Long-term efficacy and safety of percutaneous ethanol injection (PEI) in cystic thyroid nodules: A systematic review and meta-analysis

BACKGROUND

Percutaneous ethanol injection (PEI) is used for the treatment of benign cystic thyroid nodules. This systematic review and meta-analysis aimed to obtain strong evidence of its long-term efficacy and safety.

METHODS

PubMed, CENTRAL, Scopus and Web of Science databases were searched until November 2020 for studies reporting data on volume reduction rate (VRR), compressive symptoms and cosmetic concerns. Associated complications were assessed. A random-effects model was designed to pool the data.

RESULTS

Out of 385 papers, nine studies evaluating 1667 nodules were finally included. Overall, VRR at 6, 12, 24, 36, 60 and 120 months was 77%, 81%, 72%, 68%, 74% and 69%, respectively. Significant reductions in the compressive symptoms and cosmetic concerns were observed. No permanent complications were observed.

CONCLUSIONS

The present meta-analysis showed that PEI could significantly reduce the volume of benign cystic thyroid nodules. This reduction was already effective at 6 months post-treatment, and the effect was stable over time.

Benign thyroid nodules respond to a single administration of 0.3mg recombinant human thyrotropin with highly variable volume increase

INTRODUCTION

The nature of thyroid nodules is heterogenous. Most of them are benign and, in the absence of pressure symptoms of adjunct structures, no treatment is needed. Our objective was to investigate the acute effects of a low dose of recombinant human TSH (rhTSH) on the volume of benign thyroid nodules.

METHODS

we studied 27 nodules (14 isoechoic and 13 hypoechoic) in 15 (11 women and 4 men; mean age: 51.0 ± 15.9 years) consecutive patients with one to three well-separated asymptomatic benign thyroid nodules. All subjects were euthyroid, with negative thyroid antibodies, and none received levothyroxine. The total thyroid volume and thyroid nodule volume were sonographically determined by two independent examiners (P.B. and M.M.) before, 48 hours and 6 months post intramuscular (IM) administration of 0.3mg rhTSH, and the mean values of the two examiners' measurements were used; thyroid function tests were obtained at the same time points.

RESULTS

The mean volume of isoechoic nodules increased by 57.3%, of hypoechoic nodules by 46.6% and of the surrounding thyroid parenchyma by 70.4% 48 hours post-rhTSH; mean volumes had returned to baseline levels 6 months later. A large variance in the volume change responses was observed. The relative change in nodule volume (defined as the percent change in nodule volume divided by the percent change in the surrounding parenchyma) from baseline to 48 hours was significantly higher in isoechoic versus hypoechoic nodules (p<0.05).

CONCLUSIONS

A single dose of 0.3 mg rhTSH transiently increased the volume of benign thyroid nodules. The increase was more pronounced in isoechoic nodules and had a great variability. Our findings could be useful in the management of benign thyroid nodules, by helping in understanding which nodules would be more responsive to TSH suppression therapy.

Safety and efficacy of Prunella vulgaris preparation in adjuvant treatment of thyroid nodules: A meta-analysis

BACKGROUND

Prunella vulgaris (PV), a traditional Chinese medical herb, is considered beneficial for some thyroid diseases. However, the effectiveness is not consistent in different studies. This review compiles the evidence from randomized controlled trials (RCTs) and quantifies the effects of PV preparation on thyroid nodules.

METHODS

Eight databases were searched up to April 2021 to identify eligible studies. Only RCTs were included. Meta-analysis of homogeneous studies was performed by RevMan5.3 software. Cochrane risk of bias assessment tool version 2.0 was used to assess the risk of bias of each trial. The research screening, data extraction, and risk of bias assessment were employed by 2 reviewers independently, and disagreement will be decided by a third senior reviewer. The risk ratio (RR), mean difference (MD) and corresponding 95% confidence interval (CI) of each study are summarized.

RESULTS

Thirteen RCTs with 1468 patients were included in this study. A meta-analysis showed that the RR of the clinical efficacy of PV combined with levothyroxine sodium tablets was 1.22 (95% CI [1.11, 1.33]). The MD of thyroid nodule diameter was -0.43 (95% CI [-0.63, -0.22]). The MD of free triiodothyronine and free tetraiodothyronine levels was -1.99 (95% CI [-3.14, -0.86]) and -3.20 (95% CI [-5.50, -0.89]), respectively. The RR of the adverse reaction rate was 0.67 (95% CI [0.36, 1.22]), and the RR of the clinical efficacy of PV preparation combined with thyroxin tablets was 1.29 (95% CI [1.03, 1.62]).

CONCLUSIONS

PV combined with levothyroxine sodium tablets or thyroxin tablets has more benefits for thyroid nodules, further improving the clinical efficiency, reducing the diameter of nodules and reducing the occurrence of adverse reactions. However, the quality of these studies is uncertain, and higher quality and more RCTs are needed to provide comprehensive evidence-based medical evidence in the future.

Effect of Chinese herbal medicine for patients with benign thyroid nodules in adults: A protocol for systematic review and meta-analysis

BACKGROUND

Thyroid nodules (TN) are discrete lesions within the thyroid gland and are a common clinical problem detected in 19% to 68% of people. TN are more common as age increases and occur more frequently in women. TN can cause pressure symptoms, cosmetic complaints, and thyroid dysfunction. Treatment for benign thyroid nodules includes thyroid hormone therapy, surgery, radioiodine treatment, percutaneous ethanol injection therapy, and laser or radiofrequency treatment to shrink nodules. In China and many other countries, doctors use Chinese herbal medicines (CHM) to treat TN. However, systematic review and meta-analysis has not been found to assess the effects and safety of CHM in curing TN at present. Hence, the systematic review is conducted to scientifically and methodically evaluate the value of its effectiveness and safety of CHM on TN.

METHODS

Literatures related to CHM for TN from the establishment of the database to November 2020 will be retrieved from the following databases: PubMed, Excerpta Medica Database (EMBASE), MEDLINE, Web of Science, Cochrane Library, SpringerLink, WHO International Clinical Trials Registry Platform (ICTRP), Wanfang Database, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), and Chinese Scientific Journal Database (VIP). There are no language restrictions for retrieving literatures. Case reports, animal studies, editorials, expert opinions, reviews without original data, and studies on pediatric population were excluded. Eligible randomized clinical trials (RCTs) evaluating the effectiveness and safety of CHM in TN patients will be put in the study including nodule volume reduction ≥50%, pressure symptoms, cosmetic complaints, quality of life, and adverse events. By scanning the titles, abstracts and full texts, 2 reviewers will independently select studies, extract data, and assess the quality of study. Meta-analysis of RCTs will be conducted using Review Manager 5.1 software. The results will be presented as risk ratio for dichotomous data, and standardized or weighted mean difference for continuous data.

RESULT

This study will provide high-quality available evidence for the treatment of TN with CHM based on nodule volume reduction ≥50%, pressure symptoms, cosmetic complaints, quality of life, and adverse events.

CONCLUSION

The systematic review will to evaluate the efficacy of CHM in treating benign thyroid nodules in adults and provide evidence for clinicians.

INPLASY REGISTRATION NUMBER

INPLASY2020120093.

A pregnant woman with an autonomously functioning thyroid nodule: a case report

BACKGROUND

The epidemiology and natural history of autonomously functioning thyroid nodules (AFTNs) have not been elucidated. Here we report the pregnant Japanese woman with an AFTN.

CASE PRESENTATION

The patient was a 31-year-old woman who was hospitalized due to the placenta previa associated with threatened abortion at the 16 weeks of her third pregnancy. At her second pregnancy, she was euthyroid but had a single, 2.3 cm nodule on her right thyroid lobe. Her thyroid hormone level was trended increased with her pregnancy progression, and the thyrotoxic state was remained after delivery. Before her third pregnancy, her hyper-vascular nodule enlarged to 3.4 cm at regular monitoring. When she visited our hospital, she was at 16 weeks of pregnancy and had thyrotoxicosis with negative TSH-receptor antibody. She delivered a baby weighing 2615 g without hypothyroidism at 39 weeks of pregnancy by natural delivery. After delivery, a ^99mTc scintigram showed a hot spot in her right thyroid lobe. She was diagnosed with AFTN and treated with methimazole while nursing.

CONCLUSIONS

This case showed that hCG stimulation during pregnancy caused thyroid nodule enlargement and enhanced thyroid hormone production. The pregnancy could be the pathological stimulus and provides chance to diagnosis for AFTNs.

