Hyperthyroidism

Thyrotoxicosis causes a variety of symptoms and adverse health outcomes. Hyperthyroidism refers to increased thyroid hormone synthesis and secretion, most commonly from Graves' disease or toxic nodular goitre, whereas thyroiditis (typically autoimmune, viral, or drug induced) causes thyrotoxicosis without hyperthyroidism. The diagnosis is based on suppressed serum concentrations of thyroid-stimulating hormone (TSH), accompanied by free thyroxine and total or free tri-iodothyronine concentrations, which are raised (overt hyperthyroidism) or within range (subclinical hyperthyroidism). The underlying cause is determined by clinical assessment, detection of TSH-receptor antibodies and, if necessary, radionuclide thyroid scintigraphy. Treatment options for hyperthyroidism include antithyroid drugs, radioactive iodine, and thyroidectomy, whereas thyroiditis is managed symptomatically or with glucocorticoid therapy. In Graves' disease, first-line treatment is a 12-18-month course of antithyroid drugs, whereas for goitre, radioactive iodine or surgery are preferred for toxic nodules or goitres. Evidence also supports long-term treatment with antithyroid drugs as an option for patients with Graves' disease and toxic nodular goitre.

Thyrotoxicosis and dilated cardiomyopathy in developing countries

BACKGROUND

Thyrotoxicosis is the state of thyroid hormone excess. But, in sub-Saharan Africa (SSA), specifically Northern Ethiopia, scientific evidence about thyrotoxicosis and its cardiac complications like dilated cardiomyopathy is limited. Therefore, this study aimed to explore the thyrotoxicosis presentation and management and identify factors associated with dilated cardiomyopathy in a tertiary hospital in Northern Ethiopia.

METHODS

An institution-based cross-sectional study was conducted in Ayder Comprehensive Specialized Hospital from 2017 to 2018. Data from 200 thyrotoxicosis cases were collected using a structured questionnaire. After describing variables, logistic regression was conducted to identify independent predictors of dilated cardiomyopathy. Statistical significance was declared at p < 0.05.

RESULTS

Mean age at presentation of thyrotoxicosis was 45 years and females accounted for 89 % of the cases. The most frequent etiology was multinodular toxic goiter (51.5 %). As well, the most common symptoms and signs were palpitation and goiter respectively. Thyroid storm occurred in 6 % of the cases. Out of 89 patients subjected to echocardiography, 35 (39.3 %) of them had dilated cardiomyopathy. And, the odds of dilated cardiomyopathy were higher in patients who had atrial fibrillation (AOR = 15.95, 95 % CI:5.89-38.16, p = 0.001) and tachycardia (AOR = 2.73, 95 % CI:1.04-7.15, p = 0.040). All patients took propylthiouracil and 13.0 % of them experienced its side effects. Concerning β-blockers, propranolol was the most commonly (78.5 % of the cases) used drug followed by atenolol (15.0 %). Six patients underwent surgery.

CONCLUSIONS

In developing countries like Ethiopia, patients with thyrotoxicosis have no access to methimazole which is the first-line anti-thyroid drug. Besides, they greatly suffer from dilated cardiomyopathy (due to late presentation) and side effects of propylthiouracil. Therefore, we recommend that patients should get adequate health information about thyrotoxicosis and anti-thyroid drugs including their side effects. Additionally, hospitals and other concerned bodies should also avail of TSH tests and methimazole at an affordable cost. Furthermore, community awareness about iodized salt and iodine-rich foods should be enhanced.

Recombinant Human Thyrotropin-Stimulated Radioiodine Therapy in Patients with Multinodular Goiters: A Meta-Analysis of Randomized Controlled Trials

A potential reduction of goiter volume (GV) of recombinant human thyrotropin (rhTSH) on multinodular goiters (MNG) was previously reported but controversial. Hence we conducted a meta-analysis to estimate the effect of rhTSH-stimulated radioiodine therapy in patients with MNG. PubMed, Cochrane, CNKI, VIP, and Wanfang databases were searched. Mean difference (MD) and odds ratios with 95% confidence intervals (95% CI) were derived by using an inverse variance random-effects model and fixed-effects model, respectively. Six studies (n=237) were involved in the analysis. For 12 months follow up, high dose (>0.1 mg) of rhTSH significantly reduced GV (MD=17.61; 95% CI=12.17 to 23.04; p<0.00001) compared with placebo. No effective pooled results of low dose of rhTSH (<0.1 mg) were applicable for only one study included. For 6 months follow up, the source of heterogeneity was determined by subgroup and sensitivity analysis. High dose group showed vast improvement in GV reduction (MD=16.62; 95% CI=1.34 to 31.90; p=0.03). The reduction of low dose group compared with placebo was inferior to high dose group. No available data were obtained to assess the influence of rhTSH after 36 months follow up for the only included study. Hypothyroidism incidence was higher for rhTSH group. No publication bias was seen. High dose of rhTSH treatment-stimulated radioactive ¹³¹I therapy after 6 months and 12 months follow up had a better effect in reducing GV, but with higher incidence of hypothyroidism. Owing to the limited methodological quality, more clinical researches are warranted in the future.

[Sclerotherapy as an alternative to surgery for recurrent nodular goiter]

OBJECTIVE

To evaluate the results of treatment of recurrent nodular goiter using sclerotherapy with polidocanol.

MATERIAL AND METHODS

A comparative analysis of sclerotherapy (30 patients) and conventional surgical treatment (17 patients) of recurrent goiter was performed.

