Subcutaneous implantation of nodular goiter after transoral endoscopic thyroidectomy vestibular approach: A case study and review of literature

BACKGROUND

Extrathyroid implantation or dissemination of thyroid tissue secondary to a thyroid procedure is rare. Most of these belonged to thyroid carcinoma with metastatic potential and uncommon for benign pathologies.

METHODS

We report the case of a 31-year-old female who was identified to have multiple subcutaneous implantation of thyroid tissue 5 years after transoral endoscopic thyroidectomy vestibular approach. A comprehensive literature search on implantation of thyroid tissue secondary to thyroid procedures was performed.

RESULTS

Accidental tearing of the capsule during previous surgery may lead to the subcutaneous implantation. Through literature review, a total 29 articles with 47 patients were identified. 33.3% were benign lesions, and implantation was mostly secondary to fine needle aspiration biopsy (46.5%).

CONCLUSIONS

Subcutaneous or port site implantation after endoscopic thyroid surgery may occur in benign thyroid pathologies and therefore, oncologic principles must be strictly followed during surgery regardless of its histopathological nature.

Correlation between thyroid function indices and urine iodine levels in patients with nodular goiter

OBJECTIVE

To retrospectively analyze the iodine nutritional status in patients with nodular goiter (NG) and investigate a possible association between urinary iodine levels and thyroid function indices.

METHODS

A total of 173 patients diagnosed with nodular goiter in the Fourth Hospital of Hebei Medical University from January 2019 to May 2021 were selected as the NG group, and 172 healthy individuals without thyroid diseases were selected after a physical examination as a control group. The data of all the participants were retrospectively assessed to explore the association between urinary iodine levels and thyroid function indices. The content of urinary iodine in the two groups was compared, and the correlation of urinary iodine levels with thyroid stimulating hormone (TSH), free triiodothyronine (FT3), and free thyroxine (FT4) in the NG group was evaluated.

RESULTS

The level of urinary iodine in the NG group was 163.97 ± 113.75 μg/L, which was higher than 121.47 ± 53.75 μg/L in the control group (P < 0.05). The iodine excess rate in females was higher than that in males (P < 0.05). The results of Pearson correlation analysis showed that the amount of urinary iodine in patients with hyperthyroidism with different urinary iodine statuses was negatively correlated with the level of TSH and positively correlated with levels of FT3 and FT4.

CONCLUSION

There is a significant association between urinary iodine levels and thyroid hormone levels in NG patients. Therefore, regular monitoring of urinary iodine levels is essential for the appropriate use of iodine supplementation.

Outcomes of laser-induced thermotherapy for thyroid nodules at the West Vascular Center, Ukraine

Thyroid nodules are common, occurring in 50-60% of healthy patients. Currently, there are no effective conservative treatment options for nodular goiter, and surgery can have limitations and potential complications. The purpose of this study was to evaluate the efficacy, tolerability, and long-term results of using sclerotherapy and laser-induced interstitial thermotherapy (LITT) to treat benign thyroid nodules. A retrospective analysis was conducted on 456 patients with benign nodular goiter who received LITT. The volume of the nodular goiter was measured at 1, 3, 6, and 12 months post-treatment, and a repeated fine needle aspiration (FNA) with the cytological examination was performed to verify the structure of the nodular goiter in the long term. The results showed that LITT was an effective method for treating nodular mass (nodules), as evidenced by a decrease in the volume of NG by 51-85% after 6-12 months. FNA results 2-3 years after LITT showed no thyrocytes, only connective tissue, indicating the efficacy of LITT for benign thyroid nodules. LITT is highly effective in most cases, often resulting in the disappearance or significant decrease in nodular formations.

Concealed Tracheal Angiosarcoma Beneath a Large Thyroid Mass-An Unexpected Cause of Intractable Hemoptysis

Angiosarcoma is a rare primary tracheal-bronchus origin tumor which was only reported in a few cases. The diagnosis and treatment for such a rare tumor has long been a challenge. In this case, a male hemoptysis patient who was initially misdiagnosed with thyroid carcinoma with tracheal invasion was finally diagnosed with tracheal angiosarcoma. A thick-walled cystic nodular mass was found preoperatively in the right thyroid lobe overlying the tracheal angiosarcoma, which contributed to our initial misdiagnosis. Flap bleeding and necrosis occured after the surgery and patient continued to cough blood even when we excised the whole flap, which suggested the intramural growth and local invasion of the angiosarcoma. This study also reviewed previous literactures on airway angiosarcoma and discussed the treatment strategy.

Mechanism Study on Chinese Medicine in Treatment of Nodular Goiter

Nodular goiter has become increasingly prevalent in recent years. Clinically, there has been a burgeoning interest in nodular goiter due to the risk of progression to thyroid cancer. This review aims to provide a comprehensive summary of the mechanisms underlying the therapeutic effect of Chinese medicine (CM) in nodular goiter. Articles were systematically retrieved from databases, including PubMed, Web of Science and China National Knowledge Infrastructure. New evidence showed that CM exhibited multi-pathway and multi-target characteristics in the treatment of nodular goiter, involving hypothalamus-pituitary-thyroid axis, oxidative stress, blood rheology, cell proliferation, apoptosis, and autophagy, especially inhibition of cell proliferation and promotion of cell apoptosis, involving multiple signal pathways and a variety of cytokines. This review provides a scientific basis for the therapeutic use of CM against nodular goiter. Nonetheless, future studies are warranted to identify more regulatory genes and pathways to provide new approaches for the treatment of nodular goiter.

Diagnosis of Ectopic Intrathyroidal Parathyroid Adenoma with Nodular Goiter by 18F Fluorocholine: A Case Report

The occurrence of ectopic intrathyroidal parathyroid adenoma (EPTA) is very rare, which causes some difficulties in diagnosis and complicates treatment. In addition, the occurrence of EPTA with nodular goiter (NG) is rare, which makes diagnosis difficult and requires the assistance of clinical evidence, imaging data, and cytological examination results. Therefore, we present a patient with a final diagnosis of ETPA with NG.

