Total Thyroidectomy For Thyroid Cancer Research Articles

Should we still ablate all patients undergoing total thyroidectomy for thyroid cancer? - AGAINST

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

Biochemical Markers Reflecting Thyroid Function in Athyreotic Patients on Levothyroxine Monotherapy.

Background: Some investigators reported that among athyreotic patients on levothyroxine (LT4) monotherapy following total thyroidectomy, the patients with normal serum thyrotropin (TSH) levels had mildly low serum free triiodothyronine (fT3) levels, whereas the patients with mildly suppressed serum TSH levels had normal serum fT3 levels, and the patients with strongly suppressed serum TSH had elevated serum fT3 levels. The objective of the present study was to clarify which of these three patient groups is closer to their preoperative euthyroid condition.Methods: A total of 133 consecutive euthyroid patients with papillary thyroid carcinoma who underwent a total thyroidectomy were prospectively studied. The patients' serum levels of lipoproteins, sex hormone-binding globulin, and bone metabolic markers measured preoperatively were compared with the levels measured at postoperative LT4 therapy 12 months after the thyroidectomy.Results: The postoperative serum sex hormone-binding globulin (p < 0.001) and bone alkaline phosphatase (p < 0.01) levels were significantly increased in the patients with strongly suppressed TSH levels (≤0.03 μIU/mL). The postoperative serum low-density lipoprotein cholesterol levels were significantly increased (p < 0.05), and the serum tartrate-resistant acid phosphatase-5b levels were significantly decreased (p < 0.05) in the patients with normal TSH (0.3 < TSH ≤5 μIU/mL). In the patients with mildly suppressed TSH (0.03 < TSH ≤0.3 μIU/mL) and fT3 levels equivalent to their preoperative levels, all metabolic markers remained equivalent to their preoperative levels.Conclusions: The serum biochemical markers of thyroid function in patients on LT4 following total thyroidectomy suggest that the patients with mildly suppressed TSH levels were closest to euthyroid, whereas those with normal TSH levels were mildly hypothyroid and those with strongly suppressed TSH levels were mildly hyperthyroid. These data may provide novel information on the management of patients following total thyroidectomy for thyroid cancer or benign thyroid disease.

AIUM Practice Parameter for the Performance of a Thyroid and Parathyroid Ultrasound Examination.

AIUM Practice Parameter for the Performance of a Thyroid and Parathyroid Ultrasound Examination.

Hypothyroidism and hyponatremia: data from a series of patients with iatrogenic acute hypothyroidism undergoing radioactive iodine therapy after total thyroidectomy for thyroid cancer.

The aim of the present study was to evaluate the role of hypothyroidism as a cause of hyponatremia in a clinical model of iatrogenic acute hypothyroidism due to thyroid hormone withdrawal prior to ablative radioactive iodine (RAI) therapy after total thyroidectomy. The study group consisted of 101 differentiated thyroid cancer (DTC) patients (77 women and 24 men). Plasma concentration of thyroid-stimulating hormone ([TSH]) and sodium ([Na+]) was evaluated before total thyroidectomy (pre[TSH] and pre[Na+]) and on the day of RAI therapy (post[TSH] and post[Na+]). The frequency of hypothyroidism-associated hyponatremia was 4% (4/101). Pre[Na+] was significantly higher than post[Na+] (140.7±1.6 vs 138.7±2.3mEq/L, p=0.012). Moreover, a linear correlation was identified between pre[Na+] and post[Na+]. Iatrogenic acute hypothyroidism-related hyponatremia is uncommon. However, because of the significant reduction of [Na+] in the transition from euthyroidism to iatrogenic hypothyroidism, the value of pre[Na+] should be viewed as a parameter to be considered. Since it acts as an independent risk factor for the development of hyponatremia, patients with a pre[Na+] close to the lower limit of normal range may deserve a closer monitoring of [Na+].

Diminished Quality of Life and Increased Brain Functional Connectivity in Patients with Hypothyroidism After Total Thyroidectomy.

