A Novel Interpretable Radiomics Model to Distinguish Nodular Goiter From Malignant Thyroid Nodules

OBJECTIVES

The purpose of this study is to inquire about the potential association between radiomics features and the pathological nature of thyroid nodules (TNs), and to propose an interpretable radiomics-based model for predicting the risk of malignant TN.

METHODS

In this retrospective study, computed tomography (CT) imaging and pathological data from 141 patients with TN were collected. The data were randomly stratified into a training group (n = 112) and a validation group (n = 29) at a ratio of 4:1. A total of 1316 radiomics features were extracted by using the pyradiomics tool. The redundant features were removed through correlation testing, and the least absolute shrinkage and selection operator (LASSO) or the minimum redundancy maximum relevance standard was used to select features. Finally, 4 different machine learning models (RF Hybrid Feature, SVM Hybrid Feature, RF, and LASSO) were constructed. The performance of the 4 models was evaluated using the receiver operating characteristic curve. The calibration curve, decision curve analysis, and SHapley Additive exPlanations method were used to evaluate or explain the best radiomics machine learning model.

RESULTS

The optimal radiomics model (RF Hybrid Feature model) demonstrated a relatively high degree of discrimination with an area under the receiver operating characteristic curve (AUC) of 0.87 (95% CI, 0.70-0.97; P < 0.001) for the validation cohort. Compared with the commonly used LASSO model (AUC, 0.78; 95% CI, 0.60-0.91; P < 0.01), there is a significant improvement in AUC in the validation set, net reclassification improvement, 0.79 (95% CI, 0.13-1.46; P < 0.05), and integrated discrimination improvement, 0. 20 (95% CI, 0.10-0.30; P < 0.001).

CONCLUSION

The interpretable radiomics model based on CT performs well in predicting benign and malignant TNs by using quantitative radiomics features of the unilateral total thyroid. In addition, the data preprocessing method incorporating different layers of features has achieved excellent experimental results.

CLINICAL RELEVANCE STATEMENT

As the detection rate of TNs continues to increase, so does the diagnostic burden on radiologists. This study establishes a noninvasive, interpretable and accurate machine learning model to rapidly identify the nature of TN found in CT.

The role of vascular endothelial growth factor in the development of papillary thyroid carcinoma in patients with lymphocytic thyroiditis

BACKGROUND

Vascular endothelial growth factor (VEGF) plays a pivotal role in the pathogenesis of autoimmune chronic inflammatory conditions and papillary thyroid carcinoma (PTC). We hypothesized that, as VEGF expression is increased both in PTC and in lymphocytic thyroiditis (LT), it may stimulate the development of PTC in patients with LT. To evaluate this, we examined both tumor and adjacent non-tumoral tissues of PTC patients with and without LT.

METHODS

A total of 50 patients with PTC (52.50±7.41 years) and 17 patients with nodular goiter (NG) (50.47±10.38 years) were included in the study. According to the presence of LT, patients with PTC were further divided into two groups. Immunohistochemical analyses of VEGF were conducted in all patients and for PTC patients, both tumor tissue and adjacent non-tumoral tissue were evaluated.

RESULTS

The scores for intensity of staining and percentage of labeled thyrocytes for VEGF were found to be significantly higher in the PTC patients than in the NG patients (P<0.001, P<0.001, respectively). The tumor tissue revealed similar scores for PTC patients with LT and without LT. However, the scores in adjacent non-tumoral tissue were higher in PTC patients with LT than in patients without LT (P=0.004, P=0.01, respectively).

CONCLUSIONS

To the best of our knowledge, our results are the first to demonstrate that the expression of VEGF in adjacent non-tumoral tissue were higher in PTC patients with LT than in those without, which shows a possible role of VEGF expression in the progression of PTC in the presence of LT.

Thyroid Volume in Pregnancy is Associated with Parity, Gestational Age, and Body Mass Index in an Iodine-sufficient Area

OBJECTIVE

 We compared thyroid volume (TV) and presence of nodular goiter (NG) in pregnant vs. non-pregnant women in an iodine-sufficient area. We also evaluated the relationship between gestational age, parity, and TV in the pregnant women group, and determined the 2.5th and 97.5th percentiles of normal TV in pregnancy.

METHODS

 This cross-sectional study included 299 healthy women (216 pregnant) without previous thyroid diseases. Thyroid ultrasounds were performed and compared between pregnant and non-pregnant women. The range of normal distribution of TV (2.5th and 97.5th percentiles) in pregnancy was determined after excluding individuals with positive thyroid antibodies, NG, and/or abnormal serum thyrotropin (TSH) or free thyroxine (FT4).