Long-term follow-up of cystic thyroid nodules treated with percutaneous ethanol injection (PEI) using two different approaches

BACKGROUND AND AIM

Cystic thyroid nodules (CNs), although generally benign, can cause compressive or aesthetic problems. Percutaneous ethanol injection (PEI) can represent an alternative to surgery. The present retrospective study evaluates: (i) the long-term outcome of CNs after PEI; (ii) the differences between two different PEI protocols; (iii) the CNs response according to the liquid component.

MATERIALS AND METHODS

The study comprises 358 nodules post-PEI followed for at least 2 years. PEI was performed according to two different treatment protocols with a single (Foggia) or double (Turin) alcohol injection. CNs were divided according to their composition: cystic (CYS) >90%, mainly cystic (M-CYS) 75-90%, mixed (MIX) 50-75%, solid-mixed (S-MIX) 35-50%. The volume reduction rate (VRR) was defined as nodule volume (mL) after PEI/nodule volume (mL) before PEI x 100.

RESULTS

The 1-year VRR was significantly higher than that at 6 months (89.5% vs 72.9%, P = 0.0005), no differences were observed after 1 year. A significant difference between Turin and Foggia was observed only in VRR at early visit (79% vs 86%, respectively, P = 0.002) and recurrence rate (14% vs 24%, respectively, P = 0.001). Minor side-effects were infrequent. In 192 nodules with a 10-year follow-up CYS showed higher VRR than MIX and S-MIX nodules (P < 0.001).

CONCLUSION

Our study reported that the long-term outcome of CNs treated with PEI is excellent regardless of the PEI technique utilized; the larger the cystic amount, the higher the VRR. Based on present results, PEI can be considered as the first-line choice for treating thyroid CNs.

The effect of disease activity on thyroid nodules in patients with acromegaly

Nodular thyroid disease is a very common disorder in patients with acromegaly. Insulin-like growth factor-1 (IGF-1) is a thyroid growth factor, and there is a correlation between IGF-1 levels and thyroid volume (TV) in patients with acromegaly. There is no study investigating the impact of somatostatin analog (SSA) treatment on thyroid nodule volume in patients with acromegaly. We aimed to assess thyroid nodule volume change with SSA treatment in patients with persistent acromegaly. We retrospectively analyzed data from 108 consecutive patients with acromegaly who were followed up by our clinic after undergoing surgery between 2002 and 2014. Patients who were cured after surgery were excluded. We only selected 43 patients (21 males, 22 females, mean age 52.8 ± 11.9 years) who did not meet the criteria of remission postoperatively, who were treated with SSA for at least six months and had normal thyroid function. Patients were divided into three groups (well-controlled, controlled, and active) according to their IGF-1 and growth hormone (GH) levels. All patients underwent an evaluation of TV and total thyroid nodule volume (TTNV) by ultrasound. TTNV decreased significantly in patients with well-controlled acromegaly (0.44 [0.75] to 0.23 [0.73], p < 0.001). TTNV did not change in controlled patients (0.18 [1.28] to 0.13 [1.54], p = 0.959); however TTNV increased in patients with active acromegaly (0.77 [1.46] to 1.03 [1.88], p = 0.028). Successful medical treatment of patients with active acromegaly decreases thyroid nodule volume. Sustained exposure to IGF-1 may cause an increase in thyroid nodule volume in patients with acromegaly.

Role of Metformin in the Treatment of Patients with Thyroid Nodules and Insulin Resistance: A Systematic Review and Meta-Analysis

BACKGROUND

Metformin is the most-prescribed oral medication to lower blood glucose worldwide. Some data suggest that metformin may have a role in the treatment of patients with thyroid nodules, but contrasting results are reported in different settings. This study explores and critically reevaluates the knowledge on this topic.

METHODS

A literature search identified 250 records. Studies evaluating the size of thyroid nodules before and after metformin treatment were included. Assessed outcomes were the size of thyroid nodules, thyrotropin (TSH) level, thyroid gland volume, and insulin resistance index (HOMA-IR). After screening and full-text assessment, five studies were included in the systematic review. Random-effects meta-analyses of the standardized mean difference (SMD) were performed for the four outcomes of interest. Heterogeneity was estimated using I², and the quality of evidence was assessed for each outcome using the Grading of Recommendations Assessment, Development, and Evaluation guidelines.

RESULTS

A total of 189 patients were included in the final analysis. After metformin treatment, a slight but significant reduction in thyroid nodule size was found in four studies, which included a total of 167 patients (SMD 0.46 [confidence interval (CI) 0.00-0.93]; p = 0.05). Similarly, in four studies reporting on a total of 146 patients, significant reductions in TSH level (SMD 0.30 [CI 0.07-0.53]; p = 0.01) and HOMA-IR level (SMD 0.90 [CI 0.12-1.67]; p = 0.02) were reported after treatment with metformin. In two studies, which included 114 patients, no change in thyroid gland volume was discovered after treatment with metformin (SMD 0.21 [CI -0.05 to 0.47]; p = 0.11). Quality of evidence was generally assessed as low or very low.

CONCLUSIONS

Metformin induces reductions in thyroid nodule size and TSH and HOMA-IR levels in patients with thyroid nodules and insulin resistance. In contrast, no change in thyroid gland volumes was found. Whether metformin treatment for thyroid nodules has clinical significance remains to be demonstrated.

Usefulness of core needle biopsy for the diagnosis of thyroid Burkitt's lymphoma: a case report and review of the literature

BACKGROUND

Thyroid lymphomas are an exceptional finding in patients with thyroid nodules. Burkitt's lymphoma is one of the rarest and most aggressive forms of thyroid lymphomas, and its prognosis depends on the earliness of medical treatment. Given the rarity of this disease, making a prompt diagnosis can be challenging. For instance, fine-needle aspiration (FNA) cytology, which is the first-line diagnostic test that is performed in patients with thyroid nodules, is often not diagnostic in cases of thyroid lymphomas, with subsequent delay of the start of therapy.

CASE PRESENTATION

Here we report the case of a 52-year-old woman presenting with a rapidly enlarging thyroid mass. Thyroid ultrasonography demonstrated a solid hypoechoic nodule. FNA cytology was only suggestive of a lymphoproliferative disorder and did not provide a definitive diagnosis. It is core needle biopsy (CNB) that helped us to overcome the limitations of routine FNA cytology, showing the presence of thyroid Burkitt's lymphoma. Subsequent staging demonstrated bone marrow involvement. The early start of an intensive multi-agent chemotherapy resulted in complete disease remission. At 60 months after the diagnosis, the patient is alive and has not had any recurrence.

CONCLUSIONS

Clinicians should be aware that thyroid Burkitt's lymphoma is an aggressive disease that needs to be treated with multi-agent chemotherapy as soon as possible. To diagnose it promptly, they should consider to order/perform a CNB in any patient with a rapidly enlarging thyroid mass that is suspicious for lymphoma.

Galectin-3: The Impact on the Clinical Management of Patients with Thyroid Nodules and Future Perspectives

Galectins (S-type lectins) are an evolutionarily-conserved family of lectin molecules, which can be expressed intracellularly and in the extracellular matrix, as well. Galectins bind β-galactose-containing glycoconjugates and are functionally active in converting glycan-related information into cell biological programs. Altered glycosylation notably occurring in cancer cells and expression of specific galectins provide, indeed, a fashionable mechanism of molecular interactions able to regulate several tumor relevant functions, among which are cell adhesion and migration, cell differentiation, gene transcription and RNA splicing, cell cycle and apoptosis. Furthermore, several galectin molecules also play a role in regulating the immune response. These functions are strongly dependent on the cell context, in which specific galectins and related glyco-ligands are expressed. Thyroid cancer likely represents the paradigmatic tumor model in which experimental studies on galectins' glycobiology, in particular on galectin-3 expression and function, contributed greatly to the improvement of cancer diagnosis. The discovery of a restricted expression of galectin-3 in well-differentiated thyroid carcinomas (WDTC), compared to normal and benign thyroid conditions, contributed also to promoting preclinical studies aimed at exploring new strategies for imaging thyroid cancer in vivo based on galectin-3 immuno-targeting. Results derived from these recent experimental studies promise a further improvement of both thyroid cancer diagnosis and therapy in the near future. In this review, the biological role of galectin-3 expression in thyroid cancer, the validation and translation to a clinical setting of a galectin-3 test method for the preoperative characterization of thyroid nodules and a galectin-3-based immuno-positron emission tomography (immuno-PET) imaging of thyroid cancer in vivo are presented and discussed.

Do Statins Affect Thyroid Volume and Nodule Size in Patients with Hyperlipidemia in a Region with Mild-to-Moderate Iodine Deficiency? A Prospective Study

OBJECTIVE

The objective of this study was to assess the antiproliferative pleiotropic effects of statins on thyroid function, volume, and nodularity.