RESULTS

Sclerotherapy ensures reduction of nodes (linear dimensions of nodes decreased by 14.2±1.1 mm after 3 courses), correction of endocrine imbalance in patients with functional autonomy and relief of initial signs of cervical organ compression in all patients with recurrent goiter. Sclerotherapy is associated with less pain syndrome and no need for inpatient treatment. However, the most significant advantage is reduced risk of complications. Hypoparathyroidism and laryngeal paresis developed in 53 and 24% of patients after conventional surgery while these events were not observed after sclerotherapy.

CONCLUSION

Sclerotherapy with polidocanol is a perspective alternative to conventional surgery for recurrent nodular goiter.

Treatment of Toxic Multinodular Goiter: Comparison of Radioiodine and Long-Term Methimazole Treatment

Background: This study aimed to compare the effectiveness and safety of long-term methimazole (MMI) and radioiodine (RAI) in the treatment of toxic multinodular goiter (TMNG). Methods: In this randomized, parallel-group trial, 130 consecutive and untreated patients with TMNG, aged <60 years, were enrolled and randomized to either long-term MMI or RAI treatment. Both groups of patients were followed for 60-100 months, with median durations of 72 and 84 months in the MMI and RAI groups, respectively. Results: In the MMI and RAI groups, 12 and 11 patients, respectively, were excluded because of side effects, choosing other modes of treatment and not returning for follow-up; 53 and 54 patients, respectively, completed the study for 60-100 months. In the MMI group, two patients (3.8%) experienced subclinical hypothyroidism, and 51 (96.2%) remained euthyroid until the end of study. The dosage of MMI to maintain euthyroidism was 6.3 ± 2.0, 4.5 ± 0.9, and 4.1 ± 1.0 mg daily during the first, third, and fifth years of continuous MMI treatment. One patient had elevated liver enzymes, and three developed skin reactions during the first three months, but no adverse effects from MMI occurred from 4 to 100 months of therapy. In the RAI group, 22 (41%) became hypothyroid, 12 (22%) had persistence or recurrence of hyperthyroidism, and 20 (37%) became euthyroid after 16.7 ± 2.7 mCi ¹³¹I. Conclusion: Long-term, low-dose MMI treatment for 60-100 months is a safe and effective method for treatment of TMNG, and is not inferior to RAI treatment.

Treatment of autonomous and toxic thyroid adenomas by percutaneous ultrasound-guided ethanol injection

Purpose: To evaluate the feasibility and efficacy of US-guided percutaneous ethanol injection (PEI) in the treatment of autonomous and toxic thyroid adenomas.

Material and Methods: PEI was performed in 42 patients with solitary, scintigraphically "hot" nodules (n=37) or toxic nodular goiter (n=5). The nodular volume ranged from 2.5 to 38 cm3 (mean volume, 20.7±14.1 cm3). Ethanol was injected using a free-hand technique, usually in multiple sessions, using color and power Doppler US guidance. Treatment success was evaluated following 3-4 months after PEI by scintigraphy, hormonal status, and US findings.

Results: The procedure was technically successful in 39 patients (93%). Three patients were lost to follow-up. Minor complications were pain (all patients), subcutaneous hematoma (n=6), and transitory dysphonia (n=1). A complete cure was achieved in 22 patients (52%), and a partial cure in 10 patients (24%). In 4 cases (9%), the result was unsatisfactory since only moderate hormonal remission was observed. A satisfactory results was thus achieved in 32/42 patients (76%). Significant nodular volume reduction was observed in all cases. Better results were observed in smaller nodules and in cases of autonomous adenomas. There were no cases of recurrent hyperthyreosis.

Conclusion: US-guided PEI is an efficient and safe method in the treatment of autonomous thyroid nodules and it enables inactivation of nodules with minimal or transitory complications.

Etiopathology, clinical features, and treatment of diffuse and multinodular nontoxic goiters

Goiter, an enlargement of the thyroid gland, is a common problem in clinical practice associated with iodine deficiency, increase in serum thyroid-stimulating hormone (TSH) level, natural goitrogens, smoking, and lack of selenium and iron. Evidence suggests that heredity also has an important role in the etiology of goiter. The current classification divides goiter into diffuse and nodular, which may be further subdivided into toxic (associated with symptoms of hyperthyroidism, suppressed TSH or both), or nontoxic (associated with a normal TSH level). Nodular thyroid disease with the presence of single or multiple nodules requires evaluation due to the risk of malignancy, toxicity, and local compressive symptoms. Measurement of TSH, accurate imaging with high-resolution ultrasonography or computed tomography, and fine-needle aspiration biopsy are the appropriate methods for evaluation and management of goiter. This review discusses the clinical presentation, diagnostic evaluation, and treatment considerations of nontoxic diffuse and nodular goiters.

Laser ablation and 131-iodine: a 24-month pilot study of combined treatment for large toxic nodular goiter

CONTEXT

It is normally recognized that the preferred treatment in large toxic thyroid nodules should be thyroidectomy.

OBJECTIVE

The aim of the study was to assess the efficacy of combined laser ablation treatment (LAT) and radioiodine 131 (131I) treatment of large thyroid toxic nodules with respect to rapidity of control of local symptoms, of hyperthyroidism, and of reduction of administered 131I activity in patients at refusal or with contraindications to surgery.

DESIGN AND SETTING

We conducted a pilot study at a single center specializing in thyroid care.

PATIENTS

Fifteen patients were treated with LAT, followed by 131I (group A), and a series of matched consecutive patients were treated by 131I only (group B).

INTERVENTION(S)

Laser energy was delivered with an output power of 3 W (1800 J per fiber per treatment) through two 75-mm, 21-gauge spinal needles. Radioiodine activity was calculated to deliver 200 Gy to the hyperfunctioning nodule.

