The risk factors for malignancy in surgically treated patients for Graves' disease, toxic multinodular goiter, and toxic adenoma

Incidence and Risk Factors of Thyroid Malignancy in Patients with Toxic Nodular Goiter

Background. Although hyperfunctioning thyroid disorders were thought to be protective against malignancy, some recent studies reported a high incidence of incidentally discovered cancer in patients with hyperfunctioning benign thyroid disorders. We performed this study to estimate the incidence and predictors of malignant thyroid disease in patients with toxic nodular goiter (TNG). Patients and Methods. The data of 98 patients diagnosed with TNG were reviewed (including toxic multinodular goiter SMNG and single toxic nodule STN). The collected data included patients age, gender, systemic comorbidities, family history of thyroid malignancy, previous neck radiation, type of disease (multinodular or single), size of the dominant nodule by the US, operative time, and detection of significant lymph nodes during operation. Based on the histopathological analysis, the cases were allocated into benign and malignant groups. Results. Malignancy was detected in 21 patients (21.43%). Although age distribution was comparable between the two groups, males showed a significant increase in association with malignancy. Medical comorbidities and family history of cancer did not differ between the two groups. However, TMNG showed a statistically higher prevalence in the malignant group. Operative data, including operative time and lymph node detection, were comparable between the two groups. On regression analysis, both male gender and TMNG were significant predictors of malignancy. Conclusion. The presence of thyroid hyperfunction is not a protective factor against malignancy, as malignancy was detected in about 1/5 of cases. Male gender and TMNG were significant risk factors of malignancy in such patients.

Papillary Thyroid Carcinoma With Cystic Changes in a Patient With Prior History of Toxic Nodule

Thyroid nodules are palpable on up to 7% of asymptomatic patients. Cancer is present in 8% to 16% of those patients with previously identified thyroid nodules. Papillary thyroid carcinoma (PTC) is the most common type of thyroid cancer, accounting for approximately 85% of thyroid cancers. Although most appear as solid nodules on ultrasound imaging, a subset of 2.5% to 6% has cystic components. The presence of cystic changes within thyroid nodules decreases the accuracy of fine needle aspiration (FNA) in the diagnosis of thyroid cancer, given the difficulty of obtaining appropriate cellular content. This becomes a diagnostic and therapeutic challenge. We present a case of a 31-year-old female with a 1-month history of palpitations, fatigue, and night sweats, who underwent evaluation, and was diagnosed with subclinical hyperthyroidism. She presented 4 years later with compressive symptoms leading to repeat FNA, showing Bethesda III-atypia of undetermined significance and negative molecular testing. Thyroid lobectomy revealed PTC with cystic changes. This case is a reminder that patients with hyperfunctioning thyroid nodule should have closer follow-up. It poses the diagnostic dilemma of how much is good enough in the evaluation and management of a thyroid nodule. Early detection and action should be the standard of care.

[Nodular toxic goiter in children: clinical features, morphological variants]

ОБОСНОВАНИЕ. Токсический узловой зоб (ТУЗ) — редкое заболевание, при котором причиной гипертиреоза является наличие узла или узлов, автономно секретирующих гормоны щитовидной железы. У детей и подростков данное состояние встречается крайне редко — в 5–7,5% всех случаев узлового зоба. Терапия ТУЗ направлена на купирование симптомов гипертиреоза с учетом злокачественного потенциала узлового образования. В доступной литературе отсутствуют данные о клиническом течении, сравнительных результатах цитологических и гистологических данных пациентов с ТУЗ, дебютировавшим в детском возрасте.ЦЕЛЬ. Анализ особенностей клинического течения, сравнение результатов цитологического и гистологического исследований ТУЗ у детей и подростков.МАТЕРИАЛЫ И МЕТОДЫ. Ретроспективное одноцентровое исследование 21 пациента с одноузловым токсическим зобом, госпитализированных в ФГБУ «НМИЦ эндокринологии» Минздрава России в период с января 2016 г. по декабрь 2019 г.РЕЗУЛЬТАТЫ. Средний возраст на момент обследования составлял 13,9 года. У 13 пациентов (65%) отмечался манифестный тиреотоксикоз, у 7 (35%) — субклинический гипертиреоз. Больше половины детей — 57,1% (n=12) не получали тиреостатической терапии. Цитологическая картина у 11 пациентов (61,1%) соответствовала доброкачественным изменениям (узловой коллоидный зоб или аденоматозный зоб) — Bethesda II, у 4 пациентов — фолликулярной опухоли — Bethesda IV, у 4 детей исследование оказалось неинформативным. 19 пациентам (90,5%) было проведено хирургическое лечение (гемитиреоидэктомия). Фолликулярная аденома по результатам гистологического исследования встречалась у 44,4% детей с ТУЗ при доброкачественных результатах тонкоигольной аспирационной биопсии (Bethesda II) и в 50% — при выявлении фолликулярной неоплазии (Bethesda IV).ЗАКЛЮЧЕНИЕ. Впервые в Российской Федерации проведен сравнительный анализ характеристик цитологического и гистологического исследования у детей с ТУЗ. Показательно, что только в 10,5% (n=2) случаев соответствовали цитологические и морфологические результаты. Выбор тактики радикального лечения должен учитывать высокую частоту несовпадений гистологических и морфологических исследований.