SUBJECTS AND METHODS

One hundred and six hyperlipidemic patients were included in this prospective study. The 69 patients in the statin groups received atorvastatin (16 received 10 mg and 18 received 20 mg) or rosuvastatin (20 received 10 mg and 15 received 20 mg). The 37 patients in the control group, assessed as not requiring drugs, made only lifestyle changes. Upon admission and after 6 months, all patients were evaluated by ultrasonography as well as for lipid variables (total cholesterol, high- and low-density lipoprotein cholesterol, and triglycerides) and thyroid function and structure.

RESULTS

After 6 months, no differences in thyroid function, thyroid volume, the number of thyroid nodules, or nodule size were observed in the statin and control groups. In a subgroup analysis, total thyroid volume had decreased more in patients receiving 20 mg of rosuvastatin than that in the control group (p < 0.05). Maximum nodule size had decreased more in those receiving 10 mg of rosuvastatin (p < 0.05).

CONCLUSIONS

Our results suggest an association between rosuvastatin treatment and smaller thyroid volume and maximum nodule diameter; this could be attributable to the antiproliferative effects of statin therapy on the thyroid.

GAUGING THE EXTENT OF THYROIDECTOMY FOR INDETERMINATE THYROID NODULES: AN ONCOLOGIC PERSPECTIVE

OBJECTIVE

Increasing emphasis is being placed on appropriateness of care and avoidance of over- and under-treatment. Indeterminate thyroid nodules (ITNs) present a particular risk for this problem because cancer found via diagnostic lobectomy (DL) often requires a completion thyroidectomy (CT). However, initial total thyroidectomy (TT) for benign ITN results in lifelong thyroid hormone replacement. We sought to measure the accuracy and factors associated with the extent of initial thyroidectomy for ITN.

METHODS

We queried a single institution thyroid surgery database for all adult patients undergoing an initial operation for ITN. Multivariate logistic regression identified factors associated with either oncologic under- or overtreatment at initial operation.

RESULTS

There were 639 patients with ITN. The median age was 52 (range, 18 to 93) years, 78.4% were female, and final pathology revealed a cancer >1 cm in 24.7%. The most common cytology was follicular neoplasm (45.1%) followed by Hürthle cell neoplasm (20.2%). CT or initial oncologic undertreatment was required in 58 patients (9.3%). Excluding those with goiters, 19.0% were treated with TT for benign final pathology. Multivariate analysis failed to identify any factor that independently predicted the need for CT. Female gender was associated with TT in benign disease (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.0 to 4.5; P = .05). Age >45 years predicted correct initial use of DL (OR, 2.6; 95% CI, 1.2 to 5.7; P = .02). Suspicious for papillary thyroid carcinoma (OR, 5.7; 95% CI, 2.1 to 15.3; P<.01) and frozen section (OR, 9.7; 95% CI, 2.5 to 38.6; P<.01) were associated with oncologically appropriate initial TT. The highest frequency of CT occurred in patients with follicular lesion of undetermined significance (11.6%). TT for benign final pathology occurred most frequently in patients with a Hürthle cell neoplasm (24.8%).

CONCLUSION

In patients with ITN, nearly 30% received an inappropriate extent of initial thyroidectomy from an oncologic standpoint. Tools to pre-operatively identify both benign and malignant disease can assist in the complex decision making to gauge the proper extent of initial surgery for ITN.

ABBREVIATIONS

ATA = American Thyroid Association AUS = atypia of undetermined significance CI = confidence interval CT = completion thyroidectomy FLUS = follicular lesion of undetermined significance ITN = indeterminate thyroid nodule OR = odds ratio PTC = papillary thyroid carcinoma TT = total thyroidectomy.

Early detection of biochemically occult autonomous thyroid nodules

OBJECTIVE

Autonomously functioning thyroid areas may be associated with subclinical or overt hyperthyroidism, but may exist even in the presence of normal TSH. This study was aimed at comparing the rate of autonomously functioning areas and their cardiac sequelae in patients with nodular goitre studied with the usual and a novel approach.

DESIGN AND METHODS

In total 490 adult outpatients with thyroid nodular goitre, living in a mild iodine-deficient area, were selected in our referral centre for thyroid diseases from 2009 to 2014 on the basis of a suspicion of thyroid functional autonomy. They were divided in three groups according to a non-conventional approach (excessive response to thyroxine treatment: group 1) or conventional approach (low/normal TSH with clinical suspicion or low TSH: groups 2 and 3). All patients of the study with the suspicion of thyroid functional autonomy underwent thyroid scan with radioactive iodine (I¹³¹) uptake (RAIU).

RESULTS

The percentage of confirmed thyroid functional autonomy was 319/490, being significantly higher in group 3 than in groups 1 and 2 (81.5 vs 64.7 vs 52.6%; chi-square P < 0.0001). However, the diagnosis with non-conventional approach was made at a significant earlier age (P < 0.0001). Cardiac arrhythmias as well as atrial fibrillation were similarly detected by conventional and non-conventional approaches (chi-square test: P = 0.2537; P = 0.8425).

CONCLUSIONS

The hyper-responsiveness to thyroxine treatment should induce the suspicion of thyroid functional autonomy at an early stage, allowing to detect autonomous functioning areas in apparently euthyroid patients.

Laser, radiofrequency, and ethanol ablation for the management of thyroid nodules

PURPOSE OF REVIEW

The majority of benign thyroid nodules are nearly asymptomatic, remain stable in size, and do not require treatment. However, a minority of patients with growing nodules may complain of local symptoms or have cosmetic concerns, and thus seek surgical consultation.

RECENT FINDINGS

The timely use of ultrasound-guided minimally invasive procedures can change the natural history of benign enlarging thyroid nodules. The procedures produce persistent shrinkage of thyroid nodules and are associated with improvement of local symptoms. Among the various procedures, percutaneous ethanol injection represents the first-line treatment for relapsing thyroid cysts. In solid nonfunctioning nodules, laser and radiofrequency ablation produces a more than 50% reduction in nodular volume that remains persistent over several years. For hyperfunctioning nodules, thermal ablation techniques are not appropriate unless radioactive iodine is contraindicated or not accessible.

SUMMARY

MITs are best suited for the management of medium or large-sized nodules that are sonographically well visualized. Conversely, large nodules or nodular goiters that extend into the chest are difficult to treat. MITs are performed in outpatient clinics, are less expensive, and have a lower risk of complications, compared to surgery, and usually do not induce thyroid dysfunction. However, malignancy should be ruled out with a dedicated ultrasound neck assessment and repeat fine needle aspiration of the lesion before treatment.

Percutaneous ethanol injection versus conservative treatment for benign cystic and mixed thyroid nodules

OBJECTIVE

To evaluate the efficacy and safety of percutaneous ethanol injection (PEI) in reducing the volume of cystic and mixed thyroid nodules.

MATERIALS AND METHODS

A total of 36 patients with nodules treated with PEI and 13 individuals who declined PEI and were followed clinically or received other non surgical treatment (control group). Assessments were performed at baseline (immediately before treatment in the PEI group or evaluation of the nodule on ultrasonography in the control group) at short-term (on average 30 days after the last injection in the PEI group), and long-term (on average 14 months after baseline in the PEI group or 26 months after baseline in the control group).

RESULTS

In the PEI group, the mean baseline volume of 10.4 ± 9.8 cm3 reduced at short-term follow-up to 2.9 ± 3.1 cm3 (67.7 ± 19.9%, p < 0.001) and at long-term follow-up to 2.0 ± 2.5 cm3 (78.2 ± 19.5%, p < 0.01 versus baseline and p = 0.009 versus short-term follow-up). Both types of nodules showed similar degrees of reduction. In the control group, mean volume was 5.8 ± 3.4 cm3 at baseline and 6.2 ± 3.0 cm3 at long-term follow-up (p = 0.507). Compared with the control group, the PEI group showed larger reduction (p < 0.001).

CONCLUSIONS

PEI is effective in reducing the volume of cystic and mixed benign thyroid nodules, with sustained long-term efficacy and better outcome when compared with conservative therapies. Treatment with PEI is a safe alternative, with minimal, transient and self-limited adverse events.

The effects of lauromacrogol on thyroid tissue in rabbits. Is this a safe option for the treatment of nodular thyroid disease?

AIM

The effects of lauromacrogol as a sclerosing agent were evaluated on rabbit thyroid tissue.

MATERIAL AND METHODS

Twelve rabbits were divided into two equal groups. Intra-thyroid injections of 0.1 ml lauromacrogol were administered in the study group and 0.1 ml physiologic serum in the control group. The blood levels of free T3, free T4, TSH, postoperative adhesions and histopathologic differences of the thyroid tissues were evaluated.

