Efficient evaluation of thyroid nodules by primary care providers and thyroid specialists

OBJECTIVE

To determine whether primary care providers and thyroid specialists at Gundersen Lutheran Medical Center are evaluating thyroid nodules efficiently by following recently published clinical guidelines.

STUDY DESIGN

One-year retrospective chart review.

PATIENTS AND METHODS

We reviewed patient records from 1996 and tabulated the use of fine-needle aspiration cytology, radionuclide scanning, and thyroid ultrasonography by 49 primary care physicians evaluating 81 thyroid nodules and by 5 thyroid specialists evaluating 29 thyroid nodules. The results were compared with our previous findings and those recently reported by others.

RESULTS

Fine-needle aspiration cytology was widely used by both groups of Gundersen Lutheran healthcare providers. Primary care physicians used imaging studies modestly and generated $106 per patient in unnecessary costs. Thyroid specialists occasionally used radionuclide scanning but did not use thyroid ultrasonography; they generated $41 per patient in unnecessary costs. Overall, the introduction of fine-needle aspiration cytology at our institution has reduced the use of radionuclide scanning from 90% to 12% and the use of thyroid ultrasonography from 30% to 10%. We also found that the frequency of surgery in patients with thyroid nodules fell substantially, yet detection of thyroid cancer in the operative specimens increased from 16% to 43% while the cost of removing a thyroid carcinoma decreased from $64,000 to $25,000.

CONCLUSIONS

Fine-needle aspiration cytology, adopted as the initial test for diagnosing thyroid nodules by most of our healthcare providers, has reduced the use of imaging studies far below the frequency reported by others and has substantially decreased the cost of thyroid nodule management.

The rapid low-dose (1 microgram) cosyntropin test in the immediate postoperative period: results in elderly subjects after major abdominal surgery

BACKGROUND

Recently the rapid low-dose (1 microgram) cosyntropin test has been found to be superior to the standard (250 micrograms) rapid cosyntropin test for evaluating the hypothalamic-pituitary-adrenal axis. Because the 1-microgram test has not been studied in postoperative patients, we evaluated the test after major abdominal surgery.

METHODS

We performed rapid 1-microgram cosyntropin tests in 20 patients aged 65 years or older immediately and 24 hours after uncomplicated elective abdominal surgery (group A) and in 10 patients who were suspected of having adrenal insufficiency after abdominal surgery (group B). Subsequently, 250 micrograms of cosyntropin was infused over 8 hours on 2 successive days in group B patients.

RESULTS

Ninety-five percent of group A patients had normal rapid 1-microgram cosyntropin test results immediately after surgery and 90% had normal test results 24 hours postoperatively. Six group B patients had abnormal rapid 1-microgram cosyntropin test results. Additional testing indicated primary adrenal insufficiency in 2 patients and central adrenal insufficiency in 1 patient; another patient probably had primary adrenal insufficiency and 2 patients appeared to be euadrenal. Four group B patients had normal rapid 1-microgram cosyntropin test results. After additional testing, 3 of these patients appeared to have normal adrenal function; 1 probably had primary adrenal insufficiency.

CONCLUSION

The rapid 1-microgram cosyntropin test accurately evaluated adrenal gland function in selected patients after uncomplicated surgery. The test, however, was difficult to interpret in unselected seriously ill postoperative patients. Therefore we recommend that postoperative patients with unexplained hypotension or other features suggestive of adrenal insufficiency who have random plasma cortisol levels less than 20 micrograms/dL be treated with glucocorticoids and the hypothalamic-pituitary-adrenal axis be studied by standard tests after recovery.

Treatment of established postmenopausal osteoporosis with raloxifene: a randomized trial

Raloxifene is a selective estrogen receptor modulator that in experimental animals acts as an estrogen receptor antagonist in breast and endometrium but as an estrogen receptor agonist in the skeletal and cardiovascular systems. We conducted a 1-year prospective, randomized, double-blind trial in 143 postmenopausal osteoporotic women (mean +/- SD age, 68.4+/-5.0 years) with at least one prevalent vertebral fractures and low bone mineral density (BMD), comparing groups receiving raloxifene at 60 mg/day (RLX60) or 120 mg/day (RLX120) and a control group receiving supplements of 750 mg/day of calcium and 400 IU/day of vitamin D. There were no differences among groups in the occurrence of uterine bleeding, thrombophlebitis, breast abnormalities, or increased endometrial thickness (assessed by ultrasonography). As compared with controls, the changes in values over 1 year for RLX60 and RLX120, respectively, were significant for serum bone alkaline phosphatase (-14.9%, -8.87%), serum osteocalcin (-20.7%, -17.0%), and urinary C-telopeptide fragment of type I collagen/creatinine (-24.9%, -30.8%), markers of bone turnover; for serum total cholesterol (-7.0% for RLX60) and low density lipoprotein cholesterol (LDL) (-11.4% for RLX60) and for the LDL/HDL cholesterol ratio (-13.2%, -8.3%). BMD increased significantly in the total hip (1.66% for RLX60) and ultradistal radius (2.92%, 2.50%). There were nonsignificant trends toward increases over controls in BMD for lumbar spine, total body, and total hip (for RLX120). Using a >15% cutoff definition, raloxifene had no effect on incident fractures, but using a >30% cutoff, there was a dose-related reduction (p = 0.047). We conclude that raloxifene therapy is well tolerated, reduces serum lipids, and does not stimulate the uterus or breasts. It has beneficial effects on bone, although, under the conditions of this study, these appear to be of a smaller magnitude than have been reported with estrogen therapy.