Diagnosis and treatment of thyroid cancer in adult patients - Recommendations of Polish Scientific Societies and the National Oncological Strategy. 2022 Update [Diagnostyka i leczenie raka tarczycy u chorych dorosłych - Rekomendacje Polskich Towarzystw Naukowych oraz Narodowej Strategii Onkologicznej. Aktualizacja na rok 2022]

The guidelines Thyroid Cancer 2022 are prepared based on previous Polish recommendations updated in 2018. They consider international guidelines - American Thyroid Association (ATA) 2015 and National Comprehensive Cancer Network (NCCN); however, they are adapted according to the ADAPTE process. The strength of the recommendations and the quality of the scientific evidence are assessed according to the GRADE system and the ATA 2015 and NCCN recommendations. The core of the changes made in the Polish recommendations is the inclusion of international guidelines and the results of those scientific studies that have already proven themselves prospectively. These extensions allow de-escalation of the therapeutic management in low-risk thyroid carcinoma, i.e., enabling active surveillance in papillary microcarcinoma to be chosen alternatively to minimally invasive techniques after agreeing on such management with the patient. Further extensions allow the use of thyroid lobectomy with the isthmus (hemithyroidectomy) in low-risk cancer up to 2 cm in diameter, modification of the indications for postoperative radioiodine treatment toward personalized approach, and clarification of the criteria used during postoperative L-thyroxine treatment. At the same time, the criteria for the preoperative differential diagnosis of nodular goiter in terms of ultrasonography and fine-needle aspiration biopsy have been clarified, and the rules for the histopathological examination of postoperative thyroid material have been updated. New, updated rules for monitoring patients after treatment are also presented. The updated recommendations focus on ensuring the best possible quality of life after thyroid cancer treatment while maintaining the good efficacy of this treatment.

Comparative analysis and influencing factors of hospitalization expenses of three single diseases in a tertiary Class A general hospital

OBJECTIVE

To compare the hospitalization expenses among three single diseases in The First Affiliated Hospital of Hebei North University (a tertiary Class A general hospital), and analyze the factors affecting hospitalization costs, so as to provide some basis for controlling the unreasonable increase of hospitalization expenses as well as to render references for medical management.

METHODS

By retrospective investigation, we selected the basic information of inpatient medical records and detailed billing of patients hospitalized in our hospital from Jan. 1, 2016 to Dec. 31, 2018. The collected data were sorted based on the International Classification of Diseases (ICD-10). Finally, 1,199 cases of frequently-occurring diseases and common illnesses such as rectal cancer (RC), nodular goiter (NG) and chronic renal failure (hemodialysis, HD) (CRF) were selected to conduct descriptive statistics on influencing factors and cost structure. The influencing factors of hospitalization expenses were identified by one-way analysis of variance (ANOVA) and multiple linear regression analysis.

RESULTS

The hospitalization cost of inpatients with RC or CRF (HD) mainly spent on drugs, diagnosis and materials. As to NG, the cost of surgery, diagnosis and materials were the main components of hospitalization costs. Occupation and length of stay (LOS) were identified as the main influencing factors of hospitalization expenses for RC patients. While age and LOS were the main influencing factors of hospitalization cost for NG patients, and LOS alone for patients with CRF (HD). A across-sectional study was conducted on the CRF (HD) patients over 60 years old.

CONCLUSIONS

In order to reasonably control inpatient medical expenses, comprehensive intervention should be carried out in clinical work, from rational drug use and selection of consumables, to shorten the hospitalization days to an appropriate level and reduce the waste of medical resources.

Value of 99mTc-MIBI SPECT/CT in distinguishing between parathyroid lesions and nodular goiter

OBJECTIVES

Hyperfunctioning parathyroid lesions require surgical resection. 99mTc-methoxyisobutylisonitrile (99mTc-MIBI) single-photon emission computed tomography/computed tomography (SPECT/CT) plays an important role in the diagnosis of parathyroid lesions. Some nodular goiters have a higher uptake of 99mTc-MIBI, which is difficult to distinguish from hyperfunctioning parathyroid lesions. This study aims to explore the value of 99mTc-MIBI SPECT/CT in the differential diagnosis of parathyroid lesions and nodular goiter.

METHODS

This study was a retrospective analysis. A total of 68 patients who were diagnosed as parathyroid lesions by 99mTc-MIBI SPECT/CT were enrolled, with a total of 81 lesions. According to the results of pathological examination after surgical resection, the lesions were divided into a parathyroid lesion group (n=69) and a nodular goiter group (n=12). The target maximum radioactivity count (Tmax) of all lesions was measured. The mean radioactivity count of the aortic arch was used as the background mean radioactivity count (Bmean), and the ratio of the Tmax to Bmean was calculated. The difference in Tmax/Bmean between the 2 groups was compared. The minimum, mean, and maximum of CT density in the lesion were measured. The difference of CT density between the 2 groups was compared. The receiver operating characteristic (ROC) curve of patients with parathyroid lesions and patients with nodular goiter was drawn, and the diagnostic efficacy of each CT density value was evaluated.

RESULTS

The 99mTc-MIBI radioactive uptake in parathyroid lesions and nodular goiter lesions was significantly concentrated. The CT density values of the 2 lesions were lower than normal thyroid tissue, and the boundary between the 2 lesions and the thyroid was clear or blurred. There was no significant difference in Tmax/Bmean between the 2 groups (P=0.221). The differences in the minimum, mean and maximum of CT density between the 2 groups were statistically significant (all P<0.05). The diagnostic efficiency of maximum of CT density was the best, area under the ROC curve was 0.894 (P<0.001), the cut-off was 91 HU, the sensitivity was 83.3%, and the specificity was 94.2%.

CONCLUSIONS

The degree of 99mTc-MIBI radiation uptake in the focus has limited value in differentiating parathyroid lesions from nodular goiter, and the maximum density of CT possesses high diagnostic efficiency.

Significance of RAS Mutations in Thyroid Benign Nodules and Non-Medullary Thyroid Cancer

Simple Summary

Only about 4% of thyroid nodules are carcinomas and require surgery. Fine-needle aspiration cytology is the most accurate tool to distinguish benign from malignant thyroid nodules, however it yields an indeterminate result in about 30% of the cases, posing diagnostic and prognostic dilemmas. Testing for genetic mutations, including those of RAS, has been proposed for indeterminate cytology to solve these dilemmas and support the clinician decision making process. A passionate debate is ongoing on the biological and clinical significance of RAS mutations, calling into question the utility of RAS as tumor marker. Recently, the description of a new entity of non-invasive follicular thyroid neoplasm and the accurate review of more recent analyses demonstrate that RAS mutations have limited utility in both the diagnostic and prognostic setting of thyroid nodular disease.