Malignancy risk of hyperfunctioning thyroid nodules compared with non-toxic nodules: systematic review and a meta-analysis

Background

Hyperfunctioning or hot nodules are thought to be rarely malignant. As such, current guidelines recommend that hot nodules be excluded from further malignancy risk stratification. The objective of this systematic review and meta-analysis is to compare the malignancy risk in hot nodules and non-toxic nodules in observational studies.

Methods

Ovid MEDLINE Daily and Ovid MEDLINE, EMBASE, Scopus, and Web of Science databases were searched. Observational studies which met all of the following were included: (1) use thyroid scintigraphy for nodule assessment, (2) inclusion of both hyperfunctioning and non-functioning nodules based on scintigraphy, (3) available postoperative histopathologic nodule results, (4) published up to November 12, 2020 in either English or French. The following data was extracted: malignancy outcomes include malignancy rate, mapping of the carcinoma within the hot nodule, inclusion of microcarcinomas, and presence of gene mutations.

Results

Among the seven included studies, overall incidence of malignancy in all hot thyroid nodules ranged from 5 to 100% in comparison with non-toxic nodules, 3.8–46%. Odds of malignancy were also compared between hot and non-toxic thyroid nodules, separated into solitary nodules, multiple nodules and combination of the two. Pooled odds ratio (OR) of solitary thyroid nodules revealed a single hot nodule OR of 0.38 (95% confidence interval (CI) 0.25, 0.59), toxic multinodular goiter OR of 0.51 (95% CI 0.34, 0.75), and a combined hot nodule OR of 0.45 (95% CI 0.31, 0.65). The odds of malignancy are reduced by 55% in hot nodules; however, the incidence was not zero.

Conclusions

Odds of malignancy of hot nodules is reduced compared with non-toxic nodules; however, the incidence of malignancy reported in hot nodules was higher than expected. These findings highlight the need for further studies into the malignancy risk of hot nodules.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13044-021-00094-1.

Current approach to surgical management of hyperthyroidism

Hyperthyroidism is a set of disorders that involve excess synthesis and secretion of thyroid hormones by the thyroid gland, which leads to thyrotoxicosis. The most common forms of hyperthyroidism include diffuse toxic goiter (Graves' disease), toxic multinodular goiter (Plummer disease), and a solitary toxic adenoma. The most reliable screening measure of thyroid function is the thyroid-stimulating hormone (TSH) level. Options for treatment of hyperthyroidism include: antithyroid drugs, radioactive iodine therapy (the preferred treatment of hyperthyroidism among US thyroid specialists), or thyroidectomy. Massive thyroid enlargement with compressive symptoms, a suspicious nodule, Graves' orbitopathy, and patient preference are indications for surgical treatment of thyrotoxicosis. This paper reviews the current literature and controversies on the surgical approach to the management of hyperthyroidism.

