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Scappaticcio L, Caruso P, Di Martino N, Ferrazzano P, Clemente A, Maiorino MI, Regginelli A, Docimo G, Rambaldi PF, Bellastella G, Trimboli P, Cappabianca S, Esposito K. Thymic hyperplasia is accurate to detect new-onset Graves' hyperthyroidism and resolves after restoring euthyroidism. J Endocrinol Invest 2024; 47:2487-2497. [PMID: 38553585 PMCID: PMC11393051 DOI: 10.1007/s40618-024-02355-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 03/03/2024] [Indexed: 09/13/2024]
Abstract
PURPOSE Abnormal liver blood tests (ALBTs), neutropenia (NEU) and thymic hyperplasia (TH) are new features of Graves' disease (GD). Our objectives were: (a) to calculate the accuracy of TH in discriminating between Graves' and non-Graves' thyrotoxicosis, compared to ALBTs, NEU and Graves' orbitopathy (GO); (b) to explore the outcome of GD-associated TH and non-GD-associated TH. METHODS We prospectively analyzed consecutive adult patients with newly diagnosed thyrotoxicosis from January 2018 to June 2023. TH was detected via neck ultrasound (nUS) then confirmed and followed by magnetic resonance imaging (MRI). For GD vs non-GD clinical sensitivity (SE) and specificity (SPEC), accuracy, positive predictive value (PPV) and negative predictive value (NPV) of GO, TH, ALBTs and NEU were calculated. RESULTS 264 thyrotoxic patients were included. TH was found in 16.4% (20/122) of GD vs 1.4% (2/142) in non-GD (p < 0.001). SE, SPEC, accuracy, PPV and NPV of the four extrathyroidal manifestations of GD were as follows, respectively: GO 26%, 100%, 66%, 100%, 61%; ALBTs 41%, 89%, 69%, 76%, 66%; NEU 5%, 100%, 56%, 100%, 55%; TH 16%, 98%, 61%, 91%, 98%. In 18 of them, TH regressed within 12 months after achieving euthyroidism under anti-thyroid drug therapy, while in the remaining 2, TH regressed 6 months after thyroid surgery. In the two non-GD patients with TH, thymus disappeared along with euthyroidism. CONCLUSIONS TH in the hyperthyroidism scenario provides a high PPV for GD. A conservative approach for the diagnostic work-up and initial management of thyrotoxicosis-associated TH should be adopted.
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Affiliation(s)
- L Scappaticcio
- Unit of Endocrinology and Metabolic Diseases, AOU University of Campania "Luigi Vanvitelli", 80138, Naples, Italy
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - P Caruso
- Unit of Endocrinology and Metabolic Diseases, AOU University of Campania "Luigi Vanvitelli", 80138, Naples, Italy
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - N Di Martino
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - P Ferrazzano
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - A Clemente
- Radiology and Radiotherapy Unit, Department of Precision Medicine, University of Campania "L. Vanvitelli", Naples, Italy
| | - M I Maiorino
- Unit of Endocrinology and Metabolic Diseases, AOU University of Campania "Luigi Vanvitelli", 80138, Naples, Italy
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - A Regginelli
- Radiology and Radiotherapy Unit, Department of Precision Medicine, University of Campania "L. Vanvitelli", Naples, Italy
| | - G Docimo
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
- Division of Thyroid Surgery, AOU University of Campania "Luigi Vanvitelli", Naples, Italy
| | - P F Rambaldi
- Radiology and Radiotherapy Unit, Department of Precision Medicine, University of Campania "L. Vanvitelli", Naples, Italy
| | - G Bellastella
- Unit of Endocrinology and Metabolic Diseases, AOU University of Campania "Luigi Vanvitelli", 80138, Naples, Italy.