Abstract

Thyroid nodules are detected in up to 60% of people by ultrasound examination. Most of them are benign nodules requiring only follow up, while about 4% are carcinomas and require surgery. Malignant nodules can be diagnosed by the fine-needle aspiration cytology (FNAC), which however yields an indeterminate result in about 30% of the cases. Testing for RAS mutations has been proposed to refine indeterminate cytology. However, the new entity of non-invasive follicular thyroid neoplasm, considered as having a benign evolution and frequently carrying RAS mutations, is expected to lower the specificity of this mutation. The aggressive behavior of thyroid cancer with RAS mutations, initially reported, has been overturned by the recent finding of the cooperative role of TERT mutations. Although some animal models support the carcinogenic role of RAS mutations in the thyroid, evidence that adenomas harboring these mutations evolve in carcinomas is lacking. Their poor specificity and sensitivity make the clinical impact of RAS mutations on the management of thyroid nodules with indeterminate cytology unsatisfactory. Evidence suggests that RAS mutation-positive benign nodules demand a conservative treatment. To have a clinical impact, RAS mutations in thyroid malignancies need not to be considered alone but rather together with other genetic abnormalities in a more general context.

The Value of Relative Size in the Ultrasound Diagnosis of Follicular Thyroid Neoplasm

Purpose

Ultrasonography as the first choice for thyroid nodules is still difficult to distinguish between solid follicular thyroid neoplasm (FTN) and solid nodular goiter (NG). We tried to investigate the value of relative size (M/S, M: the maximum diameter of target nodule, S: the maximum diameter of the largest of the remaining nodules) that may help to differentiate FTN from NG.

Methods

T test and chi-square test were used to retrospectively analyze the differences of the clinical and ultrasonographic characteristics between FTN and NG in 422 cases in our hospital. T test was used to analyze the difference of M/S value in the two kinds of nodules. ROC was used to evaluate the accuracy of M/S value in distinguishing the two.

Results

There were statistically significant differences in age, echogenicity, calcification, peripheral halo and blood supply between the two. The M/S value is not only significantly different in the two kinds of nodules but also can be used as a quantitative indicator to guide ultrasound diagnosis. ROC analysis showed that the cutoff point and AUC of M/S value were 1.94 and 0.709, respectively.

Conclusion

In the ultrasound diagnosis of multiple thyroid nodules, the M/S value can better distinguish FTN and NG. We need to be aware of FTN when the M/S value of the nodule is greater than 2.

Percutaneous injection of ethanol for thyroid nodule treatment: a comparative study

Objective

Percutaneous ethanol injection (PEI) is an alternative to surgery for the treatment of thyroid nodules (TNs). However, size reductions of treated (TTNs) and untreated TN (UTNs) have not been compared. Volumetric reductions in TTNs with PEI were evaluated by comparing TTNs and UTNs in the same patient, and independent variables predicting good post-PEI outcomes were analyzed.

Methods

Overall, 282 patients with multinodular goiters were selected. Two nodules located in different lobes were compared for common disease behaviors. Overall, 150 nodules were selected from 75 patients (6 M: 69 F) with a mean age of 50.1 ± 17.4 years. This prospective nonrandomized intervention study prioritized treating TNs of greater volume or single hyperfunctioning TNs. A single observer experienced in PEI and an ultrasound specialist performed the interventions.

Results

TTNs (mean volume: 14.8 ± 16.2 mL) were reduced by 72.6 ± 27.3% of their initial volume, while UTNs increased by a mean of 365.7 ± 1.403.8% (p < 0.00001). The patients underwent a mean of 4.0 ± 3.1 outpatient PEI sessions without relevant complications. Logistic regression analysis showed that the magnitude of the PEI induced reduction was associated with the number of treatment sessions (p = 0.03, CI [1.1-38.2]) and not with ultrasonographic characteristics of the nodules. Each PEI session increased the rate of TN reduction by a factor of 6.7.

Conclusion

PEI is a well-tolerated outpatient procedure that effectively reduces the volume of TNs and is noticeably superior to conservative treatment for all ultrasonographic classifications.

Expert consensus workshop report: Guidelines for thermal ablation of thyroid tumors (2019 edition)

As a treatment option for cancer, thermal ablation has satisfactory effects on many types of solid tumors (such as liver and renal cancers). However, its clinical applications for the treatment of thyroid nodules and metastatic cervical lymph nodes are still under debate both in China and abroad. In 2015, the "Zhejiang Expert consensus on thermal ablation for thyroid benign nodules, microcarcinoma, and metastatic cervical lymph nodes (2015 edition)," was released by the Thyroid Cancer Committee of Zhejiang Anti-Cancer Association, China. To further standardize the application of thermal ablation for thyroid tumors, the Thyroid Tumor Ablation Experts Group of Chinese Medical Doctor Association has organized many seminars and finally produced a consensus to formulate the "Expert consensus workshop report: Guidelines for thermal ablation of thyroid tumors (2019 edition)."

Thyroid and Pseudothyroid Dysfunction as a Cause That is Promoting the Relapse of Benign Focal Thyroid Pathology

Several studies deal with learning causes stipulating nodular formations in the thyroid tissue, including those occurring against the ground of metabolic disorders of thyroid hormones. Our study’s objective was to determine the peculiarities of thyroid homeostasis disorders in patients suffering from benign nodular thyroid pathology with relapses of the disease and its relapse-free course. For this purpose, 96 female patients suffering from nodular thyroid pathology and 20 without thyroid pathology were examined. In the course of the study, the following were found in patients with benign focal thyroid pathology: disorders of the peripheral conversion of the thyroid hormones, compensatory activation of the hypothalamic-pituitary system evident in increased levels of the thyroid-stimulating hormone, ТSH/fT3 and ТSH/fT4 ratios, increasing titers of the anti-thyroid antibodies which can be hazardous for the risk of development of nodules or reflects the process of thyroid tissue damage; high level of thyroglobulin caused by an increased probability of relapse and rate of nodule growth, an increase of the thyroid gland volume associated with activation of the hypothalamic-pituitary system, increased antibodies titer and thyroid gland damage. Thus, changes of the examined indices in the blood can be used as prognostic markers concerning the relapse of nodule formation in the thyroid tissue.