MAIN OUTCOME MEASURE(S)

Thyroid function, thyroid peroxidase antibody, thyroglobulin antibody, ultrasound, and local symptoms were measured at baseline and up to 24 months.

RESULTS

Nodule volume reduction at 24 months was: 71.3 ± 13.4 vs 47.4 ± 5.5%, group A (LAT+131I) vs group B (131I), respectively; P < .001). In group A (LAT+131I), a reduction in radioiodine-administered activity was obtained (-21.1 ± 8.1%). Local symptom score demonstrated a more rapid reduction in group A (LAT+131I). In three cases, no 131I treatment was needed after LAT.

CONCLUSIONS

In this pilot study, combined LAT/131I treatment induced faster and greater improvement of local and systemic symptoms compared to 131I only. This approach seems a possible alternative to thyroidectomy in patients at refusal of surgery.

Nodular goiter with thyroid antibodies in chronic idiopathic urticaria

We report a case of chronic idiopathic urticaria associated with nodular goiter and Graves disease. The urticaria resolved with normalization of the thyroid function.

[Multinodular goitre: not always harmless]

Multinodular goitre has a slow and progressive growth. The clinical presentation of patients with multinodular goitre is variable and dependent on size, location and the functional state of the thyroid tissue. The most frequent clinical symptoms are caused by compression and deviation of the trachea and range from dyspnoea to acute asphyxia. Imaging is important to confirm the size of the multinodular goitre. Timing of the treatment can be critical. However, a good treatment guideline is lacking. There are two treatment options: radioactive iodine and surgical resection. The best treatment option and timing of treatment for patients with multinodular goitre should be assessed and decided on an individual basis. In this clinical report we present two patients who had a multinodular goitre with progressive symptoms for years. Patient A, 66 years of age, was successfully treated with radioactive iodine. Patient B, 77 years of age, underwent a total thyroidectomy.

[Current status and perspectives of the research in Pendred syndrome]

Pendred syndrome is an autosomal recessive disorder characterized by sensorineural hearing loss, goiter, and a partial defect in iodide organification, and is the most common syndromic hearing loss. Hearing loss is congenital in most cases and is accompanied by an enlarged vestibular aqueduct and a Mondini cochlea. Pendred syndrome and autosomal recessive deafness-4 (DFNB4) with enlarged vestibular aqueduct comprise a phenotypic spectrum caused by mutations in SLC26A4. Recently, mutations in FOXI1 and KCNJ10 have also been identified in DFNB4. Molecular mechanism of hearing loss and goiter remains to be elucidated, and therapies which can reverse or prevent the progression of the symptoms are not available. Here, we describe advances in the basic, clinical, and translational studies on Pendred syndrome.

Somatostatin receptor expression in thyroid disease

Somatostatin analogues are commercially available and used for the management of acromegaly and neuroendocrine tumours, but the expression of the receptors as a target in thyroid disease has not been explored. To assess somatostatin (SST) and somatostatin receptor (SSTR1-5) expression in both normal and thyroid disorders, as a potential target for somatostatin analogue therapy, 67 thyroid tissue specimens were reviewed: 12 differentiated thyroid carcinomas, 14 follicular adenomas, 17 multinodular goitres, 14 Graves disease, 10 Hashimotos thyroiditis specimens and five normal thyroids. Tissue was immunostained for SST and SSTR1-5. Positivity and the degree of positivity were recorded by double-blinded observers. Somatostatin receptor expression was highly expressed in normal tissue for SSTR1, 3, 4 and 5 (5 of 5, 4 of 5, 4 of 5 and 5 of 5 respectively) whilst SST and SSTR 2a and b were not expressed at all. The commonest receptor expressed for all pathological subtypes grouped together was SSTR2b (63 specimens). The commonest receptors expressed in differentiated thyroid cancer were SSTR5 (11 of 12 specimens) and SSTR2b (10 of 12 specimens). The commonest receptor expressed in benign disease was SSTR2b (53 of 55 specimens). SSTR5 was significantly under-expressed in Graves disease (P < 0.05). This study illustrates that SSTR 1, 3, 4 and 5 are highly expressed in normal, benign and malignant thyroid tissue. SSTR 2a and 2b appear absent in normal tissue and present in benign and malignant thyroid tissue (P < 0.02). This suggests that focussed SSTR2 treatment may be a potential therapeutic target.

[Lazer-inducted interstitial thermotherapy in the treatment of solid nodulus of thyroid]

The results of treatment 272 patients with a nodular colloid goiter with the use of lazerinducted termotherapy (LITT) are analysed. I is established that in the developed modes of LITT application does not cause destructive changes in paranodular tissue and disorders of thyroid gland hormonal function. Duration of reverse development and substituting of nodular for a connecting tissue is determined by echogene and volume. With it increase the intensity of nodulus substituting for a connecting tissue goes down, extended the terms of nodulus regress. The indication to the repeated application of termotherapy is remaining tissue in the projections of nodulus scope from 42% and more an initial volume through 6 ms treatment. Absolute indications to repeated LITT is a presence of thyroid epithelium in remaining tissue of nodulus.

[Peculiarities of formation, clinical presentations and therapy of diffuse nontoxic goiter of children]

The paper deals with the peculiarities of formation, clinical presentations and therapy of diffuse nontoxic goiter of children. The paper highlights the connection of the disease with the genetic predisposition, the impact of natural and anthropogenic strumagenes, immune processes. The clinical presentations of the diffuse nontoxic goiter are diffuse enlargement of thyroid gland, normal or high level of thyrotropichypophysis hormone when the content of thyroxin and triiodothyronine is normal, which is treated as the subclinic hypothyroidism syndrome. The variety of the disease pathogenesis theories leads to testing of different therapeutic methods, the principal ones among them are the use of iodine preparation and replacement therapy.