Acute hypothyroidism induced by thyroid hormone withdrawal (THW) in patients with thyroid cancer after total thyroidectomy can affect mood and quality of life (QoL). While loss or dysregulation of thyroid hormone (TH) has these well-known behavioral consequences, the effects of TH alterations on brain function are not well understood. Resting state functional connectivity (FC) measured by functional magnetic resonance imaging (fMRI) allows non-invasive evaluation of human brain function. This study therefore examined whether THW affects resting state FC and whether changes in FC correlate with the mood or QoL of the patients with THW status. Twenty-one patients who had undergone total thyroidectomy for thyroid cancer were recruited. Resting state fMRI scanning of the brain, thyroid function tests, and administration of the 12-Item Short Form Health Survey (SF-12) and the Patient Health Questionnaire-9 (PHQ-9) were performed before and after two weeks of THW. Regional homogeneity (ReHo), one of the measures of resting state FC, was calculated, and each voxel was compared between before and after THW in 19 patients. The ReHo values were extracted from the regions of interest showing within-group differences in ReHo values after THW, and correlations of ReHo values with thyrotropin (TSH) levels, total score of the PHQ-9, and composite scores of the SF-12 were statistically evaluated. Higher ReHo was observed after THW in the brain cortical regions across primary motor and sensory, visual, and association cortices. Among the regions, the ReHo values in the bilateral pre- and postcentral gyri, bilateral middle occipito-temporal cortices, the left precuneus, and the left lingual gyrus showed positive correlations with serum TSH levels after THW. Higher ReHo values in the bilateral pre- and postcentral gyri, the left middle temporo-occipital cortices, and the left ligual gyrus correlated with the lower mental component summary score from the SF-12, while higher ReHo values in the bilateral pre- and postcentral gyri correlated with higher total scores in the PHQ-9. Local brain FC is increased in the acute hypothyroid state. Higher FC correlates with a poorer mental QoL and increased depression in the hypothyroid state.

Vitamin D level is not a predictor of hypocalcemia after total thyroidectomy.

As the incidence of thyroid cancer has increased, hypocalcemia, a common complication of thyroid surgery, has become a serious problem. However, no definite predictor of postoperative hypocalcemia is known. In this study, our purpose was to investigate the potential role of vitamin D as a predictor of postoperative hypocalcemia. A prospective observational study was performed on patients who underwent total thyroidectomy for thyroid cancer performed by a single experienced surgeon between October 2013 and September 2014. Their serum 25-OH vitamin D levels were measured preoperatively. On the day after surgery, serum calcium and intact parathyroid hormone levels were measured, and symptoms of hypocalcemia were recorded. Of the 134 patients, laboratory and symptomatic hypocalcemia developed in 52 patients (39%) and 25 patients (19%), on the day after surgery. The preoperative vitamin D level was 16.5 ± 9.2ng/mL, and this value did not differ according to laboratory or symptomatic hypocalcemia (p = 0.94). The incidence of laboratory or symptomatic hypocalcemia did not differ according to vitamin D deficiency. Only incidental parathyroidectomy was associated with symptomatic hypocalcemia (p = 0.03). Vitamin D level is not a predictor of hypocalcemia after total thyroidectomy for thyroid cancer. Thus, routine preoperative screening for vitamin D is not recommended.

259. Parathyroid Hormone Gene Modified Mesenchymal Stem Cells for Hypoparathyroidism

Hypoparathyroidism is a prominent complication of total thyroidectomy for thyroid cancer. Hypocalcemia significantly decrease the quality of life of patients with hypoparathyroidism. Medical management with calcium supplements and activated vitamin D analogues increase risk of renal complications. Hormone replacement is an alternative. In this study, we investigated the possibility of management hypoparathyroidism using parathyroid hormone gene modified mesenchymal stem cells. Rat model of hypoparathyroidism was established through parathyroid gland removing by operation. Human prepro-PTH gene was amplified by RT-PCR from parathyroid adenoma and cloned into lentiviral vector. In order to express functional PTH by non-parathyroid cells. Specific mutation was introduced into the prepro-PTH gene. PTH expression was determined after transfection of 293T cells with the vector. Rat adipose tissue-derived mesenchymal stem cells were cultured and infected with PTH gene-expressing lentiviral vectors. The therapeutic effect of PTH gene modified MSCs on experimental hypoparathyroidism will be presented.