Thyroid Pathology in End-Stage Renal Disease Patients on Hemodialysis

Objectives: Chronic kidney disease is a rising cause of morbidity and mortality in developed countries, including end-stage renal disease (ESRD). The prevalence of thyroid comorbidities in persons with chronic kidney disease is documented higher than in normal population. The study aims to investigate the prevalence of morphological and functional thyroid disorders in patients with chronic kidney disease, with renal replacement therapy (hemodialysis). Methods: A cross-sectional study was performed on 123 consecutive patients with chronic kidney disease stage 5, on hemodialysis during a period of one month (May 2019–June 2020). All patients were enrolled for maintenance hemodialysis in B Braun Hemodialysis Center Timisoara and were examined on conventional 2B ultrasound. Thyroid blood tests were done, including serum free thyroxin (FT4), free triiodothyronine (FT3) and thyroid-stimulating hormone (TSH) at the time of starting hemodialysis. Results: We evaluated 123 patients (male to female ratio 70/53) mean age 62.2 ± 11.01, mostly above 65 years old, enrolled in the end-stage renal disease program, on renal replacement therapy. From the cohort, 76/123 presented thyroid disease, including autoimmune hypothyroidism, nodular goiter or thyroid cancer. Among them, 63 patients presented nodular goiter, including 3 thyroid cancers, confirmed by surgery and histopathological result, 22 patients had thyroid autoimmune disease. The serum thyroid-stimulating hormone levels found in the cohort was 3.36 ± 2.313 mUI/mL, which was in the normal laboratory reference range. The thyroid volume was 13 ± 7.18 mL. A single patient in the cohort presented Graves Basedow disease, under treatment and three patients present subclinical hyperthyroidism. We have found that thyroid disease risk is increased by 3.4-fold for the female gender and also the increase of body mass index (BMI) with one unit raises the risk of developing thyroid disease with 1.083 times (p = 0.018). Conclusion: To conclude, this study aimed to quantify the prevalence of thyroid disease in end-stage kidney disease population, especially nodular goiter, important for differential diagnosis in cases with secondary hyperparathyroidism. Thyroid autoimmune disease can be prevalent among these patients, as symptoms can overlap those of chronic disease and decrease the quality of life. We have found that thyroid disease has a high prevalence among patients with end-stage renal disease on hemodialysis. Thyroid goiter and nodules in ESRD patients were more prevalent than in the general population. Clinical surveillance and routine screening for thyroid disorders can improve the quality of life in these patients.

Identifying predictive factors for efficacy in high intensity focused ultrasound (HIFU) ablation of benign thyroid nodules - a retrospective analysis

Objective: Since it is unclear whether clinical parameters can independently predict the subsequent treatment response following high intensity focused ultrasound (HIFU) ablation of benign thyroid nodules, we aimed to examine clinical factors that may independently predict 12-month efficacy after HIFU treatment.Methods: One hundred and forty patients who had single ablation were categorized into two groups, those with 12-month nodule shrinkage above the median (Group I, n = 70) and with shrinkage below or equal to the median (Group II, n = 70). Baseline characteristics, treatment parameters, percentage change in serum TSH, Free thyroxine (FT4) and thyroglobulin (Tg) from baseline to Day 4 and appearance of microbubbles (hyperechoic marks (HEMs)) during treatment were compared between groups. To determine independent factors, a multivariate analysis was done by logistic regression analysis.Results: Baseline characteristics and treatment parameters were comparable between groups. However, on Day-4, group I had significantly lower serum TSH (0.49mIU/L vs. 0.84mIU/L, p = 0.011) and higher FT4 (22.11 pmol/L vs. 18.47 pmol/L, p = 0.008) than group II. The percentage change in TSH, FT4 and Tg were significantly greater in group I (p = 0.002, p = 0.009 and p = 0.001 respectively). The proportion of HEMs observed during treatment was also significantly higher in group I (42.69% vs. 31.72%, p = 0.030). Among the significant factors, the percentage change in FT4 was the only independent factor for 12-month shrinkage (OR = 1.018, 95%CI =1.003-1.032, p = 0.017).Conclusions: Percentage change in serum FT4 on post-treatment Day-4 was an independent blood parameter for the subsequent nodule shrinkage at 12 months. This finding could potentially facilitate the decision for earlier retreatment of treated nodules.

[The effectiveness of risk stratification systems in diagnosis of nodular thyroid disorders]

BACKGROUND

Risk stratification systems, one of the optimal solutions for differential diagnosis of nodular pituitary disorders, are currently under development. The high prevalence of pituitary diseases makes it necessary to evaluate the effectiveness of risk stratification systems and to widely implement them into routine clinical practice.

AIM

To evaluate the effectiveness of modern risk stratification systems used to diagnose nodular pituitary disorders.

MATERIAL AND METHODS

A total of 1,606 medical records of patients operated on for nodular pituitary disorders in 20062014 were analyzed. The preoperative ultrasonography results and cytological findings were evaluated. The ultrasonography results were classified using the TI-RADS system, while the biopsy data were classified using the TBSRTC system. The surgery protocol and the pathomorphological data were the truth criterion. The effectiveness of the TI-RADS and TBSRTC systems, as well as their contribution to the performance of endocrinologists in outpatient clinics, was analyzed.

RESULTS

Cluster analysis revealed a significant volatility of ultrasonography signs in the TI-RADS category, while there was no dominant sign that could be considered the diagnostic standard. Factor analysis proved the consistency of the imaging TI-RADS system based on individual signs. The signs being evaluated are characterized by high significance level but different priorities depending on the type of putative pathology. Discriminant analysis revealed that TI-RADS was a robust and versatile system to be used for various types of nodular pituitary disorders. The overall effectiveness of the TI-RADS system in diagnosis of pituitary tumors was low: it was characterized by 75.4% sensitivity, 84.7% specificity, and 80.1% accuracy. However, this system concretized the indications for fine-needle aspiration biopsy and drew the cytologists attention to the likelihood of pituitary tumor. The implementation of the TBSRTC system reduced the percentage of non-informative (by 9.8%) and controversial results (by 1.7%). Cytological examination was more effective in detection of pituitary cancer compared to ultrasonography (91.0% accuracy, 94.9% specificity, and 76.5% sensitivity). The impressions of ultrasound technicians and cytologists were concordant in 873 (54.4%) cases. A survey conducted among endocrinologists in outpatient clinics showed that implementation of the TI-RADS and TBSRTC risk stratification systems reduced the decision time (p0.001) and errors both in diagnostics (p0.001) and treatment approach selection (p0.001).