Approach to and treatment of goiters

The main causes of simple diffuse goiter (SDG) and multinodular goiter (MNG) are iodine deficiency, increase in serum thyroid-stimulating hormone (TSH) level, natural goitrogens, smoking, chronic malnutrition, and lack of selenium, iron, and zinc. Increasing evidence suggests that heredity is equally important. Treatment of SDG and MNG still focuses on L-thyroxine-suppressive therapy surgery. Radioiodine alone or preceded by recombinant human TSH stimulation is widely used in Europe and other countries. Each of these therapeutic options has advantages and disadvantages, with acute and long-term side effects.

Approach to the patient with nontoxic multinodular goiter

Thyroid nodules are very common, and although the majority are benign, approximately 5% may harbor malignancy. The evaluation of the patient with solitary thyroid nodule is generally straightforward and will typically include measurement of serum TSH to assess thyroid function and fine-needle aspiration biopsy of the nodule, with or without ultrasound (US) guidance. The approach to the patient with nontoxic multinodular goiter represents a more difficult problem for the clinician. All patients should have serum TSH measured to assess functional thyroid status and US examination to evaluate the number, size, and sonographic features of the nodules and assist in the selection of nodules that may need fine-needle aspiration biopsy. Patients with nodules yielding malignant cytology should be referred for surgery. Given the lack of reliable markers to predict biological behavior of nodules with suspicious (indeterminate) cytology, patients with such nodules are generally advised to have surgery, unless autonomous function of these nodules can be confirmed by scintigraphy. Most of these patients, however, will ultimately prove to have benign follicular tumors. Many patients with benign but large goiters may experience clinical symptoms of pressure, such as dysphagia, choking sensation, or airway obstruction. Such patients will often require surgery for alleviation of symptoms. In the absence of malignancy, asymptomatic patients may be observed. Radioactive iodine, commonly used in many parts of Europe, is safe and effective and may be a reasonable option for many patients. Periodic follow-up with neck palpation and US exam is recommended for all patients.

Modified-release recombinant human TSH (MRrhTSH) augments the effect of (131)I therapy in benign multinodular goiter: results from a multicenter international, randomized, placebo-controlled study

BACKGROUND

Recombinant human TSH (rhTSH) can be used to enhance (131)I therapy for shrinkage of multinodular goiter (MG).

OBJECTIVE, DESIGN, AND SETTING

The objective of the study was to compare the efficacy and safety of 0.01 and 0.03 mg modified-release (MR) rhTSH as an adjuvant to (131)I therapy, vs. (131)I alone, in a randomized, placebo-controlled, international, multicenter study.

PATIENTS AND INTERVENTION

Ninety-five patients (57.2 ± 9.6 yr old, 85% females, 83% Caucasians) with MG (median size 96.0, range 31.9-242.2 ml) were randomized to receive placebo (group A, n = 32), MRrhTSH 0.01 mg (group B, n = 30), or MRrhTSH 0.03 mg (group C, n = 33) 24 h before a calculated activity of (131)I.

MAIN OUTCOME MEASURES

The primary end point was a change in thyroid volume (by computerized tomography scan, at 6 months). Secondary end points were the smallest cross-sectional area of the trachea; thyroid function tests; Thyroid Quality of Life Questionnaire; electrocardiogram; and hyperthyroid symptom scale.

RESULTS

Thyroid volume decreased significantly in all groups. The reduction was comparable in groups A and B (23.1 ± 8.8 and 23.3 ± 16.5%, respectively; P = 0.95). In group C, the reduction (32.9 ± 20.7%) was more pronounced than in groups A (P = 0.03) and B. The smallest cross-sectional area of the trachea increased in all groups: 3.8 ± 2.9% in A, 4.8 ± 3.3% in B, and 10.2 ± 33.2% in C, with no significant difference among the groups. Goiter-related symptoms were effectively reduced and there were no major safety concerns.

CONCLUSION

In this dose-selection study, 0.03 mg MRrhTSH was the most efficacious dose as an adjuvant to (131)I therapy of MG. It was well tolerated and significantly augmented the effect of (131)I therapy in the short term. Larger studies with long-term follow-up are warranted.

Time to reconsider nonsurgical therapy of benign non-toxic multinodular goitre: focus on recombinant human TSH augmented radioiodine therapy

The treatment of benign multinodular goitre (MNG) is controversial, but surgery is recommended in large compressive goitres. While some patients decline surgery others may have contraindications due to comorbidity, since MNG is prevalent in the elderly. Therefore, non-surgical treatment alternatives are needed. Until recently, levothyroxine therapy was the preferred non-surgical alternative, but due to low efficacy and potential side-effects, it is not recommended for routine use in recent international guidelines. Conventional radioiodine ((131)I) therapy has been used for two decades as an effective and safe alternative to surgery in the treatment of symptomatic non-toxic MNG. Since much higher activities of (131)I are employed when treating non-toxic rather than toxic MNG, there has been reluctance in many countries to use this treatment modality. Frequently, the (131)I -uptake in a non-toxic MNG is low, which makes (131)I therapy less feasible. Another challenge is the negative correlation between the initial goitre size and goitre volume reduction (GVR). With its ability to more than double the thyroid (131)I-uptake, recombinant human TSH (rhTSH) increases the absorbed radiation dose and thus enhances the GVR by 35-56% at the expense of up to fivefold higher rate of permanent hypothyroidism. An alternative strategy is to reduce the administered (131)I-activity with a factor corresponding to the rhTSH induced increase in (131)I-uptake. Hereby, the extrathyroidal irradiation can be reduced without compromising efficacy. Thus, although in its infancy, and still experimental, rhTSH-augmented (131)I therapy may profoundly alter the non-surgical treatment of benign non-toxic MNG.