RESULTS

The values of serum free T3, free T4 and TSH levels did not differ significantly (p>0.05), but the free T3 levels were significantly different in the inter-group analysis (p=0.020). Postoperative macroscopic adhesion scores did not differ significantly (p>0.05). In the histopathologic evaluation, the inflammation and fibrosis scores were significantly higher in the study group (p=0.003).

DISCUSSION

In our study, we found two important outcomes. Firstly, tests of thyroid function were not significantly different between the control and study groups. This important finding suggests lauromacrogol can be safely used without the risk of hypothyroidism or hyperthyroidism. Secondly, the Erlich-Hunt Model histopathologic evaluation results revealed that inflammation and fibrosis were significantly increased in the study group. This finding shows lauromacrogol can be effectively used to treat thyroid nodules by means of fibrosis.

CONCLUSIONS

Lauromacrogol causes fibrosis in thyroid tissue without significant perithyroidal adhesion formation and functional differences. Treatment of nodular thyroid disease with lauromacrogol may be safe.

KEY WORDS

Lauromacrogol, Nodule, Thyroid.

Metformin Decreases Thyroid Volume and Nodule Size in Subjects with Insulin Resistance: A Preliminary Study

OBJECTIVE

The aim of this study was to investigate the effects of metformin on thyroid volume and nodule size.

SUBJECTS AND METHODS

Prospective data were gathered on 100 newly diagnosed subjects with insulin resistance (68 female, 32 male) between August 2008 and May 2010. Each subject followed a standard diet and exercise program, and received 1,700 mg/day of metformin therapy for 6 months. The height, weight, waist circumference (WC) and thyroid hormone levels of each subject were measured. Additionally, the dimensions of the thyroid lobes and maximum diameter of each thyroid nodule were determined by ultrasonography. BMI and thyroid volumes were also calculated. Insulin resistance was estimated by homeostasis model assessment. All these parameters were measured at the beginning and at the end of the treatment period.

RESULTS

BMI and WC decreased significantly after metformin therapy (34.5 ± 5.1 vs. 32.7 ± 4.8, p < 0.0001, and 106.3 ± 11.8 vs. 101.8 ± 19.0 cm, p = 0.008, respectively). Insulin resistance also decreased after metformin therapy (4.5 ± 1.9 vs. 2.9 ± 1.7, p < 0.0001). The mean thyroid volume (22.5 ± 11.2 vs. 20.3 ± 10.4 ml, p < 0.0001) and mean thyroid nodule size (12.9 ± 7.6 vs. 11.7 ± 7.2 mm, p < 0.0001) also decreased after treatment.

CONCLUSION

In subjects with insulin resistance, metformin therapy significantly decreased thyroid volume and nodule size.

Evolution of benign thyroid nodules under levothyroxine non-suppressive therapy

BACKGROUND

Non-suppressive or partially suppressive L-T4 treatment demonstrated to be effective in reducing the volume of the nodules. However, studies with long follow-up are lacking and significant controversy exists regarding the efficacy of non-suppressive L-T4 treatment in benign nodular goiter.

AIM

The goal of this study was to determine the evolution of thyroid nodules in subjects treated with a non-suppressive levothyroxine (L-T4) dose, compared to untreated subjects.

DESIGN AND PATIENTS

We followed for a period of 1-9 years the thyroid nodule size in 356 female patients in the age range 19-45 at study entry, of which 201 untreated (Group 0) and 165 treated with a non-suppressive L-T4 dose (Group L-T4).

MEASUREMENTS

We determined the volume of thyroid nodules by ultrasonography.

RESULTS

The initial mean nodule volume in Group 0 and Group L-T4 was 3.91 ± 6.87 and 4.01 ± 7.35 mL, respectively. Nodule volume increase was inversely correlated to the initial volume. The final volume was slightly higher in untreated than in L-T4 treated subjects (5.37 ± 8.49 and 4.39 ± 6.72 mL). In both groups, the mean of annual fold increase of nodule volume was inversely correlated with the follow-up duration (P < 0.0046), indicating a slower growth as time advances. In the subjects treated with L-T4, the mean annual increase of nodule volume was significantly minor compared to untreated subjects. Concomitant nodules in ten multinodular goiters exhibited totally independent evolution, demonstrating that intranodular factors are more important for the nodule behavior than extra nodular factors.

CONCLUSIONS

Our study demonstrates that the growth of benign thyroid nodules is inversely correlated to their size, benign nodules naturally growth slowly as time advances, and that a chronic treatment with L-T4 at a non-TSH-suppressive dose significantly reduces their growth.

Prevalence of goiter and thyroid nodules before and after implementation of the universal salt iodization program in mainland China from 1985 to 2014: a systematic review and meta-analysis

OBJECTIVES

We comprehensively estimated the prevalence of goiter and thyroid nodules (TNs) before and after the implementation of the Universal Salt Iodization (USI) program in mainland China and provided information for creating effective health policies.

METHODS

PubMed, Google Scholar, CNKI, Chinese Wanfang and Chongqing VIP databases were searched for relevant studies from Jan 1985 to Feb 2014. Data from eligible citations were extracted by two independent reviewers. All analyses were performed with Stata 11.0 and SPSS 17.0.

RESULTS

Eligible articles (N = 31; 4 in English and 27 in Chinese) included 52 studies (15 about goiter rates made before 1996 and 14 afterwards, and 23 about TNs). Our meta-analysis suggests a pooled prevalence for goiter before and after 1996 and for TNs of 22.8% (95% CI: 15.3%, 30.3%), 12.6% (95% CI: 9.4%, 15.8%) and 22.7% (95% CI: 18.3%, 27.0%), respectively. Egger's test of three independent categories revealed no evidence of publication bias (p = 0.101, 0.148 and 0.113, respectively).

CONCLUSIONS

The prevalence of goiter was reduced by almost half after 1996 in mainland China, so the USI program was considered beneficial. However, subgroup analysis suggests that both insufficient and excess iodine may be associated with goiter. The prevalence of goiter and TNs increased significantly after 2002, suggesting a risk of excessive iodine intake. Thus, salt iodization standardizations should be set according to local conditions.

Chinese herbal medicines for benign thyroid nodules in adults

BACKGROUND

A thyroid nodule is a discrete lesion within the thyroid gland that might be palpable and is ultrasonographically distinct from the surrounding thyroid parenchyma. Thyroid nodules are more common as age increases and occur more frequently in women. Benign thyroid nodules often cause pressure symptoms and cosmetic complaints. In China and many other countries, doctors use Chinese herbal medicines (CHM) to treat thyroid nodules.

OBJECTIVES

To assess the effects of Chinese herbal medicines in the treatment of benign thyroid nodules in adults.

SEARCH METHODS

Review authors searched the following electronic databases: The Cochrane Library, MEDLINE, EMBASE, the Chinese Biomedical Literature Database (CBM), the China National Knowledge Infrastructure (CNKI), VIP information (a Chinese database), WANFANG Data (a Chinese database), the Chinese Conference Papers Database and the Chinese Dissertation Database (all searched up to April 2013).

SELECTION CRITERIA

Randomised controlled trials comparing CHM or CHM plus levothyroxine versus levothyroxine, placebo or no treatment in adults with benign thyroid nodules.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, assessed studies for risk of bias and evaluated overall study quality according to GRADE (Grading of Recommendations Assessment, Development and Evaluation), with differences resolved by consensus.

MAIN RESULTS

We included one randomised trial involving 152 participants with a randomisation ratio of 2:1 (CHM vs no treatment). The trial applied adequate sequence generation; however, allocation concealment was unclear. Duration of treatment was three months, and follow-up six months. Our a priori defined outcomes of interest (i.e. nodule volume reduction ≥ 50%; pressure symptoms, cosmetic complaints or both; health-related quality of life; all-cause mortality; cancer occurrence; changes in number and size of thyroid nodules; changes in thyroid volume; and socioeconomic effects) were not investigated in the included study. Thyrotropin (TSH), thyroxine (T4) and tri-iodothyronine (T3) serum levels were normal in both groups before and after the trial was conducted. No adverse events were reported (low quality evidence).

AUTHORS' CONCLUSIONS

Firm evidence cannot be found to support or refute the use of Chinese herbal medicines for benign thyroid nodules in adults.

Clinical review: Nonsurgical, image-guided, minimally invasive therapy for thyroid nodules

CONTEXT

Nodular thyroid disease is very common. Most nodules are asymptomatic, are benign by fine-needle aspiration, remain stable, and can be followed by observation alone in the majority of the patients. Occasionally, nodules grow or cause symptoms requiring treatment. So far, surgery has been our main option for treatment.

OBJECTIVE

In this review, we discuss nonsurgical, minimally invasive approaches for small thyroid masses, including indications, efficacy, side effects, and costs.

