Prevalence of thyroid cancer in hyperthyroidism treated by surgery

Finasteride for hair loss: a review

BACKGROUND AND OBJECTIVES

Finasteride 1 mg/day is indicated for androgen-dependent conditions such as male androgenetic alopecia (AGA).

METHODS

The literature is comprehensively summarized on the pharmacodynamics, pharmacokinetics, mechanism of action, and metabolism of finasteride. Pairwise and network meta-analyses were performed to assess the efficacy of finasteride reported in clinical trials. The adverse events profile is described along with the post-marketing reports.

RESULTS AND CONCLUSION

Finasteride 1 mg/day significantly increased total hair count compared to placebo after 24 weeks (mean difference = 12.4 hairs/cm², p < .05), and 48 weeks (mean difference = 16.4 hairs/cm², p < .05). The efficacy of the two doses of finasteride (5 mg/day and 1 mg/day) and topical finasteride (1% solution) were not significantly different. The most commonly reported sexual events include erectile dysfunction and decreased libido. Increasing patient complaints and analysis of the FAERS database led to the inclusion of depression in the FDA label in 2011, as men were found to be at a risk of suicide due to the persistent sexual side effects, commonly termed as post-finasteride syndrome. Finasteride is shown to be reasonably tolerated in both men and women; however, patients need to be educated about the possible short- and long-term side-effects.

Clinical characteristics associated with the finding of thyroid cancer originating from hot nodules in patients with hyperthyroidism: a case report and systematic review of the literature

Coexistence between thyroid cancer and hyperthyroidism is rare, and most of the nodular lesions from which a malignant tumor is documented in this group of patients correspond to cold nodules. Justified by the increasing number of reports in the literature about malignant tumors diagnosed from hot nodules, a systematic review was carried out to determine possible factors associated with the diagnosis of thyroid cancer from hot nodules in patients with hyperthyroidism. The results suggest that the clinical diagnosis of toxic nodular goiter, nodular lesions of diameter > 10 mm and a histological type compatible with a follicular carcinoma, are factors that on their own increase the risk of making the diagnosis of cancer from a hot nodule.

Can we still consider thyroid hyperfunction a protective condition for the onset of thyroid cancer?

Background

Thyroid cancer is the ninth most commonly diagnosed cancer in the world, and the most common endocrine carcinoma. It was originally believed to be a rare event in patients with thyroid hyperfunction and it was reported that hyperthyroidism had a protective role against thyroid neoplasms. However, in recent years, several studies have hypothesized that differentiated thyroid carcinomas and hyperthyroidism may coexist. Our study aims therefore to evaluate the incidence of differentiated thyroid carcinomas on definitive histological examination, in patients undergoing total thyroidectomy or hemithyroidectomy with coexisting hyperfunctioning thyroid disease, to understand whether hyperthyroidism can be considered a protective condition against the onset of thyroid neoplasms.

Methods

The study involved 1,449 patients underwent to thyroid surgery from 2010 to 2018 at the General Surgery Unit, Department of Surgery, University Hospital of Parma, Parma, Italy, presenting thyroid cancer at postoperative histological exam. Patients were divided in two groups based on the presence (Group A) or absence (Group B) of hyperfunction. All data were collected in a dedicated database and include demographic data, such as age and sex, preoperative cytology, date and type of surgery, postoperative diagnosis, characteristics of aggressiveness of the neoplasm and postoperative complications. For data analysis, a P value of less than 0.05 was considered statistically significant.

Results

The incidence of thyroid carcinomas was lower in patients suffering from hyperfunction compared to the incidence found in non-hyperthyroid patients, both in preoperative cytological examination and in postoperative diagnosis through histological examination. Furthermore, the tumors that have developed in patients with hyperfunction had a comparable degree of aggression and invasiveness in the two groups studied. However, we have found an equal incidence of microcarcinomas and occult carcinomas on postoperative histological examination. Postoperative complications in patients with cancer were similar, regardless of the presence or absence of hyperfunctioning thyroid disease.

Conclusions

Our study confirms that hyperthyroidism is a protective condition against thyroid carcinoma, but the finding of an equivalent incidence of occult carcinomas in the two groups stresses the need to perform a cytological examination in case of a nodular pathology in a hyperthyroid patient before performing a treatment.

Prognosis of papillary thyroid cancer in patients with Graves' disease: a propensity score-matched analysis

Background

Patients with Graves’ disease (GD) are at a 2.5 times higher risk of developing thyroid cancer than the general population. Previous studies reported conflicting results about the prognosis of thyroid cancer concomitant with GD. This study aimed to investigate the effect of GD to the recurrence rates of papillary thyroid carcinoma (PTC).