RESULTS

 Thyroid volume was larger among pregnant compared to non-pregnant women (8.6 vs 6.1 cm3; p < 0.001) and was positively correlated with gestational age (rs = 0.221; p = 0.001), body mass index (BMI, rs 0.165; p = 0.002), and FT4 levels (rs 0.118 p = 0.021). Nodular goiter frequency did not differ between the two groups. There was a negative correlation between TV and TSH (rs -0.13; p = 0.014). Thyroid volume was lower among primiparous compared to multiparous patients (7.8 vs 8.9; p < 0.001) and was positively correlated with parity (rs 0.161; p = 0.016). The 2.5th and 97.5th percentiles of TV were 4.23 and 16.47 cm3, respectively.

CONCLUSION

 Thyroid volume was higher in pregnant compared to non-pregnant women and was positively related to parity, BMI, and gestational age in a normal iodine status population. Pregnancy did not interfere with the development of NG.

Diagnostic Value and Challenges of BRAF V600E Molecular Testing and Thyroid Fine-Needle Aspiration Cytology: A Retrospective Study from a Tertiary Institution in Southern Hunan Province, China

INTRODUCTION

Combined thyroid fine-needle aspiration (FNA) cytology and valine-to-glutamate substitution at codon 600 of B-Raf proto-oncogene, serine/threonine kinase (BRAF V600E) mutation detection are procedures used for diagnosing thyroid nodules in many Chinese tertiary institutions. This retrospective study at our institution aimed to explore the effectiveness and challenges of the combined approach in diagnosing thyroid nodules and the correlation between BRAF V600E mutation status and behavior of papillary thyroid carcinoma.

METHODS

Thyroid FNA cytology and BRAF V600E mutation detection results were reviewed between November 2020 and July 2022. A total of 623 patients, each of whom underwent thyroidectomy and final pathological examination after FNA cytology diagnosis, were included in the study. The relationship between the BRAF V600E mutational status and pathological parameters was analyzed using the χ2 test. The effectiveness and challenges of FNA cytology alone and the combined procedure were also evaluated based on the final pathology.

RESULTS

Of 623 patients, 591 were diagnosed with papillary thyroid carcinoma (PTC), of which 456 were positive for the BRAF V600E mutation. It demonstrated near-perfect specificity for identifying PTC, and its incidence rate showed an age-specific curve with an inverted U-shaped distribution. The final pathological examination showed that the combined procedure had a higher sensitivity (83.91%) than FNA cytology alone (63.45%) for distinguishing PTC from other lesions (p < 0.001). Mutational status was associated with a larger maximum tumor diameter (p = 0.003) and a tendency of capsular invasion (p = 0.0542) but possibly unrelated to central lymph node metastasis (p = 0.1846). Nodular goiters accounted for most benign entities initially designated as Bethesda categories III-V.

CONCLUSION

BRAF V600E mutational analysis complements cytopathology and improves the PTC detection rate in FNA cytology samples due to the high prevalence of the mutation in China. BRAF V600E mutation does not show a statistical correlation with tumor aggressiveness. Morphological pitfalls such as histocyte aggregation, cystic-lining cells in nodular goiters, and oncocytes in Hashimoto's thyroiditis, were overwhelmingly found in BRAF V600E-negative specimens.

Case Report: Life-threatening hypercalcemia associated with MMR-deficient endometrial carcinoma secreting parathyroid hormone

Ectopic secretion of parathyroid hormone (PTH) is a rare cause of hypercalcemia in malignancy patients. A 56-year-old woman with life-threatening hypercalcemia was caused by poorly-differentiated endometrial carcinoma secreting PTH with concomitant nodular goiter mimic parathyroid tumors. The elevated level of PTH and calcium decreased immediately after cytoreductive surgery (CRS). The pathology confirmed mismatch repair (MMR)-deficient endometrial carcinoma with PTH expression. The patient received four-course chemotherapy and one-course immunotherapy after CRS. The disease progression led to multiple organ failure and death about five months after CRS. To our knowledge, this is the first case of hypercalcemia caused by MMR-deficient endometrial carcinoma with ectopic PTH secreting and the first report of malignancy associated hypercalcemia complicated with nodular goiter.

MiR-203a-3p, miR-204-3p, miR-222-3p as useful diagnostic and prognostic tool for thyroid neoplasia spectrum

PURPOSE

The challenge in the diagnosis and treatment of thyroid carcinoma is to correctly classify neoplasias with overlapping features and to identify the high-risk patients among those with a less aggressive form, in order to personalize the treatment of thyroid carcinoma patients accordingly.

METHODS

MiR-203a-3p, miR-204-3p, and miR-222-3p levels were determined in 99 cases of thyroid neoplasias (77 papillary thyroid carcinomas (PTC) of diverse variants, 12 follicular thyroid adenomas (FTA) and 10 nodular goiters (NG)) along with 99 adjacent non-malignant thyroid tissues using quantitative RT-PCR. The results were evaluated in comparison with the clinicopathological features of the patients and available TCGA data.