Management of thyroid cancer of follicular cell origin: Gundersen/Lutheran Medical Center, 1969-1995

BACKGROUND

Most reports regarding the treatment of thyroid cancer originate from university referral centers. In this article, we report our experience in managing thyroid cancer of follicular cell origin at a non-university institution over a 26-year period.

STUDY DESIGN

We reviewed the medical records of all patients treated for thyroid cancer at the Gundersen/Lutheran Medical Center from 1969 to 1995. Histologic types, demographic and clinical characteristics, laboratory results, treatment, complications, and followup observations were tabulated. Risk was assigned according to the age, presence of distant metastasis, extent of the primary tumor, and site of the primary tumor (AMES) staging system.

RESULTS

The histologic classification was as follows: papillary, 139; follicular, 24; Hürthle cell, 14; and anaplastic, 11. Low-risk lesions were identified in 96%, 79%, and 71% of the patients with papillary, follicular, and Hürthle cell (collectively designated differentiated) carcinoma, respectively. We treated 60% of our patients with differentiated thyroid cancer with near-total or total thyroidectomy. Clinically involved cervical lymph nodes were removed singly or by modified neck dissection. We frequently ablated thyroid remnants after operation with 29.9 mCi (1,110 MBq) of 131I, after which we treated the patient with suppressive doses of levothyroxine. Patients were evaluated yearly with thyroglobulin measurements and, in some high-risk patients, with total-body 131I scans. Cancer recurred in 13%, 8%, and 7% of our patients with papillary, follicular, and Hürthle cell carcinoma, respectively. Only three patients died of differentiated thyroid cancer; eight are alive with malignancy. In anaplastic thyroid cancer, cervical lymph node metastases, local invasion, and distant metastases were present in 18%, 64%, and 45% of patients at the time of initial evaluation. Total or near-total thyroidectomy was possible in only four of nine patients treated surgically. External radiation (11 patients) and chemotherapy (two patients) were used. Additional metastases developed in 45% of the patients, and nine patients died within a year. Permanent hypoparathyroidism or hoarseness complicated 2.7% of the thyroid operations.

CONCLUSIONS

Although our followup was relatively short, the results of treating thyroid cancer by general surgeons at a nonuniversity hospital compare favorably with results obtained from university referral centers.

Diffuse Sclerosing Variant of Papillary Thyroid Carcinoma: Case Report and Review of the Literature

OBJECTIVE

To describe a patient with a diffuse sclerosing variant of papillary (DSVP) thyroid cancer and to summarize the reported clinical manifestations and treatment of other patients with this malignant tumor.

METHODS

We reviewed the pathologic findings in a 14-year-old girl, who had survived for 19 years after treatment of a presumed undifferentiated thyroid cancer. When reassessment revealed histologic features of DSVP cancer, we reviewed the case reports of this type of malignant lesion identified from a MEDLINE search of articles published between 1985 and 1995.

RESULTS

Review of the pathologic features showed a diffuse tumor in the thyroid gland without an identifiable mass and extensive bilateral lymph node metastatic lesions. Histologic examination disclosed pronounced fibrosis, numerous psammoma bodies, primarily a solid growth pattern, lymphocytic infiltration, and extensive invasion of lymphatic spaces. The nuclear features were characteristic of papillary carcinoma. Review of 63 cases of DSVP cancer indicated that this variant accounted for 0.2 to 5.7% of papillary cancer, affected primarily young women, and usually manifested with diffuse involvement of one or both thyroid lobes. Thyroid antibodies were frequently detected in the serum. Cervical lymph node metastatic lesions, local invasion, and distant metastatic involvement were described in 75, 35, and 16% of patients, respectively. Although the cancer recurred in 37% of patients, only two died of this malignant tumor.

CONCLUSION

DSVP cancer can be confused with nontoxic goiter, chronic thyroiditis, nonthyroidal malignant tumors, or undifferentiated thyroid cancer. We suggest that the same therapy used for young patients with conventional papillary thyroid cancer is also appropriate for most patients with the diffuse sclerosing variant.