Recombinant human TSH increases the efficacy of a fixed activity of radioiodine for treatment of multinodular goitre

CONTEXT

High doses of (131)I are usually needed in the treatment of multinodular goitre (MNG) for effective thyroid volume (TV) reduction. Recombinant human thyroid-stimulating hormone (rhTSH) is an adjuvant to enhance (131)I uptake, allowing a decrease in radiation activity and enhancing (131)I efficacy.

OBJECTIVE

To evaluate whether rhTSH increases the efficacy of a fixed activity of (131)I for the treatment of MNG.

DESIGN

Two-year, observational, placebo-controlled study.

SETTING

Patients received 0.1 mg rhTSH (A), 0.005 mg rhTSH (B) or placebo (C). A fixed activity of 1.11 GBq of (131)I was administered 24 h after rhTSH or placebo.

PATIENTS

A total of 28 outpatients (26 females and two males) with MNG.

MEASUREMENTS

TSH, free T4, T3, thyroglobulin (Tg) and TV.

RESULTS

Basal radioactive iodine uptake and TV values were comparable among all groups. After rhTSH or placebo, peak levels of TSH, free T4, T3 and Tg were higher in A than in B or in C (p < 0.05). Hyperthyroidism was observed in A (n = 2), B (n = 6) and C (n = 4). Thyroid enlargement was reported in A (n = 3) and B (n = 6). After 24 months, 10 patients developed hypothyroidism (four in A, three in B and three in C). TV reduction was similar between A and B (37.2 +/- 25.5% vs. 39.3 +/- 27.9%, p = 0.88), but different from the non-significant reduction in C (15.3 +/- 28.3%, p = 0.08).

CONCLUSIONS

Followed by 1.11 GBq, a very low dose of 0.005 mg rhTSH was equally safe and effective as 0.1 mg rhTSH. Both doses increased the efficacy of radioiodine. Adverse events were mild, transient and readily treatable.

[Adenomatous goiter--concept, etiology, treatment]

Adenomatous goiter has an accompanying tumor formation due to the overgrowth of the cells of the thyroid tissue. The tumor formation may be single or multiple. In Japan which is iodine-rich country, adenomatous goiter is not so much concerned because its incidence is relatively low and fundamentally benign disease. However, it has various interesting aspects or problems including the etiology of goiter or nodules, the progression to functioning nodules or non-functioning nodules, the development of cancer, thyroid hormone synthesis and therapeutic problems etc. We have to be more interested in this disease.

Management of multinodular goiter in Germany (Papillon 2005): do the approaches of thyroid specialists and primary care practitioners differ?

AIM

Large-scale survey to focus on management of multinodular goiter and to compare the approaches of practitioners in primary care and thyroid specialists in Germany.

METHODS

Replies to a questionnaire were received from 2,191 practitioners and 297 thyroid specialists between June 1 and September 30, 2005. The hypothetical cases and their modifications described multinodular goiters of different sizes with and without toxic nodules.

RESULTS

In the workup, TSH determination and thyroid sonography were found to be standard procedures. Scintigraphy was selected by 80.2% of practitioners and 92.9% of specialists (p < 0.001), in preference to fine needle aspiration cytology (17.9% of practitioners and 34.5% of the specialists, p < 0.001). Only 6.1% of practitioners and 24.4% of specialists (p < 0.001) advocated calcitonin screening. Euthyroid multinodular goiter (50-80 ml) was treated medically by 67.1% of practitioners and 65.6% of specialists, the combination of levothyroxine with iodine being clearly preferred (54.5% of practitioners, 52.3% of specialists). For toxic nodular goiter the preference for radioiodine therapy was significantly higher (p < 0.001) among specialists (67.7%) than among practitioners (47.5%). Referral to surgery was recommended for cold nodules with negative cytology by 64.9% of practitioners and 73.5% of specialists (p = 0.004).

CONCLUSIONS

Treatment and diagnostic procedures are used to nearly the same extent in primary care and specialist institutions, but the opinions diverge over the issues of calcitonin screening and referral for radioiodine therapy.

[Toxic multinodular goiter]

The prevalence of toxic multinodular goiter (TMNG) is very rare in Japan which iodine intake is sufficient or excessive. It accounts for about < 1.0% of hyperthyroidism. The pathogenesis of TMNG is unknown, especially iodine rich area like in Japan although in iodine-deficient arears iodine insufficiency and TSH stimulating is the major promoting factors in its pathogenesis. Unlike Graves' disease, TMNG is more prevalent among aged patients and its symptoms of hyperthyroidism develops insidiously. Radionuclide imaging and ultrasonography provide very important information about the diagnosis of TMNG in addition to thyroid function tests. The treatments for TMNG are surgery after amelioration of thyroid function with antithyroid drugs, radioiodine treatment and PEIT (percutaneous ethanol injection therapy). We always have to pay attention to the existence of thyroid cancer complicated with TMNG.

Increased serum CXCL10 in Graves' disease or autoimmune thyroiditis is not associated with hyper- or hypothyroidism per se, but is specifically sustained by the autoimmune, inflammatory process

OBJECTIVE

Serum CXCL10 (an interferon-gamma-inducible chemokine) levels (sCXCL10) are increased in several autoimmune conditions, including Graves' disease (GD) and autoimmune thyroiditis (AT). Longitudinal assessment of sCXCL10 in autoimmune hypo- or hyperthyroidism has not yet been performed.

