT) and possibility of prognosis of the long-term results of surgical treatment.Materials and methods. The analysis has been performed for the long-term results of hemithyroidectomy in 101 femalepatients aged 23 to 72 years with unilateral nodular goiter against the background of AIT (NGAIT) with compression syndrome. The pre-operational levels of the following parameters, definingsatisfactory and unsatisfactory treatment results, have been analyzed: volume of the lobe of the gland, blood levels of thyroid stimulating hormone, free thyroxine and triiodothyronine, antibodies to thyroid peroxidase, indices of apoptosisand proliferation, variants ofechostructure.Results. Satisfactory results have been established in 75 patients based on the following results of examinations 3 years after hemithyroidectomy: no violations of thyroid gland functional state, andno progression of preoperative AIT signs or progression without hypothyroidism and changesin ultrasound picture in the parenchymaof the remaining lobe of the gland according to the data of ultrasound investigation.Unsatisfactory results were definedin 26 subjects: an increase in the volume of the remaining thyroid gland and the progression of autoimmune process with the development of hypothyroidism. A satisfactory result of hemithyroidectomy in the treatment of patients with NGAIT with compression syndrome can be expected in cases where at the time of surgery the volume of the lobe was not more than 12.7 cm3, its echostructure corresponded to hypoechoic and heterogeneous and pseudomicronodular variants, and the following blood levels were established: thyroid stimulating hormone < 2.85 IU/L, free thyroxine > 16.7 pmol/l, free triiodothyronine > 5.3 pmol/l, antibodies to thyroid peroxidase < 137 IU/ml.Conclusions. One of the possible options for surgical treatment of patients with unilateral nodular goiter against the background of AIT with compression syndrome may be hemithyroidectomy in conditions of preserved hormonal function of the gland with moderately pronounced processes of proliferation and apoptosis, structural changes in the parenchyma at the level of hypoechoic and heterogeneous and pseudomicro-nodal echostructural variants. The use of hemithyroidectomy is contraindicatedin cases of pseudo-large-nodular and more severe variants of the echostructure of the thyroid parenchyma, regardless of the indicators of hormone-producing function, antibodies to thyroid peroxi­dase, proliferation and apoptosis.

Five-year follow-up results of thermal ablation for low-risk papillary thyroid microcarcinomas: systematic review and meta-analysis.

Confidence in long-term treatment results of thermal ablation for papillary thyroid microcarcinoma (PTMC) is required in comparison with active surveillance. The objective of this meta-analysis is to report 5-year follow-up results of thermal ablation for PTMC. Ovid MEDLINE and EMBASE databases were searched through May 30, 2020, for studies reporting outcomes in patients with PTMC treated with thermal ablation and followed up for at least 5 years. Data were extracted and methodological quality was assessed independently by two radiologists according to the PRISMA guidelines. Three studies, involving 207 patients with 219 PTMCs, met the inclusion criteria through database searches. None of these patients experienced local tumor recurrence, lymph node metastasis, or distant metastasis or underwent delayed surgery during a mean pooled 67.8-month follow-up. Five new tumors appeared in the remaining thyroid gland of four patients, with four of these tumors successfully treated by repeat thermal ablation. The pooled mean major complication rate was 1.2%, with no patient experiencing life-threatening or delayed complications. Thermal ablation is an excellent local tumor control method in patients with low-risk PTMC, with low major complication rates at 5 years. • No local tumor recurrence, lymph node metastasis, or distant metastasis was noted by thermal ablation during follow-up of 5 years and none underwent delayed surgery. • The pooled mean major complication rate was 1.2%.