A quality improvement project to increase the use of postmenopausal hormonal replacement therapy (HRT)

Many medical institutions are initiating quality improvement and disease prevention programs. In this paper, we report the results of a program designed to increase the rate of hormonal replacement therapy (HRT) in a postmenopausal population. After initially assessing the rate of HRT use, we instituted an educational program directed at both physicians and patients. Reassessment two years later indicated the rate of HRT had increased from 31% to 48.4%. Further educational efforts were followed by a reassessment three years later that showed a further improvement in prescription rate to 64%. We conclude that our educational program directed at physicians and patients dramatically increased the rate of HRT prescription of postmenopausal women.

Serum parathyroid hormone-related protein levels during lactation

We measured parathyroid hormone-related protein (PTHrP) in the serum of 15 healthy women within three days of beginning breast-feeding and within one hour of completing nursing. A sensitive immunoradiometric assay that measures N-terminal PTHrP containing at least the first 74 amino acids was used. We found normal PTHrP values in all patients. Values one day before and two days after delivery in a hypoparathyroid woman who chose not to breast-feed were also normal. Since N-terminal PTHrP fragments of 1-36 amino acids or more are biologically active, we believe additional studies using sensitive PTHrP assays that measure smaller fragments and investigations performed under other conditions of breast-feeding are necessary before concluding that PTHrP does not have a role in calcium homeostasis in nursing mothers. Furthermore, additional studies in hypoparathyroid nursing mothers should be performed.

A simplified method for treating Graves' disease with radioactive 131I

We reviewed the medical records of 53 patients treated in 1986 for Graves' disease with moderate doses of 131I. The cumulative incidence of hypothyroidism at 3 and 12 months after therapy was 38 and 80%, respectively. The hyperthyroidism, however, was rapidly cured and only 4(7.5%) patients required a second dose of 131I. In a separate study of 21 patients with Graves' disease, we determined that the 4-hour 123I uptake measurement was as reliable as the standard 24-hour test for supporting the diagnosis of hyperthyroidism. We also demonstrated that the 4-hour uptake accurately predicted the 24-hour uptake. Based on these findings and a review of the literature, we believe that either a 4 or 24-hour 123I uptake study followed by the administration of a fixed dose of 131I (10 or 15 mCi) provides a convenient and cost-effective method for treating Graves' disease.

Postoperative acute adrenal failure caused by transient corticotropin deficiency

BACKGROUND

Acute adrenal insufficiency after a surgical procedure or trauma is rarely reported. In recent years, however, we have treated seven patients with acute primary adrenal insufficiency and three patients with secondary adrenal insufficiency who presented with shock after a surgical procedure or trauma. The standard cosyntropin test was misleading for the diagnosis of corticotropin deficiency.

METHODS

In this study we measured serum cortisol in patients older than 65 years who had unexplained hypotension after an abdominal surgical procedure. If the serum cortisol was less than 15 micrograms/dl, we performed 1 microgram and standard (250 micrograms) cosyntropin tests and measured thyroxine, thyrotropin, leutinizing hormone in all patients, and free testosterone in men.

RESULTS

We identified five (5%) of 105 patients after an operation who displayed evidence of corticotropin deficiency (i.e., serum cortisol < 15 micrograms/dl during hypotension, prompt hemodynamic improvement with glucocorticoid therapy, and normal response to standard dose cosyntropin). In these patients 1 microgram cosyntropin produced abnormal peak cortisol levels. These patients also had thyrotropin or leutinizing hormone deficiency. After recovery the low hormone levels improved or became normal.

CONCLUSIONS

Postoperative adrenal insufficiency, particularly that caused by transient corticotropin deficiency, is more common in patients than currently recognized. The 1 microgram cosyntropin test may be more sensitive than the standard test for identifying secondary adrenal insufficiency.

Subclinical hormone secretion by incidentally discovered adrenal masses

OBJECTIVE

To determine the frequency of subclinical hormone secretion in incidentally discovered adrenal masses.

DESIGN

We reviewed the radiologic reports of 1779 consecutive computed tomographic scans of the chest, abdomen, and pelvis.

SETTING

Regional referral medical center.

PATIENTS

Eighty-nine patients with abnormalities of one or both adrenal glands were identified. Patients with nonadrenal gland malignant neoplasms, primary aldosteronism, adrenal hemorrhage, and death or severe illness were not investigated. The final study group consisted of 26 patients with incidentally discovered adrenal masses.