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - P Trimboli
- Clinic of Endocrinology and Diabetology, Lugano and Mendrisio Regional Hospital, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - S Cappabianca
- Radiology and Radiotherapy Unit, Department of Precision Medicine, University of Campania "L. Vanvitelli", Naples, Italy
| | - K Esposito
- Unit of Endocrinology and Metabolic Diseases, AOU University of Campania "Luigi Vanvitelli", 80138, Naples, Italy
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
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Zeng J, Li L, Wei D. Association between thymic hyperplasia and serum calcium level in Graves' disease. BMC Endocr Disord 2024; 24:15. [PMID: 38281931 PMCID: PMC10823656 DOI: 10.1186/s12902-024-01541-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 01/17/2024] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Graves' disease increases bone resorption in hyperthyroidism, leading to elevated serum calcium levels and a negative bone balance. Thymic hyperplasia is observed in some Graves' disease patients. What's more, there have been a few reports of increased serum calcium and severe osteoporosis induced by Graves' disease with thymic hyperplasia. It remains unclear whether Graves' disease with thymic hyperplasia is associated with higher serum calcium levels. Our study aimed to investigate the possibility of elevated serum calcium levels and aggravated bone mobilization in Graves' disease patients with thymic hyperplasia. METHODS Newly diagnosed and untreated patients with Graves' disease (n = 96) were enrolled. They were divided into two groups based on the incidental detection of thymic hyperplasia during imaging. Albumin, alkaline phosphatase, calcium, free triiodothyronine, free thyroxine, thyroid-stimulating hormone, and thyrotrophin receptor antibody (TRAb) were measured, and a computerized tomography of the chest was obtained. RESULTS Patients with Graves' disease who had thymic hyperplasia were notably younger (P=0.018) and exhibited higher serum calcium levels (P=0.001) compared to those with Graves' disease without thymic hyperplasia. In the multiple regression analysis, thymic hyperplasia, TRAb, and female gender were significant variables associated with elevated serum calcium levels in patients with Graves' disease, collectively accounting for 31.7% of the variation in serum calcium. CONCLUSIONS Graves' disease patients with thymic hyperplasia showed higher serum calcium levels. thymic hyperplasia, TRAb, and female gender were found to be correlated with increased serum calcium levels in Graves' disease, suggesting a potential association between thymic hyperplasia and bone mobilization in Graves' disease.
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Affiliation(s)
- Jing Zeng
- Department of Endocrinology and Metabolism, The Second People's Hospital of Chengdu, No.10 Qingyunan Street, Jinjiang District, Chengdu, 610017, China
- Department of General Internal Medicine, West China Second University Hospital, Sichuan University, No.20, Section 3, Ren Min Nan Lu, 610041, Chengdu, China
| | - Lan Li
- Department of Endocrinology and Metabolism, The Second People's Hospital of Chengdu, No.10 Qingyunan Street, Jinjiang District, Chengdu, 610017, China
- Medical Examination Center, The Second People's Hospital of Chengdu, No.10 Qingyunan Street, Jinjiang District, Chengdu, 610017, China
| | - Dong Wei
- Department of Endocrinology and Metabolism, The Second People's Hospital of Chengdu, No.10 Qingyunan Street, Jinjiang District, Chengdu, 610017, China.
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Haider U, Richards P, Gianoukakis AG. Thymic Hyperplasia Associated with Graves' Disease: Pathophysiology and Proposed Management Algorithm. Thyroid 2017; 27:994-1000. [PMID: 28578595 DOI: 10.1089/thy.2017.0086] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The association between Graves' disease (GD) and thymic hyperplasia (TH) was first described in 1912 and has been reported numerous times thereafter. TH associated with GD presents as an incidental mediastinal mass on chest X-ray or computed tomography (CT). The pathogenesis of TH in the setting of GD is unclear but seems to involve a complex interplay of hormonal and immunological mechanisms. SUMMARY Here, the effect that thyroid hormones and autoimmunity have on thymic growth and size is reviewed. The authors' experience, along with a review of published case reports, reveals that general physicians may be unfamiliar with this association. This lack of familiarity may result in an aggressive management course, including surgical intervention, along with its associated risks and costs. The differential diagnosis and diagnostic workup of thymic enlargement associated with GD is discussed in light of the available clinical evidence. CONCLUSION Recent literature confirms the generally benign nature of TH associated with GD, and supports a conservative approach for the diagnostic workup and initial management. Practical management recommendations for thymic enlargement associated with GD have been formulated and are presented here.