CONCLUSION

The combined use of the TI-RADS and TBSRTC systems allows one to personalize the treatment approaches for patients with nodular pituitary disorders. The implementation of these systems has a positive effect on endocrinologists performance as it reduces the decision time and the likelihood of making errors in diagnosis and treatment strategy selection.

A Comparison of Doppler Flow Parameters in the Ophthalmic Artery and Central Retinal Artery in Patients With Graves' Disease and Toxic Nodular Goiter

Purpose: Despite unquestionable clinical usefulness of Clinical Activity Score, the evaluating system needs frequent supplementation. One of such diagnostic tools is Doppler imaging that is used for the analysis of flow in the retrobulbar vessels. The improvement of the reliability and sensibility of measurements could make Doppler imaging an everyday clinical tool and improve the efficacy of treatment in patients with active thyroid-associated orbitopathy. However, the systemic influence of hyperthyroidism on the orbital vessels can falsify the assessment of local inflammation severity. Methods: To eliminate the influence of systemic hyperthyroidism on orbital vessels, we compared peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistance index (RI) in the central retinal artery (CRA), and ophthalmic artery (OA) in patients with hyperthyroidism in the course of Graves' disease without any detectable orbital changes, (CAS = 0) and toxic nodular goiter. Results: There were no statistically significant differences between the patients with Graves' disease and toxic nodular goiter in terms of the examined parameters in either of the arteries. However, higher PSV and RI and lower EDV in the CRA as well as higher PSV and EDV and unchanged RI in the OA were found in the patients with Graves' diseases and toxic nodular goiter. Conclusion: Hyperthyroidism and hyperthyroidism-induced hyperkinetic flow have a systemic influence on the orbital vessels, irrespective of the cause of hyperthyreosis. Thus, it is necessary to compare the flow parameters in retrobulbar vessels in Graves' patients with the toxic nodular goiter patients to eliminate the systemic influence of hyperthyroidism on the orbital vessels.

Plasma ω-3 and ω-6 fatty acids in thyroid diseases

The incidences of nodular goiter (NG), thyroid adenoma (TA), and thyroid cancer (TC) are increasing rapidly; however, the etiologies of these diseases remain unclear. The present study aimed to evaluate the differences in plasma fatty acids among these three thyroid diseases to facilitate etiological research. Four ω-3 and seven ω-6 polyunsaturated fatty acids were measured from 97 TC, 14 TA and 11 NG patient plasma samples with gas chromatography-flame ionization detector. Fatty acids levels were expressed as the percentage of each fatty acid out of the total fatty acids evaluated. The present study identified that the level of 22:6n-3 [median, interquartile range (IQR)] was significantly increased in TA (5.2%, 4.3-6.4%) compared with NG (3.6%, 3.1-4.6%) and TC patients (4.2%, 3.2-4.8%). Though not statistically significant, the levels of 20:5n-3 and 22:5n-3 demonstrated a similar pattern. The level of 22:4n-6 expressed (median, IQR) was significantly increased in NG patients (0.21%, 0.18-0.26%) compared with TA (0.16%, 0.15-0.18%) and TC (0.17%, 0.14-0.22%) patients. Furthermore the fatty acids 18:3n-6, 20:2n-6, 20:3n-6, 20:4:6, and 22:5n-6 demonstrated a similar but statistically insignificant pattern. This suggests that different fatty acids exhibit various etiological roles in NG, TA and TC and warrant further study.

The analysis of correlation between frailty index and postoperative complications of aged patients with nodular goiter

OBJECTIVE

To explore the correlation between frailty index (FI) and postoperative complications of aged patients with nodular goiter (NG).

METHODS

A total of 120 aged patients with NG undergoing operative treatment from May 2013 to October 2015 in our hospital were selected. All of them were divided into 3 groups according to the FI as follows: nonfrail group (FI < 0.2), intermediately frail group (0.2 ≤ FI < 0.4), and frail group (FI ≥ 0.4). Clinical data of patients about general data, body mass index, American Society of Anesthesiology (ASA) classification, hospital stays, and postoperative complications were examined. Then, the correlations between the indexes above and FI were examined.

RESULTS

Frailty index and the ASA classification have some relevance (r = .265, P = .007). The postoperative complication rates of total nonfrail group, intermediately frail group, and frail group were, respectively, 4 cases (11.4%), 11 cases (31.4%), and 24 cases (48.0%). With the increase in FI, the incidence of postoperative complications and hospital stays had also significantly increased. The area under receiver operating characteristic curve examining frailty's ability to forecast postoperative complications was 0. 815 (95% CI: 0.675-0.954, P = .000).

CONCLUSION

The level of frailty index is a risk factor for postoperative complications of aged patients with NG. The preoperative frailty index evaluation can provide reference evidence for the treatment of aged NG patients undergoing surgery.

Temporal Changes in Thyroid Nodule Volume: Lack of Effect on Paranodular Thyroid Tissue Volume

BACKGROUND

The term "nodular goiter" has long been used to refer to a nodular thyroid gland, based on the assumption that nodule growth may be associated with hyperplasia of the surrounding non-nodular tissue. The aim of this prospective, multicenter, observational study was to determine whether nodule growth is accompanied by growth in the non-nodular tissue.

METHODS

Eight Italian thyroid-disease referral centers enrolled 992 consecutive patients with one to four benign nodules. Nodular and non-nodular thyroid tissue volumes were assessed for five years with annual ultrasound examinations.

RESULTS

In participants whose nodules remained stable (n = 839), thyroid volumes did not change (baseline 15.0 mL [confidence interval (CI) 14.5-15.6]; five-year evaluation 15.1 mL [CI 14.5-15.7]). In participants with significant growth of one or more nodule (n = 153), thyroid volumes increased and by year 5 were significantly greater than those of the former group (17.4 mL [CI 16-18.7]). In 76 individuals with unilateral nodules that grew, the mean nodular lobe volume significantly exceeded that of the contralateral lobe (8.6 mL [CI 7.4-9.8] vs. 6.7 mL [CI 6-7.4]). The unaffected lobe volumes remained stable over time, while nodular lobes grew steadily and were significantly greater at the end of follow-up (10.1 mL [CI 8.9-11.3]). Excluding the volume of the largest growing nodule in these cases, the remaining volume of the affected lobe remained virtually unchanged with respect to its baseline value. Furthermore, there was no significant difference in the non-nodular tissue volume between the unaffected lobe and the affected lobe (with the largest growing nodule volume subtracted), both at baseline and at the end of follow-up.