RESULTS

Down-regulated miR-203a-3p indicates the presence of thyroid tumor (PTC or FTA) with high sensitivity (75%) and specificity (73%), while its up-regulation indicates NG. If miR-203a-3p is down-regulated, up-regulated miR-204-3p with high sensitivity (83.3%) and specificity (74.4%) indicates FTA presence, while up-regulated miR-222-3p, with high sensitivity (76.6%) and specificity (75.0%), points to PTC. The expression of miR-204-3p and miR-222-3p depends on the PTC subtype (P < 0.05). While the deregulated expression of tested miRs is associated with a long-range of unfavorable clinicopathological parameters of PTC, only abundant expression of miR-222-3p may be used as an independent predictive factor for the presence of extrathyroid invasion and advanced pTNM stage of PTC (P < 0.05).

CONCLUSION

Successive evaluation of miR-203a-3p, miR-204-3p, and miR-222-3p expression can help in the differential diagnosis of thyroid neoplasias. A high relative value of miR-222-3p expression is an independent predictive factor for the presence of extrathyroid invasion and advanced pTNM stage of PTC. The panel consisting of miR-203a-3p, miR-204-3p, and miR-222-3p could be used as a diagnostic and prognostic tool for personalizing the treatment of thyroid cancer patients.

Associations between environmental exposure to polybrominated diphenyl ethers and nodular goiter risk: A case-control study

Polybrominated diphenyl ethers (PBDEs) are widespread and persistent environmental contaminants, but their association with nodular goiter (NG) remains unknown. The present case-control study of 179 NG cases and 358 matched normal controls aimed to investigate the association between PBDEs and risk of NG. The plasma concentrations of 8 PBDEs congeners (BDE-28, -47, -99, -100, -153, -154, -183, and -209) were determined by gas chromatograph-mass spectrometer. Conditional logistic regression model was used to evaluate the odds ratio (OR) and 95% confidence interval (CI) for the association between each PBDEs congener and NG. Bayesian kernel machine regression (BKMR) was used to evaluate the association between overall levels of 8 PBDEs mixture and NG. The results of logistic model suggested that increased risk of NG was associated with elevated concentrations of all PBDEs congeners, except for BDE-209. In BKMR model, the risk of NG increased with the increase in overall exposure level of 8 PBDEs mixture. Compared to when all PBDEs mixture were at their median value, the risk of exposure-response function for NG increased by 0.34 units when all PBDEs were at their 75th percentile. In women, the results showed similar trends after additional adjustment for age at menarche and menopausal status. These findings provide novel epidemiological evidence for the prevention of NG. However, larger prospective studies are required to address the associations between PBDEs exposure and NG risk.

Empiric radioiodine for hyperthyroidism: Outcomes, prescribing patterns, and its place in the modern era of theranostics

BACKGROUND

The modern era of radioiodine (I-131) theranostics for metastatic differentiated thyroid cancer requires us to rationalize the role of traditional empiric prescription in nonmalignant thyroid disease. We currently practice empiric I-131 prescription for treatment of hyperthyroidism. This study aims to assess outcomes after treatment of hyperthyroidism by empiric I-131 prescription at our centre, evaluate factors that impact on outcomes and prescribing practice, and gain insight into whether there is a place for theranostically-guided prescription in hyperthyroidism.

PATIENTS AND METHODS

A retrospective review was undertaken of all patients with Graves' disease, toxic multinodular goitre (MNG) and toxic adenoma treated with I-131 between 2016 and 2021. Associations between clinical or scintigraphic variables and remission (euthyroid or hypothyroid) or persistence of hyperthyroidism at follow-up were performed using standard t test as well as Pearson's product correlation.

RESULTS

Of 146 patients with a mean follow-up of 13.6 months, 80.8% achieved remission of hyperthyroidism. This was highest in toxic nodules (90.1%), compared with Graves' disease (73.8%) and toxic MNG (75.5%). In patients with Graves' disease, higher administered activity was associated with remission (p = .035). There was a weak inverse correlation between the Tc-99m pertechnetate uptake vs prescribed activity in Graves' disease (r = -0.33; p = .009). Only one patient (0.7%) had an I-131 induced flare of thyrotoxicosis.

CONCLUSION

Traditional empiric I-131 prescription is a safe and effective treatment of hyperthyroidism and suitable for most patients. However, there may be a role for personalized I-131 prescription by theranostic guidance in selected patients with high thyroid hyperactivity.