Prevalence and risk factors for thyroid cancer in patients with multinodular goitre

BACKGROUND

Rates of thyroid cancer in patients with multinodular goitre (MNG) vary widely, from 3 per cent in older studies to 35 per cent in more recent studies. The purpose of the present study was to evaluate the prevalence of thyroid cancer in patients operated on for MNG, and to determine risk factors for incidental thyroid malignancy.

METHODS

A prospectively developed database of all patients who underwent thyroidectomy for a benign MNG at the high-volume endocrine surgery unit of a tertiary referral university hospital was interrogated.

RESULTS

A total of 3233 patients were analysed, separated into three groups according to their functional thyroid status (hypothyroid, hyperthyroid or euthyroid). There were 2788 women (86.2 per cent); the mean patient age was 56.4 years and mean preoperative disease duration was 106.2 months. Incidental thyroid cancer was identified in 1026 patients (31.7 per cent), of which 917 (89.4 per cent) were papillary cancers. Multivariable regression analysis identified functional thyroid status, younger age, male sex, smaller adenoma size, smaller thyroid glands, Hashimoto's thyroiditis and chronic non-specific thyroiditis as independent risk factors for thyroid cancer.

CONCLUSION

MNG was associated with a considerable rate of incidental thyroid cancer, which has been underestimated. A variety of factors should be taken into account when considering the malignant potential of a presumed benign MNG.

A systematic review of the incidence of thyroid carcinoma in patients undergoing thyroidectomy for thyrotoxicosis

INTRODUCTION

Hyperthyroidism (HT) has been associated with no insignificant rates of thyroid malignancy. There are no current specific guidelines that suggest routine preoperative imaging for thyroid nodules in patients with Grave's disease. We therefore performed a systematic review assessing rates of thyroid malignancy in patients undergoing surgery for different causes of HT: Grave's disease (GD), toxic adenoma (TA) and toxic multinodular goitre (TMNG).

METHODS

Major databases (MEDLINE, PubMed and the Cochrane library) were searched to identify eligible studies.

RESULTS

After searching and appraising, 33 papers were found to be eligible for analysis. The mean overall rate of malignancy was 8.5% (range 0.8%-32.4%). The mean rates based on histological subtype were as follows: papillary thyroid cancer (PTC), 3.1% (range 0%-13.2%); micropapillary carcinoma (mPTC), 5.1% (range 0%-16.9%); and follicular thyroid cancer (FTC), 0.8% (range 0%-4.4%). In those patients who had preoperative imaging, mean malignancy rates were higher in patients with pre-identified nodules (19.8%) compared to those without any nodules (8.7%). Mean rates were lower in patients with GD/diffuse goitre (5.9%) compared to patients with TA (6.5%) and TMNG (12%).

CONCLUSION

Hyperthyroidism is associated with notable rates of thyroid cancer, although the mechanisms for this are not clear. The presence of nodules increases this risk. This review raises the question for considering preoperative assessment of nodules in all patients undergoing surgery for HT, in order to correctly assess and evaluate any patients with suspected concurrent thyroid malignancy, before proceeding with surgery.

Evaluation of ultrasonographical and cytological features of thyroid nodules in patients treated with radioactive iodine for hyperthyroidism

BACKGROUND

In this study, we aimed to evaluate ultrasonographical and cytological features of thyroid nodules in patients who were treated with radioactive iodine (RAI) for hyperthyroidism years ago.

METHODS

Patients who had a history of RAI treatment for hyperthyroidism and had thyroid nodules that were evaluated with fine-needle aspiration biopsy (FNAB) were included in the study.

RESULTS

There were 27 patients (22 female and 5 male) with a mean age of 59.3 ± 13.5. The indication for RAI treatment was Graves in 5 (18.6%), toxic nodular or multinodular goiter in 16 (69.2%), and unknown in 6 (22.2%) patients. A total of 48 thyroid nodules were evaluated with FNAB and cytological diagnosis were benign in 24 (50.0%), nondiagnostic in 15 (31.2%), atypia of undetermined significance in 5 (10.4%), suspicous for malignancy in 2 (4.2%), and malignant in 2 (4.2%) nodules. Thyroidectomy was performed in 10 patients, 5 were benign (50.0%), and 5 (50.0%) were malignant histopathologically. Ultrasonography features of 31 cytologically/histopathologically benign and five cytologically/histopathologically malignant nodules were compared. Prevalence of isoechoic nodules was higher in benign nodules (P = .025). Macrocalcification was observed in 4 (80.0%) of malignant and 10 (32.3%) of benign nodules (P = .042).