MAIN OUTCOME MEASURES

Aldosterone secretion was assessed by measuring plasma renin activity and the plasma aldosterone concentration in patients with unexplained hypokalemia. We evaluated cortisol secretion by performing a 1-mg overnight dexamethasone suppression test and by measuring the corticotropin concentration at 8 AM by a sensitive method. In patients with low corticotropin values, we also measured the 24-hour urinary excretion of free cortisol and 17-ketosteroids and assessed diurnal variation by measuring plasma cortisol concentrations at 8 AM and 4 PM. Adrenal medullary function was studied by measuring urinary free catecholamines.

RESULTS

One patient had unrecognized primary aldosteronism, two patients had elevated free catecholamine excretion, and three patients (12%) had subclinical Cushing's syndrome.

CONCLUSION

Based on our observations and a review of the literature, we conclude that subclinical hormone secretion, especially cortisol secretion, is more common in patients with incidentally discovered adrenal masses than previously appreciated. Surgeons and anesthesiologists must be alert to the possibility that adrenal insufficiency or a hypertensive crisis may develop in the perioperative period in patients with incidentally discovered adrenal masses.

Hürthle cell neoplasms of the thyroid gland: reassessment of functional capacity

We treated a hyperthyroid man and a euthyroid woman who had autonomously functioning Hürthle cell adenomas and demonstrated uptake of radioactive 131I in a woman with recurrent Hürthle cell carcinoma. Since these tumors are thought to be inactive, we reassessed the functional capacity of Hürthle cell neoplasms by reviewing the medical records of all patients operated upon for these tumors at our medical center from 1950 through November, 1993. We also reviewed series of Hürthle cell neoplasms identified from a MEDLINE search of papers published from 1960 to November, 1993. We identified 92 patients with Hürthle cell neoplasms. Thyroid scintigraphy was performed in 28 of 72 patients with benign adenomas and six of 20 patients with Hürthle cell carcinomas. In addition to the two index cases, four euthyroid patients had hot nodules that partially suppressed the extranodular tissue; seven patients had warm nodules. Thyroid scans performed in patients with Hürthle cell carcinomas revealed five cold nodules and one warm nodule. Our index patient with carcinoma displayed elevated serum thyroglobulin levels when the cancer recurred. This patient and another had uptake of 131I by recurrent or metastatic cancer that allowed for treatment with this nuclide. Of 539 patients identified in a literature survey, 489 had benign Hürthle cell adenomas and 50 had Hürthle cell carcinoma. Thyroid scans performed in 282 patients revealed 247 cold nodules, 20 warm nodules, and 8 hot nodules. Our results, added to those published in case series of Hürthle cell neoplasms, indicated that 4.4% of thyroid scans were hot and 8.9% were warm.(ABSTRACT TRUNCATED AT 250 WORDS)

Reduced calcitriol requirements for treating hypoparathyroidism during lactation. A case report

We reduced the dose of calcitriol from 0.75 to 0.25 microgram/d to maintain low normal serum calcium levels in a hypoparathyroid woman during lactation. Calcitriol requirements quickly returned to 0.75 microgram/d when she discontinued breast-feeding. In her previous pregnancy, failure to reduce the dose of calcitriol resulted in serious hypercalcemia 11 days after she began breast-feeding. The changing requirement for calcitriol in our patient related directly to the falling level of estradiol. Although the cause or causes of diminished calcitriol requirements in hypoparathyroid women during lactation remains unclear, increased bone resorption promoted by low plasma estrogen levels may be an important mechanism. We conclude that the dose of calcitriol should be reduced during lactation and that both the hypoparathyroid mother and her infant should be carefully monitored to detect abnormal serum calcium levels.

Transient corticotropin deficiency in critical illness

We describe three critically ill patients who displayed indirect evidence of transient corticotropin deficiency. All these patients were elderly, were poorly nourished, and had unexplained hypotension intraoperatively or immediately postoperatively. During the hypotensive episodes, they had inappropriately low plasma cortisol levels (10, 12, and 6 micrograms/dl) and responded dramatically to the administration of glucocorticoids. A normal response to infusion of synthetic corticotropin excluded primary adrenal insufficiency. Two patients tested had low thyroxine levels without increased thyrotropin concentrations and depressed levels of gonadotropins. In all three patients, the dose of glucocorticoids was successfully tapered and then discontinued. After recovery, serum thyroxine levels increased, gonadotropins reverted to normal concentrations, and the administration of metyrapone to two patients demonstrated normal hypothalamic-pituitary-adrenal function. Cortisol levels of less than 15 micrograms/dl in critically ill patients suggest the presence of adrenal insufficiency. The infusion of synthetic corticotropin may not exclude adrenal insufficiency attributable to corticotropin deficiency. If direct tests of corticotropin reserve are impractical, treatment with glucocorticoids is warranted.

Treatment of postmenopausal osteoporosis with transdermal estrogen

OBJECTIVE

To evaluate the tolerance and effectiveness of transdermal estrogen for women with established postmenopausal osteoporosis and vertebral fractures.

