Treatment Of Toxic Multinodular Goiter Research Articles

Long-term Effects of Radioiodine in Toxic Multinodular Goiter: Thyroid Volume, Function, and Autoimmunity.

Long-term studies evaluating the treatment of toxic multinodular goiter (TMNG) with fixed activities of radioiodine (RAI) are lacking. The objective of this work is to describe the effects of 15 mCi on thyroid volume, function, and autoimmunity in the long term. A population-based, retrospective analysis with up to 12 years of follow-up was conducted in Siena, Italy. Adult patients (n = 153) with TMNG, naive to RAI, were included. Evaluation was performed of thyroid function, antithyroid antibodies, and ultrasound scans before and yearly after RAI. Evaluations included hyperthyroidism cure, hypothyroidism, volume reduction, nadir and regain, and antibody titer change. The study revealed mean volume reductions greater than or equal to 50% at 3 years after RAI; the greatest annual reduction was observed during the first year (30 ± 17.8%; P < .001). Most patients (60%) achieved their volume nadir 3 to 6 years after RAI. Although 22% patients showed volume regain, the net reduction was statistically significant as late as 9 years after RAI (P = .005). The mean time to hypothyroidism was 2.7 ± 2.4 years, and it was associated with greater reductions in volume (P = .01). During the first 3 years after treatment, hyperthyroid patients decreased approximately by 50% per year without additional RAI. There was no statistically significant association of antibody titers with thyroid function except for antithyrotropin receptor antibodies and hyperthyroidism (P = .004). At the end of follow-up there were 61.6% euthyroid patients, 11% hyperthyroid (4.8% overt), and 27.4% hypothyroid patients (2.7% overt). Hyperthyroidism was cured in 89%. The treatment of TMNG with 15 mCi of RAI induced low hypothyroidism rates while providing high cure rates and significant volume reduction, which was maintained in the long term.

Long-term Methimazole is As Effective as Radioiodine Therapy for the Treatment of Toxic Multinodular Goiter

Long-term Methimazole is As Effective as Radioiodine Therapy for the Treatment of Toxic Multinodular Goiter

Treatment of toxic multinodular goiter with 131 radioactive iodine - effects in volume reduction, thyroid function and autoimmunity

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

Abstract #1139: Metastatic Anaplastic Thyroid Cancer Following Treatment of Toxic Multinodular Goiter

Abstract #1139: Metastatic Anaplastic Thyroid Cancer Following Treatment of Toxic Multinodular Goiter

Therapeutic Plasmapheresis in Preparation of Toxic Multinodular Goiter for Surgery

Thyrotoxicosis is a condition characterized by excessive amounts of thyroid hormones in bloodstream leading to multisystem involvement with a high mortality rate (1,2). Antithyroid drugs, radioactive iodine and thyroidectomy are three conventional forms of treatment selected according to the specific cause of hyperthyroidism. Thyroidectomy is the definitive treatment especially in patients resistant to other treatment options. Surgical intervention should be performed when the patient is euthyroid to decrease perioperative cardiac risks (3). Plasmapheresis is a medical procedure that removes the thyroid hormones and antibodies from the bloodstream of patients who are in need of urgent surgical intervention. It has been utilized for the treatment of several immunologic and nonimmunologic disorders such as Graves’ disease, intoxication of levothyroxin and amiodarone (4,5). Here, we report the case of a patient with toxic multinodular goiter (TMNG) who was prepared for surgery by plasmapheresis due to the side effects of antithyroid drugs. In the literature, there are many cases of hyperthyroidism diagnosed as Graves’ disease treated with plasmapheresis for the removal of circulating thyroid hormones. However, the role of plasmapheresis in the treatment of TMNG is not fully determined.

Reduction in relapse rate of radioiodine therapy in patients of toxic multinodular goiter: A quality improvement project

Introduction:Radioiodine (I-131) therapy is the definitive treatment of toxic multinodular goiter (TMNG). Treatment failure may result in relapse after I-131 therapy. The present study was undertaken to reduce treatment failure rate of I-131 therapy in TMNG patients.Materials and Methods:Multiple causes may have lead to treatment failure of I-131 in TMNG patients making it difficult to establish a direct cause–effect relationship and take corrective action. Therefore, the JURAN methodology of quality improvement was applied. The treatment failure rate in 80 TMNG patients treated with I-131 in the period 2003–06 was 29%. The root cause analysis identified delay in decision to radioablate and concomitant antithyroid drugs (ATD) with I-131 therapy as factors leading to relapse. In 2007, a change in management was introduced with decision to radioablate all TMNG patients not remitting at 1 year of ATD and to withdraw ATD for 2 weeks prior to I-131 therapy. A total of 63 patients of TMNG followed the changed protocol between 2007 and 2009. Further analysis showed that one of the factors identified in the initial brainstorming (high iodide pool in the patient) had not been addressed in the protocol currently followed. The protocol was modified to include patient preparation and implemented after standardization.Results:The post-I-131 relapse rate in patients treated after implementation of the new protocol from 2007 to 2009 was 18% which further reduced to 16% in 2011 after modification of the protocol.Conclusion:The failure rate of I-131 therapy in TMNG reduced from 29% to 16% through standardization of the treatment procedure achieved by the use of Juran Methodology that helped to identify process-related defects.

