Thyroidectomy For Graves Research Articles

Calming the Storm: Preoperative Iodine for Thyroidectomy in Graves' Disease

Calming the Storm: Preoperative Iodine for Thyroidectomy in Graves' Disease

Evaluation for primary hyperparathyroidism after radioactive iodine treatment in patients with Graves' disease

BackgroundRetrospective studies are conflicting regarding the risk of primary hyperparathyroidism after radioactive iodine treatment. We hypothesized that primary hyperparathyroidism rates are greater after radioactive iodine than after thyroidectomy and that patients with hypercalcemia after treatment for Graves' disease are not adequately evaluated for primary hyperparathyroidism, contributing to underdiagnosis of radioactive iodine–associated primary hyperparathyroidism. MethodsThis retrospective review considers patients undergoing radioactive iodine or thyroidectomy for Graves' disease at a tertiary referral center between January 1, 2000, and January 31, 2022. Patients were identified using a hospital-based cohort discovery tool; exclusions included history of head/neck radiation, primary hyperparathyroidism/parathyroidectomy, renal dysfunction diagnoses, or treatment with both radioactive iodine and thyroidectomy. Patients with an elevated calcium (>10.2 mg/dL) level measured after treatment were classified as “incomplete workup” (no parathyroid hormone), “likely primary hyperparathyroidism” (parathyroid hormone >40 pg/dL), or “unlikely primary hyperparathyroidism” (parathyroid hormone <40 pg/dL). ResultsOf 900 patients, 468 (52%) had been treated with radioactive iodine and 432 (48%) with thyroidectomy. At a median follow-up of 9.39 years (interquartile range, 5.12–13.25), 25% (n = 224) of patients did not have a serum calcium measured and 52 (8%, n = 676) patients had an elevated calcium level. Hypercalcemia was more common after radioactive iodine (10%) than thyroidectomy (6%, P = .061). Of patients with hypercalcemia, 33 (63%) were “incomplete workup,” 5 (10%) were “likely primary hyperparathyroidism,” and 14 (27%) were “unlikely primary hyperparathyroidism.” There was no difference in primary hyperparathyroidism workup rates between patients treated with radioactive iodine (n = 23) and thyroidectomy (n = 10, P = .389). ConclusionsPatients treated with radioactive iodine for Graves' disease may experience an elevated rate of hypercalcemia, but the majority are not adequately evaluated for primary hyperparathyroidism. Patients with a history of radioactive iodine should undergo regular calcium screening and, if elevated, appropriate workup for primary hyperparathyroidism.

TSH receptor antibody as a predictor of difficult robotic thyroidectomy in patients with Graves’ disease

Thyroidectomy in Graves’ disease can be challenging due to greater thyroid size and vascularity. While thyroid stimulating hormone receptor antibody (TRAb) level is associated with disease severity and thyroid vascularity, its impact on operative outcomes remains unclear. This study aimed to compare challenging factors for robotic thyroidectomy (RT) and open thyroidectomy (OT) in Graves’ disease patients, including TRAb as a predictive factor for difficult thyroidectomy. This retrospective study included Graves’ disease patients who underwent total thyroidectomy between September 2013 and January 2023. The clinical characteristics and operative outcomes were compared between patients who received OT and bilateral axillo-breast approach RT. Factors affecting operation time and estimated blood loss (EBL) were evaluated in both groups using regression analyses. A total of 85 patients received either OT (n = 48) or RT (n = 37). Median thyroid volumes in the OT and RT groups were 72.4 g and 57.6 g, respectively. Operation time was affected by thyroid volume in both groups. Additionally, higher thyroid hormone levels and bilateral central neck node dissection prolonged operation time in the RT group. EBL was marginally associated with thyroid volume in the OT group. However, in the RT group, TRAb level was independently associated with greater EBL (p = 0.04), while no significant association was found with thyroid volume. Predictive factors for difficult thyroidectomy differed by operation approaches. TRAb significantly predicted intraoperative bleeding in RT, while this association was absent in OT. Caution is warranted when performing RT on Graves’ disease patients with high TRAb levels.