CONCLUSIONS

The growth of thyroid nodules is a local process, not associated with growth of the surrounding non-nodular tissue. Therefore, a normal-sized thyroid containing nodules should be referred to as a "uni- or multinodular thyroid gland" and considered a distinct entity from "uni- or multinodular goiter."

Correlation between serum lead and thyroid diseases: papillary thyroid carcinoma, nodular goiter, and thyroid adenoma

Studies have showed that lead was associated with human health. However, the effects of lead on thyroid functions are inconsistent, and studies based on Chinese population are fragmentary. To evaluate the correlation between lead and thyroid functions of Chinese with different thyroid diseases, we conducted a hospital-based study. Ninety-six papillary thyroid carcinoma (PTC), 10 nodular goiter (NG), and 7 thyroid adenoma (TA) patients were recruited from the First Affiliated Hospital of Wenzhou Medical University, China. Serum triiodothyronine (T3), free triiodothyronine (FT3), free thyroxin (FT4), and thyroid stimulating hormone (TSH) were evaluated with chemiluminescent microparticle immunoassay. Serum lead was assessed with ICP-MASS. Partial correlation was used to explore the correlations of serum lead and thyroid diseases. Compared to PTC, the level of lead was significantly higher in TA, and lower in NG (p < 0.05). This difference remained significant in females when stratified by sex. Serum lead was negatively correlated with TSH (r_s =  - 0.27, p < 0.05) in PTC group. T3 was positively related to lead at quartile4 (r_s = 0.61, p < 0.05) in PTC group. No significant correlations were observed between lead and FT3 or FT4 in any group. The results suggested that lead might have different etiological roles in these three thyroid diseases.

Association between single nucleotide variants of vascular endothelial growth factor A and the risk of thyroid carcinoma and nodular goiter in a Han Chinese population

The aim of the present study was to investigate whether genetic variants in the vascular endothelial growth factor A gene (VEGFA) were risk factors for papillary thyroid carcinoma (PTC) or nodular goiter (NG) in Han Chinese. A total of 2,319 subjects (861 PTC patients, 562 NG patients, and 896 healthy controls) were included. Five tag single nucleotide polymorphisms (tagSNPs: rs3024997, rs3025040, rs833070, rs25648, and rs10434) in VEGFA were genotyped. SNP rs3025040 T allele was associated with a decreased risk of NG (P<0.05). SNP rs3024997 was associated with an increased risk of PTC (P<0.05) and NG (P<0.001) when an over-dominant model (AA+GG vs. AG) was considered. PTC patients carry the less frequent TT genotype (compared to the CC genotype) (P <0.05) of SNP rs3025040. Likewise, NG patients have the less frequent TC genotype compared to the CC (P <0.05). No significant association of SNPs rs833070, rs25648, and rs10434 with PTC or NG was observed. Haplotypes AT (rs3024997 and rs3025040) and GTA (rs10434, rs3025040, and rs3024997) showed a lower risk for NG (P <0.01 and P <0.05, respectively), while haplotypes GTT (rs833070, rs3025040, and rs3024997) and GGGT (rs833070, rs10434, rs3024997, and rs3025040) predicted the risk of progression to NG (both P <0.05). Haplotype AGAC (rs833070, rs10434, rs3024997, and rs3025040) conferred protection for PTC (P <0.05). In summary, this study indicated for the first time that SNPs rs3024997 and rs3025040 in VEGFA were significantly associated with PTC and/or NG. Haplotypes of the VEGFA may influence the risk of PTC and NG.

Higher urinary bisphenol A concentration and excessive iodine intake are associated with nodular goiter and papillary thyroid carcinoma

In the present study, we investigated whether bisphenol A (BPA) levels and excessive iodine intake were associated with papillary thyroid carcinoma (PTC) and nodular goiter (NG). We determined total BPA concentrations (TBC) in paired serum and urine samples, and urinary iodine concentrations (UIC) in urine samples collected from PTC patients, NG patients, and healthy individuals, then compared BPA concentrations and UIC within and between each patient group. The results showed that there were no gender-specific differences in serum TBC and UIC in each group, and no differences across all patient groups. Urinary BPA concentrations (UBC) were higher in the NG and PTC groups compared with the control group. UBC showed gender-specific differences in the NG and PTC group. Furthermore, UIC were higher in the NG and PTC groups compared with the control group. Higher UBC and excessive iodine intake were risk factors for NG and PTC according to multivariate logistic regression analysis. There was a significant correlation between UBC and UIC in each group. These data suggested that higher UBC and excessive iodine intake are associated with NG and PTC. The metabolic and functional pathways between BPA and iodine are potentially linked to the pathogenesis and progression of NG and PTC.

Frequency assessment of BRAF mutation, KRas mutation, and RASSF1A methylation in nodular goitre based on fine-needle aspiration cytology specimens Ocena częstości występowania mutacji genów BRAF, KRas oraz

INTRODUCTION

Standard pre-operative diagnosis of nodular goitre is not always conclusive. The decision about nodular goitre surgery is increasingly based on molecular methods. The aim of the study was to determine BRAF T1799A mutation and KRas proto-oncogene mutation, and the analysis of RASSF1A promoter methylation level in cytological material obtained from FNAB specimens of thyroid nodules.

MATERIAL AND METHODS

The study population consisted of 85 women and 12 men. The study material was genomic DNA isolated from peripheral blood and thyroid bioptates. Pyrosequencing was used for the evaluation of RASSF1 methylation level. KRas mutation was investigated with Sanger sequencing. BRAF mutation was analysed by standard methods of real-time amplification detection (real-time PCR) with the use of specific starters surrounding the mutated site.

RESULTS

A significant positive correlation was demonstrated between mean methylation of four CpG islands of RASSF1A gene and thyroid tumour volume and its largest diameter (p < 0.05). KRas mutation was not detected in any of the 97 patients. In 7/85 subjects (8.2%) BRAF mutation was observed. In 6/7 patients with BRAF mutation, FNAB of thyroid nodules confirmed a benign nature of the lesions; the material was non-diagnostic in one patient, and papillary thyroid cancer was diagnosed on the basis of postoperative histopathology assessment.

CONCLUSIONS

The results of genetic tests reported in our study indicate that the presence of BRAF mutation or higher RASSF1A methylation levels in FNAB cytology specimens of benign lesions may be useful in the assessment of oncological risk, while the evaluation of KRas proto-oncogene mutation is not a valuable test in pre-operative diagnosis of nodular goitre.