EVIDENCE ACQUISITION

We selected recent publications related to minimally invasive thyroid techniques, with the focus on large-scale and preferably randomized studies, available via PubMed search in authors' files, using appropriate searches and keywords.

MAIN FINDINGS

In large centers with experienced hands, minimally invasive approaches appear effective and safe. At present, percutaneous ethanol injection therapy is recommended for recurrent benign thyroid cysts. Either ultrasound-guided laser or radiofrequency ablation can be used for symptomatic solid nodules with normal or abnormal thyroid function. Microwave ablation and high-intensity focused ultrasound are newer approaches that need further clinical evaluation. These techniques have also been applied to recurrent locoregional cervical thyroid cancer with encouraging initial results, although still limited data.

CONCLUSIONS

Surgery and radioiodine remain as conventional and established treatments for nodular goiters. However, the new image-guided minimally invasive approaches appear safe and effective and can be used to treat symptomatic or enlarging thyroid masses.

A novel formulation of L-thyroxine (L-T4) reduces the problem of L-T4 malabsorption by coffee observed with traditional tablet formulations

The purpose of this work is to evaluate if the coffee-associated malabsorption of tablet levothyroxine (L-T4) is reduced by soft gel capsule. We recruited 8 patients with coffee-associated L-T4 malabsorption including one hypothyroid patient. For 6 months, the patients were switched to the capsule maintaining the L-T4 daily dose. Patients took the capsule with water, having coffee 1 h later (proper habit, PH) on days 1-90, or with coffee ≤ 5 min later (improper habit, IH) on days 91-180. After 6 months, 2 patients volunteered for an acute loading test of 600 μg L-T4 (capsule) ingested with water (PH) or with coffee (IH). In the single hypothyroid patient, the post-switch TSH ranged 0.06-0.16 mU/L (PH) versus 5.8-22.4 mU/L pre-switch (PH) and 0.025-0.29 mU/L (IH) versus 26-34 mU/L pre-switch (IH). In the other 7 patients, post-switch TSH was 0.41 ± 0.46 (PH) versus 0.28 ± 0.20 pre-switch (PH) (P = 0.61) and 0.34 ± 0.30 (IH) versus 1.23 ± 1.47 pre-switch (IH) (P < 0.001). Importantly, TSH levels in PH versus IH habit did not differ post-switch (P = 0.90), but they did pre-switch (P < 0.0001). The proportions of post-switch TSH levels <0.10 mU/L with PH (33.3 %) or with IH (33.3 %) were borderline significantly greater than the corresponding pre-switch levels with PH (10.3 %) (P = 0.088) or with IH (0 %) (P = 0.0096). In the two volunteers, the L-T4 loading test showed that coffee influenced L-T4 pharmacokinetics minimally. Soft gel capsules can be used in patients who are unable/unwilling to change their IH of taking L-T4.

Thyroid cysts treatment with the sclerosing agent Atossiclerol. Long-term (5 to 15 years) follow-up

AIM

The aim of this study was to evaluate the long-term efficacy of the sclerosing agent Atossisclerol in the treatment of benign, ecolucent, thyroid cysts.

METHODS

Two groups of cysts, one between 1 and 3 cm and a group smaller than 0.99 mm in maximum diameter (range 0.6-0.99) were considered in the inclusion plan. The localization of the cysts was at lobar level. A limited quantity of Atossisclerol (0.5 to 2%) was injected.

RESULTS

No side effects were noted. After 5 years in the group treated with the sclerosing agent 93% of the cysts were completely disappeared (vs 60% in controls). However the initial target cyst at 5 and years was completely cured in most patients (>80%) treated with the sclerosing agent; at 10 years more than 90% of the original, sclerosed target cysts were not visible. Another control of most of these patients (53/68) at 15 years indicated that sclerosis of the cyst is safe and allow a better occlusion/obliteration (in almost all patients) of the cyst in comparison with aspiration only (slow recurrence in some 25% of the cysts).

CONCLUSION

The sclerosing agent can be re-injected in the same patients without significant reaction or clinical problems or immunological reactions.

[The use of phytotherapy for treatment of thyroid diseases]

The main tasks during treatment of hyperplastic thyroid diseases--to stop the growth of thyroid nodules; compensation of hypothyrosis; normalization of thyroid size. One of the perspective methods in combine therapy of diffuse and mix goiter is a phytotherapy. The most often for thyroid diseases we have used the plant drug Polentilla alba, which on Ukrainian market was registered as "Alba". Investigation has shown, that phytodrug of Polentilla alba could be recommended for monotherapy and for combine conservative therapy of diffuse and mix benign euthyroid goiter, and also for complex treatment of toxic and hypothyroid goiters.

Serum TSH and risk of papillary thyroid cancer in nodular thyroid disease

CONTEXT

TSH is the main factor involved in the control of proliferation of thyrocytes. Recently, a strong relationship between serum TSH and risk of thyroid malignancy has been reported.

OBJECTIVES

The aim was to review published papers about the relationship between serum TSH and frequency of differentiated thyroid cancer.

EVIDENCE ACQUISITION

PubMed was used to identify studies focused on the relationship between TSH and differentiated thyroid cancer.

EVIDENCE SYNTHESIS

In patients with nodular thyroid disease, the risk of thyroid malignancy increases with serum TSH, and even within normal ranges, higher TSH values are associated with a higher frequency and more advanced stage of thyroid cancer. The likelihood of papillary thyroid carcinoma is reduced when TSH is lower, as in thyroid autonomy, and increased when TSH is higher, as in thyroid autoimmunity. Treatment with l-thyroxine (LT4), which reduces serum TSH, is associated with significantly lower risk of developing clinically detectable thyroid cancer.

CONCLUSIONS

TSH plays a key role in the development of clinically detectable thyroid cancer, and LT4 treatment reduces the risk of thyroid malignancy in patients with nodular thyroid disease. According to the guidelines of the main scientific societies, LT4 therapy is not currently recommended for the treatment of patients with nodular goiter. Even if the available data are not sufficient to advise LT4 treatment in all patients with nodular goiter with the aim of reducing the risk of papillary thyroid carcinoma, we propose that this indication should be reconsidered, taking into account recent evidence reported in the literature.

Severe Graves' ophthalmopathy after percutaneous ethanol injection in a nontoxic thyroid nodule

BACKGROUND

Percutaneous ethanol injection (PEI) is used to treat cystic or mixed benign thyroid nodules. This treatment can result in rare complications, and three cases of Graves' disease (GD) without Graves' ophthalmopathy (GO) have been reported after PEI treatment of toxic thyroid adenomas. Here we present a 55-year-old male patient who developed GD and severe GO after PEI treatment of a mixed cystic-solid, nontoxic thyroid nodule.

PATIENT FINDINGS

Six months after PEI, the nodule volume had decreased from 8.9 to 3.0 mL, but we observed severe hyperthyroidism with elevated serum free triiodothyronine, free thyroxine, and thyrotropin receptor antibody levels. We also observed ophthalmopathy with symmetrical orbit and soft tissue involvement (grade b/c) and a clinical activity score of 4/7. The diagnosis of GO was confirmed by bilateral corneal damage, increased intraocular pressure on upgaze, and inconstant diplopia. A computed tomography scan showed that the inferior, medial, and superior extraocular muscles were bilaterally enlarged, the perineural space at the orbital cone was slightly reduced and the ophthalmic vein was congested.

SUMMARY

A cause-effect relationship between PEI and GD/GO was likely in this patient because of the temporal sequence. Although the mechanism was unknown, we speculated that the thyroid tissue damage caused by PEI released a large amount of antigenic materials from follicular thyroid cells, including thyrotropin receptor protein, which triggered the autoimmune inflammatory response against the thyroid itself and the orbital soft tissues. The patient did not have any risk factors for either GD or GO.

CONCLUSIONS

This observation raises the concern, therefore, that unpredictable and severe complications, such as GD and GO, may occur in a few patients treated with PEI.

Do patients gain weight after thyroidectomy for thyroid cancer?

BACKGROUND

Patients who undergo thyroidectomy often complain of weight gain, which they frequently attribute to inadequate thyroid hormone replacement. To assess the weight changes associated with thyroid hormone replacement or suppressive therapy after thyroidectomy, we measured the weights of patients before and after thyroidectomy and compared them to the weights of euthyroid patients with thyroid nodules who were being followed for many years.