Frequent visualization of thyroglossal duct remnant on post-ablation 131I-SPECT/CT and its clinical implications

To evaluate the frequency of thyroglossal duct remnant (TGDR) uptake on post-therapy (131)I-scintigraphy in thyroid cancer patients, to analyse the rate of persistent TGDR uptake on follow-up combined (131)I-single-photon emission CT/CT (SPECT/CT), and to identify the differential clinical characteristics between patients with positive and negative TGDR uptake on (131)I-SPECT/CT. A total of 179 patients treated with total thyroidectomy for thyroid cancer were enrolled in the study. At (131)I-whole-body scan (WBS), TGDR uptake was defined as an increase in radioactivity at the midline of the neck versus the thyroid bed. TGDR uptake on (131)I- SPECT/CT was defined as the presence of radioactivity at the expected pathway of the thyroglossal duct without evidence of metastatic foci. Persistent TGDR uptake was confirmed when TGDR uptake on follow-up (131)I-SPECT/CT corresponded to previous TGDR uptake detected by post-therapy (131)I-SPECT/CT. At SPECT/CT, TGDR uptake was noted in 86 of 179 patients. Stimulated thyroglobulin (sTg) levels were significantly higher (p = 0.02) in patients with positive TGDR uptake. Persistent TGDR uptake on follow-up (131)I-SPECT/CT was noted in 15 of 86 patients; sTg levels were significantly higher (p = 0.03) in the patients with persistent TGDR uptake. TGDR uptake is frequently visualized on post-therapy (131)I-SPECT/CT images and can be resistant to (131)I ablation. TGDR uptake has the potential to result in an elevation of serum thyroglobulin levels. (131)I-SPECT/CT clarifies TGDR uptake without additional invasive procedures or imaging studies, eliminating confusion among clinicians for managing differentiated thyroid cancer patients.

Preoperative imaging modalities to predict the risk of regional nodal recurrence in well-differentiated thyroid cancers.

Introduction Thyroid cancer incidence has increased in the previous 2 decades. Preoperative identification of lymph node metastasis is a suggested risk factor associated with recurrence following thyroidectomy. Objectives We aimed to evaluate the accuracy of preoperative radiologic investigations of nodal status in determining the postoperative risk of regional nodal recurrence in cases of well-differentiated thyroid cancer. Methods This is a case series. We retrospectively reviewed data, including preoperative ultrasonography and/or computed tomography results, on patients who underwent total thyroidectomy for thyroid cancer at our hospital between 2006 and 2012. Prognostic factors for predicting recurrence, including age, sex, tumor diameter, and nodal diameter, were evaluated. Results Total thyroidectomy was performed on 24 male and 74 female patients (median age, 43 years). The median follow-up time was 21 months. Sixty-eight patients had papillary thyroid cancer, and 30 had follicular cancer. Nodal recurrence was evident in 30% of patients, and 4% of patients died. Identification of lymph node involvement during preoperative radiologic investigations was strongly prognostic for recurrence: 35.3% of patients with positive preoperative ultrasonography findings and 62.5% of those with positive preoperative computed tomography findings had recurrence (p = 0.01). Conclusions Preoperative identification of lymph node metastasis on radiologic studies was correlated with an increased risk of regional nodal recurrence in well-differentiated thyroid cancer. Computed tomography was superior to ultrasonography in detecting metastatic nodal involvement preoperatively and is therefore recommended for preoperative assessment and postoperative follow-up.

Retroperitoneal Bronchogenic Cyst Presenting Paraadrenal Tumor Incidentally Detected by (18)F-FDG PET/CT.

A follow-up (18)F-fluorodeoxyglucose ((18)F-FDG) PET/CT scan of a 57-year-old asymptomatic male who had undergone total thyroidectomy for thyroid cancer revealed a 5.0 × 4.0-cm, well-defined, ovoid-shaped mass around the left adrenal gland without definite FDG uptake. On the adrenal CT scan, the left paraadrenal tumor showed high attenuation on the precontrast scan without enhancement. The average Hounsfield unit (HU) was 58.1 on the precontrast scan and 58.4 on the postcontrast scan. The patient underwent laparoscopic adrenalectomy for resection of the left paraadrenal tumor. The final histopathologic examination revealed a bronchogenic cyst. Although retroperitoneal bronchogenic cysts are rare, they should be considered in the differential diagnosis of retroperitoneal cystic tumors. The preoperative diagnosis is difficult, but a contrast-enhanced CT scan or (18)F-FDG PET/CT scan may be useful for differentiating hyperattenuated cysts from other soft tissue masses.