New insights into thyroid dysfunction in patients with inactivating parathyroid hormone/parathyroid hormone-related protein signalling disorder (the hormonal and ultrasound aspects): One-centre preliminary results

OBJECTIVE

This study aimed to present the spectrum of thyroid dysfunction, including hormonal and ultrasound aspects, in a cohort of paediatric and adult patients diagnosed with inactivating parathyroid hormone (PTH)/PTH-related protein signalling disorders 2 and 3 (iPPSD).

METHODS

The medical records of 31 patients from 14 families diagnosed with iPPSD between 1980 and 2021 in a single tertiary unit were retrospectively analysed. Biochemical, hormonal, molecular, and ultrasonographic parameters were assessed.

RESULTS

In total, 28 patients from 13 families were diagnosed with iPPSD2 (previously pseudohypoparathyroidism [PHP], PHP1A, and pseudo-PHP) at a mean age of 12.2 years (ranging from infancy to 48 years), and three patients from one family were diagnosed with iPPSD3 (PHP1B). Thyroid dysfunction was diagnosed in 21 of the 28 (75%) patients with iPPSD2. Neonatal screening detected congenital hypothyroidism (CH) in 4 of the 20 (20%) newborns. The spectrum of thyroid dysfunction included: CH, 3/21 (14.2%); CH and autoimmune thyroiditis with nodular goitre, 1/21 (4.8%); subclinical hypothyroidism, 10/21 (47.6%); subclinical hypothyroidism and nodular goitre, 1/21 (4.8%); primary hypothyroidism, 4/21 (19%); and autoimmune thyroiditis (Hashimoto and Graves' disease), 2/21 (9.6%). Thyroid function was normal in 7 of the 28 (25%) patients with iPPSD2 and in all patients with iPPSD3. Ultrasound evaluation of the thyroid gland revealed markedly inhomogeneous echogenicity and structure in all patients with thyroid dysfunction. Goitre was found in three patients.

CONCLUSION

The spectrum of thyroid dysfunction in iPPSD ranges from CH to autoimmune thyroiditis and nodular goitre. Ultrasonography of the thyroid gland may reveal an abnormal thyroid parenchyma.

Vestibular Function in Pendred Syndrome: Intact High Frequency VOR and Saccular Hypersensitivity

OBJECTIVE

Although Pendred syndrome involves anatomical abnormalities in the vestibular system and patient-perceived dizziness, the literature on vestibular function is scarce. The objective was to evaluate objective vestibular function in patients with PS using the video head impulse test (VHIT) and the cervical vestibular evoked myogenic potential (cVEMP) test, assessing the high frequency vestibulo-ocular reflex (VOR) and the saccular function, respectively.

METHODS

Twenty-six subjects (52 ears) with Pendred Syndrome and severe-to-profound hearing loss (cochlear implant candidacy) were studied retrospectively. Main outcome measures were VHIT VOR gain, refixation saccades, cVEMP stimulus thresholds and amplitudes.

RESULTS

In total, 4 of 52 ears (8%) had pathological VHIT outcomes (2 ears with low VHIT gain and 2 ears with saccades). The mean VHIT gain value was 0.96 (range 0.63-2.02). No patients had complete VOR loss. CVEMP responses were present in 76% of tested ears and absent in 24%. The mean cVEMP amplitude value was 192 μV. Absence of cVEMP response was associated with the presence of VHIT saccades (p = 0.038) and advanced age (rs = -0.34; p < 0.05). cVEMP amplitude was correlated with VHIT gain (rs = 0.46; p < 0.001).

CONCLUSION

Despite dysmorphic vestibular anatomy and severe loss of hearing, the VHIT VOR function is normal in patients with Pendred Syndrome. However, saccular function appears to be abnormally sensitive, as documented by low cVEMP thresholds and high amplitudes, which agrees with a "third window" effect secondary to the large vestibular aqueduct.

Genetic architecture and phenotypic landscape of SLC26A4-related hearing loss

Mutations of coding regions and splice sites of SLC26A4 cause Pendred syndrome and nonsyndromic recessive hearing loss DFNB4. SLC26A4 encodes pendrin, a transmembrane exchanger of anions and bases. The mutant SLC26A4 phenotype is characterized by inner ear malformations, including an enlarged vestibular aqueduct (EVA), incomplete cochlear partition type II and modiolar hypoplasia, progressive and fluctuating hearing loss, and vestibular dysfunction. A thyroid iodine organification defect can lead to multinodular goiter and distinguishes Pendred syndrome from DFNB4. Pendred syndrome and DFNB4 are each inherited as an autosomal recessive trait caused by biallelic mutations of SLC26A4 (M2). However, there are some EVA patients with only one detectable mutant allele (M1) of SLC26A4. In most European-Caucasian M1 patients, there is a haplotype that consists of 12 variants upstream of SLC26A4, called CEVA (Caucasian EVA), which acts as a pathogenic recessive allele in trans to mutations affecting the coding regions or splice sites of SLC26A4. This combination of an M1 genotype with the CEVA haplotype is associated with a less severe phenotype than the M2 genotype. The phenotype in EVA patients with no mutant alleles of SLC26A4 (M0) has a very low recurrence probability and is likely to be caused by other factors.