DESIGN AND METHODS

We longitudinally assayed sCXCL10 in the following groups: thirty-three GD and 11 toxic nodular goiter (TNG) patients when hyperthyroid (Hyper) and when reaching euthyroidism (Eu) with methimazole therapy (MMI) sixty-six AT (33 hypothyroid (Hypo) and 33 Eu) patients, basally and after reaching EU (for Hypo) with levothyroxine (L-T4) therapy twenty-two patients with thyroid cancer (CA) under L-T4-suppressive treatment, of whom 11 were re-evaluated after L-T4 withdrawal for diagnostic WBS, and 11 after recombinant TSH (rhTSH) administration thirty-three healthy controls.

RESULTS

At initial evaluation, Hyper GD and AT (Hypo significantly higher than Eu) showed significantly higher mean sCXCL10 than all other groups. MMI treatment led to a significant decrease in sCXCL10 only in GD (not in TNG), while restoration of Eu, in Hypo AT, by L-T4 was not accompanied by significant sCXCL10 change. CA showed sCXCL10 comparable to controls, and both Hypo after L-T4 withdrawal and rhTSH injection had no effect on sCXCL10.

CONCLUSIONS

Treatment of Hyper leads to a significant decrease in sCXCL10 only in GD, and this probably depends upon the MMI immunomodulatory effect. L-T4 correction of Hypo is not accompanied by significant modification of sCXCL10 in AT. Increased sCXCL10 is not associated with Hyper or Hypo per se, but is specifically sustained by the autoimmune inflammatory event occurring in both GD and AT.

[Treatment of hyperthyroidisms in Brazzaville Teaching Hospital, Congo]

Between January 1994 and December 2003, a total of 118 patients (MIF = 1/13) with thyrotoxicosis was studied at the endocrine and metabolic diseases unit of the Centre Hospitalier Universitaire de Brazzaville, in Congo. 72 patients (61%) had Graves' hyperthyroidism, 23 (19.6%) had toxic multinodular goitre while the rest had toxic adenoma (7.6%), and thyroiditis (4.2%). The mean age was 26.6 +/- 7.9 years for Graves' cases and 49.4 +/- 9.3 years for toxic multinodular goitre cases. The clinical presentation was similar to other reported series. Thirty-seven patients (31.3%) did not return after the first admission. All patients responded to carbimazole therapy and no major side-effect was recognized. Ten patients (8.5%/) underwent subtotal thyroidectomy, among them one developed hypothyroidism a year later. The result of this study shows that thyrotoxicosis is not a rare condition in Congo.

Multinodular goiter management in Western Saudi Arabia

OBJECTIVE

The aim of this study was to provide epidemiological data and summarize the different modalities of management of multinodular goiters (MNG) in the Western Province of Saudi Arabia (KSA).

METHODS

A total of 135 patients had MNG, which were diagnosed by ultrasonography at King Abdul-Aziz University Hospital in Jeddah, KSA between January 2003 and June 2004. The data collected includes the age, gender, physical examination of the thyroid gland (trifluorothymidine, free thyroxine, free triiodothyronine, thyroid stimulating hormone), ultrasonographic findings and Tc99 radioiodine nuclear scan of the thyroid gland, fine needle aspiration (FNA) of the gland and antithyroid antibodies. The study group was divided according to the thyroid status: nontoxic euthyroid MNG, hypothyroid MNG and toxic hyperthyroid MNG. The management of MNGs according to the patients' clinical presentations and thyroid status was reviewed.

RESULTS

The mean age was 39 +/- 12.66 years with a range of 10-79 years. Forty-two patients (31%), with no history of thyroid cancer, had ultrasoundguided FNA; 41 (97.6%) of the FNAs were benign. One FNA (2.3%) was positive for papillary carcinoma in a 56-year-old female patient. Thyroid antibodies (anti-microsomal antibodies and anti-thymoglobulin antibodies) were measured in 50 patients (37%). Thirty-one (62%) were positive, 11 (35%) of which were positive in patients with documented hypothyroidism. All patients with hypothyroidism were treated with levothyroxine; however, only 25.6% with euthyroid MNG were treated with suppressive doses of levothyroxine. Twelve patients (44.4%) with toxic MNG were treated with antithyroid medications. Radioiodine therapy was not given to any patient with nontoxic MNG; however, 48% of those with hyperthyroid MNG received radioactive iodine treatment. Surgery was carried out in 25.6% of patients with euthyroid nontoxic MNG, and in 11 patients with toxic MNG. Nearly half of those with nontoxic MNG (46.5%) and 14.8% of those with a subclinical hyperthyroid MNG refrained from any therapy. They were followed-up by their clinician in the outpatient clinic.

CONCLUSION

Serum thyroid stimulating hormone levels, ultrasound and fine needle biopsy were the cornerstones of the diagnostic evaluation of patients with MNG. Review of the management of these patients was comparable to that found in the literature. The treatment strategy was similar to the recommendations by the American Thyroid Society; however, radioactive iodine treatment was not used as a treatment for patients with nontoxic goiters.