The prevalence of thyroglossal tract thyroid tissue on SPECT/CT following 131I ablation therapy after total thyroidectomy for thyroid cancer

To determine the prevalence of thyroglossal tract thyroid tissue on SPECT/CT and to assess the contribution of this tissue to total neck radioactive iodine (RAI) activity in patients given (131) I ablation therapy after total thyroidectomy for thyroid cancer. Eighty-three consecutive patients with thyroid cancer treated with total thyroidectomy underwent whole-body planar and SPECT/CT imaging of the neck following initial RAI ablation. On SPECT/CT, thyroglossal tract thyroid tissue was defined as RAI in the anterior neck, superior to the thyroid bed in close proximity to the midline without evidence of localization to lymph nodes. Quantification was performed using region of interest analysis on planar imaging following localization on SPECT/CT. SPECT/CT, and planar images were classified by two reviewers as positive, negative or equivocal with interobserver agreement quantified using a Kappa score. Disagreement was resolved using a third reviewer. Thyroglossal tract thyroid tissue was present in 39/83 (47%; 95%CI: 36-58%) patients on SPECT/CT. In these 39 patients, this tissue contributed to a significant amount of total neck activity (median = 50%; IQR 19-74%). Interobserver agreement for the presence of thyroglossal tract thyroid tissue was substantial on SPECT/CT (Kappa = 0.73) and fair on planar imaging (Kappa = 0.31). Thyroglossal tract thyroid tissue was present in one half of our study population and contributed to a significant amount of total neck RAI activity. Given the high prevalence of this tissue, our results suggest that total neck RAI activity on planar imaging may not be suitable to assess the completeness of thyroid bed surgery.

Risk Factors of Hypoparathyroidism Following Total Thyroidectomy for Thyroid Cancer

The risk factors responsible for hypoparathyroidism after total thyroidectomy have not been completely defined. The present study evaluated one surgeon's personal experience of postoperative hypoparathyroidism after total thyroidectomy for thyroid cancer and predisposing risk factors of postoperative hypoparathyroidism. We performed a retrospective analysis of 531 consecutive total thyroidectomy cases for thyroid cancer operated by single surgeon at the Center for Thyroid Cancer, National Cancer Center, Korea, from March 2003 to August 2006. Postoperative hypoparathyroidism occurred in 135 patients (25.4 %), 19 of whom (3.6 % of total patients) experienced permanent hypoparathyroidism. Parathyroid autotransplantation, bilateral central lymph node dissection, gross extrathyroidal extension, and the presence of parathyroid gland in the pathologic specimen were associated with postoperative hypoparathyroidism in multivariate analysis (p < 0.05, respectively). The presence of parathyroid gland in the pathologic specimen and the early period of surgeon's practice were statistically significant risk factors for permanent hypoparathyroidism in multivariate analysis (p < 0.05, respectively). Careful surgical technique for in situ preservation of parathyroid gland and autotransplantation of inadvertently removed parathyroid gland are important, especially in case of gross extrathyroidal extension. Adequate surgical experience is also an important factor. And routine bilateral central lymph node dissection should be done thoughtfully for its effect on postoperative hypoparathyroidism.

Perioperative management of a patient with thyroid hormone resistance who underwent total thyroidectomy for thyroid cancer

Resistance to thyroid hormone (RTH) is a rare, predominantly inherited syndrome that involves impaired tissue responsiveness to thyroid hormones. We describe the perioperative management of a patient with RTH who underwent total thyroidectomy. Although surgery performed under general anesthesia was uneventful, after the surgery the patient developed difficult-to-treat hypocalcemia that lasted until postoperative day 4. Moreover, thyroid function even after discharge remained unstable despite replacement therapy. We suggest that the parathyroid and thyroid function of patients with RTH be followed very closely and that nociceptive stimulus of the surgery and postoperative pain be reduced as much as possible.

Do Patients Gain Weight After Thyroidectomy for Thyroid Cancer?