ALK-1-positive inflammatory myofibroblastic tumor of the thyroid complicated by Hashimoto\u2019s thyroiditis: report of a rare case and a literature review

BackgroundInflammatory myofibroblastic tumors (IMTs) of the thyroid are extremely rare soft-tissue tumors. In the literature, IMTs are sometimes called plasma cell granulomas (PCGs) or inflammatory pseudotumors, which often causes ambiguity. To date, 17 cases of PCGs and five cases of thyroid IMTs have been reported. These cases reveal that IMTs of the thyroid are often negative for the anaplastic lymphoma kinase (ALK-1) gene. To provide further information on this rare lesion, we present a case of an ALK-1-positive thyroid IMT and a review of IMTs of the thyroid.Case presentationA 34-year-old Chinese woman presented with a painless neck mass that had persisted for over a month. Ultrasonography revealed a 4.28 × 2.53 cm2 hypoechoic mass, in the left lobe of the thyroid gland. Serum levels of thyroglobulin and anti-thyroglobulin antibodies were high. Subsequently, left lobectomy was performed. Macroscopically, the lesion was a gray-brown nodular mass with a partial envelope. Histologically, two different lesion types were observed. The first lesion showed classic spindle cell proliferation, with spindle cells arranged in fascicles, accompanied by mature inflammatory cells. The other lesion showed a large number of infiltrating lymphocytes, with lymphoid follicles in the remaining thyroid gland, which was atrophic. Immunohistochemical staining showed that the spindle cells were negative for CK19, CyclinD1, Gelectin-3, EMA, CD34, S100, Bcl-2, and STAT-6, but strongly positive for ALK-1, vimentin, and TTF1. CK was focally expressed, and the Ki-67 index was 5%. A diagnosis of IMT was proposed according to immunohistochemical findings and morphology. Hashimoto’s thyroiditis was confirmed according to serum levels of thyroglobulin and anti-thyroglobulin antibodies and morphology. The patient did not receive adjuvant therapy. She remained alive without disease recurrence for 10 months after lobectomy.ConclusionsIMTs should be considered in the diagnosis when spindle cell proliferation accompanied by mature inflammatory cells is observed, spindle cells are mildly atypical, and myofibroblast differentiation is present in the thyroid. A uniform diagnostic term is crucial to avoid ambiguity. Clinicians and pathologists should be aware of the necessity for long-term follow-up, especially in ALK-positive cases. The therapeutic potential of ALK-1 positivity should be explored further.

Effect of Rifampin on Thyroid Function Test in Patients on Levothyroxine Medication.

BackgroundLevothyroxine (LT4) and rifampin (RIF) are sometimes used together; however, no clinical studies have assessed the effects of these drugs on thyroid function or the need to adjust LT4 dose.MethodsWe retrospectively reviewed the records of 71 Korean patients who started RIF during LT4 treatment. Clinically relevant cases that required dose adjustment according to the American Thyroid Association (ATA)/American Association of Clinical Endocrinologists (AACE) guidelines were identified, and risk factors of increased LT4 dose were analyzed.ResultsAfter administering RIF, median serum thyroid-stimulating hormone (TSH) level (2.58 mIU/L, interquartile range [IQR] 0.21–7.44) was significantly higher than that before RIF (0.25 mIU/L, IQR, 0.03–2.62; P < 0.001). An increased LT4 dose was required for 50% of patients in the TSH suppression group for thyroid cancer and 26% of patients in the replacement group for hypothyroidism. Risk factor analysis showed that remaining thyroid gland (odds ratio [OR] 9.207, P = 0.002), the time interval between starting RIF and TSH measurement (OR 1.043, P = 0.019), and baseline LT4 dose per kg body weight (OR 0.364, P = 0.011) were clinically relevant variables.ConclusionsIn patients receiving LT4, serum thyroid function test should be performed after starting RIF treatment. For patients with no remnant thyroid gland and those receiving a lower LT4 dose, close observation is needed when starting RIF and TB medication.

Nodular recurrence and hypothyroidism following partial thyroidectomy for benign nodular thyroid disease in children and adolescents