Microsomal reductase activity in patients with thyroid neoplasms

OBJECTIVE

Cytochrome b5-reductase (CYB5R) and cytochrome P450 reductase (CYPOR) are important for cell metabolism; however, their role in thyroid hormonogenesis and carcinogenesis has not been elucidated yet. The activity of CYB5R correlates with the metastasis in breast cancer, but there are no similar studies for CYB5R and CYPOR for thyroid tumors. The aim of this study was to elucidate the activity of CYB5R and CYPOR changes in benign euthyroid and hyperthyroid neoplasms and in papillary thyroid cancer for their potential application as biomarkers for diagnosis and prognosis prediction of thyroid cancer.

METHODS

Thirty-six patients with thyroid diseases participated in the study. The control euthyroid nodular goiter group included ten patients; the thyrotoxic nodular or diffuse goiter group included 14 patients; the papillary thyroid cancer T1-2N0-1M0 (PTC) group included 12 patients. The activity of CYB5R and CYPOR was assessed with lucigenin-enhanced chemiluminescence stimulated by NADH and NADPH, respectively.

RESULTS

Compared to the control euthyroid nodular goiter group, activity of CYB5R and CYPOR increased ~5 and 10 times, respectively, in toxic goiter, and 15 and 30 times, respectively, in half of cases of PTC. The change in activity of CYPOR was more pronounced compared to CYB5R. Within the PTC group, the subgroups with low and high activities of microsomal reductases were identified. Microsomal reductases in follicular adenoma was 2-4-fold less active compared to the euthyroid nodular goiter and the low-activity PTC group.

CONCLUSIONS

Activity of tissue microsomal reductases varies in thyroid pathology and can be considered as a promising biomarker for differential diagnostics of benign and malignant thyroid tumors.

Relationship between urinary metabolites of polycyclic aromatic hydrocarbons and risk of papillary thyroid carcinoma and nodular goiter: A case-control study in non-occupational populations

Exposure to polycyclic aromatic hydrocarbons (PAHs) has been linked to the development of certain diseases. However, the relationship between PAH exposure and thyroid disorders remains unknown. We measured 10 of the most common hydroxylated PAHs (OH-PAHs) in the urine of thyroid nodular goiter (NG) patients, papillary thyroid carcinoma (PTC) patients, and healthy controls by gas chromatography-triple-quadrupole mass spectrometry (GC-MS/MS). We found that the concentrations of 2-hydroxyfluorene (2-OH-FLU), 2-hydroxydibenzofuran (2-OH-DBF), and 1-hydroxyphenanthrene (1-OH-PHE) in the NG group, and of 2-hydroxynaphthalene (2-OH-NAP), 2-OH-DBF, and 1-OH-PHE in the PTC group were significantly higher than those in controls. In addition, participants in the high tertiles of 2-OH-FLU and 1-OH-PHE had higher risk of NG. Besides these two OH-PAHs, elevated risk of NG was observed in women in the high tertiles of 1-hydroxynaphthalene (1-OH-NAP), 2-OH-NAP, 2-OH-DBF, and 3-hydroxyfluorene (3-OH-FLU). Furthermore, participants in the high tertiles of seven OH-PAHs, namely, 1-OH-NAP, 2-OH-NAP, 2-OH-DBF, 2-OH-FLU, 3-OH-FLU, 3/9-hydroxyphenanthrene (3/9-OH-PHE), and 1-OH-PHE, had elevated risk of PTC, and females in these high tertiles had an even higher risk of PTC. Our findings suggest that PAH exposure may increase the risk of NG/PTC, and there may be a gender-specific effect of PAH exposure on the development of NG/PTC.

[Nodular goiter]

The indications for surgery of benign goiter should be balanced and professional as the prevalence of benign nodular goiter in Germany is high and not all goiters must be surgically treated. Thyroid nodules are detected in up to 76% of healthy people using modern high-resolution ultrasound (US) and only a few of these nodules are malignant or symptomatic. Even today a thorough medical history, detailed examination of the neck region, a qualified US of the thyroid gland, a 99m-technetium scintigraphy and fine needle aspiration help to select patients who will benefit from thyroid surgery. In the last 10 years several thyroid imaging reporting and data systems (TI-RADS) classifications have been introduced. The TI-RADS classification is a standardized assessment of thyroid nodules and risk stratification system in thyroid US which helps to select those nodules with a high risk of cancer. Asymptomatic euthyroid nodular goiter without any suspicion of malignancy and scintigraphically cold thyroid nodules without any other evidence of malignancy are not indications for thyroid surgery. The decision to operate should be made on an interdisciplinary basis in conformity with the relevant guidelines and exhaustion of diagnostic tools.