[Multinodular goiters]

The incidence of multinodular goiters (MNG) differs according to the countries, and seems to be widely dependent of the iodine status. In France, the SU.VI.MAX study indicates that 4.75% of the active population is suffering from MNG, this incidence is increased with gender and age. The role of genetic factors is estimated as being around 80%. The remaining 20% are related to environmental factors, some of them being still unknown. Admit these external factors, the iodine deficiency is predominant and should be theoretically easy to avoid. Most of MNG develop on diffuse goiters and could be prevented when these underlying lesions are treated early by the administration of thyroid hormone alone or associated with iodide potassium. Once the nodularity of the thyroid tissue is present, the medical treatment is of weak efficacy, it usually stabilises the goiter and prevents the occurrence of new nodules. The two main treatments are surgery and radioactive iodine, the latter is currently used not only when the former is contra-indicated. In some countries, radioactive iodine is considered as the best alternative in the majority of cases.

[Sclerotherapy in patients with nodular colloid goiter]

Results of percutaneous sclerotherapy with ethanol (PSTE) in 89 patients with nodular colloid goiter were analyzed. Indications and method of PSTE in different types of nodular formations were determined. All the patients were divided into 3 groups: 1st group -- 8 (9%) patients with free-functioning nodes, 2nd -- 16 (18%) patients with symptoms of cervical organs compression, 3rd -- 65 (73%) patients with cosmetic defect on neck. It is concluded that PSTE may be regarded as alternative for surgical treatment in the patients with high surgical risk. It is not pathogenic method of treatment and it should be accompanied with medicament therapy of iodine-deficient goiter. Liquidation of clinical symptoms is the criterion of treatment efficiency.

Management of the nontoxic multinodular goiter in Latin America: comparison with North America and Europe, an electronic survey

To assess diagnostic and therapeutic approaches to nontoxic multinodular goiter and to compare them with previously reported American Thyroid Association (ATA) and European Thyroid Association (ETA) surveys, an online questionnaire was distributed to Latin American Thyroid Society (LATS) members. An index case was presented (42-yr-old woman with an enlarged, irregular, nontender, 50- to 80-g thyroid and no clinical suspicion of malignancy or dysfunction), and 11 variations were proposed to evaluate how each alteration would affect management. We obtained 148 responses (response rate, 50%). In the index case, the most used blood tests were TSH (96%), antithyroid peroxidase antibodies (76%), and free T(4) (64%); 5% included a calcitonin assay. Nearly 90% would perform ultrasound, and only 16% used scintigraphy. Fine needle biopsy was indicated by 88%, with ultrasound guidance in 75% of times. For treatment, observation was preferred by 39%, surgery by 28%, levothyroxine by 21%, and radioiodine by 7% (60% with recombinant TSH prestimulation). A suppressed TSH level prompted 45% of the respondents to recommend radioiodine, whereas 70-78% indicated surgery in the presence of a large goiter or suspicion of malignancy. In conclusion, no consensus exists concerning the ideal management of nontoxic goiter among LATS members, in agreement with previous ATA and ETA surveys. Levothyroxine therapy is less used by LATS than by ATA or ETA members, and a more aggressive therapeutic strategy is generally preferred by members of LATS and ETA compared with ATA.

Administration of a single dose of recombinant human thyrotrophin enhances the efficacy of radioiodine treatment of large compressive multinodular goitres

OBJECTIVE

Patients with very large multinodular goitres, frequently found among elderly people, often suffering from cardiovascular or other disabling disorders, may be considered as unsuitable for surgery. We have evaluated the feasibility of relatively high-dose 131I therapy in such patients. As subclinical or clinical hyperthyroidism is commonly found in these patients, associated with a low radioiodine (RAI) uptake at 24 h, we pretreated a group of patients with a single intramuscular injection of recombinant human TSH (rhTSH 0.45 mg) in order to increase the uptake of the therapeutic dose of RAI.

DESIGN AND PATIENTS

Forty-one patients with large, long-standing multinodular goitres, were recruited for this study. After a careful and detailed clinical and laboratory evaluation, 34 patients (28 women, six men) were included and randomly assigned to group 1 (control, n = 17, 15 women, two men, age 63.1 +/- 11.2 years) receiving only RAI. Patients in group 2 (n = 17, 13 women, four men, age 63.6 +/- 12.3 years) received the therapeutic dose of RAI, having been pretreated (24 h) with 0.45 mg of rhTSH. Both groups of patients were submitted to a low iodine diet, 4-6 months before RAI treatment, while seven thyrotoxic patients also received methimazole (40 mg/day) until they reached euthyroidism. Ultrasonographic studies were performed for all patients and fine-needle aspiration biopsy (FNAB) were performed on one or two nodules before RAI treatment. RAI was given as a single oral dose to the hospitalized isolated patients. Blood samples for thyroid function tests and serum thyroglobulin (Tg) were collected daily during the first week following RAI treatment, and at 1, 3, 6, 9 and 12 months thereafter.

MEASUREMENTS

Goitre volume was estimated by computed tomography scan. Thyroid function tests (total T3, free T4, TSH and serum Tg) were assayed with commercial kits. Urinary excretion of iodine was assayed by the Sandell-Kolthoff method.

RESULTS

After the RAI therapeutic dose, serum thyroid function tests were carried out daily for the first week and then on a monthly basis (1, 3, 6, 9 and 12 months). Serum TSH levels rose to a peak level of 45.9 +/- 19.1 mU/l (24 h) in group 2 returning to normal at 72 h. Free T4 serum concentrations rose significantly to 59.35 +/- 21.61 pmol/l at 48 h (in group 2) returning to normal at 7 days. Similarly, serum TT3 also peaked above normal levels only in group 2 (6.12 +/- 1.89 nmol/l) at 24 h. Serum Tg increased in both groups (significantly higher in group 2) and remained elevated during the following 12 months. Both groups had a significant reduction in goitre volume at 12 months (group 2: 57.8%vs. group 1: 39.7%, P < 0.05). Hypothyroidism was detected after RAI treatment, respectively, in 21.4% (group 1) and 64.7% (group 2), of the patients at 12 months.