DESIGN

Double-blind, randomized, placebo-controlled clinical trial lasting 1 year.

SETTING

Referral-based outpatient clinic.

PATIENTS

Seventy-five postmenopausal women, 47 to 75 years of age, with one or more vertebral fractures due to osteoporosis.

INTERVENTIONS

Thirty-nine women received dermal patches delivering 0.1 mg of 17 beta-estradiol for days 1 to 21 and oral medroxyprogesterone acetate for days 11 to 21 of a 28-day cycle. Another 39 women received placebo.

MEASUREMENTS

Bone turnover assessed by biochemical markers and iliac bone histomorphometry; bone loss assessed by serial measurement of bone density; and vertebral fracture rate.

RESULTS

Compared with the placebo group, the median annual percentage change in bone mineral density in the estrogen group reflected increased or steady-state bone mineral density at the lumbar spine (5.3 compared with 0.2; P = 0.007), femoral trochanter (7.6 compared with 2.1; P = 0.03), and midradius (1.0 compared with -2.6, P less than 0.001) but showed no significant difference at the femoral neck (2.6 compared with 1.4; P = 0.17). Estrogen treatment uniformly decreased bone turnover as assessed by several methods including serum osteocalcin concentration (median change, -0.35 compared with 0.02 nmol/L; P less than 0.001). Histomorphometric evaluation of iliac biopsy samples confirmed the effect of estrogen on bone formation rate per bone volume (median change, -12.9 compared with -6.2% per year; P = 0.004). Also, 8 new fractures occurred in 7 women in the estrogen group, whereas 20 occurred in 12 women in the placebo group, yielding a lower vertebral fracture rate in the estrogen group (relative risk, 0.39; 95% CI, 0.16 to 0.95).

CONCLUSIONS

Transdermal estradiol treatment is effective in postmenopausal women with established osteoporosis.

Incidentally discovered adrenal masses

This report describes a retrospective study of 23 patients with incidentally discovered adrenal masses. Two patients with subclinical cortisol secretion developed adrenal insufficiency after removal of benign adenomas. Another patient, who probably harbors an asymptomatic pheochromocytoma, developed a hypertensive crisis when a mass was palpated during aortic vascular surgery. Twelve patients underwent surgery. Seven benign adenomas, an angiomyolipoma, and a cyst were removed. Three patients had malignant masses that include an angiosarcoma, an adrenal adenocarcinoma, and a congenital neuroblastoma. We conclude that hormones, especially cortisol, may be secreted in subclinical amounts by incidentally discovered masses. We recommend a concise laboratory evaluation that includes an overnight dexamethasone suppression test. Based on our interpretation of the literature, we believe masses greater than 3 cm in size should be removed. Patients who do not undergo surgery should have computed tomographic scans repeated for one year and should be reassessed periodically for the development of hormone secretion.

Recurrence of 131I-induced thyroid storm after discontinuing glucocorticoid therapy

A 19-year-old woman with Graves' disease developed thyroid storm 8 days after radioactive iodine therapy. The clinical manifestations of thyroid storm promptly improved after treatment with large doses of propylthiouracil, potassium iodide, propranolol hydrochloride, and dexamethasone. Four days after discontinuing dexamethasone, the syndrome recurred and was corrected by reinstitution of the glucocorticoid. We conclude that dexamethasone was an important adjunct for treating thyroid storm and was effective mainly by reducing peripheral triiodothyronine production.

Fine-needle aspiration biopsy of thyroid nodules. A cost-effective diagnostic plan

Fine-needle aspiration biopsy is a safe and accurate method for diagnosing thyroid nodules. Personnel who have experience with the aspiration technique and with the cytologic classification of specimens are crucial to accurate results. One important advantage of using fine-needle biopsy to initially screen patients with nodules is that it can save substantially on healthcare resources.

Fine needle aspiration biopsy of thyroid nodules

Between April 1982 and December 1988, we performed 611 fine needle aspiration (FNA) biopsies in 502 patients with solitary thyroid nodules. The biopsy results were classified as follows: unsatisfactory, 19%; benign, 53%; suspicious, 23%; and malignant, 5%. Malignant lesions were found at surgery in 24 of 25 patients with malignant cytology and 31 of 68 patients with suspicious cytology. Autonomous nodules, obviating the need for surgery, were detected in 5 of 36 (14%) patients with cytology suspicious for follicular neoplasm. We conclude that FNA biopsy of the thyroid nodule is a safe and accurate diagnostic test. Thyroid scintigraphy remains useful in patients with cytologic results suspicious for follicular neoplasm. A cost-effective strategy for managing thyroid nodules is presented.

