Thyroxine Suppressive Therapy Research Articles

SAT554 Follicular Variant of PTCA Initially Presenting with Widespread Metastases

Abstract Disclosure: N.N. Bisquera: None. R.C. Mirasol: None. Background: Papillary thyroid carcinoma accounts for most cases of thyroid cancer. Most cases of PTC have a good prognosis and low incidence of metastases. The follicular variant is the most common variant. First described in the 1960’s, the understanding of FV-PTC began to evolve with molecular profiling demonstrating a similarity with FTC, and clinical behavior profiling showing that a subtype may behave like PTC with a propensity for lymph node metastases. We are presented with an unusual case of an infiltrative FV-PTC presenting with widespread multiple metastases on diagnosis. Clinical Case: A 64-year-old female, presented with 1-year history of a slowly enlarging mass on the left mandible, which was also associated with an enlarging anterior neck mass. She had no constitutional symptoms and had previously been in good health. On examination, there was a 7x8x3 cm hard, fixed left mandibular mass. There was also a palpable right thyroid nodule measuring 2.5x2 cm. There was no difficulty in swallowing or breathing, but she had some difficulty in eating due to trismus. There were no associated symptoms of hypo/hyperthyroidism. Investigations revealed a euthyroid status. CT scan showed a solid lobulated heterogeneously enhancing mass measuring 4.2x5.1x5.2cm on the body and angle of the left mandible. Ultrasound showed multiple thyroid nodules, the largest - a mixed cystic and solid mass measuring 2.9 x 2.7 x 2.17 cm on the right thyroid lobe, for which FNA was performed. Histopathology showed benign follicular nodules. Incision biopsy of the mandibular mass showed presence of thyroid tissue. Further imaging showed metastases to the left frontal, parietal bone, T7 vertebra, and bilateral lungs. The case was discussed in a multi-disciplinary tumor board meeting. With a pre-operative diagnosis of a primary thyroid malignancy, the patient then underwent a total thyroidectomy with segmental mandibulectomy. Post-operative histopathology showed a metastatic multifocal infiltrative follicular variant of PTC. RAI was administered post-surgery, and she was started on suppressive thyroxine therapy. Steroids were given during RAI, with no untoward events post treatment. Post-ablative whole body scanning revealed increased tracer uptake in multiple areas: left frontal and parietal bone, bilateral thyroidal beds, left supraclavicular lymph node, the sternomanubrial junction, bilateral lung lobes, right humeral head and T7 vertebra. Further doses of RAI was planned and she is currently maintained on suppressive thyroxine therapy. Conclusion: Diagnosis of FV-PTC may be a greater challenge than conventional forms because of possible false-negative results on cytology. The infiltrative subtype has greater metastatic potential and higher recurrence rates. Multidisciplinary team management and careful preparation prior to treatment with RAI is indicated in these cases. Presentation Date: Saturday, June 17, 2023

Metastatic Malignant Struma Ovarii in a Nulliparous Patient: A Case Report

Introduction: Malignant struma ovarii is a rare tumor, Due its rarity treatments and follow-up approaches are not clearly standardized. Case Presentation: we present a case of a 29 -year-old, nulliparous woman with metastatic malignant struma ovarii revealed by abnormal vaginal bleeding and abdominal-pelvic pain. After surgical resection, the patient had complementary radioiodine therapy (131I) after total thyroidectomy. She received a treatment dose of 100 mCi of 131I followed by post-therapy whole-body scintigraphy. Discussion: Histological diagnosis of malignant struma ovarii is similar to that of well differentiated thyroid carcinoma. there are no guidelines regarding the management of this type of cancer. After surgical resection of malignant struma ovarii, adjuvant therapy with thyroidectomy followed by radioactive 131 I therapy and suppressive thyroxine therapy is suggested. The same follow-up as thyroid cancer is commonly adopted, with abdomino-pelvic evaluation. Conclusion: Large clinical studies are needed to standardize the care of patients with malignant struma ovarii.

Warthin-like papillary thyroid carcinoma: a case report and comprehensive review of the literature.