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Affiliation(s)
- Uzma Haider
- 1 Division of Endocrinology and Metabolism, Harbor-UCLA Medical Center , Torrance, California
- 2 David Geffen School of Medicine at UCLA , Los Angeles, California
| | - Patrick Richards
- 1 Division of Endocrinology and Metabolism, Harbor-UCLA Medical Center , Torrance, California
- 2 David Geffen School of Medicine at UCLA , Los Angeles, California
| | - Andrew G Gianoukakis
- 1 Division of Endocrinology and Metabolism, Harbor-UCLA Medical Center , Torrance, California
- 2 David Geffen School of Medicine at UCLA , Los Angeles, California
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Jinguji M, Nakajo M, Nakajo M, Koriyama C, Yoshiura T. Thymic Involution After Radioiodine Therapy for Graves Disease: Relationships With Serum Thyroid Hormones and TRAb. J Endocr Soc 2017; 1:852-860. [PMID: 29264536 PMCID: PMC5686677 DOI: 10.1210/js.2017-00182] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 05/31/2017] [Indexed: 11/19/2022] Open
Abstract
Context: The mechanisms of thymic hyperplasia in Graves disease and its involution after radioiodine (I-131) therapy remain unknown. Objective: To examine whether computed tomography (CT) findings of the thymus in patients with Graves disease change before and 6 months after I-131 therapy and to elucidate factors that affect these changes. Design, Setting: A retrospective, single-center study was conducted. Thymic and thyroid volumes and thymic density were measured on CT. The associations of thymic volume or density with the following factors before I-131 therapy were examined: age; serum triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone receptor antibody (TRAb) levels; and thyroid volume. The changes in thymic volume and density and TRAb levels before and after I-131 therapy, and the correlations of thymic volume with T3 and T4 decline rates and TRAb changing rate and age were examined. Patients: We studied 40 consecutive patients with Graves disease who underwent neck and chest CT before and 6 months after I-131 therapy. Intervention: Observational study. Results: A significant negative correlation was observed only between thymic density and age before I-131 therapy. Thymic volume and density decreased and TRAb levels increased significantly after I-131 therapy. The thymic volume decline rate significantly positively correlated with serum T3 and thyroid volume decline rates. No significant correlation was found between thymic volume decline and TRAb changing rates. Conclusions: Significant thymic involution occurs after I-131 therapy in patients with Graves disease. Serum T3, but not TRAb, may be related to thymic hyperplasia and involution following I-131 therapy.
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Affiliation(s)
- Megumi Jinguji
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima 890-8544, Japan
| | - Masayuki Nakajo
- Department of Radiology, Nanpuh Hospital, Kagoshima 892-8512, Japan
| | - Masatoyo Nakajo
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima 890-8544, Japan
| | - Chihaya Koriyama
- Department of Epidemiology and Preventive Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima 890-8544, Japan
| | - Takashi Yoshiura
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima 890-8544, Japan
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Lee HY, Yoo SM, Kim HR, Chun EJ, White CS. Diagnosis of Grave's disease with pulmonary hypertension on chest CT. Clin Imaging 2017; 43:188-193. [PMID: 28363119 DOI: 10.1016/j.clinimag.2017.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 03/08/2017] [Accepted: 03/22/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of chest CT findings to diagnose Grave's disease in pulmonary hypertension. METHODS We retrospectively evaluated chest CT and the medical records of 13 patients with Grave's disease with (n=6) or without pulmonary hypertension (n=7) and in 17 control patients. RESULTS Presence of iso-attenuation of diffusely enlarged thyroid glands compared with adjacent neck muscle on non-enhanced CT as a diagnostic clue of Grave's disease, and assessment of pulmonary hypertension on CT has high diagnostic accuracy. CONCLUSION Chest CT has the potential to diagnose Grave's disease with pulmonary hypertension in the absence of other information.