Hypercalcemia in a calcitriol-treated hypoparathyroid woman during lactation

We treated a hypoparathyroid woman with calcitriol during pregnancy and did not reduce the dosage after delivery. Despite lactation, the serum calcium level increased to 15.4 mg/dL 11 days postpartum. We treated two other hypoparathyroid women during four pregnancies with either calcitriol or dihydrotachysterol. In all five pregnancies, requirements for the vitamin D preparations increased beginning at the 20-28th week of gestation. Hypercalcemia did not occur in the two women who did not breast-feed and in whom we reduced the dose of calcitriol or dihydrotachysterol after delivery. We conclude the following: 1) Calcitriol is effective for treating hypoparathyroidism during pregnancy; 2) the dose usually needs to be increased during the latter half of gestation; 3) the calcitriol dose should be reduced during lactation; and 4) both mother and infant should be monitored to detect hypercalcemia during breast-feeding. We speculate that low serum estrogen levels associated with breast-feeding promote bone resorption and diminish calcitriol needs in lactating hypoparathyroid women.

Spurious elevation of plasma immunoreactive adrenocorticotropic hormone in cyclic Cushing's syndrome

We studied a 40-year-old woman with cyclic Cushing's syndrome who demonstrated abnormal high-dose dexamethasone suppression and metyrapone stimulation tests. These results, associated with persistent elevations of plasma adrenocorticotropic hormone (ACTH) levels, suggested ectopic secretion of ACTH. Surprisingly, an adrenal adenoma with atrophy of the contralateral adrenal gland was found at exploratory laparotomy. Subsequent ACTH determinations that extract ACTH from the plasma before assay suggested that the apparent increase in ACTH concentration in our routine assay was due to the presence of an interfering substance(s). We conclude that the diagnosis of Cushing's syndrome continues to depend on a battery of adrenal function tests and radiographic procedures and recommend that measurements of ACTH be performed only after extraction of ACTH from specimens.

Adrenal insufficiency after operative removal of apparently nonfunctioning adrenal adenomas

We describe a woman who developed adrenal insufficiency after removal of an apparently nonfunctional adrenal adenoma. She displayed no stigmata of Cushing's syndrome and had normal plasma and urinary cortisol levels. A second patient without clinical findings of Cushing's syndrome also had normal basal steroid levels. This patient displayed partial suppressibility with dexamethasone, had low-normal levels of serum corticotropin, and excreted a low concentration of urinary 17-ketosteroids. She also developed mild adrenal insufficiency after the operation. We believe the adrenal adenomas in these patients secreted enough cortisol to suppress the contralateral adrenal gland but not enough hormone to elevate basal steroid levels. Therefore, we suggest that all patients with adrenal masses be studied with the overnight dexamethasone suppression test rather than basal steroid hormone measurements to detect low levels of autonomous cortisol secretion. In addition, patients with adrenal masses that are not removed surgically should have serial adrenal function tests performed.

Thyroid gland size in pregnancy. An ultrasound and clinical study

We estimated the size of the thyroid gland by palpation and measured thyroid gland volume with ultrasound in the immediate postpartum period and six months after delivery in 16 women. The 13% reduction in the mean thyroid gland volume detected six months after delivery implied that the thyroid gland enlarges slightly during pregnancy. Physical examination, however, did not detect any goiters during the immediate postpartum period and did not identify a change in thyroid gland size six months after delivery. The thyroid gland enlargement that occurs during pregnancy is not large enough to be detected by physical examination. We urge physicians to discard the commonly held notion that goiter frequently develops during pregnancy.

Hürthle cell tumors of the thyroid gland. A clinicopathologic review and long-term follow-up

We reviewed the pathology and clinical follow-up of 26 patients with H urthle cell adenomas and three patients harboring H urthle cell carcinomas, who were treated at our medical center from 1950 to 1979. Although benign lesions could not be distinguished from malignant tumors by cytologic features alone, other pathologic features allowed differentiation. A total thyroidectomy was performed in only one patient; the remaining patients were treated by less extensive operations. None of the patients with benign adenomas, including those with tumors greater than 2 cm in diameter, experienced recurrent or metastatic disease. The period of observation varied from two to 22 years (mean, 8.5 +/- 7.7 years). We conclude that lobectomy is a satisfactory operation for removal of benign H urthle cell tumors, and reserve total or near-total thyroidectomy for cases displaying pathologic evidence of malignancy.