Hygienic assessment of the effects of pesticides application on adult population morbidity with thyroid gland diseases

OBJECTIVE

Introduction: It is proved that some groups of fungicides and herbicides are capable of affecting the thyroid gland, provoking its growth, leading to a compensatory change in the activity of the hormones synthesis. Therefore, the presence of their residual amounts in plant may affect the level of thyroid gland pathology. The aim of the work was to analyze the influence of pesticide application on the Ukrainian adult population morbidity with thyroid diseases in the period from 2001 to 2014.

PATIENTS AND METHODS

Materials and methods: The methods of empirical and theoretical research of scientific information, namely analysis, synthesis, induction, deduction and systematization, epidemiological, cartographic and statistical methods were used.

RESULTS

Results: The maximum level of thyroid pathology was found in the northern, western and northwestern regions, where the diffuse goiter dominates in the morbidity and prevalence of thyroid diseases; minimal - in the southern, eastern and south-eastern regions. It was established that the highest volumes of application of chemical plant protection products in the period 2001-2013 took place in the southern and central regions of Ukraine, namely in Poltava, Vinnitsa, Kharkiv, Dnipropetrovsk, Khmelnytsky, Odesa and Mykolaiv regions. Sufficiently high levels of pesticide application were in the Kyiv, Kherson regions, Crimea, Zaporizhia, Kirovograd and Cherkasy regions.

CONCLUSION

Conclusions: The probability of the active chemical plant protection products usage effect on the level of prevalence and incidence of thyroid cancer, various types of goiter, hypothyroidism, thyrotoxicosis and thyroiditis in the central and southern regions was determined. Are regions with well-developed agricultural production.

Thyrotoxicosis - investigation and management

Graves' disease (GD) and toxic nodular (TN) goitre account for most cases of thyrotoxicosis associated with hyperthyroidism. Hyperthyroidism is confirmed with measurement of a suppressed serum thyrotropin concentration (TSH) and elevated free thyroid hormones. The three therapeutic options are antithyroid drugs, radioactive iodine and surgery. Thionamides achieve long-term remission in 35% of cases. Many centres administer fixed doses of iodine-131; larger doses result in improved rates of cure at the cost of hypothyroidism. Surgery is usually considered for patients who have a large goitre, compressive symptoms or significant ophthalmopathy.

Histopathological pattern of thyroid diseases among patients in Hadhramout-Yemen

OBJECTIVE

To determine the histopathological pattern of thyroid diseases among patients in Hadhramout Province, Yemen Methods: A descriptive retrospective study was conducted at Ibn Sina Central Teaching Hospital, in Mukalla city, Hadhramout, Yemen between January 2007 and December 2012. Eight hundred and seventeen patients with thyropathy were included in this study diagnosed histologically by experienced pathologists using fine needle aspiration cytology. This was followed-up by postoperative pathological thyroid specimen study. The patients in the study were treated medically and surgically by authors.

RESULTS

817 patients with thyropathy were included in the study. There were 716 (87.6%) females and 101 (12.4%) males, with a female to male ratio of 7:1. The age of the patients ranged from 5 to 80 years, with a mean age of 37.7±12.2 years. Median age was 35. More than half of the patients aged between 21-40 years. The majority of the thyroid lesions were non neoplastic = 703 (86%). The most common lesion was simple colloid goiter = 578 (82%) followed by thyroid Hashimoto = 75 (10.7%). The minority were granulomatous (subacute) thyroiditis, hyperplastic nodule and thyroglossal cyst, 5 (0.7%), 6 (0.9%), 8 (1.1%) respectively. 114 (14%) patients have neoplastic lesions. 61 (7.5%) patients have benign adenoma, 2 (1.75%) patients have Hurthel cell adenoma. 43 (5.3%) patients have papillary carcinoma while 3 (2.63%) patients have anaplastic carcinoma. The less common malignant neoplastic thyroid lesions were primary lymphoma, follicular and medullary carcinoma, and mucoepidermoid carcinoma, 2 (1.75%), 1 (0.9%), 1 (0.9%), and 1 (0.9%) respectively.

CONCLUSION

The most common non-neoplastic thyroid disorder reported in this study is a simple colloid goiter. Adenoma was found to be the most common benign tumor while papillary carcinoma was found to be the most common malignant one. Most cancerous lesions were found within the age groups in the third and the fourth decade, mostly females.