CONCLUSION

In patients with a history of RAI treatment for hyperthyroidism, thyroid nodules with suspicious ultrasonography features, particulary hypoechoic appearence and macrocalcification, should be evaluated with FNAB irrespective of the time elapsed after RAI treatment.

PROGNOSIS OF DIFFERENTIATED THYROID CARCINOMA IN PATIENTS WITH GRAVES DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Objective: It is still controversial whether differentiated thyroid carcinoma (DTC) in patients with Graves disease (GD) can be more aggressive than non-Graves DTC. We conducted a systematic review and meta-analysis to examine the association between GD and prognosis in patients with DTC. Methods: We comprehensively searched the databases of MEDLINE and EMBASE from inception to March 2019. We included published studies that compared the risk of mortality and prognosis between DTC patients with GD and those with non-GD. Data from each study were combined using the random-effects model. Results: Twenty-five studies from February 1988 to May 2018 were included (987 DTC patients with GD and 2,064 non-Graves DTC patients). The DTC patients with GD had a significantly higher risk of associated multifocality/multicentricity (odds ratio, 1.45; 95% confidence interval, 1.04 to 2.02; I², 6.5%; P = .381) and distant metastasis at the time of cancer diagnosis (odds ratio, 2.19; 95% confidence interval, 1.08 to 4.47; I², 0.0%; P = .497), but this was not associated with DTC-related mortality and recurrence/persistence during follow-up. Conclusion: Our meta-analysis demonstrates a statistically significant increased risk of multifocality/multicentricity and distant metastasis at the time of cancer diagnosis in DTC patients with GD than those without GD. Abbreviations: CI = confidence interval; DTC = differentiated thyroid carcinoma; GD = Graves disease; LN = lymph node; OR = odds ratio; PTC = papillary thyroid carcinoma; TC = thyroid carcinoma; TSAb = thyroid-stimulating antibody; TSH = thyroid-stimulating hormone.

Does hyperthyroidism worsen prognosis of thyroid carcinoma? A retrospective analysis on 2820 consecutive thyroidectomies

Background

Hyperthyroidism is associated with high incidence of thyroid carcinoma; furthermore, tumors arisen in hyperthyroid tissue show an aggressive behavior. Thyroid Stimulating Hormone (TSH) and Thyroid-stimulating antibodies, present in Graves’s disease, seem to play a key role in carcinogenesis and tumoral growth.

Methods

We retrospectively reviewed our series of patients who underwent thyroidectomy for thyroid carcinoma. We compared pathological features and surgical outcomes of hyperthyroid versus euthyroid patients.

Results

From 2007 to 2015, 909 thyroidectomies were performed at our institution for thyroid cancer: 87 patients were hyperthyroid and 822 euthyroid. We observed, in hyperthyroid patients, a higher rate of transient hypoparathyroidism (28.1% vs 13.2%; p < 0.01) and of node metastases (12.6% vs 6.1%; p = 0.03); also local recurrence rate was higher (5.7% vs 2.5%) even if not statistically significant (p = 0.17). Five-year disease free survival rate was significant lower in the same group (89.1% vs 96.6%; p = 0.03).

Conclusion

Thyroid cancers in hyperthyroid patients have an aggressive behavior, with high incidence of local invasion and a worse prognosis than euthyroid patients. All hyperthyroid patients should undergo a careful evaluation with ultrasound and scintigraphy; in case of suspicious nodules, an aggressive approach, including thyroidectomy and lymphectomy, is justified. In patients with toxic adenoma, thyroid cancer is uncommon, thus a loboisthmectomy can be safely performed.

Trial registration number

Research registry n. 2670 registered 19 June 2017 (retrospectively registered).