ObjectivesDiagnostic and therapeutic processing of a thyroid nodule in children and adolescents may require lobectomy–isthmusectomy (LI) or nodule-resection (NR). Very few data in the literature report the long-term evolution of the remaining thyroid lobe in a defined pediatric population. In this study, we aimed to answer the following questions: Does a nodule recurrence occur in the remainder lobe? Is a post-operative thyroxine treatment necessary? Material and methodsThis retrospective study describes 28 patients under 18 who underwent LI (22 cases) or NR (6 cases) from January 2004 to March 2012. Ten of them were lost to follow up, 18 could be assessed (4 NR (22%) and 14 LI (78%) - mean follow-up 45±31 months). All patients benefited of post-operative thyroid ultrasonography, and regular endocrinologic follow-up. The following data were analysed: emergence of new thyroid nodules, evolution of pre-existing nodules, occurrence of post-operative hypothyroidism and requirement for completion thyroidectomy. ResultsThe mean age at the time of surgery was 14.3±1.9 years. Two patients (11%) had pre-existing nodules in the remaining thyroid gland, none of which showed an increase in size after surgery. De novo nodules developed in five patients (27.8%). Three patients who underwent LI (21.4%) needed thyroxine treatment for post-operative hypothyroidism. One patient (5.5%) needed completion thyroidectomy. ConclusionsIn this children and adolescents population, after performing LI or NR, remaining thyroid tissue stays free of nodules in 72.2% of the cases. A post-operative thyroxin treatment is necessary in 21.4% of cases after LI.

A Case of Marine-Lenhart Syndrome with a Negative TSH Receptor Antibody Titer Successfully Treated with a Fixed, Low Dose of I (131.).

We herein describe a case of Marine-Lenhart syndrome with a negative TSH receptor antibody titer. A 75-year-old female presented to our hospital with malaise, palpitations, and mild fine tremors. She did not have any signs suggestive of Graves' ophthalmopathy, including conjunctival injection, periorbital edema, or proptosis. Her laboratory data were negative for thyroid autoantibodies, including anti-thyroid peroxidase antibodies, anti-thyroglobulin antibodies, and anti-TSH receptor antibodies (TRAb). Ultrasonography of the thyroid gland revealed a tumor in the right lobe. The remaining thyroid gland had an inhomogeneous and rough texture with a high color Doppler flow. I123 scintigraphy disclosed a hot nodule in the right thyroid gland corresponding to the tumor detected on ultrasonography, suggesting Plummer disease. Furthermore, there was an increased uptake of radionuclide in the rest of the thyroid gland, despite the suppressed level of TSH and negative titer of TRAb, suggesting underlying Graves' disease. The present findings suggested a diagnosis of Marine-Lenhart syndrome with a negative TRAb titer. Treatment with 10 mCi of radioiodine was highly effective in treating hyperthyroidism in this case. A negative TSH receptor antibody titer does not necessarily rule out the existence of Graves' disease in patients with Plummer disease.

Prognosis of thyroid function after hemithyroidectomy

AbstractIdentify criteria and create a risk scoring system to predict hypothyroidism after hemithyroidectomy. We have retrospectively studied 216 cases of patients with goiter who had undergone hemithyroidectomy from January 2002 to December 2007 at Vilnius University Hospital Santariškių Klinikos. Patients were divided into two groups according to their thyroid function after hemithyroidectomy: 168 (77.8%) patients’ thyroid function was normal (group A), 48 (22.2%) patients had symptoms of hypothyroidism (group B). The relationship between groups and parameters such as patients’ sex, age, patient’s weight, preoperative serum thyroid-stimulating hormone (TSH) level, weight of the remnant gland, ratio of the remaining thyroid gland weight to patient’s weight was statistically analysed. The patients’ mean age was 41.6 ± 14.1 years in group A and 52.9 ± 13.9 years in group B (p=0.0002). The mean preoperative TSH level was 0.79 ± 0.5 mU/L in group A, compared with 1.42 ± 1.00 mU/L in group B (p= 0.005). The mean ratio of the remaining thyroid gland weight to patient’s weight was 0.102 ± 0.053 g/kg in group A and 0.063 ± 0.027 g/kg in group B (p=0.04). The groups did not establish a significant difference between patients’ sex, patient’s weight or weight of the remaining gland. Patient’s age, preoperative serum TSH level, ratio of the remaining thyroid gland weight to patient’s weight is the main factors of hypothyroidism after hemithyroidectomy. A risk scoring system was created to predict hypothyroidism after hemithyroidectomy before the operation.