Changes in haemostasis and thrombosis associated with thyroid disease: Presentation of 2 cases

There is a relationship between thyroid diseases and primary and secondary changes in haemostasis. The most frequent association between them are hypocoagulability states with clinical hypothyroidism and vascular thrombophilia (hypercoagulability and/or hypofibrinolysis) with hyperparathyroidism. However, there are recent studies that have detected changes in haemostasis -primary and secondary- associated with thyroid diseases with normal hormone levels, suggesting other pathogenic mechanisms not yet known. The cases are presented of 2 patients with thyroid disease that required surgery: one multinodular goitre and one papillary carcinoma of the thyroid, both with normal hormone levels. They were shown to have haemostasis disorders during the preoperative work up. These showed a Factor VII deficiency and a Factor XI deficiency along with a thrombotic disease of unknown origin, respectively.

Pendrin and anoctamin as mediators of apical iodide efflux in thyroid cells

PURPOSE OF REVIEW

Thyroid hormones are essential for normal development, growth, and metabolism. Their synthesis occurs in thyroid follicles and requires an adequate iodide supply and a sequence of regulated biochemical steps. The uptake of iodide into thyrocytes is well characterized, but its efflux at the apical membrane is poorly understood. This review discusses potential mechanisms underlying iodide efflux with emphasis on recent developments and controversies.

RECENT FINDINGS

The functional characterization of pendrin (PDS/SLC26A4), a multifunctional anion exchanger, suggested that it could be involved in mediating iodide efflux. This is supported by the phenotype of patients with Pendred syndrome (deafness, goiter, partial iodide organification defect), which is caused by biallelic mutations in the SLC26A4 gene, as well as functional studies. However, apical iodide efflux is also possible in the absence of pendrin, implicating the presence of at least another channel. Recently, Anoctamin 1 (TMEM16A), a calcium-activated anion channel has been identified at the apical membrane of thyrocytes and functional studies suggest that it may play a predominant role in mediating iodide efflux.

SUMMARY

Anoctamin and pendrin are two plausible candidates as mediators of apical iodide efflux. Their relative affinity for iodide and their exact physiological role await, however, further characterization.

[Differential diagnostic value of contrast-enhanced ultrasound in calcified thyroid nodules]

OBJECTIVE

To evaluate the diagnostic value of contrast-enhanced ultrasound(CEUS) in calcified thyroid nodules.

METHODS

A total of 179 cases with calcified thyroid nodules between February 2009 and September 2012 underwent CEUS by injection of microbubbles via superficial vein was included in the study. Pathological diagnosis as a gold standard, the sensitivity, specificity, positive predictive, negative predictive and diagnostic coincidence rate of CEUS were evaluated.

RESULTS

Among 110 cases of benign nodules, 62 cases were nodular goiter (46 cases with macrocalcification and 16 cases with microcalcification); 29 cases were adenoma (28 cases with macrocalcification and 1 case with microcalcification); 17 cases were Hashimoto's thyroid (13 cases with macrocalcification and 4 cases with microcalcification); and 2 cases were granuloma with microcalcification. Among 69 cases of malignant nodules (t = 14.33, P < 0.05), 68 cases were papillary carcinoma (60 cases with microcalcification and 8 cases with macrocalcification), and 1 case of medullary carcinoma with microcalcification. Malignant nodules mainly showed weak inhomogeneous enhancement, with the mean; peak intensity (51.38 ± 14.33)dB that was lower than that (92.37 ± 33.36)dB in benign nodules, and benign nodules showed isoenhancement or hyperenhancement, with significant differences compared to malignant nodules (t = 14.33, P < 0.05) , however, there were significant differences in the enhanced time and the time to peak between benign and malignant nodules. The sensitivity, specificity, positive predictive, negative predictive and diagnostic coincidence rate of CEUS for the diagnoses of thyroid nodules were 92.75%, 90.91%, 86.49%, 95.24% and 91.62%, respectively.

CONCLUSION

CEUS has high value in differential diagnosis of benign and malignant calcified thyroid nodules.

Intrathyroid lymph node tissue in multinodular goiter in an Egyptian female

We report a case of an incidental finding of intrathyroid lymph node tissue in a 40-year-old Egyptian female presenting with multinodular goiter. Collections of lymphoid tissue surrounded by capsule and mature fat cells were seen enclosed by normal thyroid follicles. Heteroplasia or deviation of the normal anatomy of the cervical lymph node groups may explain the presence of this lymphoid tissue.

Profound refractory hypocalcemia after thyroidectomy in a patient receiving chronic oral bisphosphonate therapy

The use of oral bisphosphonates in the primary care setting is increasing, most commonly to preserve bone density and prevent the development or progression of osteoporosis. We report a case of profound hypocalcemia occurring in a patient who underwent thyroidectomy while receiving chronic oral risedronate therapy for osteoporosis. In addition, the hypocalcemia was refractory to treatment for several days, necessitating a prolonged hospital stay. A review of the literature yielded no similar cases to date. We propose that the frequently observed transient hypocalcemia after thyroidectomy was exacerbated by the alterations in calcium homeostasis produced by bisphosphonate therapy and urge cessation of these agents for several weeks prior to surgery. A review of the relevant literature is provided.