Hyperthyroidism in Patients with Thyroid Cancer

We present a retrospective case series of patients with hyperthyroidism and thyroid cancer. Our goal was to look at their clinical characteristics and outcomes to determine which patients would require further investigation. We reviewed the case notes of all patients with a histopathologic diagnosis of thyroid cancer and biochemical evidence of hyperthyroidism who had been treated at a thyroid cancer center from January 2006 through October 2013. During that time, 66 patients had been diagnosed with thyroid cancer. Of these, 8 patients (12%)—all women, aged 29 to 87 years (mean: 55.6; median: 50.5)—had biochemical evidence of hyperthyroidism. Among these 8 patients, 4 had an autonomously functioning toxic nodule (AFTN), 3 were diagnosed with Graves disease, and 1 had a toxic multinodular goiter. Five patients had suspicious features on preoperative ultrasonography. All 8 patients were diagnosed with the papillary type of thyroid carcinoma. The mean size of the tumor in the 4 patients with AFTN was significantly larger than it was in those with Graves disease (42.3 ± 23.8 mm vs. 3.8 ± 1.6; p = 0.04). The 3 patients with Graves disease all had incidentally found papillary microcarcinoma. Between these two groups, the patients with AFTN had a poorer prognosis; 2 of them had extracapsular invasion and lymph node metastasis, and another died of her disease. We found that the incidence of hyperthyroidism in thyroid cancer patients was relatively high (12%). In contrast to what has previously been reported in the literature, patients with AFTN seem to have more aggressive disease and poorer outcomes than do patients with Graves disease. Any suspicious nodule associated with hyperthyroidism should be evaluated carefully.

Risk factors associated with benign and malignant thyroid nodules in autoimmune thyroid diseases

Objectives. Assess the prevalence of thyroid nodules and predictors of malignant origin in patients with autoimmune thyroid diseases. Patients and Methods. Retrospective study including 275 patients, 198 with Graves' disease and 77 with Hashimoto's thyroiditis. Clinical and demographical data, ultrasonographical nodule characteristics, total thyroid volume and histological characteristics were recorded. Results. Graves' disease: the prevalence of thyroid nodules and thyroid carcinoma were 27.78% and 5.05%, respectively. Older age (OR = 1.054; 95% CI = 1.029–1.080) and larger thyroid volumes (OR = 1.013; 95% CI = 1.003–1.022) increased the chance of nodules. Younger age (OR = 1.073; 95% CI = 1.020–1.128) and larger thyroid volume (OR = 1.018; 95% CI = 1.005–1.030) predicted thyroid carcinoma. Hashimoto's thyroiditis: the prevalence of thyroid nodules and carcinomas were 50.7% and 7.8%, respectively. Nodules were predicted by thyroid volume (OR = 1.030; 95% CI = 1.001–1.062). We found higher number of nodules in patients with thyroid carcinoma than in those with benign nodules (3 versus 2; P = 0.03). Patients with Hashimoto's thyroiditis presented nodules more frequently than patients with Graves' disease (50.65% versus 27.28%; P < 0.001), while the prevalence of carcinoma was similar (P = 0.751). Conclusions. Larger goiter was associated with carcinoma in Graves' disease and Hashimoto's thyroiditis. Younger patients presented higher risk of papillary thyroid carcinoma in Graves' disease. The prevalence of carcinoma was similar in both conditions.

A solitary hyperfunctioning thyroid nodule harboring thyroid carcinoma: review of the literature

Hyperfunctioning nodules of the thyroid are thought to only rarely harbor thyroid cancer, and thus are infrequently biopsied. Here, we present the case of a patient with a hyperfunctioning thyroid nodule harboring thyroid carcinoma and, using MEDLINE literature searches, set out to determine the prevalence of and characteristics of malignant “hot” nodules as a group. Historical, biochemical and radiologic characteristics of the case subjects and their nodules were compared to those in cases of benign hyperfunctioning nodules. A literature review of surgical patients with solitary hyperfunctioning thyroid nodules managed by thyroid resection revealed an estimated 3.1% prevalence of malignancy. A separate literature search uncovered 76 cases of reported malignant hot thyroid nodules, besides the present case. Of these, 78% were female and mean age at time of diagnosis was 47 years. Mean nodule size was 4.13 ± 1.68 cm. Laboratory assessment revealed T₃ elevation in 76.5%, T₄ elevation in 51.9%, and subclinical hyperthyroidism in 13% of patients. Histological diagnosis was papillary thyroid carcinoma (PTC) in 57.1%, follicular thyroid carcinoma (FTC) in 36.4%, and Hurthle cell carcinoma in 7.8% of patients. Thus, hot thyroid nodules harbor a low but non-trivial rate of malignancy. Compared to individuals with benign hyperfunctioning thyroid nodules, those with malignant hyperfunctioning nodules are younger and more predominantly female. Also, FTC and Hurthle cell carcinoma are found more frequently in hot nodules than in general. We were unable to find any specific characteristics that could be used to distinguish between malignant and benign hot nodules.