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Affiliation(s)
- Hwa Yeon Lee
- Smile Radiologic Clinic, Seoul, Republic of Korea
| | - Seung Min Yoo
- Department of Diagnostic Radiology, CHA University College of Medicine, Bundang, Republic of Korea.
| | - Hye Rin Kim
- Department of Diagnostic Radiology, CHA University College of Medicine, Bundang, Republic of Korea
| | - Eun Ju Chun
- Department of Diagnostic Radiology, Seoul National University College of Medicine, Bundang, Republic of Korea
| | - Charles S White
- Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore, MD, USA
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Shilovsky GA, Feniouk BA, Skulachev VP. Thymic Involution in Ontogenesis: Role in Aging Program. BIOCHEMISTRY (MOSCOW) 2016; 80:1629-31. [PMID: 26638690 DOI: 10.1134/s0006297915120135] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In most mammals, involution of the thymus occurs with aging. In this issue of Biochemistry (Moscow) devoted to phenoptosis, A. V. Khalyavkin considered involution of a thymus as an example of the program of development and further--of proliferation control and prevention of tumor growth. However, in animals devoid of a thymus (e.g. naked mice), stimulation of carcinogenesis, but not its prevention was observed. In this report, we focus on the involution of the thymus as a manifestation of the aging program (slow phenoptosis). We also consider methods of reversal/arrest of this program at different levels of organization of life (cell, tissue, and organism) including surgical manipulations, hormonal effects, genetic techniques, as well as the use of conventional and mitochondria-targeted antioxidants. We conclude that programmed aging (at least on the model of age-dependent thymic atrophy) can be inhibited.
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Affiliation(s)
- G A Shilovsky
- Lomonosov Moscow State University, Belozersky Institute of Physico-Chemical Biology, Moscow, 119991, Russia.
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Chiu HK, Ledbetter D, Richter MW, Iyer RS, Merati AL. Reversible left recurrent laryngeal nerve palsy in pediatric Graves' disease. Pediatrics 2013; 132:e1704-8. [PMID: 24249820 DOI: 10.1542/peds.2013-0437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Vocal cord paralysis associated with goiter usually indicates the presence of a malignancy. Pediatric patients retain significant thymic tissue that regresses only later in life. This thymic tissue can develop significant hyperplasia during an acute autoimmune process. We describe a case of a 17-year-old girl who presented with a goiter secondary to severe Graves' disease and a 2-month history of hoarseness, choking on liquid intake, and small-volume vomiting especially after eating. She demonstrated a left vocal cord paralysis probably secondary to a unilateral left recurrent laryngeal nerve palsy. A marked enlargement of the thymus was discovered on thoracic imaging. Treatment was initiated with methimazole, with near complete remission of her vocal cord paralysis within 3 months. Given the immunomodulatory effects of methimazole, a potential mechanism of the left recurrent laryngeal nerve palsy was autoimmune hyperstimulation of the thymus and consequent hyperplasia, resulting in distension of the nerve. Attenuation of the hyperactive immune process with methimazole may have resulted in regression of the mass effect of the thymus and associated reduction of the nerve distension. This case illustrates the unique risk of left recurrent laryngeal nerve palsy in pediatric patients with an acute immune stimulation and hyperplasia of the thymus and the reversibility in the context of mitigation of the immune hyperactivity. Methimazole may be an optimal initial treatment choice in pediatric patients with Graves' disease and left recurrent laryngeal nerve palsy.
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Affiliation(s)
- Harvey K Chiu
- David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, MDCC 22-315, Los Angeles, CA 90095.
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Steenkamp DW, Junqueira A, Braverman LE. Unusual problems in the management of hyperthyroid Graves' disease. Endocr Pract 2013; 19:162-5. [PMID: 23435045 DOI: 10.4158/ep12129.co] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Devin W Steenkamp
- Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center, Boston, MA 02118, USA.