Evaluation of the ultrasonic dissector in thyroid surgery. A prospective randomised study

BACKGROUND

The use of ultrasonic dissectors in endoscopic surgery has proved to be of value, particularly for the prevention of bleeding and the reduction of electrical internal burns. This prospective randomised study was performed in order to evaluate the efficacy, security and cost of using the ultrasonic hook in thyroid surgery.

METHODS

Thirty-four consecutive euthyroid patients with multinodular goitre for whom a total thyroidectomy was indicated, were randomly assigned either to group I, Ultracision or to group II, conventional hemostasis. Pre-, peri-, and postoperative biochemical, clinical, surgical and economical variables were compared between both groups.

RESULTS

The use of the ultrasonic hook resulted in a significant reduction in operating time, blood loss, and maybe in "transitory hypoparathyroidism"; postoperative analgesic consumption was also reduced in this group. Considering the cost, the ultrasonic hook was no more expensive than conventional hemostasis, as long as a minimum of 15 patients shared the initial unit cost of the device.

CONCLUSION

Even if the use of the ultrasonic dissector is not of major interest in terms of patient management or cost-saving in the context of total thyroidectomy, essential advantages reside in significant reductions of operating time, blood loss and organ injury, (particularly parathyroid). The reduced operating time undoubtedly represents a positive feature of the ultrasonic dissection technique.

Isolation and characterization of human thyroid endothelial cells

From collagenase digests of human thyroid, endothelial cells were separated from follicular cells by their greater adherence to gelatin-coated plates. Endothelial cells were further purified using fluorescence-activated cell sorting, selecting for cells expressing factor VIII-related antigen. Isolated cells were negative for thyroglobulin and calcitonin when examined by immunostaining. The receptor for the angiopoietins, Tie-2, was expressed by the cells, and expression was increased by agents that elevate cAMP. Nitric oxide synthase (NOS) 3, the endothelial form of NOS, was expressed by the cells and similarly regulated. Cells responded strongly to the mitogen fibroblast growth factor (FGF)-2 in growth assays but only weakly to vascular endothelial growth factor (VEGF). VEGF was, however, able to stimulate nitric oxide release from the cells consistent with their endothelial origin. The FGF receptor (FGFR1) was full length (120 kDa) and immunolocalized to the cytosol and nucleus. Thyrotropin (TSH) did not regulate FGFR1, but its expression was increased by VEGF. Thrombospondin, a product of follicular cells, was a growth inhibitor, but neither TSH nor 3,5,3'-triiodothyronine had direct mitogenic effects. Thyroid follicular cell conditioned medium contained plasminogen activator activity and stimulated the growth of the endothelial cells, but when treated with plasminogen to produce the endothelial-specific inhibitor, angiostatin, growth was inhibited. Human thyroid endothelial cell cultures will be invaluable in determining the cross talk between endothelial and follicular cells during goitrogenesis.

A hydatid cyst of the thyroid gland

Echinococcosis, although eradicated in many countries, is still widespread in communities in which agriculture is dominant, and cystic hydatidosis is a significant public health problem in regions where echinococcosis is endemic. Hydatid cysts may be found in almost any part of the body, but most often in the liver and lungs. Other organs affected occasionally include the brain, muscle, kidney, bone, heart and pancreas. This report documents a rare case with a cystic nodule in the thyroid detected by ultrasonography. The patient was a 40-year-old woman with an euthyroid multinodular goitre. Ultrasonography revealed a cystic nodule, and the ultrasonic appearance of the cyst liquid showed multiple echoes, suggesting that the nodule could be a hydatid cyst. Bilateral subtotal thyroidectomy was performed. Postoperative examination of the nodule showed it to be a solitary primary thyroid hydatid cyst.

Solitary adrenal gland metastasis of a follicular thyroid carcinoma presenting with hyperthyroidism

Follicular thyroid carcinoma typically manifests under euthyroid conditions, and diagnostic scintigraphy usually identifies a cold nodule. Sometimes, such tumors can appear in the context of hyperthyroidism, which can be caused by a toxic multinodular goitre, a toxic adenoma, or even carcinoma. We report a case of follicular thyroid carcinoma discovered after surgical treatment of a toxic multinodular goiter, in which solitary adrenal gland metastasis was detected five years later. A (131)I whole body scan is the diagnostic method of choice for functioning thyroid metastasis.

The relationship between the nodular goitre and carcinoma of the thyroid

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