What's new in general surgery: endocrine.

There have been many advances in the field of endocrine surgery over the past year. We continue to gain a better understanding of the pathophysiology of endocrine dis- ease through the use of intraoperative hormone mea- surement. Standard surgical procedures have been mod- ified to allow a less invasive approach to surgically cure several endocrine problems. Videoscopic technology has also improved to allow safe operative resection of adre- nal, pancreatic, thyroid, and parathyroid pathology. These procedures have shortened hospital stays, time off work, and improved patient comfort after the proce- dure. A summary of some of these advances, resulting from thoughtful investigation by endocrine surgeons throughout the world, is presented below. solved in only 6% of patients 1 month after undergoing RAI ablation. Hyperthyroidism eventually resolved in 84% of RAI patients with a mean RAI treatment dose of 28 mCi and only 10 (6%) required a second treatment dose. More than half of the patients studied had local symptoms of compression, and size reduction of the goi- ter was seen in only 55 patients (38%) treated with RAI. Thyroidectomy resulted in no postoperative mortality and recurrent nerve paresis and hypoparathyroidism each occurred in three patients (2%). Surgical treatment of toxic multinodular goiter results in rapid and reliable correction of hyperthyroidism with low morbidity. RAI ablation is also safe and effective, usually with a single dose, but resolution of hyperthyroidism is delayed and thyroid goiter persists in many patients. Fine needle aspiration biopsy (FNAB) continues to play an important role in the characterization and treat- ment of thyroid nodules, but distinguishing benign from malignant follicular nodules remains difficult if not impossible. The accuracy of FNAB in detecting thy- roid malignancy is well known in both the academic and community healthcare environments. 2 Thyroid nodules containing follicular cytopathologic features, often de- scribed as follicular neoplasms, are almost always treated with thyroidectomy and are associated with a 20% to 30% malignancy rate. 3 Goldstein and colleagues 4 fur- ther characterized follicular thyroid nodules based on the presence or absence of cytologic atypia. Thyroid ma- lignancy was found by histopathologic examination in only 6.8% of patients without atypia in their FNAB sample, and all of these tumors were a follicular variant of papillary carcinoma. In contrast, 44% of patients with atypia in their FNAB samples harbored thyroid carci- noma, including two invasive follicular carcinomas. This observation may allow for a more conservative ap- proach for carefully selected patients with follicular thy- roid nodules without atypia. The thyroid malignancy

Advances in the management of patients with thyroid disease

Discoveries related to thyroid immunology, especially concerning the thyroid-stimulating hormone (TSH) receptor, may facilitate new immunologic approaches to the therapy of Graves' disease and the thyroiditis syndromes. Advances in genetics are being applied to the thyroid hormone resistance syndromes and papillary and medullary carcinomas. The development of ever more sensitive TSH assays has led to the detection of subclinical thyroid disease, which has special implications for the sick and elderly patients. Sensitive TSH assays also allow more precise titration of levothyroxine (T4) dosages, especially for patients with a past history of thyroid cancer. Evidence continues to accumulate suggesting that postmenopausal women on T4 doses that suppress the TSH level below 0.1 ulU/mL have lower bone mineral density than matched patients with healthy TSH levels. Also, pregnant hypothyroid women need higher T4 doses to normalize the TSH levels. In the evaluation of thyroid nodules, fine-needle aspiration biopsy is the single most definitive modality in selecting the patients for surgery. Scintigraphy provides a complimentary role, especially in defining autonomously functioning thyroid adenomas (AFTA), because these should not be treated with T4 suppression. Ultrasound-guided needle biopsy is occasionally helpful with nodules that are difficult to palpate. Concern for possible tracheal compression after treatment of toxic multinodular goiter with large doses of radioactive iodine (I-131) in the range of 50 to 150 mCi (1.85 to 5.5 GBq) does not seem warranted. Work, primarily out of Italy, suggests AFTA can be ablated with repeat ethanol injections. Residual tissues after thyroidectomy for differentiated carcinoma can be "stunned" by tracer doses of 131I greater than 3.0 mCi (111 MBq), which diminishes the uptake and effectiveness of a subsequent therapy dose. Positron emission tomograph, imaging with thallium-201, and Technetium 99m Sestamibi can identify a small number of patients shown to have metastases from differentiated thyroid carcinoma by increasing thyroglobulin levels in the absence of 131I uptake. Several groups have recently advocated treating such patients empirically with 131I.