Gender-Specific Variation in the Prognosis of Papillary Thyroid Cancer TNM Stages II to IV

To investigate the correlation between gender and the clinical presentation of papillary thyroid cancer and the long-term followup results, 435 patients who underwent total or near-total thyroidectomy were enrolled in this study. Among these papillary thyroid cancer patients, 12.2% showed lymph node metastases and a higher incidence of male patients in the N1b group. There were 65 from 316 female (20.6%) and 49 from 120 male (40.8%) patients who had a postoperative disease progression. A total of 55 (12.6%) patients died of thyroid cancer. Male patients showed a higher thyroid cancer mortality than the females. Multiple regression analysis showed that male gender was an independent risk factor for cancer recurrence and mortality. Male patients with TNM stages II to IV of papillary thyroid cancer need to adopt aggressive surgical and postoperative (131)I therapy.

Guidelines of the French society of endocrinology for the management of thyroid nodules

The present document is a follow-up of the clinical practice guidelines of the French Society of Endocrinology, which were established for the use of its members and made available to scientific communities and physicians. Based on a critical analysis of data from the literature, consensuses and guidelines that have already been published internationally, it constitutes an update of the report on the diagnostic management of thyroid nodules that was proposed in France, in 1995, under the auspices of the French National Agency for Medical Evaluation (l'Agence nationale d'évaluation médicale). The current guidelines were deliberated beforehand by a number of physicians that are recognised for their expertise on the subject, coming from the specialities of endocrinology (the French Thyroid Research Group) and surgery (the French Association for Endocrine Surgery), as well as representatives from the fields of biology, ultrasonography, cytology and nuclear medicine. The guidelines were presented and submitted for the opinion of the members of the Society at its annual conference, which was held in Nice from 7-10 October 2009. The amended document was posted on the website of the Society and benefited from additional remarks of its members. The final version that is presented here was not subjected to methodological validation. It does not claim to be universal in its scope and will need to be revised in concert with progress made in technical and developmental concepts. It constitutes a document that the Society deems useful for distribution concerning the management of thyroid nodules, which is current, efficient and cost effective.

Endoscopic thyroidectomy via breast approach for patients with Graves' disease

BACKGROUND

Endoscopic thyroidectomy via breast approach provides excellent results from a cosmetic viewpoint. We applied this procedure to Graves' disease and evaluated its feasibility and outcomes.

METHODS

From May 2006 to November 2009, a total of 37 patients (34 women and 3 men) with Graves' disease were included in this study. Bilateral subtotal thyroidectomy, which left behind 4-6 g of thyroid remnant, was the standard procedure. For markedly enlarged goiter, fractional resection was performed.

RESULTS

This procedure was performed successfully in all 37 patients. The mean operative time, mean blood loss, and mean excised thyroid weight were 84.7 min, 64 ml, and 51.8 g, respectively. Fractional resection was performed in six cases, where the mean operative time, mean blood loss, and mean excised thyroid weight were 119 min, 138.3 ml, and 102.2 g, respectively. Postoperative transient hypocalcemia occurred in 5 cases (13.5%), and no other complications were noted. The average postoperative hospital stay was 3.4 (range, 3-5) days. One case experienced recurrent hyperthyroidism during a mean follow-up period of 13 months. All patients were satisfied with the cosmetic result of the procedure.

CONCLUSIONS

Endoscopic subtotal thyroidectomy performed via breast approach is a technically feasible and safe procedure with excellent cosmetic results for patients with Graves' disease. In patients with markedly enlarged thyroid glands, subtotal thyroidectomy can be achieved through a fractional resection strategy.