Papillary Thyroid Carcinoma (PTC) is the most frequent endocrine malignancy with a variety of histological presentations. Warthin-like Papillary Thyroid Carcinoma (WLPTC) is an uncommon neoplasm that is recognized as a distinct subtype of PTC in the WHO classification of thyroid tumors. In this report, we present a novel case of WLPTC in a female patient and provide an in-depth review of the available literature on its clinical, pathological, and therapeutic characteristics. A 27-year-old female patient was referred for neck swelling. Ultrasound showed two suspicious thyroid nodules leading to a thyroidectomy. She was diagnosed with intermediate-risk bifocal foci of classic PTC and WLPTC, arising from a background of chronic lymphocytic thyroiditis (CLT). This pT1b(m) N1b M0 malignancy was treated with adjuvant isotopic ablation and suppressive thyroxine therapy. The 1-year outcomes were favorable. It covered articles published from 1995 to 2022, by searching PubMed and Google Scholar using specific terms. Out of 148 articles reviewed by two authors, 25 relevant articles were selected, including 13 case reports and 12 case series. The study included 150 cases of WLPTC. Data related to clinical presentation, imaging, histological features, management, and outcomes, were extracted. The mean age of diagnosis was 39 years, with a female predominance. The most common clinical presentation was neck swelling. Thyroid autoimmunity was positive in 71.6% of patients. Lymph node metastases were present in 28% of cases, with no reported distant metastases. Overall, the outcomes were favorable. WLPTC shares similar clinical and radiological presentations as classic PTC. The hallmark histological features of WLPTC are papillae lined with oncocytic tumor cells with papillary nuclear changes and lymphoid stroma. WLPTC is almost constantly associated with CLT. The management of WLPTC aligns with that of classic PTC with comparable stage and risk category, often resulting in favorable outcomes.

Papillary Thyroid Carcinoma Arising in Thyroglossal Duct Cyst and Locally Infiltrated to Hyoid Bone: Issue of Individualized Management

Thyroglossal duct cyst (TGDC) is the most common developmental anomaly of the thyroid gland, while TGDC carcinoma with local infiltration to the hyoid bone is extremely rare. The reported case of papillary thyroid carcinoma (PTC) was diagnosed in TGDC along with local infiltration to the hyoid bone and needed individualized management. A 70-year-old male patient presented with a history of PTC arising in TGDC and locally infiltrated to the hyoid bone followed by total thyroidectomy and radical sistrunk operations and was referred to National Institute of Nuclear Medicine and Allied Sciences (NINMAS) for radioactive iodine therapy (RAIT). His post-operative ultrasound of the neck revealed an irregular shaped, fungating, grossly non-homogenous mixed echogenic mass lesion invading the hyoid bone, measuring about 25 X 28 mm. Radioactive iodine(131I) of 150 mCi was administered because the residual hyoid bone mass was inoperable and he was on thyroxine suppression therapy. The post-therapy 131I scan (RxWBS) showed two intense foci of radiotracer concentration (RTC) in the upper area (above the thyroid bed) and an intense focal RTC in the fundal region of the stomach. The activity in the stomach region was evaluated by ultrasound imaging, which revealed a soft tissue mass or thickening of the mid-region of the posterior wall of the stomach (3.3 cm X 1.6 cm). A CT scan of the chest was also performed to rule out metastasis, and it revealed multiple nodular lesions in both lung fields (most likely secondary) as well as tiny subcentric lymphnodes in the lower pre- and right paratracheal regions after nearly one month of RAIT when the patient was stable for examination. EBRT is still under consideration as adjuvant therapy. Tyrosine kinase inhibitors (TKI) may be considered in cases of refractoriness to radioiodine and disease progression. Bangladesh J. Nuclear Med. 26(1): 67-70, 2023

The Role of Aspiration and Thyroxine Suppression Therapy in Management of Benign Thyroid Nodules