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Boyd JD, Juskevicius R. Mediastinal neoplasms in patients with Graves disease: a possible link between sustained hyperthyroidism and thymic neoplasia? Thyroid Res 2012; 5:5. [PMID: 22824515 PMCID: PMC3411457 DOI: 10.1186/1756-6614-5-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 07/23/2012] [Indexed: 11/21/2022] Open
Abstract
Background Anterior mediastinal masses are a rare but well documented finding in Graves disease. The vast majority of these lesions represents benign thymic hypertrophy and regress after treatment of the hyperthyroidism. A small percentage of these cases however represent neoplastic/malignant diseases which require further treatment. Cases 12 year old boy with one year history of refractory Graves disease was found to have an anterior mediastinal mass and underwent curative thyroidectomy for sustained hyperthyroidism. Cervical lymphadenopathy was detected during the procedure and biopsy was obtained. A 23 year old woman who presented with a one month history of hyperthyroid symptoms, was diagnosed with Graves disease and also was found to have an anterior mediastinal mass on imaging. Biopsy of the anterior mediastinal mass was obtained and subsequently the patient underwent robotic thymectomy. Histologic examination and immunophenotyping of the cervical lymph node in a 12 year old boy revealed neoplastic proliferation of T lymphoblasts diagnostic of T lymphoblastic leukemia/lymphoma. Examination of the anterior mediastinal mass biopsy in the 23 year old woman revealed type B1 thymoma which was confirmed after examination of the subsequent robotic thymectomy specimen. Conclusion This is the first reported case of T cell lymphoblastic lymphoma and the third reported case of thymoma associated with sustained hyperthyroidism due to Graves disease. These cases indicate that an anterior mediastinal mass in a patient with active Graves disease may be due to a neoplastic cause, which may require definitive treatment. Caution should be exercised when dismissing a mediastinal mass as benign thymic hyperplasia in patients with active Graves disease.
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Affiliation(s)
- Jonathan D Boyd
- Department of Pathology & Laboratory Medicine, Vidant Medical Center and Brody School of Medicine, East Carolina University, Greenville, NC, USA.
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Hamzaoui AA, Klii RR, Salem RR, Kochtali II, Golli MM, Mahjoub SS. Thymic hyperplasia in a patient with Grave's disease. Int Arch Med 2012; 5:6. [PMID: 22321290 PMCID: PMC3296585 DOI: 10.1186/1755-7682-5-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Accepted: 02/09/2012] [Indexed: 12/04/2022] Open
Abstract
Hyperplastic changes of the thymus may be found in patients with Graves' disease. However, this rarely presents as an anterior mediastinal mass, particularly among adults. In this report, we describe a 46-year old woman with Graves' disease and thymic hyperplasia.
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Affiliation(s)
- Amira A Hamzaoui
- Department of Internal Medicine and Endocrinology- Fattouma Bourguiba Hospital- Monastir 5000- Tunisia.
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Desforges-Bullet V, Petit-Aubert G, Collet-Gaudillat C, Cerceau R, Fraleu-Louer B, Meckenstock R, Greder A, Cordoliani Y, Beressi JP. Hyperplasie thymique et maladie de Basedow : une association non fortuite. Cas clinique et revue de la littérature. ANNALES D'ENDOCRINOLOGIE 2011; 72:304-309. [DOI: 10.1016/j.ando.2011.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Revised: 05/02/2011] [Accepted: 05/05/2011] [Indexed: 11/16/2022]
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A case report of hyperthyroid-associated thymic hypertrophy in a child, presenting as an anterior mediastinal mass. Eur J Pediatr 2011; 170:937-40. [PMID: 21274565 DOI: 10.1007/s00431-011-1395-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 01/11/2011] [Indexed: 10/18/2022]
Abstract
We present the case of an 8-year-old boy with an anterior mediastinal mass and signs of hyperthyroidism. The anterior mediastinal mass had radiologic characteristics suggestive of thymic hypertrophy and regressed with antithyroid therapy. Though thymic hypertrophy is a known manifestation of hyperthyroidism, this is the youngest reported case. In selected cases, the diagnosis may be made based on the clinical picture, radiologic appearance, and response to antithyroid therapy without the need of a thymic biopsy or thymectomy.