Content of RNA originating from thyroid in washouts from fine-needle and core-needle aspiration biopsy - preliminary study

INTRODUCTION

In the evaluation of molecular markers in washouts from fine-needle aspiration biopsy (FNAB) the extremely small amount of material can be a major problem. Some authors tried to use washouts from core-needle aspiration biopsy (CNABs) to gain more material from larger needles. However, according to some studies, CNAB samples are commonly contaminated with blood. The aim of our study was to evaluate the proportion of nucleic acids from thyroid cells in washouts from FNAB and CNAB by measuring the relative expression of cytokeratin 17 (KRT17) on the mRNA level.

MATERIAL AND METHODS

Relative expression of KRT17 and GADPH (reference gene) in washouts from FNAB and CNAB was measured using real-time PCR technique and compared to the results from surgical specimens.

RESULTS

Surgical specimens form 22 nodules, FNAB samples from 20 lesions and CNAB samples from 24 lesions were analysed. The median difference in cycle threshold (Ct) between FNAB samples and surgical specimens was 3.3 (p = 0.047). In CNAB samples KRT17 was undetectable in most cases (median incalculable; proportion of samples with undetectable KRT17 significantly higher than in FNAB samples).

CONCLUSIONS

Samples obtained with different biopsy techniques had different proportions of contents. The proportionally low content of epithelial cells in CNAB can result in underestimated expression of molecular markers of malignancy. Consequently, the risk of malignancy or unfavourable prognosis can also be underestimated. To conclude, results obtained from samples gained with one biopsy technique cannot be directly related to thresholds, and generally with experiences gained with other techniques, because it can lead to incorrect clinical interpretation of the results. (Endokrynol Pol 2016; 67 (6): 550-553).

Prevalence of hypothyroidism and thyroid nodule in chronic hemodialysis Iranian patients

INTRODUCTION

End stage renal disease (ESRD) reasons several changes in the function of thyroid gland as; lower levels of thyroid hormones, altered hormone metabolism, and increased iodine storage. The aim of this study was to evaluate the prevalence of nodular goiter and hypothyroidism in hemodialysis (HD) patients compared with normal population.

METHODS

This cross-sectional study was conducted among HD patients and healthy people as the control group for thyroid function evaluation. Thyroid gland was evaluated by physical examination and ultrasonography. Blood level of FT3, FT4, TSH, TPO Ab, and urinary iodine excretion were checked in both groups. Data were analyzed using SPSS-17 and P-value less than 0.05 was considered as the significance level.

FINDINGS

Eighty six HD patients (57.2 ± 17.2 mean age, 48 men) and 86 healthy people (56.6 ± 16.8 mean age, 48 men) were enrolled in this study. Goiter was confirmed by physical examination in 29.0% of the HD patients and 12.8% of the control group (P = 0.04). Nodular goiter that was shown by ultrasonography was found in 27.9% and 3.5% of the HD and control groups, respectively (P = 0.01). HD patients had a higher frequency of reduced FT3 (40.9% vs. 4.6%, P < 0.01) and increased TSH (18.6% vs. 8.1%, P < 0.03(. TPO Ab was positive in 15.1% of the HD and 11.6% of the control groups (P = 0.14).

DISCUSSION

The high incidence of nodular goiter and hypothyroidism in ESRD patients shows that screening for thyroid dysfunction and goiter, using appropriate laboratory tests, should be considered in evaluations of ESRD patients.

Transcriptional activity of TGFβ1 and its receptors genes in thyroid gland

INTRODUCTION

Determination of gene-candidates' profile expression responsible for fibrosis, immunosuppression, angiogenesis, and neoplasia processes in the pathogenesis of thyroid gland disease.

MATERIAL AND METHODS

Sixty-three patients underwent thyroidectomy: 27 with non-toxic nodular goitre (NG), 22 with toxic nodular goitre (TNG), six with papillary cancer (PTC), and eight with Graves' disease (GD). In thyroid tissues, transcriptional activity of TGFbeta1 and its receptors TGFbetaRI, TGFbetaRII, and TGFbetaRIII genes were assessed using RT-qPCR (Reverse Transcriptase Quantitative Polymerase Chain Reaction). Molecular analysis was performed in tissues derived from GD and from the tumour centre (PTC, NG, TNG) and from peripheral parts of the removed lobe without histopathological lesions (tissue control). Control tissue for analysis performed in GD was an unchanged tissue derived from peripheral parts of the removed lobe of patients surgically treated for a single benign tumour.

RESULTS/CONCLUSIONS

Strict regulation observed among transcriptional activity of TGFb1 and their receptor TGFbetaRI-III genes in control tissues is disturbed in all pathological tissues - it is completely disturbed in PTC and GD, and partially in NG and TNG. Additionally, higher transcriptional activity of TGFb1 gene in PTC in comparison with benign tissues (NG, GD) and lower expression of mRNA TGFbRII (than in TNG, GD) and mRNA TGFbetaRIII than in all studied benign tissues (NG, TNG, GD) suggests a pathogenetic importance of this cytokine and its receptors in PTC development. In GD tissue, higher transcriptional activity of TGFbetaRII and TGFbetaRIII genes as compared to other pathological tissues was observed, indicating a participation of the receptors in the pathomechanism of autoimmune thyroid disease (AITD). TGFbeta1 blood concentrations do not reflect pathological processes taking place in thyroid gland. (Endokrynol Pol 2016; 67 (4): 375-382).

A rare presentation of a large goiter with papillary thyroid microcarcinoma as a chest wall mass: A case report

Nodular goiter affects numerous individuals worldwide. As the thyroid enlarges, it normally extends into the mediastinum as a result of its anatomical location under the investing layer of the deep cervical fascia. The present study reports the rare case of a 76-year-old man who suffered from a goiter with papillary thyroid microcarcinoma, who presented as a subcutaneous partially cystic with solid areas lesion over the chest. The patient underwent surgery and on histopathological examination, the predominant mass was characterized as a multinodular goiter with hemorrhage, necrosis and cystic change. A papillary thyroid microcarcinoma with a diameter of 0.2 cm was identified. The present study demonstrated a rare, to the best of our knowledge, presentation of a benign multinodular goiter in this way.

Primary thyroid lymphoma has different sonographic and color Doppler features compared to nodular goiter

OBJECTIVES

The purpose of this study was to determine the specific sonographic features of primary thyroid lymphoma and its color Doppler pattern compared to nodular goiter.