Patients who undergo thyroidectomy often complain of weight gain, which they frequently attribute to inadequate thyroid hormone replacement. To assess the weight changes associated with thyroid hormone replacement or suppressive therapy after thyroidectomy, we measured the weights of patients before and after thyroidectomy and compared them to the weights of euthyroid patients with thyroid nodules who were being followed for many years. The weights and heights of 67 women and 35 men who underwent total thyroidectomy for thyroid cancer were recorded before and for a mean of 8.3 years after thyroidectomy. All patients received either suppressive or replacement doses of levothyroxine. As a comparison group, 70 women and 22 men with goiter or thyroid nodules and were euthyroid had serial measurements of height and weight. They were followed for a mean of 7.6 years. The body mass index (BMI) and age-adjusted BMI percentiles were calculated. The weight, BMI, and BMI percentile changes were compared both unadjusted and adjusted for age, gender, thyrotropin (TSH) level, and duration between measurements. At baseline, patients with thyroid nodules were older (mean 50.4 years) than those with thyroid cancer (mean 45.8 years). There were no significant differences in baseline weight, BMI, or BMI percentile. The baseline TSH levels were lower for patients with thyroid cancer (mean 0.8 mIU/L) than for those with nodules (mean 1.8 mIU/L) (p=0.002). There were no significant differences between the changes in weight, BMI, or BMI percentile from the start to the completion of the study whether unadjusted or after adjustment for age, gender, TSH, and duration of follow-up. Despite the perception of many patients that their thyroidectomy and thyroid hormone replacement or suppressive therapy is responsible for their subsequent weight gain, there were no significant differences in weight gain over time in comparison to a control group of euthyroid patients with thyroid nodules or goiter.

Role of Sonography After Total Thyroidectomy for Thyroid Cancer

High-resolution neck ultrasound plays a vital role in the evaluation and management of patients after total thyroidectomy for thyroid cancer. This technique is increasingly used by endocrinologists and head and neck surgeons to detect potential locoregional recurrences or metastases and map malignant lymph nodes before reoperation. It is also invaluable as guidance for fine-needle aspiration of suspicious lesions.Thorough knowledge of the compartments of the neck and meticulous scanning technique are essential for success.The purpose of this article is to review the common pattern of recurrences of differentiated thyroid cancer, describe our scanning protocol, and depict the characteristics of benign, indeterminate, and suspicious lesions in the postthyroidectomy neck.

Sialoadenite após terapia ablativa com altas doses de radioiodo no tratamento do carcinoma diferenciado de tireóide

We analyzed eight-three patients who received 3.7 GBq (100 mCi) or 7.4 GBq (200 mCi) after total thyroidectomy for thyroid cancer. This study consisted in clinical and lab analysis (amylase serum level), followed by iodine whole body scan. The sialoadenitis was defined by hyperamylasemia (> 200 U/L). Eleven (13.25%) patients referred spontaneous local pain or after mastication post I 131 ablative therapy. Hyperamylasemia was detected in 31 (37.3%) patients in the second day after treatment. After seven days, serum amylase levels were in normal values in all patients. The symptomatic sialoadenitis was detected more frequently in patients with residual cervical uptake who received I-131 7.4 GBq (70%). The uptake in topography of salivary glands was present in 93.5% of sialoadenitis cases (p < 0.05). Significant statistical correlation was detected between absent of distance metastases and higher incidence of sialoadenitis (p < 0.05). No correlation was demonstrated between this complication and cervical remnants or I-131 dose administered. The sialoadenitis post high dose ablative therapy is a relative common complication with low clinical repercussion. The absent of distance metastases is directly correlated to this complication.

Two patients with metastasis of cancer to other neoplasm: A thyroid carcinoma metastatic to a lung carcinoma and a gastric carcinoma metastatic to a thyroid adenoma.

Two patients with rare cancer-to-neopiasm metastasis are presented. One patient was a 69-year-old woman who had undergone gastrectomy for gastric cancer 10 months previously and died of generalized metastases. An autopsy revealed generalized metastases of the gastric carcinoma, together with a cystic, hemorrhagic thyroid tumor measuring 2.0 cm in diameter. Histologically, the thyroid tumor was an oxyphilic adenoma with multiple metastatic foci of gastric adenocarcinoma. Because no metastasis was found in the background thyroid tissue, this metastasis might have developed specifically and not by chance, most likely due to the rich vascularity and good circulation of the thyroid adenoma. The other patient was an 82-year-old man who had undergone total thyroidectomy for thyroid cancer 6 years previously. An abnormal lung shadow was found on a chest radiograph during postoperative follow-up. Transbronchial biopsy of the lung tumor revealed a squamous-cell carcinoma. The resected lung tumor measured 2.7 cm in diameter, with small foci of metastatic papillary carcinoma of the thyroid gland and multiple small metastases in the background lung tissue, indicating that the metastases to lung cancer had occurred by chance. Metastasis of cancer to other neoplasms is discussed, and a review of the literature is presented.