Reoperative thyroid surgery

Thyroid resection is often performed for a number of benign conditions including compression from multinodular goiter, for cosmetic reasons, or an inability to determine before surgery whether a thyroid nodule is benign or malignant. For goiters that are multinodular and bilateral, total thyroidectomy is definitive treatment and will prevent recurrent disease. Patients who have undergone partial thyroid resection for benign conditions may develop recurrent symptomatic disease in the remaining thyroid gland. The mass effect of recurrent thyroid disease, despite hormonal suppression, may progress to occlude adjacent anatomical structures such as the larynx, trachea, and/ or esophagus. The latter two structures can become compressed either in the neck or the mediastinum, and this compression necessitates not only dissection in the contralateral neck, but re-exploration of the ipsilateral thyroid bed to remove the offending thyroid tissue. Sometimes a large goiter may not necessarily cause compression, but is nonetheless deemed unsightly by an anxious patient Although uncommon, malignancy can subsequently develop in the remaining thyroid following partial thyroidectomy performed for benign disease.l” More commonly, partial thyroidectomy is initially performed for reported benign disease on frozen section examination, but is later determined postoperative11 as containing malignancy on final pathology sections. l, -6 Total thyroidectomy is the preferred surgical treatment for well-differentiated thyroid cancer greater than 1 cm in size, Hurthle cell cancer, cancer in a radiated thyroid, and early poorly differentiated thyroid cancer. The diagnosis of follicular variant of papillary cancer is particularly difficult to make on frozen section, as capsular invasion may be determined only on further sectioning of the permanent specimen.‘,* Patients, who underwent initial thyroid lobectomy for what is finally determined as thyroid cancer, are frequently considered for a second operation to “complete” the thyroidectomy. Few people advocate 1311 ablation of the remaining thyroid gland to achieve a total thyroidectomy because of the associated risks with multiple doses of radioactive treatment, secondary injury to adjacent parathyroid glands, and pulmonary fibrosis.4 The rationale for re-operation include four main reasons: 1) to identify and remove possible residual or multicentric foci of carcinoma in the contralateral lobe; 2) to allow for low-dose 1131 radioactive ablation of microscopic amounts of residual thyroid tissue postoperatively; 3) to facilitate the early detection of cancer recurrence with thyroglobulin levels and thyrogen-

Autonomous thyroid nodules visualized by positron emission tomography with 18F-fluorodeoxyglucose: a case report and review of the literature.

A 41-year-old white female underwent a positron emission tomography with (18)F-fluorodeoxyglucose (FDG-PET) scan as part of staging follow-up for breast cancer. Focal FDG uptake was noted in the right neck. Further evaluation revealed only thyroid nodules and subclinical hyperthyroidism. A sodium pertechnetate thyroid scan showed two "hot" nodules in the right thyroid lobe corresponding to the focal uptake visualized on FDG-PET scan. Technetium-99m uptake was suppressed in the remaining thyroid gland. The patient underwent a subtotal thyroidectomy. Histopathologic evaluation revealed two hyperplastic nodules in each thyroid lobe. We review the literature with regard to FDG-PET imaging of normal and diseased thyroid tissue.

Current Management of the Patient with Autonomously Functioning Nodular Goiter

Autonomously functioning thyroid nodules (AFTNs) are presumably independent of TSH for growth and function and appear "hot" on scintiscan because they selectively concentrate radionuclide to a greater extent than the remaining thyroid gland, which is controlled by the normal TH-TSH feedback mechanism. Such autonomously functioning tissue may occur in "patchy" areas, as a solitary nodule, or as multiple nodules (classic Plummer's disease), with the mass of hyperfunctioning tissue and the related secretion of thyroid hormones determining whether the patient is euthyroid or hyperthyroid. Important diagnostic tests include a 99mTc thyroid scan, T4 RIA, T3 uptake, FTI, TSH RIA, and occasionally T3 RIA ("T3 thyrotoxicosis"). Solitary autonomous nodules in adult patients characteristically progress slowly over many years, with toxicity rarely developing in nodules less than 2.5 cm in diameter and occurring primarily in nodules 3 cm or larger and in older patients. The decision to treat a solitary nodule depends upon the size and degree of function of the nodule and the patient's age. Surgery and radioactive iodine are effective therapies. Hyperfunctioning thyroid nodules in children and adolescents (under age 18) have a more rapidly progressive course than those in adults and should be treated by thyroid lobectomy at the time of diagnosis. Subtotal thyroidectomy is the preferred treatment for most patients with toxic multinodular goiter, because it achieves prompt control of the hyperthyroidism and removes the goiter. Radioiodine therapy and long-term antithyroid drug therapy are alternative forms of treatment for patients who are poor surgical risks or who develop recurrent hyperthyroidism following thyroid surgery.