CONCLUSIONS

Our results indicate that the use of hTSH increased the efficacy of the RAI therapeutic dose. This was basically due to an increased uptake of the radionuclide (as a consequence of the higher serum TSH levels) and a more extensive distribution of 131I within the nodules of the multinodular goitre. A more intense radiation effect was reflected in there being a higher output of serum Tg and thyroid hormones (group 2). As a consequence this group had a significantly higher reduction of the goitre volume. Also incidence of hypothyroidism post-RAI was significantly higher in group 2. We concluded that pretreatment with rhTSH in elderly patients with large multinodular goitres increases the uptake of the RAI therapeutic dose, thereby significantly reducing the multinodular goitre volume and relieving the compressive symptoms with relatively few side-effects.

Calcitonin Measurement to Detect Medullary Thyroid Carcinoma in Nodular Goiter: German Evidence-Based Consensus Recommendation

Serum calcitonin (CT) has become a very specific and sensitive marker for human medullary thyroid carcinoma (MTC), a neuroendocrine tumor affecting about 1 % of patients with nodular thyroid disease. MTC is characterized by early micrometastasis and a lack of curative non-surgical treatment, so that early diagnosis is desirable. Based on a systematic review of scientific evidence, we propose multidisciplinary consensus recommendations for the clinical use of CT in patients with nodular goiter. To exclude MTC, serum CT should be determined in patients with nodular thyroid disease, using a two-site CT immunoassay. If basal serum CT exceeds 10 pg/ml, CT should be analysed by pentagastrin stimulation testing, after renal insufficiency and proton pump inhibitor medication have been ruled out. As the risk for MTC is higher than 50 % in patients with stimulated CT values > 100 pg/ml, thyroidectomy is advised in these individuals. If stimulated CT exceeds 200 pg/ml, thyroidectomy and lymphadenectomy is strongly recommended. Pentagastrin-stimulated CT values < 100 pg/ml are associated with a low risk of MTC, or very rarely, non-metastasizing micro-MTC (size < 10 mm). Therefore, regular clinical and biochemical follow-up is the preferred treatment in such patients, unless thyroid malignancy is suspected otherwise.

Die Knotenstruma. Die molekulare Entstehung - Konsequenzen für die Therapie?

Up to 15 % of the adult German population display an enlarged thyroid gland and up to 30 % present thyroid nodules. Iodine deficiency is the most important factor in the etiology of nodular goiter. Insulin-like growth factor-I is overexpressed in thyroids in severely iodine deficient areas. There is evidence that iodolactones are mediators of thyroid hormone autoregulation. However familial and twin studies demonstrated a genetic component in the etiology of nodular goiter. Linkage analysis identified two chromosomal regions (MNG-1, Xp 22) in multinodular goiter. Other possible candidate genes or markers such as TG, TPO, NIS, PDS and TSH-R were not identified. Nodular goiter certainly comprises a number of genotypes. TSH receptor mutations result in activation of the cAMP cascade. Cells with a constitutively activated cAMP cascade have an increased growth advantage due to their TSH independent cAMP stimulation. Alimentary iodine supply should be the first choice in primary prevention of nodular thyroid disease in iodine deficient areas, because prevalence of nodular goiter is negative correlated with individual iodine status in epidemiological surveys. Surgical removal of nodular goiters should include nearly the hold thyroid tissue to avoid recurrent goiter.

[Diagnosis and treatment of thyroid nodules]

The paper presents current diagnostic and therapeutic approach of thyroid nodules. TSH and iodine are the main goitrogenic agents, but there are also other auto- para-endocrinal factors that play very important roles in goiter growth as well as in the intrinsic growth potential of some thyroid follicular cells. The diagnosis of thyroid nodule demands further investigation such as thyroid function evaluation and distinction between benign from malignant nodules using FNAB. The confirmation or suspicion of malignancy or presence of compressive symptoms is indication for surgery. In benign lesions, without features of hyperthyroidism observation may be advised. Thyroxine therapy may be proposed to some patients but the possibility of side-effects should always be taken into account, as well as the low efficacy of this treatment.

Management of simple nodular goiter: current status and future perspectives

The simple nodular goiter, the etiology of which is multifactorial, encompasses the spectrum from the incidental asymptomatic small solitary nodule to the large intrathoracic goiter, causing pressure symptoms as well as cosmetic complaints. Its management is still the cause of considerable controversy. The mainstay in the diagnostic evaluation is related to functional and morphological characterization with serum TSH and (some kind of) imaging. Because malignancy is just as common in patients with a multinodular goiter as patients with a solitary nodule, we support the increasing use of fine-needle aspiration biopsy (cytology). Most patients need no treatment after malignancy is ruled out. In case of cosmetic or pressure symptoms, the choice in multinodular goiter stands between surgery, which is still the first choice, and radioiodine if uptake is adequate. In addition to surgery, the solitary nodule, whether hot or cold, can be treated with percutaneous ethanol injection therapy. If hot, radioiodine is the therapy of choice. Randomized studies are scarce, and the side effects of nonsurgical therapy are coming into focus. Therefore, the use of the optimum option in the individual patient cannot at present be based on evidence. However, we are of the view that levothyroxine, although widely used, should no longer be recommended routinely for this condition. Within a few years, the introduction of recombinant human TSH and laser therapy may profoundly alter the nonsurgical treatment of simple nodular goiter.