Bone mass in totally thyroidectomized patients. Role of calcitonin deficiency and exogenous thyroid treatment

Calcitonin has an uncertain role in the preservation of bone mass. Since surgical thyroidectomy abolishes the calcitonin secretion in response to calcium, the bone mineral density at the radius shaft and lumbar spine was measured in 60 patients (5 men, 16 premenopausal, 34 postmenopausal euparathyroid and 5 postmenopausal hypoparathyroid women) who had undergone near total thyroidectomy for thyroid cancer 8.4 +/- 0.7 years before the study. All patients were maintained on suppressive doses of thyroid hormones. Bone mineral density values of the radius shaft (expressed as Z-score) of 34 postmenopausal euparathyroid women was significantly below the normal average (mean +/- SEM = -0.59 +/- 0.2; p = 0.01). Bone mineral density of the lumbar spine was also below the normal average although the difference only approached statistical significance (-0.36 +/- 0.2; 0.05 less than p less than 0.1). The bone mineral density of neither the radius nor the spine differed from normal levels in the premenopausal women and the postmenopausal hypoparathyroid women. Unexpectedly, the bone mineral density of the spine was significantly increased in the 5 thyroidectomized men. The results indicate that thyroidectomized women have a diminished bone mass after the menopause only if parathyroid function is normal. Since the patients were receiving thyroid hormone at suppressive doses, the present study is not able to separate the relative contributions of calcitonin deficit and exogenous thyroid on bone mass loss.

Thyroid cancer: The case for total thyroidectomy

Since there are no prospective studies concerning the treatment of thyroid cancer, there continues to be a considerable disagreement about the ‘best’ or most appropriate form of surgical treatment for patients with papillary or follicular thyroid cancer. Some surgeons recommend selective treatment depending upon the type of thyroid tumor and stage of the disease. Some advocate thyroid lobectomy and isthmusectomy, some near total thyroidectomy, and some total thyroidectomy for patients with papillary and follicular thyroid cancer. Total thyroidectomy for thyroid cancer would be the treatment of choice for virtually all patients with thyroid cancers if it could be done without complications. We therefore reviewed 160 consecutive patients who had total thyroidectomy for suspected or proven thyroid cancer to determine the complication rate of total thyroidectomy. One hundred and three patients had primary operations, 57 had reoperations with completion of total thyroidectomy and 124 had thyroid cancer. Serious complications (i.e. vocal cord paralysis or hypoparathyroidism) included two cases of transient bilateral recurrent nerve palsy, two patients with presumed transient unilateral vocal cord paralysis, three recurrent laryngeal nerves that were purposely sacrificed because of invasion of the nerve, and one case of permanent hypoparathyroidism. Two other patients developed postoperative wound infections. Only one of the permanent complications, the case of permanent hypoparathyroidism, could have been avoided by a lesser procedure. The experienced surgeon can perform a total thyroidectomy with minimal morbidity, and this procedure has certain theoretical and practical advantages. It should not be done, however, if it will result in a significant complication rate and, in selected patients, it may be preferable to leave a small amount of thyroid tissue to protect the blood supply to the parathyroid glands or recurrent laryngeal nerve.

Cervical Distribution of Iodine 131 Following Total Thyroidectomy for Thyroid Cancer

The use of postoperative radioiodine thyroid scanning has questioned whether total thyroidectomy is surgically possible. Similar to earlier studies, we have found functioning iodine 131 (131I)-avid thyroid tissue in our patients following total thyroidectomy for thyroid cancer. Preoperative and postoperative thyroid scans were compared in 24 patients to study the cervical location of postthyroidectomy residual thyroid tissue. Thyroid scanning detected 44 distinct sites of uptake. Thirty-eight of these foci were located either at the extremes of the upper poles of the thyroid gland (24) or along the embryonic thyroid descent tract (14). We conclude that these foci of 131I uptake represent incomplete resection of normal thyroid tissue, and that surgical attention to these areas should result more frequently in extirpation of the entire thyroid gland.