Comparison of Perioperative Outcomes in Patients with Graves' Disease Undergoing Total Thyroidectomy With or Without Near Infrared Autofluorescence Imaging.

Background: The impact of near-infrared autofluorescence (NIRAF) imaging on postthyroidectomy hypocalcemia is controversial. As patients with Graves' disease are at increased risk, our aim was to compare postoperative parathyroid function in these patients undergoing total thyroidectomy (TT) with or without NIRAF imaging. Methods: This was a retrospective "before and after" study, comparing outcomes of patients who underwent TT without or with NIRAF imaging at a single center. Primary outcome was the incidence of temporary hypocalcemia and secondary outcomes, rates of incidental parathyroidectomy on final specimens and permanent hypocalcemia. Analyses were performed using Mann-Whitney U and chi-Square tests. Continuous data are expressed as median (interquartile range). Results: There were 85 patients in NIRAF and 100 patients in non-NIRAF group. Groups were comparable regarding age, gender, body-mass index, and thyroid weight. Number of parathyroid glands identified intraoperatively was 3 in both groups (p = 0.47). Intraoperative parathyroid implantation rate was 16.5% in NIRAF and 6% in non-NIRAF group (p = 0.02). Incidental parathyroidectomy rate on final pathology was 12.9% in NIRAF and 32% in non-NIRAF group (p = 0.002). The rates of temporary (11.7% vs. 16%) and permanent hypocalcemia (2.4% vs. 2%) were similar between the two groups, respectively (p = 0.66). Conclusion: To our knowledge, this is the first comparative study investigating the impact of NIRAF on postoperative parathyroid function after thyroidectomy for Graves' disease. The rate of incidental parathyroidectomy on final pathology was lower with use of NIRAF, without an impact on temporary or permanent hypocalcemia rates compared to conventional technique.

Advancing Preoperative Strategies for Thyroidectomy in Graves' Disease: A Narrative Review.

Graves' disease is an autoimmune disorder characterized by thyroid-stimulating antibodies that can potentially lead to thyrotoxicosis, goiter, skin disease, and eye disease. Available treatment options for Graves' disease include management with antithyroid drugs (ATDs), thyroid ablation with radioactive iodine (RAI), and surgical thyroid gland removal. For individuals unable to reach a normal thyroid hormone level, promptly considering a thyroidectomy is essential. Preoperative strategies to achieve a euthyroid state prevent thyroid storms and minimize postoperative complications and are therefore crucial. While variations in professional guidance exist, this review focuses on standard medical interventions as well as compares respective guidelines set forth by the American Thyroid Association, the European Thyroid Association, the American Association of Clinical Endocrinology, and the American Association of Endocrine Surgeons. There is consensus among these organizations underscoring the importance of rendering patients euthyroid prior to surgery and the use of ATDs. Most guidelines recommend screening for vitamin D deficiency as well as endorse thyroidectomy as the preferred treatment option for hyperthyroidism with skilled surgeons. Nevertheless, discrepancies do become apparent in aspects such as potassium iodide (SSKI) course duration and preoperative dexamethasone administration. By understanding these differing approaches, healthcare professionals can more effectively manage Graves' disease prior to surgery, resulting in improved patient outcomes and enhanced surgical success.

Thyroidectomy in Graves' disease

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Attaining biochemical euthyroidism early after total thyroidectomy in Graves' disease may lower long-term morbidity risk.