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Popoveniuc G, Sharma M, Devdhar M, Wexler JA, Carroll NM, Wartofsky L, Burman KD. Graves' disease and thymic hyperplasia: the relationship of thymic volume to thyroid function. Thyroid 2010; 20:1015-8. [PMID: 20718680 DOI: 10.1089/thy.2009.0383] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Thymic hyperplasia is associated with Graves' disease, particularly in young patients. The degree of thymic transformation is minimal in most but not all patients. In the latter group radiological measurements of thyroid size and their change with treatment have rarely been reported. We present two patients with Graves' disease and relatively rapid resolution of thymic enlargement after successful treatment of their hyperthyroidism. SUMMARY Three patients with thyrotoxicosis secondary to Graves' disease and marked thymic enlargement were seen at our institution during a 2-year period. On computed tomography (CT) studies their volumes were 67, 81, and 54 cm(3). Thymic hyperplasia in the setting of Graves' disease was the diagnosis of exclusion. Two of the patients returned for follow-up after successful treatment of thyrotoxicosis as requested. On repeat CT their thymic volumes had decreased by 72% and 78%, respectively. Two types of histological modifications of the thymus have been described in association with Graves' disease, namely, thymic parenchyma hyperplasia and medullary lymphoid hyperplasia. The mechanisms underlying thymic transformation in patients with Graves' hyperthyroidism are not completely elucidated, but autoimmune processes underlying Graves' disease are presumed to play a role. The clinical course of our patients is consistent with earlier literature, indicating that thymic enlargement may occur in conjunction with Graves' hyperthyroidism, and that it usually resolves as hyperthyroidism is treated, but there is little quantitative pre- and posttreatment of hyperthyroidism data. CONCLUSION Although every patient must be individually considered, it appears that thymic hyperplasia can be diagnosed in most Graves' hyperthyroid patients by considering the clinical context and appropriate radiologic studies such as CT. Raising awareness of the association of thymic hyperplasia in patients with Graves' hyperthyroidism and its resolution with the reversibility of the hyperthyroid state should prevent unnecessary thymic evaluation and surgery with its attendant risks.
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Affiliation(s)
- Geanina Popoveniuc
- Division of Endocrinology, Department of Medicine, Georgetown University Hospital, Washington, DC 20010, USA.
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McCullen MK, Miller JL. Incidental radiologic finding of an anterior superior mediastinal mass masquerading as metastatic thyroid cancer in patients with treated thyroid cancer. Endocr Pract 2010; 17:65-9. [PMID: 20713344 DOI: 10.4158/ep10111.or] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To demonstrate that an anterior superior mediastinal mass on radiologic imaging may represent an incidental finding and not metastases in patients with a history of treated well-differentiated thyroid cancer. METHODS We report the clinical presentation and outcomes of 4 patients with a history of thyroid cancer who were incidentally found to have anterior superior mediastinal masses on imaging. We also review the relevant literature. RESULTS Four young adults with a history of stage I papillary thyroid cancer treated with total thyroidectomy and radioiodine were incidentally found to have thymic enlargement on imaging studies within a 3-year posttreatment window. In each case, this enlargement was believed to be secondary to thymic hyperplasia and not metastatic disease, and each patient has exhibited a benign clinical course. Review of the literature revealed few reports of an association between thymic hyperplasia and thyroid cancer. CONCLUSIONS Thymic hyperplasia may be discovered on posttreatment imaging studies in patients with a history of well-differentiated thyroid cancer, particularly in young adults who have received radioiodine therapy. Recognition of the possible coexistence of this incidental finding in patients with thyroid cancer may help to avoid unnecessary invasive procedures and treatments.
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Affiliation(s)
- Mary Kate McCullen
- Division of Endocrinology and Metabolism, Jefferson Medical College, Philadelphia, Pennsylvania, USA.
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