A prospective study on 142 patients presenting with (benign euthyroid nodule) , after diagnostic work-up included a clinical evaluation, thyroid function tests, ultrasonography, thyroid scintigraphy and fine needle aspiration cytology. Based on the investigations, patients were managed with aspiration andthyroxine suppression therapy for sex month . Patients were divided into four groups according to their response of treatment ,group( 1) complete shrinkage response ,group( 2) reduction in size ,group (3) no response but same size and group (4) enlarge in size non responders’.Of the 142 patients17 (12 %) were male, and 125 (88 %) were female. The age rangein 99 (69.7%) patients were between 21 and 50 years and forty three patients were above 50 years of age. We divided our result into four groups,group( 1) complete shrinkage response29 patients’ (20.5%),group( 2) reduction in size 45 patients’ (31.8%),group (3) no response but same size38 patients’ (26.7%) and group (4) enlarge in size non responders30 patients’(21% )Thyroxine suppressive treatment were effective in shrinking about one fifth of thyroid nodules. Similarly, there was reduction in size in about one third of nodule.From 17 male 6 patients (35 %) achieve complete response ,while only23 female patients (18 %) achieve complete response, and from17 male patients 5 (29 %) achievereduction in size,while only 40 female patients (32 %) achieve reduction in size. Young age less than fifty achieve good response than older patients(63.6%).Single aspiration needed in26 patients(18.3%) while multiple aspiration needed in 116 patients(81.7%).

The effect of suppressive thyroxine therapy in nodular goiter in postmenopausal women and 2 year's bone mineral density change.

The efficacy of thyroxine suppressive therapy in reducing nodular growth and its effect to bone mineral density (BMD) in postmenopausal women is still debated. This study aimed to evaluate the therapeutic effect of thyroxine and its influence on BMD. Postmenopausal women with nodular or multinodular goiter during 2013-2015 at Chang Gung Memorial Hospital were enrolled and retrospectively traced back to the first date of visit or treatment. Ninety-four eligible patients were enrolled, of whom 45 were thyroxine-treated (LT-4 group) and 49 were treatment-naïve (control group). Data, including volume of nodules, were analyzed retrospectively. BMD was measured in each LT-4 group patient since the year of enrollment. Nodular volumes were reduced in both LT-4 (from 4.89 ± 4.46 to 4.10 ± 4.57 mL, p = 0.033) and control group (3.48 ± 4.36 to 3.09 ± 2.88 mL, p = 0.239) at initial 2-year follow-up. Nodular volume in LT-4 group increased insignificantly (from 4.89 ± 4.46 to 4.91 ± 5.40 mL, p = 0.711) at the end of 7-year follow-up. The best cut-off predictive nodular volume that may have responded to thyroxine is 2.6 mL (AUC, 0.740; sensitivity, 0.750; specificity, 0.733) during first 2 year. Lumbar spine, total hip and femoral neck BMD were not significantly changed during 2 year's thyroxine suppression therapy. In conclusion, thyroxine suppressive therapy in postmenopausal women had significant reduction in nodule volume at initial 2 years of treatment, especially in volume larger than 2.6 mL. Prolonged thyroxine treatment did not benefit nodular size reduction and may affect BMD minimally in postmenopausal women.

Relationship between sarcopenia and dose-limiting toxicity (DLT) of sorafenib (SOR) in patients (pts) with advanced radioactive iodine-refractory differentiated thyroid cancer (RAI-R DTC) in the phase III DECISION trial.