BackgroundThe relationship between good early control of thyroid hormone levels after thyroidectomy for Graves’ disease (GD) and subsequent risks of mortality and morbidities is not well known. The aim of this study was to examine the association between thyroid hormone levels within a short interval after surgery and long-term mortality and morbidity risks from a population-based database.MethodsPatients with GD who underwent complete/total thyroidectomy between 2006 and 2018 were selected from the Hong Kong Hospital Authority clinical management system. All patients were classified into three groups (euthyroidism, hypothyroidism, and hyperthyroidism) according to their thyroid hormone levels at 6, 12, and 24 months after surgery. Cox proportional hazards models were performed to compare the risks of all-cause mortality, cardiovascular disease (CVD), Graves’ ophthalmopathy, and cancer.ResultsOver a median follow-up of 68 months with 5709 person-years, 949 patients were included for analysis (euthyroidism, n = 540; hypothyroidism, n = 282; and hyperthyroidism, n = 127). The hypothyroidism group had an increased risk of CVD (HR = 4.20, 95 per cent c.i. 2.37 to 7.44, P < 0.001) and the hyperthyroidism group had an increased risk of cancer (HR = 2.14, 95 per cent c.i. 1.55 to 2.97, P < 0.001) compared with the euthyroidism group. Compared with patients obtaining euthyroidism both at 6 months and 12 months, the risk of cancer increased in patients who achieved euthyroidism at 6 months but had an abnormal thyroid status at 12 months (HR = 2.33, 95 per cent c.i. 1.51 to 3.61, P < 0.001) and in those who had abnormal thyroid status at 6 months but achieved euthyroidism at 12 months (HR = 2.52, 95 per cent c.i. 1.60 to 3.97, P < 0.001).ConclusionsThis study showed a higher risk of CVD in postsurgical hypothyroidism and a higher risk of cancer in hyperthyroidism compared with achieving euthyroidism early after thyroidectomy. Patients who were euthyroid at 6 months and 12 months had better outcomes than those achieving euthyroidism only at 6 months or 12 months. Attaining biochemical euthyroidism early after thyroidectomy should become a priority.

Accumulation of Experience and Newly Developed Devices Can Improve the Safety and Voice Outcome of Total Thyroidectomy for Graves’ Disease

Total thyroidectomy (TT) in patients with Graves’ disease is challenging even for an experienced thyroid surgeon. This study aimed to investigate the accumulation of experience and applying newly developed devices on major complications and voice outcomes after surgery of a single surgeon over 30 years. This study retrospectively reviewed 90 patients with Graves’ disease who received TT. Forty-six patients received surgery during 1990–1999 (Group A), and 44 patients received surgery during 2010–2019 (Group B). Major complications rates were compared between Group A/B, and objective voice parameters were compared between the usage of energy-based devices (EBDs) within Group B. Compared to Group B, Group A patients had higher rates of recurrent laryngeal nerve palsy (13.0%/1.1%, p = 0.001), postoperative hypocalcemia (47.8%/18.2%, p = 0.002), and postoperative hematoma (10.9%/2.3%, p = 0.108). Additionally, Group A had one permanent vocal cord palsy, four permanent hypocalcemia, and one thyroid storm, whereas none of Group B had these complications. Group B patients with EBDs had a significantly better pitch range (p = 0.015) and jitter (p = 0.035) than those without EBDs. To reduce the major complications rate, inexperienced thyroid surgeons should remain vigilant when performing TT for Graves’ disease. Updates on surgical concepts and the effective use of operative adjuncts are necessary to improve patient safety and voice outcome.

Safety and Feasibility of Robotic Transaxillary Thyroidectomy for Graves' Disease: A Retrospective Cohort Study.

Despite the increase in experience and understanding of robotic thyroidectomy, its application for Graves' disease (GD) remains controversial. This study aimed to assess the safety and feasibility of robotic transaxillary thyroidectomy (RTT) for GD in comparison with the conventional open thyroidectomy (open group: OG) approach. A total of 192 patients who underwent surgical resection for GD were retrospectively reviewed. Among them, 51 patients underwent RTT and the remaining 141 patients were in the conventional OG. All robotic operations were performed successfully without open conversion. Patients who underwent RTT were significantly younger (P < 0.001) and predominantly of the female sex. Operative time was longer for RTT than for the OG (182.5 ± 58.1 vs. 112.0 ± 29.5; P < 0.001). The mean intraoperative blood loss was not statistically different between RTT and the OG (113.3 ± 161.6 vs. 95.3 ± 209.1, P = 0.223). The mean weight of the resected thyroid was reduced in those who underwent RTT compared with open thyroidectomy (P = 0.033). The overall complication rate for RTT and open thyroidectomy was not significantly different (33.3% vs. 22.7%, P = 0.135). In RTT, the most common complication was transient hypocalcemia (21%). Permanent hypocalcemia and recurrent laryngeal nerve injury occurred in only one patient in each group. The weight of the resected thyroid was not related to the incidence of complications in patients receiving RTT. Considering excellent cosmesis, findings of this study support the safety and feasibility of RTT. Nevertheless, it should be performed by expert surgeons with extensive robotic surgery experience.