METHODS

The weights and heights of 67 women and 35 men who underwent total thyroidectomy for thyroid cancer were recorded before and for a mean of 8.3 years after thyroidectomy. All patients received either suppressive or replacement doses of levothyroxine. As a comparison group, 70 women and 22 men with goiter or thyroid nodules and were euthyroid had serial measurements of height and weight. They were followed for a mean of 7.6 years. The body mass index (BMI) and age-adjusted BMI percentiles were calculated. The weight, BMI, and BMI percentile changes were compared both unadjusted and adjusted for age, gender, thyrotropin (TSH) level, and duration between measurements.

RESULTS

At baseline, patients with thyroid nodules were older (mean 50.4 years) than those with thyroid cancer (mean 45.8 years). There were no significant differences in baseline weight, BMI, or BMI percentile. The baseline TSH levels were lower for patients with thyroid cancer (mean 0.8 mIU/L) than for those with nodules (mean 1.8 mIU/L) (p=0.002). There were no significant differences between the changes in weight, BMI, or BMI percentile from the start to the completion of the study whether unadjusted or after adjustment for age, gender, TSH, and duration of follow-up.

CONCLUSIONS

Despite the perception of many patients that their thyroidectomy and thyroid hormone replacement or suppressive therapy is responsible for their subsequent weight gain, there were no significant differences in weight gain over time in comparison to a control group of euthyroid patients with thyroid nodules or goiter.

Thyroid diseases in elderly

Thyroid diseases are the commonest endocrine disorders in the general population. In most of the cases, they are consistent with benign conditions which may be asymptomatic or affect people at a variable extent. Since they often represent chronic conditions their prevalence increases by age and reaches in elderly the highest rates. Thyroid nodules are a common clinical finding. Most subjects with thyroid nodules have few or no symptoms. Thyroid nodules are more commonly non-functioning. However, in elderly, toxic multinodular goiter is the most frequent cause of spontaneous hyperthyroidism and often, it emerges insidiously from nontoxic multinodular goiter. Although autoimmune thyroiditis is the most common cause of hypothyroidism in elderly subjects, other causes, such as drugs, neck radiotherapy, thyroidectomy or radioiodine therapy, are frequently observed among these subjects. A small subset of medications including dopamine agonists, glucocorticoids and somatostatin analogs affect thyroid function through suppression of TSH. Other medications that may affect TSH levels are metformin, antiepileptic medications, lithium carbonate and iodine-containing medications. Other drugs can alter T4 absorption, T4 and T3 transport in serum and metabolism of T4 and T3, such as proton-pump inhibitors and antacids, estrogens, mitotane and fluorouracil, phenobarbital and rifampin. Amiodarone administration is associated with thyrotoxicosis or hypothyroidism. Thyroid cancer has similar characteristics in elderly as in general population, however the rate of aggressive forms such as the anaplastic histotype, is higher in older than younger subjects. Diagnosis of thyroid diseases includes a comprehensive medical history and physical examination and appropriate laboratory tests. A correct diagnosis of thyroid diseases in the elderly is crucial for proper treatment, which consists in the removal of medications that may alter thyroid function, in the use of levo-thyroxine in case of hypothyroidism, anti-thyroid drugs in case of hyperthyroidism and use of surgery, radioiodine therapy and percutaneous ablative procedures in selected cases. In conclusion, thyroid diseases in patients older than 60 years deserve attention from different points of view: the prevalence is different from the young adult; symptoms are more nuanced and makes difficult the diagnosis; age and comorbidity often force therapeutic choices and may limit safety and efficacy of therapy. Finally, in elderly patients for whom specific therapy is necessary, more gradual and careful therapeutic approach and close follow-up are recommended in order to minimize the alterations of thyroid function which are induced by many drugs commonly used in clinical practice.

Reduction of thyroid nodule volume by levothyroxine and iodine alone and in combination: a randomized, placebo-controlled trial

CONTEXT

Nodular goiter is common worldwide, but there is still debate over the medical treatment.

OBJECTIVE

The objective of the study was the measurement of the effect of a treatment with (nonsuppressive) T(4), iodine, or a combination of both compared with placebo on volume of thyroid nodules and thyroid.

DESIGN

This was a multicenter, randomized, double-blind trial in patients with nodular goiter in Germany [LISA (Levothyroxin und Iodid in der Strumatherapie Als Mono-oder Kombinationstherapie) trial].

SETTING

The study was conducted in outpatient clinics in university hospitals and regional hospitals and private practices.

PARTICIPANTS

One thousand twenty-four consecutively screened and centrally randomized euthyroid patients aged 18-65 yr with one or more thyroid nodules (minimal diameter 10 mm) participated in the study.

INTERVENTION

Intervention included placebo, iodine (I), T(4), or T(4)+I for 1 yr. T(4) doses were adapted for a TSH target range of 0.2-0.8 mU/liter.

OUTCOME MEASURES

The primary end point was percent volume reduction of all nodules measured by ultrasound, and the main secondary end point was a change in goiter volume.

RESULTS

Nodule volume reductions were -17.3% [95% confidence interval (CI) -24.8/-9.0%, P < 0.001] in the T(4)+I group, -7.3% (95% CI -15.0/+1.2%, P = 0.201) in the T(4) group, and -4.0% (95% CI -11.4/+4.2%, P = 0.328) in the I group as compared with placebo. In direct comparison, the T(4)+I therapy was significantly superior to T(4) (P = 0.018) or I (P = 0.003). Thyroid volume reductions were -7.9% (95% CI -11.8/-3.9%, P < 0.001), -5.2% (95% CI -8.7/-1.6%, P = 0.024) and -2.5% (95% CI -6.2/+1.4%, P = 0.207), respectively. The T(4)+I therapy was significantly superior to I (P = 0.034) but not to T(4) (P = 0.190).

CONCLUSION

In a region with a sufficient iodine supply, a 1-yr therapy with a combination of I and T(4) with incomplete suppression of thyrotropin reduced thyroid nodule volume further than either component alone or placebo.

Changes associated with percutaneous ethanol injection in the treatment of thyroid nodules

Percutaneous ethanol injection (PEI) is an alternative therapy for thyroid nodules (TN). However, some concern is raised on its carcinogenic effects. To evaluate the cytological and clinical changes caused by PEI in patients with benign TN. Thirty-nine patients with TN (23.1% hyperfunctioning) were submitted to a median of three PEI sessions. After a median of 17 months, patients were reassessed. A new ultrasound-guided fine needle biopsy (US-FNB) was performed, and the smears were analyzed after May-Grünwald-Giemsa staining. The diagnostic findings and the cellular characteristics were compared before and after treatment. There was an increase in the proportion of nondiagnostic/unsatisfactory results (from 2.5% to 18.9%). No malignant cases were observed. The proportion of moderate/intense macrophage infiltration decreased from 60% to 15%. Before treatment, 23.1% patients had hyperthyroidism, which was completely or partially resolved in 66.7%. By ultrasound, the percentage of homogeneous nodules decreased from 64.0% to 38.4% (p=0.0235), and the mean nodule volume decreased from 13.4 ± 12.2 to 5.3 ± 5.1 cm(3). We demonstrate that PEI increases the proportion of nondiagnostic/unsatisfactory results from US-FNB. Therefore, cytological findings after PEI must be evaluated with caution. Our results also suggest that PEI is an efficacious and safe therapeutic option, with no carcinogenic effects observed on cytological evaluations. Safety and efficacy must be evaluated in larger studies with longer follow-up periods.

Effect of levothyroxine suppression therapy on plasma thrombin activatable fibrinolysis inhibitor antigen levels in benign thyroid nodules

OBJECTIVE

The aim of this prospective study was to investigate the effect of LT4 suppression therapy on plasma thrombin activatable fibrinolysis inhibitor (TAFI) antigen and plasminogen activator inhibitor-1 (PAI-1) levels in benign thyroid nodules. We also compared hyperthyroid patients and healthy controls.

SUBJECTS AND METHODS

Twenty premenopausal women with benign thyroid nodules were given LT4 suppression therapy for 1 year. Plasma TAFI and PAI-1 antigen levels were measured at baseline and after LT4 suppression treatment. The endogenous hyperthyroid group was composed of 19 premenopausal females with newly diagnosed endogenous hyperthyroidism. Eighteen age-matched euthyroid healthy premenopausal women were enrolled as the control group.

RESULTS

TAFI antigen levels decreased after LT4 suppression treatment; however, the difference was not statistically significant (p = 0.057). LT4 treatment resulted in a nonsignificant increase in PAI-1 levels. Patients with endogenous hyperthyroidism had decreased levels of TAFI antigen and increased levels of PAI-1 antigen (p < 0.05). There was a negative correlation between the FT(4) and TAFI antigen levels. Serum TSH was positively correlated with the plasma levels of TAFI antigen.

CONCLUSION

LT4 suppression therapy for benign thyroid nodules did not result in a significant decrease in TAFI antigen levels in premenopausal women, but endogenous hyperthyroidism was associated with significantly decreased levels of TAFI antigen.