Methods

We reviewed 3628 patients who underwent total thyroidectomy for PTC at the Ewha Womans University Medical Center from January 2006 to June 2014. Of those, 114 patients had non-occult PTC with concomitant GD. To reduce potential confounding effects and selection bias, we conducted 1:5 propensity score matching and analyzed the recurrence-free survival.

Results

Thyroid cancer in patients with GD showed lower rate of lymphatic invasion (1.8% vs. 6.7%; p = 0.037), microscopic resection margin involvement (0.9% vs. 5.8%; p = 0.024), and lymph node metastasis (29.8% vs. 37.3%; p = 0.001) than in patients without GD, respectively. During the median follow-up of 94.1 months, recurrence occurred in one patient (0.9%) with GD. After propensity score matching for adjusting clinicopathological features, 5-year recurrence-free survival was comparable between patients with GD and euthyroid patients (100% vs. 98.4%, p = 0.572). Both tumor size [hazard ratio (HR) 1.585, p < 0.001] and lymph node metastasis (HR for N1a 3.067, p = 0.024; HR for N1b 15.65, p < 0.001) were predictive factors for recurrence-free survival, while GD was not associated with the recurrence.

Conclusions

Our data suggest that GD does not affect the prognosis of PTC. Thyroid cancer in patients with GD is not more aggressive than in euthyroid patients.

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.

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.

Thyroid cancer in Plummer's disease

Thyroid cancer with concomitant hyperthyroidism is rare. Most foci of malignancy are small and seen postoperatively as incidental findings after surgery for hyperthyroidism. Thyroid masses with clinical features of malignancy and concomitant hyperthyroidism are less-commonly reported. We report two cases of multinodular toxic goitre or Plummer's disease with clinical features of malignancy. Both patients had large multinodular goitres with evidence of metastasis to the manubrium for the first patient and to the lymph node and lungs for the second patient. Both were clinically euthyroid but with free hormone excess and suppressed thyroid stimulating hormone (TSH) on laboratory testing. Both patients received methimazole prior to thyroidectomy. Histopathology revealed follicular variant of papillary cancer with metastasis to the manubrium for the first patient and follicular thyroid cancer with lymph node metastasis for the second. While rare, thyrotoxicosis can occur with malignancy, Plummer's disease may harbour cancer and behave aggressively.

A rare case of hyperfunctioning papillary carcinoma of the thyroid gland

We report a rare case of hyperfunctioning papillary carcinoma of the thyroid. A 32-year-old man was referred to our hospital for the treatment of a painless mass in the left neck, which had been detected on routine physical check-up. Cervical ultrasonography and computed tomography showed a solid tumor with calcification in the left lobe of the thyroid gland. Serum examinations demonstrated hyperthyroidism with a high level of thyroglobulin. Fine needle aspiration biopsy revealed a cytological diagnosis of class II. Tc-99m scintigraphy showed a hot nodule in the left lobe, which implied that the tumor was a hyperfunctioning thyroid tumor. Left lobectomy of the thyroid gland was performed to treat the hyperfunctioning tumor. Postoperative pathological examinations revealed a follicular variant papillary carcinoma. Postoperative thyroid function became within the normal range. Although hyperfunctioning thyroid carcinomas are rare, it is important to correctly diagnose them and to perform appropriate surgical interventions.

Anaplastic thyroid carcinoma associated with Graves' disease

This report concerns a 79-year-old woman with coexisting anaplastic thyroid carcinoma (ATC) and Graves' disease (GD). The patient was referred to our clinic because of palpitation and a palpable mass on the left side of her neck. Thyroid function tests showed hyperthyroidism with elevated thyroid-stimulating antibodies. Ultrasonography of the thyroid demonstrated an adenomatous nodule-like marcated nodule (27.6 x 26.5 x 36.4 mm) with cystic degeneration inside the left lobe. (123)I thyroid scintigraphic imaging showed a cold area corresponding to the nodule with continuous uptake in the remaining thyroid tissue despite suppressed TSH levels. These findings led to a diagnosis of GD. On the other hand, the thyroid nodule could not be definitely diagnosed even after fine needle aspiration biopsy (FNAB) which produced findings suggestive of both papillary thyroid carcinoma and ATC. Open biopsy of the nodule showed an ATC. Regional lymph node metastases as well as multiple lung metastases, which could not be found at the initial visit, had been already developed by that time. Our case is pathophysiologically interesting because it suggests that GD or thyroid-stimulating antibodies (TSAb) may stimulate malignant transformation of differentiated carcinoma. It is also clinically important because it indicates that all thyroid nodules, particularly palpable cold nodules, associated with GD require careful management to detect malignancy because they are at higher risk of harboring malignancy.