Greetings From the Editor of Clinical Thyroidology

Clinical ThyroidologyVol. 34, No. 1 Greetings from the EditorFree AccessGreetings From the Editor of Clinical ThyroidologyAngela M. LeungAngela M. LeungSearch for more papers by this authorPublished Online:4 Jan 2022https://doi.org/10.1089/ct.2022;34.4-5AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail DEAR COLLEAGUES,Happy new year! We're pleased to ring in the new year with this first issue of 2022. I'm particularly thrilled to introduce the newest members of our editorial board, toward the mission of continually providing a diverse set of perspectives, areas of focus, and commentaries to the literature we review. Please join me in welcoming our newest experts to the Clinical Thyroidology editorial board: Dr. Sara Ahmadi, Brigham and Women's Hospital, U.S.A.Dr. Takashi Akamizu, Kuma Hospital, Japan.Dr. Lindsay Bischoff, Vanderbilt University, U.S.A.Dr. Kenneth Burman, Georgetown University, U.S.A.Dr. Mayumi Endo, University of Washington, U.S.A.Dr. Natalia Genere, Washington University, U.S.A.Dr. Giorgio Grani, Sapienza University of Rome, ItalyDr. Allen Ho, Cedars Sinai Medical Center, U.S.A.Dr. Joana Klubo-Gwiezdzinska, National Institutes of Health, U.S.A.Dr. Anupam Kotwal, University of Nebraska Medical Center, U.S.ADr. Elizabeth McAninch, Stanford University Medical Center, U.S.A.Dr. Alex Tessnow, University of Texas Southwestern Medical Center, U.S.A.In this issue, we begin with Dr. Gary Francis reviewing a study that examines the associations between thyroid disorders in adolescence and incident type 2 diabetes mellitus in adulthood. Is there good news for those waiting for a thyroid hormone treatment that can maintain sustained serum T3 concentrations? Dr. Elizabeth McAninch discusses a Phase 1 clinical trial of PZL, a new compound that shows promise to do just that. Addressing the topic of hyperthyroidism, Drs. Matthew Balcerek and Donald McLeod review a meta-analysis assessing the associations between radioactive iodine use and incident cancer risks, while Dr. Lilah Morris-Wiseman shares her perspective on a patient survey study surrounding quality of life and thyroid-specific symptoms before and after thyroidectomy for Graves’ disease.Dr. Natalia Genere summarizes a study assessing the very common clinical scenario of incidentally finding a thyroid nodule on FDG PET CT scanning — should these incidentalomas be standardly evaluated for a potential biopsy? On a similar topic, Dr. Giorgio Grani provides his perspectives on a recent meta-analysis assessing the appropriateness of thyroid ultrasonography use in routine clinical practice.Epidemiologic considerations of the rising incidence of thyroid cancer is assessed in a study discussed by Drs. Reem ElSheikh and Spyridoula Maraka. Drs. Omar El Kawkgi and Juan Brito discuss a survey study assessing the demographic characteristics of patients with thyroid cancer and their clinicians who advise their diagnostic and treatment recommendations. The mechanisms of resistance from lenvatinib combined with anti-PD-1 combination therapy are explored in a recent study covered by Dr. Benjamin Gigliotti. From a surgical perspective, Drs. Amanda Bastien and Allen Ho provide their insights on how anatomic variations of the recurrent laryngeal nerve may be an important consideration during thyroid surgery.Finally, we are thrilled to feature the top-scoring abstracts presented at the 2021 Annual Meeting of the American Thyroid Association throughout the journal this year. Our first abstract this year is authored by Drs. Malik Faheem, Yasaman Motlaghzadeh, Ivana Jankovic, and Chrysoula Dosiou, who describe a case series of 3 patients who all experienced silent thyroiditis following receipt of an mRNA vaccine for SARS-CoV-2. I urge you all to read their description of these interesting patients and proposed possible mechanisms for this entity.We invite our readers to join us through our social media channels. Through the following, we discuss content featured in each month's issue and other issues related to hot topics in the clinical thyroid literature:Twitter:https://twitter.com/clinicalthyroid(@clinicalthyroid)Facebook:https://www.facebook.com/ThyroidAssociationLinkedIn:https://www.linkedin.com/company/american-thyroid-associationYoutube:https://www.youtube.com/user/thyroidorgAlso, note that most of the material covered in Clinical Thyroidology is also translated into shorter lay summaries in our sister journal, Clinical Thyroidology for the Public [CTFP] (https://www.thyroid.org/patient-thyroid-information/ct-for-patients), that is edited by Dr. Alan Farwell and his team each month. The summaries in CTFP may be of use to patients and the public who are interested in reading more about recently published studies in the clinical thyroid literature.I hope that each issue provides helpful reviews, commentaries, editorials, and perspectives regarding how best to treat patients with thyroid disease. Guidelines for submitting Letters to the Editor and select Guest Editorials that cover timely and innovative aspects of clinical thyroid disease management may be found at https://home.liebertpub.com/publications/clinical-thyroidologyand174/623/for-authors.Thank you again for your interest in Clinical Thyroidology. Please feel free to send me any questions or comments at clinicalthyroidology@thyroid.org.Warmest regards,Angela M. Leung, MD, MScEditor-in-Chief, Clinical ThyroidologyFiguresReferencesRelatedDetails Volume 34Issue 1Jan 2022 InformationCopyright 2022 American Thyroid Association, Inc.To cite this article:Angela M. Leung.Greetings From the Editor of Clinical Thyroidology.Clinical Thyroidology.Jan 2022.4-5.http://doi.org/10.1089/ct.2022;34.4-5Published in Volume: 34 Issue 1: January 4, 2022PDF download