e17594 Background: In the phase III DECISION trial comparing SOR with placebo, pts with advanced RAI-R DTC treated with SOR experienced higher rates of adverse events (AEs) than pts with renal cell carcinoma and hepatocellular carcinoma treated with SOR (Brose et al. Lancet 2014). We hypothesized that long-term thyroxine suppressive therapy might result in a high prevalence of sarcopenia, which is known to be associated with increased toxicity of SOR (Antoun et al. Ann Oncol 2010), and we investigated whether sarcopenia at baseline correlated with DLT. Methods: In DECISION, pts with an analyzable baseline lumbar CT scan were eligible. Skeletal muscle cross-sectional area at the third lumbar vertebra was measured, and the median value for each sex defined the cut-off points for sarcopenia. DLT was defined as any AE leading to dose modification; early toxicities occurred ≤30 days after treatment initiation. Results: Of 365 eligible pts, 199 (55%) were sarcopenic (SOR n = 100, placebo n = 99) with large geographic differences: 65/91 Asians (71%), 29/62 North Americans (47%), and 105/212 Europeans (50%). Sarcopenia was 3-fold more frequent than non-sarcopenia in pts ≥75 years of age (19% vs 6%) and was associated with lower body weight (mean [standard deviation]: 71.3 [16.8] vs 80.8 [19.5]; P < 0.0001). Among SOR pts, 76/180 (42%) experienced early DLT of which 44/76 (58%) occurred in sarcopenic pts (P = 0.6497). Among the 90 males, 61 (68%) were sarcopenic and of the 35 males with early DLT, 27 (77%) were sarcopenic. Median time to DLT in sarcopenic vs non-sarcopenic pts who received SOR was 63 vs 95 days, respectively (log-rank P = 0.5328). Conclusions: In this exploratory analysis from DECISION, approximately half of the pts were sarcopenic. In the overall population, no association between sarcopenia and early DLT or DLT were found. Clinical trial information: NCT00984282.

Management of Thyroid Nodules

Thyroid nodules are common in ENT practice with a prevalence of 4-8% on clinical palpation and up to 8 - 76% when evaluated with an Ultrasound Scan (US). When the nodule size is 1 cm or more it becomes clinically palpable. Approximately 5% of thyroid nodules are malignant. Detailed history and clinical examination are important in the evaluation of patients with thyroid nodules. Though US and Fine Needle Aspiration Cytology (FNAC) are useful investigations for thyroid nodules, it may not be possible to arrive at a diagnosis in all cases. Several US features suspicious for malignancy have been identified. Classification systems based on the FNAC results have been devised and are useful in surgical decision-making and management. Molecular testing can be used in nodules with FNAC results of atypia or follicular neoplasm, to stratify the risk of cancer. Patients with benign cytology may need a lobectomy for compressive symptoms or cosmetic concerns. Follicular lesions on FNAC need a diagnostic lobectomy followed by completion thyroidectomy, if proven to be malignant. Majority of the Differentiated Thyroid Cancers (DTC) will require total thyroidectomy, radio-active ablation and suppressive thyroxine therapy.

Solitary skin metastasis of papillary thyroid carcinoma.

A solitary skin metastasis is a rare manifestation of papillary thyroid carcinoma (PTC). A 55-year-old woman presented with a movable subcutaneous nodule in her anterior neck for several months. Three years ago, she underwent total thyroidectomy and remnant ablation for classical PTC (pT3N0M0) and was under thyroxine suppression therapy without any evidence of recurrent disease. The subcutaneous nodule was 0.4 cm in size, firm, and movable without any change in the overlying skin. Recurrent PTC was confirmed after excision biopsy. Eight months after, she got a new nodule along the previous excision site. After punch biopsy, metastatic PTC was confirmed in the deep dermis and was re-excised with a clear resection margin. This is the first report of a case of solitary skin metastasis of PTC in Korea. Although solitary skin metastasis of PTC is rare, it should be considered in patients with a skin nodule.

Thyroid Carcinoma in Children and Young Adults: Retrospective Review of 19 Cases

Thyroid carcinoma is rare in children and young adults. Most of management guidelines are based in data from adult population. Several controversies remain regarding the aggressiveness of clinical presentation and therapeutic approach. To evaluate all differentiated thyroid carcinoma patients with less than 20 years-old at presentation reflecting the experience of our unit in relation to diagnosis, treatment and follow-up of this clinical entity. This is a retrospective review of clinical records of all children and young adults followed at Oncology Consultation of Department of Endocrinology of Centro Hospitalar e Universitário de Coimbra between 1996 and 2012. Nineteen patients with mean age of 16 years old were followed, 13 girls and 6 boys. None of the patients had previous neck irradiation. A palpable cervical mass was the presenting complaint in 84.6%. FNA was performed in 15 patients and was diagnostic or suspicious of malignancy in 71.4%. Total thyroidectomy was performed in 18 cases (94.7%). Papillary carcinoma was identified in all. Vascular invasion and multicentry occurred in 21.1%. Mean tumor size was 2.5cm. Cervical lymph node involvement was diagnosed in 31.6% and distant metastases in 5.2%. The majority of patients (18 in 19) were classified as stage I disease. All patients received thyroxine suppressive therapy and postoperative radioiodine ablation was given to 84.2% (mean dose 85.7mCi). During mean follow-up of almost 6 years, 16 patients remain disease free. In our series, cervical lymph node and distant metastases rates were similar to that found in adult population. Overall prognosis was very good.