Burkitt-like lymphoma infiltrating a hyperfunctioning thyroid adenoma and presenting as a hot nodule

BACKGROUND

Most solitary hyperfunctiong regions on thyroid scan consist of benign tissue. Here we report a patient with a Burkitt-like lymphoma that was infilterated into a region containing a hyperfunctioning nodule.

SUMMARY

A 56-year-old man was referred to our Endocrine Unit in May 2009 due to the incidental discovery of a large left thyroid lobe nodule by a computed tomography study. This had been performed to search for a primitive tumor in a patient with bone metastasis. He was clinically and biochemically thyrotoxic with no evidence of humoral thyroid autoimmunity. The nodule had a dyshomogenous appearance at neck ultrasonography, with multiple hypoechogenic areas and calcifications. (99m)-Technetium thyroid scintiscan revealed a hot nodule with suppression of the contralateral lobe. Fine-needle aspiration cytology indicated the presence of neoplastic cells not of thyroid origin. Remission of hyperthyroidism was obtained with methimazole, and the patient was submitted to left lobe thyroidectomy and istmectomy. Histological analysis of the surgical specimen led to a diagnosis of Burkitt-like large B-cell lymphoma harbored within a thyroid adenoma. After further staging, the final diagnosis was stage IV E Burkitt-like lymphoma with the involvement of the bone and the thyroid. This is the first description of an aggressive Burkitt-like lymphoma that infiltrated an hyperfunctioning thyroid adenoma, thus presenting as a hot nodule at thyroid scintiscan. In our patient there was no humoral or histological evidence of thyroid autoimmunity, thus suggesting a metastatic seeding of the lymphoma within the hyperfunctioning thyroid nodule.

CONCLUSIONS

Involvement of the thyroid gland by Burkitt-like lymphoma is extremely rare as is close localization of malignancy and a hyperfunctioning thyroid nodule. As highlighted by the present report, performing fine-needle aspiration cytology should be always considered in the clinical context of a metastatic disease of unknown origin or when there are ultrasonography signs suggesting malignancy, even when the nodule is hyperfunctioning.

Drosophila as a novel therapeutic discovery tool for thyroid cancer

BACKGROUND

Multiple endocrine neoplasia type II (MEN2) is a rare but aggressive cancer for which no effective treatment currently exists. A Drosophila model was developed to identify novel genetic modifier loci of oncogenic RET, as well as to provide a whole animal system to rapidly identify compounds that suppressed RET-dependent MEN2. ZD6474 (Vandetanib), currently in phase III trials, suppressed tumorigenesis in MEN2 model flies, demonstrating for the first time the effectiveness of a Drosophila-based whole animal model for identifying therapeutically useful compounds.

SUMMARY

Clinical data suggest that drug mono-therapy for MEN2 and other cancers typically yield only moderate benefits as patients develop drug resistance and suffer from drug-induced pathway feedback. Combinations of drugs that target different nodes of the oncogenic pathway are an effective way to prevent resistance as well as feedback. Identifying the optimal drug-dose combinations for therapy poses a significant challenge in existing mouse models. Fly models offer a means to quickly and effectively identify drug combinations that are well tolerated and potently suppress the MEN2 phenotype. This approach may also identify differences in therapeutic responses between the two subtypes of MEN2--MEN2A and MEN2B--providing additional therapeutic insights.

CONCLUSIONS

Fly models have proven useful for identifying known drugs as well as novel compounds that, as single agents or in combinations, effectively suppress the MEN2 syndrome. These findings validate the use of fly models for both drug discovery as well as identification of useful drug combinations. In the future, rapid pairing of new genomic information with increasingly complex fly models will aid us in efforts to further tailor drug treatments toward personalized medicine.

TSH suppressive therapy: an overview of long-term clinical consequences

An overview of long-term clinical consequences of TSH suppressive therapy provides evidence that serum TSH levels should be maintained at levels <0.1 mU/l in high-risk (stage III and IV) patients, whereas lower-risk patients should be allowed to have their TSH levels rise into the normal range after residual disease has been ruled out by imaging and/or stimulated thyroglobulin measurement. The proper management of patients with known residual thyroid cancer, who are also elderly or who have underlying serious comorbidities (e.g., osteoporosis, cardiovascular disease, diabetes), is uncertain and requires a high degree of clinical experience and judgment.

[Medullary thyroid cancer, a tumour with many appearances]

Medullary thyroid cancer (MTC) has a variable clinical presentation. We present 3 patients with this endocrine tumour. The first patient, a 41-year-old woman complaining of diarrhoea, a painful abdomen, weight loss and sensibility disorders in both legs, had metastases of MTC in the spine, with little progression during 2 years of follow-up. The second patient, a 64-year-old woman suffering from a painful nodule in the neck and a painful shoulder, was diagnosed with MTC and liver, lung and bone metastases. She died after 14 months due to progressive disease. The third patient, an 81-year-old woman with hyperparathyroidism, was coincidentally diagnosed with MTC after goitre surgery at the age of 67. When she was evaluated for rising calcitonin levels, a pheochromocytoma was found. RET mutation analysis confirmed a MEN2A syndrome. Current diagnostic procedures of MTC may include positron emission tomography with 18F-deoxyglucose (FDG-PET) and 18F-diphenylalanine (DOPA-PET). MTC is usually treated surgically. Tyrosine kinase inhibitors appear to offer potential new therapeutic possibilities.

Levothyroxine (LT4) suppression treatment for benign thyroid nodules alters coagulation

OBJECTIVE

Endogenous hyperthyroidism is associated with altered coagulation. The aim of the present study is to investigate the effect of levothyroxine (LT(4)) suppression treatment for benign thyroid nodules on coagulation system.

DESIGN

Prospective case-control study. Patients Thirty consecutive euthyroid pre-menopausal women with nodular goitre disease and 28 healthy controls were included in the study.

MEASUREMENTS

Plasma fibrinogen, d-dimer, von Willebrand factor (vWF), tissue factor (TF), tissue plasminogen activator (tPA), plasminogen activator inhibitor (PAI-1) and tissue factor pathway inhibitor (TFPI) levels were measured at baseline and after LT(4) suppression therapy.

RESULTS

Plasma levels of fibrinogen, d-dimer, vWF, TF and PAI-1 increased significantly after treatment with LT(4) for 1 year. Serum FT(4) was a significant predictor of increased fibrinogen, vWF and PAI-1 levels, when the data was controlled for age and BMI.

CONCLUSIONS

Our results suggest that LT(4) suppression therapy for benign thyroid nodules is associated with enhanced coagulation.

Cold benign thyroid nodule volume reduction predictability after percutaneous ethanol injection

OBJECTIVE

To determine the effect of percutaneous ethanol injection (PEI), a suppressive therapy for cold benign thyroid nodules (CBNs), on cytology.

STUDY DESIGN

The study group consisted of 31 CBNs, treated with PEI for 1 year, aspirated before and while the patients were on suppressive therapy. A control group consisting of 22 patients, whose nodule characteristic, PEI treatment and follow-up were similar to those of the study patients group, was monitored to confirm the results. By analogy with a similar study, the following factors were considered: an initial volume of the CBNs > 25 mL, abundant colloid, degree of cellular hyperplasia and presence ofdegenerative changes. To verify these hypotheses, we tested the differences using the t test for the initial volume and the Mann-Whitney U test for the remaining features.

RESULTS

The study has proved the unpredictability of the volume reduction in a single nodule on the basis of cytologic evaluation.

CONCLUSION

The lack of cytologic features that can be considered statistically predictive of large nodule reduction as a result of PEI treatment confirms that fine needle aspiration cytology may help establish the correct diagnosis.

[The effect of levothyroxine suppression therapy for benign thyroid nodules on bone metabolism in premenopausal women]

OBJECTIVES

This prospective study was designed to investigate the effect of levothyroxine suppression therapy for benign thyroid nodules on markers of bone turnover in premenopausal women.

PATIENTS AND METHODS

The study included 28 premenopausal women who received levothyroxine suppression therapy for benign thyroid nodules for one year. The size of the thyroid gland and nodules, biochemical markers of bone turnover and urinary calcium excretion were measured before and after levothyroxine suppression therapy.

RESULTS

No significant adverse effects were seen during levothyroxine treatment. Decreases in total thyroid volume and the size of the nodules were not significant at the end of treatment. Although levothyroxine suppression therapy did not result in changes in serum levels of calcium and phosphor, and urinary calcium excretion, bone turnover markers, namely serum osteocalcin and urinary deoxypyridinoline levels, increased significantly. Serum intact parathyroid hormone levels showed a minimal decrease, which was not statistically significant.