Thyroidectomy for Graves’ Disease Rapidly Improves Symptoms and Quality of Life

Thyroidectomy for Graves’ Disease Rapidly Improves Symptoms and Quality of Life

Thyroid Neoplasm in Graves' Disease: A Single Center Experience

Objective: Different comments are stated in the studies about the association between Graves’ disease and thyroid neoplasms. The aim of this research was to evaluate the prevalance of thyroid neoplasm in patients with Graves’ disease who underwent thyroidectomy. Materials and Methods: A retrospective examination was made of 200 patients, who were followed up with the diagnosis of Graves' disease between 2008 and 2020. A total of 46 patients who underwent thyroidectomy were evaluated in the study. Euthyroidism was achieved in all patients before the operation. Results: Thyroidectomy for Graves’ disease was performed in 46 cases. Thyroid neoplasm was identified in the surgically-resected specimens of 12 patients (26.1%). The prevalence of thyroid neoplasm was higher in patients with nodules than in those without (p= 0.08). The level of white blood cells was higher in patients with neoplasm than in those without. The levels of thyroglobuline antibody and thyroid peroxidase, which are increased in autommune thyroiditis, were higher in patients without neoplasms than in those with neoplasm. Conclusion: In addition to careful physical examination, thyroid ultrasonography should be performed in patients with Graves’ disease. Surgery should be recommended for patients with suspicious or malignant findings on thyroid ultrasonography and fine needle aspiration biopsy. Also, increased white blood cell count and low thyroid autoantibody levels should raise suspicion of the presence of neoplasm.