Peripheral resistance to thyroid hormone in a family: heterogeneity of clinical presentation

We describe a family with thyroid hormone resistance. Juvenile Graves disease was diagnosed in the propositus, an 8-month-old boy. He was initially given propylthiouracil, and at 22 months of age underwent subtotal thyroidectomy. A diagnosis of hyperthyroidism was made in a younger sister at 3 months of age. Because of the unusual occurrence of juvenile Graves disease in two siblings, we evaluated the parents. The mother was euthyroid on physical examination and by thyroid hormone measurements. The father, although clinically euthyroid, had markedly elevated thyroid hormone values. In the three affected members, serum thyrotropin concentrations and results of thyrotropin-releasing hormone infusion tests were inappropriate for the elevated serum thyroid hormone levels. The father was given increasing doses of triiodothyronine. Complete suppression of TRH-induced TSH release did not occur until a daily dose of 300 micrograms triiodothyronine was administered. Furthermore, this large dose of T3 did not produce clinical evidence of hyperthyroidism or result in changes in his systolic ejection time intervals. This family therefore had the unusual feature of clinical heterogeneity. The two children had mainly pituitary resistance to thyroid hormone and were hyperthyroid; the euthyroid father, on the other hand, had generalized tissue resistance to thyroid hormone.

Constant intravenous insulin infusion during labor and delivery in diabetes mellitus

We treated 30 diabetic women (31 pregnancies) during the peripartum period with a continuous insulin infusion. A mean infusion rate of 1.0 micron/h maintained the mean plasma glucose concentration below 100 mg/dl in 84% of the patients; the plasma glucose concentration was below 100 mg/dl within an hour of delivery in 71% of the women. Mild hypoglycemia developed during the infusion in three women and after delivery in another patient. Only two infants of the diabetic mothers developed transient and asymptomatic hypoglycemia. We conclude that continuous insulin infusion is a practical, safe, and effective method for treating diabetic mothers during the peripartum period and suggest that this technique may decrease the frequency and severity of neonatal hypoglycemia.

Elevation of the free thyroxine index in psychiatric patients

We calculated a free triiodothyronine (FT3) index on 124 patients who exhibited symptoms and signs of hyperthyroidism and elevations of the free thyroxine (FT4) index on initial screening. A thyrotropin-releasing hormone (TRH) test served as the final arbiter of thyroid function if the clinical presentation was not characteristic of hyperthyroidism or if the FT3 index was not elevated. Forty-one of the 124 patients had normal TRH tests and were thus classified as euthyroid. Of these patients with the so-called euthyroid sick syndrome, 23 had psychiatric disorders. In a separate study, we measured a FT4 index on 100 unselected admissions to the psychiatric ward. Of six patients with elevated FT4 values, only one had hyperthyroidism. We conclude that false positive FT4 index elevations occur commonly in psychiatric patients. The mechanism(s) for the FT4 index elevations remain obscure. Despite some limitations, the TRH test is a valuable diagnostic adjunct for diagnosing hyperthyroidism in the mentally ill patient when other tests and serial observations are inconclusive.

Serum concentrations of the iodothyronines in elderly subjects: decreased triiodothyronine (T3) and free T3 index

In four groups of subjects free of thyroid disease, the following determinations were made: serum concentrations of thyroxine (T4), triiodothyronine (T3), reverse T3(rT3) and diiodothyronine (T2), and calculated indices of free thyroxine (FT4) and free triiodothyronine (FT3). Group A comprised healthy subjects aged 16-64; Group B, 24 healthy elderly subjects aged 68-95; Group C, 23 elderly patients with mild well-controlled chronic illnesses, aged 70-85; Group D, 40 nursing home residents aged 66-100. Serum T4 and T2 concentrations and the FT4 index were not affected by age; the rT3 concentration was slightly but significantly elevated only in Group D patients. Serum T3 concentration was significantly lower in all groups of elderly subjects and decreased FT3 index measurements were detected after age 75. It was concluded that old age, without complicating illness, is accompanied only by a decrease in the serum level of T3 and the FT3 index; values for other iodothyronines are unchanged. Clinicians should consider the age-related changes in T3 and FT3 values when interpreting thyroid function tests.

Thyroxine toxicosis. A common variant of hyperthyroidism

To determine the frequency of thyroxine (T4) toxicosis, we calculated a free triiodothyronine index (FT3I) on 124 patients who displayed elevations of the free T4 index (FT4I) on initial screening. If the clinical presentation was not characteristic of hyperthyroidism or if the FT3I was not elevated, a thyrotropin-releasing hormone (TRH) test was performed. Of 83 hyperthryoid patients, 70 displayed elevations of both the FT4 and FT3 indices. Thirteen patients, however, had elevations of the FT4I alone. This frequency of T4 toxicosis is higher than generally appreciated. Forty-one patients, most of whom were ill with nonthyroidal diseases, had normal TRH test results and were classified euthyroid. We conclude that FT4I elevations owing to T4 toxicosis and nonthyroidal illnesses are common and that the laboratory differentiation between the syndromes may be difficult.