METHODS

The sonographic findings for 13 surgically proven primary thyroid lymphomas were analyzed and compared to those for 27 nodular goiters.

RESULTS

In accordance with the suggested pathologic patterns, the sonographic patterns of primary thyroid lymphoma could be classified into diffuse and nodular or segmental types based on the distribution of hypoechoic and echogenic structures within the lesions. Some common sonographic characteristics suggesting thyroid malignancy could not facilitate differentiation of primary thyroid lymphoma from nodular goiter. However, a central blood flow pattern would favor the diagnosis of primary thyroid lymphoma, whereas a peripheral pattern would suggest the diagnosis of nodular goiter.

CONCLUSIONS

Primary thyroid lymphoma has characteristic sonographic and Doppler flow features. Along with several other parameters, a central blood flow pattern would highly suggest the diagnosis of primary thyroid lymphoma rather than nodular goiter.

Should asymptomatic retrosternal goitre be left untreated? A prospective single-centre study

BACKGROUND AND AIMS

Retrosternal goiter may cause symptoms of airway obstruction and dysphagia, but often it is asymptomatic and is increasingly detected incidentally with imaging investigations. Consensus has been reached that sternotomy is not necessary in most cases, as a collar incision normally suffices. Yet, surgery for retrosternal goiter is associated with more complications than cervical goiter. There is controversy over whether patients with asymptomatic retrosternal goiter should be operated. Proponents argue that retrosternal goiter may be a risk for thyroid cancer and may progress to later cause symptoms, although clear evidence is missing.

PATIENTS AND METHODS

Between 1984 and 2012, 132 patients underwent surgery for benign retrosternal goiter. Preoperatively, the benign nature was clinically apparent and confirmed by fine needle cytology in most cases.

RESULTS

Sternotomy was required in only 4 of the 132 operations. Three patients died in the postoperative period. The risk of morbidity and mortality was 16.7% in 60 patients with compression symptoms and 13.9% in 72 patients without compression symptoms (P = 0.808). Histology revealed no case of unsuspected cancer.

CONCLUSION

Surgery for retrosternal goiters involves a higher risk for complications than do cervical goiters, and the risk does not differ between patients with and without symptoms. This, and the fact that no patient in this study had unsuspected cancer, calls into question the rationale for surgery in patients with asymptomatic retrosternal goiter without suspected cancer.

Peri-operative treatment of giant nodular goiter

OBJECTIVE

To summarize the experience in the peri-operative treatment of giant nodular goiter.

METHODS

A total of 123 patients with giant nodular goiter sized 6~20 cm were admitted into our hospital from 1990 to 2011 and the clinical data were retrospectively analyzed. These patients underwent total or subtotal thyroidectomy.

RESULTS

All patients underwent surgical intervention. Unilateral subtotal thyroidectomy was performed in 40 patients, unilateral total thyroidectomy in 1 patient, bilateral subtotal thyroidectomy in 79 patients, and unilateral total thyroidectomy, removal of entire isthmus and contralateral subtotal thyroidectomy in 3 patients. Nodular goiter was pathologically proven post-operatively. No short-term complications such as dyspnea or thyroid storm were found postoperatively. Post-operative follow up was done for 9 months to 6 years and no recurrence was observed.

CONCLUSION

Comprehensive pre-operative preparation, pre-operative evaluation, complete exposure of the operative field, meticulous operation, effective control and prevention of hemorrhage and prevention against damage to superior and recurrent laryngeal nerves are crucial for the successful surgical intervention of giant nodular goiter.

[Follicular thyroid neoplasia (a lecture)]

Nodular thyroid formations are detected in approximately 4-7% of individuals living in regions with normal iodine supply. In regions of iodine deficiency, the prevalence of nodular goiter is significantly higher, especially in women older than 40 years, in which it can exceed 30%.

[Clinical guidelines developed by the Russian Association of Endocrinologists for the diagnosis and treatment of nodular goiter]

The guidelines presented do not pretend to be a systematic presentation of all aspects of the diagnosis and treatment of nodular goiter and are not intended to replace guidelines for various medical disciplines. In real clinical practice, situations may arise that are beyond the scope of the recommendations presented, in connection with which the final decision regarding a specific patient and responsibility for him lies with the attending physician.The recommendations presented are mainly devoted to the diagnosis and treatment of nodular (multinodular) euthyroid colloid, differently proliferating goiter in adults (over 18 years of age) and are the agreed opinion of the RAE experts who developed them. Nodular (multinodular) toxic goiter, tumors (malignant and benign), as well as other diseases that can manifest themselves by nodular formations of the thyroid gland (thyroid gland), are discussed mainly in the context of differential diagnosis. The recommendations also do not affect the features of diagnosis and treatment of nodular goiter in children and adolescents.

[The role of thin-needle aspiration biopsy in the diagnosis of thyroid nodules]

The paper analyzes the results of thin-needle aspiration biopsy (TNAB) performed in 1155 patients with thyroid nodules. The purpose of the paper was to evaluate the efficiency of TNAB in the differential diagnosis of thyroid nodules and in the detection of carcinoma among them. A prospective open uncontrolled study was conducted. According to the data of TNAB, benign, malignant, and suspected malignant masses were found in 808 (69.96%), 49 (4.2%), and 148 (12.8%) patients, respectively. The data of TNAB were compared with the histological findings in 333 patients undergoing surgery. The sensitivity, specificity, and other indices of the efficiency of TNAB were calculated by and without taking into account a group of suspected malignant changes. The sensitivity, specificity, and diagnostic accuracy were 93.9, 97.5, and 96.5%, respectively; the prognostic values as for the presence and absence of cancer were 93.8 and 97.5%, respectively, The presence of a group of suspected malignant changes substantially lowered the efficiency of TNAB. The specificity of TNAB in detecting thyroid cancer, assessed by taking into account this group was 52.5%; the prognostic value as to the presence of cancer was 39.8%. The diagnostic accuracy (63.2%), sensitivity (93.9%), and the prognostic value of TNAB in relation to the absence of cancer (97.5%) substantially unchanged. The presence of a rather large number of unrepresentative aspirates (13.0%), the bulk (74.7%) of which is presented by the contents of a cyst is another disadvantage of TNAB. A histological study revealed thyroid cancer in 6 out of these patients. The high (62%) incidence of cancer in the cystic nodes reasonably warrants the use of surgery in case of the repeated accumulation of the contents with a cystic node.