Colorectal endometriosis with a large polypoid lesion

A 39-year-old woman was referred to our hospital because of a positive fecal occult blood test result. She had undergone uterine myomectomy 6 years earlier, and she had been treated with levothyroxine for hypothyroidism after thyroidectomy for Graves’s disease. A physical examination revealed a left-sided abdominal mass without tenderness. A laboratory test showed that the levels of serum tumor markers were within normal range. A barium enema revealed a 4-cm protruding lesion in the descending colon (A). The lesion looked like a submucosal tumor with reddish mucosa and dilatated vessels (B). Magnifying endoscopy with crystal violet staining showed 2 types of pit pattern: most was regular and rounded, whereas a small area had an enlarged and irregular pit pattern (C). Surgical histopathologic examination confirmed that the protruding lesion was composed of endometrial glands and stroma surrounded by smooth muscle bundles (D, H&E, orig. mag. ×40). The results of testing for immunohistochemistry, estrogen receptor (ER), and progesterone receptor were positive. Therefore, we diagnosed polypoid endometriosis. Retrospectively, a biopsy specimen from the lesion with irregular pits showed that a few glands were positive for ER (E, Immunohistochemistry for ER, orig. mag. ×200). Colorectal endometriosis usually presents as eccentric wall thickening and surface nodularities, and diagnosis by endoscopic biopsy is difficult. Our case suggests that magnifying endoscopy is useful for diagnosis with target biopsy for intestinal endometriosis.

Thyroidectomy for Graves’ disease

Thyroidectomy for Graves’ disease

Thyroidectomy for Graves' Disease Predicts Postoperative Neck Hematoma and Hypocalcemia: A North American cohort study.

Objective:Examine the association of Graves’ disease with the development of postoperative neck hematoma.Design:A cohort of patients participating in the Thyroid Procedure-Targeted Database of the National Surgical Quality Improvement Program from January 1, 2016 to December 31, 2018.Setting:A North American surgical cohort study.Methods:17 906 patients who underwent thyroidectomy were included. Propensity score matching was performed to adjust for differences in baseline covariates. Multivariate logistic regression was used to ascertain the association between thyroidectomy for Graves’ disease and risk of postoperative adverse events within 30 days of surgery. The primary outcome was postoperative hematoma. Secondary outcomes were postoperative hypocalcemia and recurrent laryngeal nerve injury.Results:One-to-three propensity score matching yielded 1207 patients with mean age (SD) of 42.6 (14.9) years and 1017 (84.3%) female in the group with Graves’ disease and 3621 patients with mean age (SD) of 46.7 (15.0%) years and 2998 (82.8%) female in the group with indications other than Graves’ disease for thyroidectomy. The cumulative 30-day incidence of postoperative hematoma was 3.1% (38/1207) in the Graves’ disease group and 1.9% (70/3621) in other patients. The matched cohort showed that Graves’ disease was associated with higher odds of postoperative hematoma (OR 1.65, 95% CI 1.10-2.46) and hypocalcemia (OR 2.04, 95% CI 1.66-2.50) compared with other indications for thyroid surgery. There was no difference in recurrent laryngeal nerve injury among the 2 groups.Conclusions:Patients with Graves’ disease undergoing thyroidectomy are more likely to suffer from postoperative hematoma and hypocalcemia compared to patients undergoing surgery for other indications.

Hemodynamic Instability during Thyroidectomy in Graves’ Disease

Background The aim of this study was to investigate the changes in vital signs and hemodynamic status that occur in patients during the intraoperative course of thyroidectomy in Graves’ Disease (GD). Methods A total of 71 patients were included in the study. Patients were directed to surgery when they had large goiters with compressive symptoms or suspicious nodules, were pregnant or lactating, were unresponsive or intolerant to antithyroid drugs (ATDs), or expressed a preference to have surgery. All patients scheduled for operations underwent surgery while in the euthyroid state. Results Hemodynamic instability was observed in 18 patients during thyroidectomy. Disease duration, sample weight, and thyroid-stimulating hormone receptor antibodies (TRAb) levels were found to be effective on hemodynamic instability. Logistic regression analysis revealed an 11-fold increase in the instability risk in patients with a period of disease shorter than 21 months (P = 0.037). A TRAb value >11.5 increased the risk by 235fold (p < 0.001). Conclusion High levels of TRAb values and new onset of disease with shorter periods of ATDs use may be risk factors for hemodynamic instability during thyroidectomy. Patients with larger thyroid glands are at greater risk for instability during surgery. Those risks should be taken into account during surgery, and the surgical and anesthetic management of the patient should be made more carefully in concordance with the anesthesia team.

Total versus near-total thyroidectomy in Graves' disease: a systematic review and meta-analysis of comparative studies.