Recurrent Cushing's disease: successful treatment by pituitary irradiation or trans-sphenoidal hypophysectomy in two cases

Two patients developed recurrent Cushing's disease 3 and 7 years after total bilateral adrenalectomy. In the first patient, a 65-year-old man, the adrenal tissue was not localized by radioactive cholesterol scintigraphy. Plain x-ray films of the skull revealed a normal sella turcica. Although clinical improvement resulted from the discontinuation of cortisone replacement therapy, urinary free cortisol levels remained elevated and the patient was treated with pituitary irradiation. Serum and urine cortisol levels gradually returned to normal. Four years after irradiation, the plasma adrenocorticotropic hormone (ACTH) concentration was elevated, but tomography of the sella turcica and urinary cortisol excretion remained normal. The second patient, a 41-year-old man, displayed elevated ACTH levels and x-ray evidence of a pituitary tumor at the time of recurrent Cushing's disease. After trans-sphenoidal hypophysectomy, the hypercortisolism abated and the ACTH concentration returned to normal. Adrenal scintigraphy frequently locates cortisol-secreting tissue in patients with recurrent Cushing's disease, and some investigators suggest treatment by the surgical removal of the adrenal remnant. Although the etiology of Cushing's disease is controversial, current evidence suggests that most cases result from ACTH-producing pituitary tumors. We suggest, therefore, that the anterior pituitary gland may be a more suitable target than the adrenal remnant for the treatment of recurrent Cushing's disease.

Ocular sporotrichosis mimicking mucormycosis in a diabetic

Primary sporotrichosis of the eye is very rare; most infections are limited to the conjunctiva or adnexa. We report a case of Sporothrix endophthalmitis associated with necrotizing ethmoid sinusitis developing in a young diabetic man with ketoacidosis. The infection clinically resembled rhino-ophthalmic mycormycosis. Cure followed evisceration and an abbreviated course (215 mg) of amphotericin B. Sporothrix must now be regarded as another fungal agent capable of causing primary rhino-ophthalmic infection similar to Mucor.

Cure of acromegaly by operative removal of an islet cell tumor of the pancreas

We studied a 30 year old woman in whom acromegaly was cured by operative removal of a large cystic beta cell adenoma of the pancreas. We detected substantial amounts of immunoreactive human growth hormone (hGH)-like activity in a tumor tissue extract. Extracts of the tumor and a normal human pituitary gland eluted from a Sephadex G-75 column in two identical peaks. Serial dilutions of the tumor extract displaced radioactive 125I hGH parallel to a standard curve. Surprisingly, an extract of a normal human pancreas contained large amounts of hGH-like activity and gave results similar to those of the tumor extract on gel chromatography and on serial dilution displacement in the growth hormone immunoassay. Paper electrophoretic studies of 125I hGH after incubation with normal pancreatic and tumor extracts with and without enzyme inhibitors suggested that pancreatic proteolytic enzymes damaged the 125I hGH used in growth hormone radioimmunoassay and produced a false detection of hGH.

Thyroid function tests in elderly hyperthyroid patients

Several tests of thyroid function were performed in 35 hyperthyroid patients over the age of 65 (elderly). The results were compared to those of similar tests in 48 hyperthyroid patients under the age of 65 (young). Total serum thyroxine (T4) was within the normal range in 14 percent of the elderly and 11 percent of the young hyperthyroid patients. The free thyroxine index (FTI) was within the normal range in 11 percent of both groups. The triiodothyronine uptake (T3U) proved to be a poor test in both groups. Although elevation of the triiodothyronine (T3) level allowed a diagnosis of "T3-toxicosis" in 2 elderly and 3 young hyperthyroid patients, the T3 level was normal in 34 percent of the elderly and 13 percent of the young subjects. Correction of the T3 range for age reduced the number of normal T3 values to 12.5 percent in the elderly hyperthyroid patients. The 24-hour uptake of radioactive iodine was normal in 12 percent of the young hyperthyroid patients, 27 percent of the elderly patients with Graves' disease, and 70 percent of the elderly patients with toxic nodular goiter, despite recent readjustment of the normal range for the test. It is concluded that the diagnosis of hyperthyroidism in the elderly may be difficult and that no single test can be relied upon to exclude the diagnosis.

Thyroid uptake of radioactive iodine in hyperthyroidism

We compared the 24-hour uptake of radioactive iodine (RAIU) in hyperthyroid patients diagnosed from 1970 to 1972 (Group A) and from 1975 to 1976 (Group B). Mean RAIU values in Group B decreased from those in Group A. In 1969 we lowered the normal range for the RAIU test to 0% to 24%, and used the new range for the diagnosis of hyperthyroidism in both groups of patients. The RAIU in Group B is within normal limits in 14% of the patients with Graves' disease and 80% of the patients with toxic nodular goiter (TNG). This study demonstrates that in our geographic area, the 24-hour RAIU has become a poor test for the diagnosis of hyperthyroidism, particularly TNG. However, the test should be performed before radioactive iodine therapy because it is necessary in calculating the therapeutic dose.