CONCLUSION

Data from our study suggest that levothyroxine suppression therapy is associated with increased osteoblastic and osteoclastic activity in premenopausal women with benign thyroid nodules.

Reduced thyroid volume and nodularity in dyslipidaemic patients on statin treatment

BACKGROUND

Little information is available concerning the possible antiproliferative effects of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) on the thyroid gland. We have hypothesized that the antiproliferative effects of statins observed in thyroid cell lines in vitro may have a clinical counterpart that could be detected by investigating the prevalence and size of thyroid nodules in patients on long-term treatment with statins.

METHODS

We retrospectively evaluated 135 dyslipidaemic patients receiving statin therapy continuously for at least 5 years, and 137 controls. All the subjects were submitted to ultrasound investigation of the thyroid gland, to establish prevalence, number and volume of thyroid nodules.

RESULTS

Subjects treated with statins showed markedly lower prevalence of thyroid nodules (36.3%vs. 67.9%, P < 0.001), as well as reduced number and smaller total volume of lesions, as compared to the control group. A logistic regression analysis, taking into account age, sex, risk factors for the development of thyroid nodules and concomitant drug treatment, revealed that treatment with statins remained the only important predictor of the presence of thyroid nodules [odds ratio (OR) 0.312, 95% confidence interval (CI) 0.156-0.625, P < 0.001] besides risk factors.

CONCLUSIONS

Our data provide the first circumstantial evidence of an association between HMG-CoA reductase inhibitor treatment and reduced prevalence, number and volume of thyroid nodules. This finding may be explained by an antiproliferative and/or pro-apoptotic effect of long-term statin treatment on thyroid cells, in vivo.

Thyroxine therapy in euthyroid patients does not affect body composition or muscular function

OBJECTIVE

The main objective of the study was to evaluate the effects of small increments in thyroxine (T4) levels following levothyroxine (L-T4) administration on the body composition of women patients. The secondary objective was to assess the effect of the therapy on energy expenditure and muscular function.

METHODS

The prospective, randomized study consisted of a 12-month follow-up of 37 women with thyroid nodules. The patients were divided into two groups for comparison, one treated with L-T4 (20 women) and the other untreated (17 women). L-T4 dose was individually adjusted to obtain a serum thyroid-stimulating hormone in the lower portion of the normal range. Multiple tests, including bioelectrical impedance analysis, dual-energy X-ray absorptiometry, air displacement plethysmography, measurement of waist circumference, and skinfold anthropometry, were used to investigate the muscular, fat, and water compartments; energy expenditure and muscular function were assessed by cycle ergometry.

RESULTS

There were no significant differences in body composition, heart rate, energy metabolism, or muscular function between the group of women treated with L-T4 and the untreated group.

CONCLUSION

The controlled increase of circulating T4 does not appear to modify the body composition or muscular function in women patients.

Thyroid nodules: clinical importance, assessment, and treatment

In the general population, thyroid nodules are found in 5% by palpation and in 50% by ultrasonography (US). Initial evaluation of nodules should include serum thyroid-stimulating hormone measurement, fine-needle aspiration (FNA) biopsy, and US. Thyroid micronodules are being detected with increasing frequency and are currently evaluated by US-FNA. Routine measurement of serum calcitonin and thyroglobulin and FNA rebiopsy are not recommended. Cytologically benign thyroid nodules should be followed rather than treated. Novel treatment options including iodine 131, percutaneous ethanol injection, and percutaneous laser thermal ablation have specific indications, advantages, and adverse effects.

Feasibility, Accuracy, and Clinical Relevance of a Rapid Thyroid Evaluation During Carotid Duplex Ultrasonography in Hypertensive Patients

Carotid ultrasonography can detect thyroid nodules without increasing examination duration. The authors analyzed whether management is influenced by reporting such findings during routine carotid ultrasonography in hypertensive patients vs waiting for 6 months to repeat them. This is a population-based study of 1216 hypertensive patients. During carotid ultrasonography, nodule cystic/solid characteristics and size of thyroid changes were recorded. Patients with nodules were divided into those with nodules reported at the moment of diagnosis (group A) and those reported 6 months after diagnosis (group B). The authors monitored patients who underwent thyroid treatment 12 months after carotid ultrasonography. A total of 255 participants had thyroid nodules detected on screening and 99 patients started therapy after discovery. Six months later, as expected, there were more patients undergoing thyroid treatment in the group with nodules reported at time of diagnosis. This difference between groups was not significant, however, 6 months after reporting the nodules, in group B, because the number of patients on therapy significantly increased. Thyroid nodules cannot be ignored during carotid ultrasonography, and reporting their presence is valuable to general practitioners. Thyroid screening during carotid ultrasonography is cost-effective, rapid, sensitive, and specific and may affect the patient's diagnostic and therapeutic management.

Nonsurgical approaches to the management of thyroid nodules

Epidemiologic studies have documented substantial increases in the frequency of nodular thyroid disease. This trend is largely due to the increasing detection of nodules by the routine use of sonography in clinical practice. Only a small percentage of the nodules currently being detected will prove to be malignant. The probability of malignancy is similar in nonpalpable and palpable nodules. Fine-needle aspiration cytology has a central role in identifying malignant nodules, which are generally treated with surgery. Most thyroid nodules are cytologically benign and can be managed nonsurgically. Nodules that are completely asymptomatic require follow-up without treatment. Cosmetic problems and/or compression-related symptoms may be indications for surgery. When surgery is contraindicated or refused, several nonsurgical approaches are available. These include levothyroxine therapy, radioiodine treatment, percutaneous ethanol injections, and the new technique of laser photocoagulation. Levothyroxine therapy is the most widely used approach, but its clinical efficacy and safety are controversial. Levothyroxine might, nonetheless, be appropriate in selected cases characterized by low risk for adverse effects and nodule characteristics associated with response to this type of therapy. Radioiodine is the therapy of choice for toxic nodules or for symptomatic nodular goiters when surgery is not possible. Percutaneous ethanol injection should be used, in our opinion, as the first-line therapy only for recurrent symptomatic cystic nodules. Laser therapy should be reserved for selected patients treated in experienced centers only. With these options, clinicians can personalize the management of nodular thyroid disease according to a careful cost-benefit analysis.

Thyroid nodule: A potentially malignant lesion; optimal management from a surgical perspective

Thyroid nodules are very common lesions, frequently detected by modern imaging methods (mainly ultrasonography). Despite that most thyroid nodules represent benign lesions, a small but significant percentage of them are malignant. Surgery is indicated when there is underlying malignancy (or suspicion for), pressure symptoms, or for cosmetic reasons. Total/near total thyroidectomy is the most radical procedure, which achieves cure, avoids the possibility of reoperation in the future (completion thyroidectomy), and facilitates postoperative management of the patient with underlying malignancy. Simple observation and thyroid hormone suppressive therapy are acceptable management options for patients with presumably benign thyroid nodules. Radioiodine therapy may be used for the management of patients with hyperfunctioning ("hot") thyroid nodules. Ablation of thyroid nodules (sclerosing therapy [alcohol injection] and laser photocoagulation) have been used for the in situ destruction of thyroid nodules; ablation therapy is currently viewed as experimental therapeutic method. Careful evaluation is required in order to avoid both overtreatment (mainly unnecessary surgery) as well as undertreatment of these potentially malignant, but highly curable lesions.

Efeito da injeção percutânea de etanol na redução de nódulos tireoideanos

Para verificar a eficácia da injeção percutânea de etanol (IPE) no tratamento de nódulos tireoideanos (NT) comparou-se o volume de 86 nódulos (77 pacientes), antes e após uma ou duas sessões de alcoolização. As medianas do volume inicial e final foram respectivamente: 3,5 mL (0,3 a 82,7) e 1,8 mL (0 a 29,4). Sete por cento dos nódulos desapareceram e a média de redução volumétrica foi de 52,6% ± 31,1 (p< 0,0001). Os diferentes padrões ultra-sonográficos responderam distintamente ao tratamento, com as seguintes medianas de redução: 37,3% (variando de -39,0 a 82,6) nos NT sólidos; 53,5% (14,6 a 88,0) nos predominantemente sólidos; 58,0% (21,0 a 64,5) nos mistos; 71,0% (18,8 a 100,0) nos predominantemente císticos e 90,9% (45,9 a 100,0) nos císticos. Adicionalmente, buscou-se comparar a variação do maior diâmetro dos NT, inicialmente sem tratamento, e após a alcoolização, cuja diferença foi estatisticamente significante (p< 0,00001). A complicação mais freqüente foi dor moderada, em 27,6% dos casos. Concluímos que a IPE mostrou ser uma forma de tratamento segura e eficaz no tratamento de NT benignos.