Papillary Carcinoma of the Thyroglossal Duct Cyst: A Case Report and Review of Literature

ABSTRACTPapillary carcinoma arising in thyroglossal cyst is rare and is usually detected on postoperative histopathology after routine Sistrunk operation. Further management is a matter of debate and the choice lies between regular follow-up after Sistrunk operation or total thyroidectomy with or without radioiodine ablation and thyroxine suppression therapy. Here, we present a case of papillary carcinoma of thyroglossal duct cyst in a 26- year-old lady. Papillary carcinoma was detected after a routine Sistrunk operation was done for a seemingly innocuous thyroglossal cyst. A total thyroidectomy was carried 1 week later followed by hormone replacement therapy to suppress serum thyroid-stimulating hormone levels.How to cite this articleMunjal M, Garg B, Sood N, Bhardwaj V. Papillary Carcinoma of the Thyroglossal Duct Cyst: A Case Report and Review of Literature. Int J Otorhinolaryngol Clin 2013;5(3):148-150.

Incidental thyroid papillary carcinoma in a thyroglossal duct cyst – management dilemmas

Benign thyroglossal duct tract remnants typically thyroglossal duct cysts, (TDCs) are one of the commonest congenital childhood midline neck masses. Clinical presentation of persistent TDCs in adults is uncommon and the occurrence of incidental primary thyroid papillary carcinoma (TPC) in these cysts is rare. We report the case of a 32-year-old female with an asymptomatic midline neck mass compatible with a TDC that was excised by Sistrunk's procedure. Histopathological examination revealed an incidental primary intraluminal TPC arising from the wall of the TDC. Management dilemmas regarding the roles for total thyroidectomy, regional lymph node dissection, radioactive iodine, and suppressive thyroxine therapy are reviewed in the context of relevant evidence based literature. The occurrence of incidental TPC in a TDC is rare. Though Sistrunk's procedure is adequate treatment for TDC, based on low, moderate, and high risk stratification, recommendations for further management of incidental TPC in TDC is discussed.

Thyroid carcinoma in children and adolescents: A retrospective review

Objective To describe clinical presentation, preoperative study, intervention, histology, surgical complications and follow-up characteristics, and survival in patients with thyroid carcinoma (TC) with less than 18 years at presentation.

Thyroid carcinoma in children and adolescents: A retrospective review

To describe clinical presentation, preoperative study, intervention, histology, surgical complications and follow-up characteristics, and survival in patients with thyroid carcinoma (TC) with less than 18 years at presentation. retrospective analysis of clinical data of all children and adolescents followed in S. João Hospital from January 1, 2000 to March 31, 2010 with histologic diagnosis of TC. Twenty-three patients were identified, 19 girls, and 4 boys. Median age at presentation was 17.0 years. Annual incidence was 2.3 cases/year. The main presenting symptom was a solitary thyroid nodule (60.8%). Three (13%) patients had risk factors for TC, 2 of the 3 had previous cervical irradiation. The other was a smoker. Total thyroidectomy was performed in 16 (69.6%), and 10 patients underwent a second surgical procedure. Four (17.4%) patients had postoperative complications. Histologic examination revealed differentiated TC in all, papillary thyroid carcinoma (PTC) in 86.9%, follicular carcinoma in the remaining. All patients received thyroxine suppressive therapy and 20 underwent therapeutic radioactive iodine (131I). During follow-up (7.1 years), 7 out of the 23 patients presented new metastases and needed new treatment. All patients are currently alive. TC is a reality in pediatric population, thyroid routine examination should take part in all clinical examination in children and adolescents.