Papillary carcinoma of the thyroid: Recurrence in the thyroid gland after initial surgical treatment

The purpose of this study was to evaluate the clinical significance of multicentricity of papillary carcinoma by determining the incidence of recurrent carcinoma in the remaining thyroid gland after primary surgical treatment. “Clinical recurrence” usually implies reactivity of the primary tumor which is discernible to the clinician. However, in this report it is used in a broader sense to denote microscopic, minute or gross evidence of cancer found in the remaining thyroid gland after the initial surgical procedure. In the narrower sense some of these are not “clinical recurrences” in that they were not grossly visible or palpable but are included in determining our incidence of “clinical recurrence.” If they were excluded, our percentages of “clinical recurrence” would be much lower. From 1930 to June 1957, 282 patients received their initial surgical treatment on the Head and Neck Service and, when previously reported in 1963, had a minimal follow-up study of five years [9]. Of the 164 patients who underwent lobectomy, thyroid cancer was found subsequently in the remaining contralateral lobe in 3.7 per cent. At the same time the pathologic study showed a 30 per cent incidence of minute carcinoma in the opposite lobe of patients who underwent total thyroidectomy for carcinoma that was grossly confined to one lobe. This group has now been followed up for a minimum of fourteen years. Upon restudying these 164 lobectomized patients, we found a clinical recurrence rate of only 4.2 per cent, even after the passage of an additional nine years. By extending the time interval from 1930 to 1966, a larger group of 376 patients (including the aforementioned 282) with papillary carcinoma of the thyroid also received their initial thyroid surgery at this hospital. These patients with a minimal follow-up period of five years also comprise clinical material for this study. In this larger group, 216 patients underwent total lobectomy and clinically recurrent thyroid cancer was found in the remaining contralateral lobe in 4.6 per cent. (Figure 1.) During the same interval we found from the pathology laboratory study a 38 per cent incidence of occult carcinoma in the opposite lobe of forty-five patients who had undergone total thyroidectomy for clinically unilateral carcinoma. We are convinced that this percentage would be much higher if our Pathology Department used the serial section technic utilized by Clark, and that it would approach his reported incidence of 58 per cent in a similar clinical situation [4]. Thus the rate of occult carcinoma (38 per cent) is eight times greater than the rate of “clinical recurrence” (4.6 per cent). We previously concluded that total thyroidectomy for papillary carcinoma confined to one lobe did not appear to be indicated. The additional clinical material from this study lends further support to the validity of this conclusion.

Papillary carcinoma of the thyroid: Recurrence in the thyroid gland after initial surgical treatment

Our purpose was an evaluation of the clinical significance of the multicentricity of papillary carcinoma of the thyroid by determination of the incidence of recurrent carcinoma in the remaining thyroid gland after primary surgical treatment. From 1930 to June 1957, 282 patients with papillary carcinoma of the thyroid received their initial surgical management of the thyroid gland at this hospital. These patients, with an average follow-up study of eleven years, and a minimum of five years, comprised the clinical material for this study. Of our patients who had a total thyroid lobectomy, in 3.7 per cent recurrent thyroid cancer developed in the remaining contralateral lobe. At the same time, we found a 30 per cent incidence of microscopic carcinoma in the opposite lobe of patients who had a total thyroidectomy for clinically unilateral papillary carcinoma. Hence, there was an eightfold difference between the frequency of microscopic papillary cancer and the rate of ultimate clinical recurrence. The routine performance of total thyroidectomy for papillary carcinoma confined to one lobe, therefore, did not seem indicated.