Total thyroidectomy (TT), near-total thyroidectomy (NT), and subtotal thyroidectomy (ST) are three surgical procedures for Graves' disease (GD) patients, but most previous studies have only evaluated the complications of TT versus ST or TT/NT versus ST; there is not a meta-analysis of NT versus TT, so whether NT is superior to TT for GD patients still unclear. We comprehensively searched PubMed, Embase, Web of Science, and the Cochrane Library, without restriction to region, publication type, or language, on 10 June, 2020. We conducted this systematic review and meta-analysis of all included studies assessing the two surgical procedures. In total, 528 cases were identified from two randomized controlled trials (RCTs) and three retrospective studies. The incidence of permanent hypoparathyroidism after NT was lower than with TT [odds ratio (OR), 0.22; 95% confidence interval (CI), 0.06-0.80; P=0.02], and there was no statistical difference in the recurrence of hyperthyroidism (OR, 0.33; 95% CI, 0.01-8.12; P=0.50) and other postoperative complications (P>0.05). NT for GD was superior to TT regarding permanent hypoparathyroidism, but there was no significant difference in preventing recurrent hyperthyroidism, as well as the other postoperative complications.

Difficult total thyroidectomy in radioiodine refractory Graves’ disease with pre-operative voice change

Thyroidectomy for Graves’ disease is challenging and if the patient had radioiodine ablation with its inflammatory changes which can make total thyroidectomy a herculean task. Here, we present a case of Graves’ disease with exophthalmos who underwent total thyroidectomy following 4 times radio ablation.

MON-439 Graves’ Disease and Papillary Thyroid Cancer: A Rare Clinical Case?

Background: Nodules on the background of Graves’ disease are less common among men than among women, but more than one in three patients have carcinoma. Despite the improvement of diagnostic methods, most often thyroid cancer is a random histological finding after thyroidectomy for Graves’ disease. Clinical case: A 55-year women complained of discomfort in the neck, sweating, irritability, palpitation. From anamnesis: in 2012 she was diagnosed with thyrotoxicosis syndrome. For 5 years, the patient was treated with thyrostatics, but when trying to reduce the dose, the syndrome of thyrotoxicosis recurred. In March 2017, the patient’s condition worsened, at the time of treatment she took Thyrosol 30 mg/day. Objectively: hypersthenic body type, BMI 33 kg/m2. Thyroid gland visually was increased in volume, dense with palpation, homogeneous, mobile. Elevated titer of antibodies to the TSH receptor was discovered, according to the ultrasound - increase thyroid gland 30.2 cm3, hyperechogenic formation of the left lobe 10х10х9 mm with hypoechoic rim, clear smooth contours, intranodular blood flow. As a result, the Graves’ disease, goiter grade 2, manifest thyrotoxicosis was verified, surgical treatment was recommended. Thyroidectomy, histological examination was performed: Graves’ disease was confirmed, papillary microcarcinoma with metastasis to 1 regional lymph node was revealed. Diagnosed: papillary thyroid cancer I st (pT1aN1aM0x), 2 clinical group. The patient was prescribed suppressive therapy with L-thyroxine 100 µg/day, against which after 3 months TSH reached the target values (0.2–0.5 Mme/l). Taking into account the histological characteristics of the tumor, the nature and volume of the lesion, age, the patient belongs to the group of intermediate cancer risk of progression of cancer. According to scintigraphy residual functioning thyroid tissue (20x15 mm) was detected. Radioiodine therapy was carried out in a specialized hospital. Suppressive therapy of L-thyroxine 150 µg/day, target values of TSH 0.1 - 0.5 Mme/l was recommended. After 6 months, TSH reached target values, and according to the results of ultrasound of thyroid gland no data for structural relapse was found. Conclusion: Patients with long-existing, often recurrent Graves’ disease and questionable effect of conservative therapy, in the presence of nodular formation should be assigned to the risk group for the presence of thyroid cancer and carefully examined, because the need for further surgery depends on it.

Comment on “Total Versus Near-Total Thyroidectomy in Graves’ Disease Results of the Randomized Controlled Multicenter TONIG-Trial”

Comment on “Total Versus Near-Total Thyroidectomy in Graves’ Disease Results of the Randomized Controlled Multicenter TONIG-Trial”