Response to "Does thyroxine suppression therapy help to rationalize surgery in benign euthyroid nodules"

Response to "Does thyroxine suppression therapy help to rationalize surgery in benign euthyroid nodules"

Axillary lymph node metastasis in papillary thyroid carcinoma: Report of a case and review of the literature

We report a case of axillary lymph node metastasis as a consequence of recurrent papillary thyroid carcinoma (PTC) in a 64-year-old lady. The patient initially presented in 2004 with a 10 × 10 cm size thyroid swelling of approximately 3-year duration and bilateral cervical lymphadenopathy. She underwent total thyroidectomy with bilateral neck dissection then. Pathological examination confirmed that the resected lesions were PTC and nodal metastases from thyroid. On follow-up over the next 6 years, she underwent excisions twice for cervical nodal recurrences. She presented to us in January 2010 with multiple right axillary adenopathy. Therapeutic right axillary dissection was done. Histopathologic examination revealed metastatic PTC with tall cell differentiation in 7 out of the 17 nodes. The patient is currently on thyroxine suppression therapy and remains disease free for the past 6 months. We review our experience and present a brief review of literature.

Radioiodine therapy for differentiated thyroid carcinoma

Thyroid cancer is the most frequent endocrine malignancy. The histologic subtype of thyroid carcinoma is mainly differentiated thyroid carcinoma. The treatment modality of thyroidectomy followed by 131I and thyroxine-suppressive therapy has been approved and applied widely. A brief introduction and a commentary on this topic is presented in this article. Key words: Iodine isotopes; Therapy; Differentiated thyroid carcinoma

Low bone turnover and increase of bone mineral density in a premenopausal woman with postoperative hypoparathyroidism and thyroxine suppressive therapy

We report the case of a 36-year-old woman who developed permanent hypoparathyroidism after thyroidectomy for differentiated thyroid carcinoma. A 6-year follow-up showed an increase of 11% in absolute bone mineral density at the spine and 6% at the hip accompanied by low bone turnover despite thyroid-stimulating hormone suppressive thyroxine therapy.

The Effect of Thyroxine-Suppressive Therapy in Patients With Euthyroid Nodular Disease

This study evaluates the effect of L-thyroxin therapy on euthyroid nodular disease. The efficacy of treatment was evaluated by ultrasonography in 62 patients with benign euthyroid nodular goiter. Patients have been subdivided in 2 groups. About 35 patients were treated for 1 year with suppressive doses of thyroxine (study group) and 27 were followed without therapy. After L-thyroxin suppressive treatment, no significant difference was observed in both right and left thyroid lobe volume and dominant nodule volume. Only left thyroid volume significantly increased in control group. In our study, there was no significant effect on nodule volume with L-thyroxin treatment. Only left thyroid volume significantly increased in control (without treatment) group. Thus, the potential risks of long-term L-thyroxine therapy outweigh the potential benefits for most patients.

Does thyroxine suppression therapy help to rationalize surgery in benign euthyroid nodules?

Background:Nodular thyroid disease is a common endocrine problem. Most thyroid nodules are benign hyperplastic lesions, but 5–20% may be a true neoplasm. It is important to differentiate a benign from a malignant nodule early as the approach to treatment in the two is radically different. Early institution of medical management in a benign nodule may obviate the need for surgery.Purpose of the Study:The present work aims to study the efficacy of thyroxine suppression in the management of benign thyroid nodules.Materials and Methods:A prospective study on patients presenting with thyroid nodule was undertaken. The diagnostic work-up included a clinical evaluation, thyroid function tests, thyroid scintigraphy and fine needle aspiration cytology. Based on the investigations, patients were segregated in Group A (toxic nodular goiter), Group B (benign euthyroid nodule) and Group C (malignant nodule). Group A patients were managed with antithyroid drugs and radioiodine and Group C patients were managed surgically. Group B patients were put on thyroxine suppression. Patients who failed to show reduction in size of the nodule at 18 months were treated surgically.Conclusion:The response rate of benign euthyroid nodule to thyroxine suppression was 76% in the present study.