Fine-needle aspiration biopsy of the thyroid. Diagnostic accuracy when performing a moderate number of such procedures.

The diagnostic accuracy of fine-needle aspiration biopsy of the thyroid was evaluated. Between June 1982 and July 1987, 354 fine-needle aspiration biopsies were performed on 289 patients with thyroid nodules. The ages of the patients ranged from 21 to 86 years (median, 45 years); 61 (21%) were men and 228 (79%) were women. Surgical confirmation of the cytologic diagnosis was obtained in 59 patients. Fine-needle aspiration biopsy identified 10% of the nodules as probably malignant and 10% as possibly malignant. Of these nodules, 30.5% were proved to be malignant by histologic examination. The accuracy of distinction between a benign (class I or II) or probably malignant (class IV) diagnosis was 95.2%. Patient acceptance of this procedure was good and complications were infrequent. These results indicate that fine-needle aspiration biopsy of the thyroid is accurate, safe, well tolerated, and easily applied, without its highly desirable features being compromised, even when a moderate number of such procedures are performed.

Importance of repeat fine-needle biopsy in the management of thyroid nodules.

Fine-needle aspiration (FNA) biopsy of a thyroid nodule was performed in 797 patients. Ninety-six patients had resection of the thyroid nodule performed subsequent to a one-time FNA biopsy. The surgical pathology of these 96 cases demonstrated a 5.8% false-negative rate and a 9.9% false-positive rate. As a consequence, we prospectively evaluated the routine practice of repeat FNA of cytologically benign thyroid nodules. Repeat FNA confirmed the original benign cytology in 183 (93%) of 196 patients. Seventeen of these 183 patients with benign FNA on both biopsies had resection of the nodule performed because of the development of suspicious clinical signs or in response to the patient's choice; 1 recurrent cyst was found to be carcinomatous. Of the 13 patients demonstrating a change in cytology on repeat FNA biopsy, 9 had a nodule that was classified as possibly malignant (suspicious); 6 of these patients underwent resection, and 1 patient was found to have a carcinomatous nodule. Four patients had nodules that were classified as probably malignant on repeat FNA biopsy; all of their nodules were resected, and three of them were found to be carcinomatous. This study demonstrates that, although one-time FNA biopsy of thyroid nodules is highly accurate, with a relatively low false-negative rate, repeat fine-needle biopsy improves on this diagnostic accuracy, thereby decreasing the risk of misdiagnosing a thyroid nodule that is malignant.

Hyperthyroidism during lithium therapy for depression.

OBJECTIVE: To report three cases of hyperthyroidism encountered within a period of 32 months in patients receiving lithium therapy for depression. METHODS: Three detailed case reports are presented, and the related literature is discussed. RESULTS: Although hypothyroidism during lithium therapy is well recognized and documented, appearance of cases of hyperthyroidism during lithium therapy is considered uncommon. The antithyroid effect of lithium through inhibition of generation of cyclic adenosine monophosphate tends to mask the underlying hyperthyroidism. Nevertheless, during a 32-month period, three cases of hyperthyroidism were encountered in patients who had received lithium treatment (900 to 1,200 mg/day) for 7 months to 17 years. These patients had symptoms of heat intolerance, palpitations, and tremor, and they were subsequently treated successfully with radioactive iodine. CONCLUSION: Most likely, cases of hyperthyroidism that occur during lithium therapy may be under-diagnosed, underreported, or both.

Isolated familial hyperparathyroidism with a novel mutation of the MEN1 gene.

OBJECTIVE: To describe two cases of familial hyperparathyroidism with genetic analysis and report a new gene mutation. METHODS: Clinical and laboratory details of a brother and sister with hyperparathyroidism and nephrolithiasis are presented. The family history is reviewed, and results of direct sequencing analysis for mutations in the MEN1 gene are discussed. RESULTS: Isolated familial hyperparathyroidism is uncommon. Whether this condition is a partial expression of multiple endocrine neoplasia type I, a well-known genetic disorder, or an independent entity is being debated and studied. Two cases of hyperparathyroidism were diagnosed in a brother and a sister from a family that has expressed isolated hyperparathyroidism in several family members as the only manifestation thus far. A novel genetic mutation involving a CGG to CGT alteration in codon 219 of the MEN1 gene was discovered; to our knowledge, this particular variation has not been reported previously. CONCLUSION: In patients with isolated familial hyperparathyroidism, a search for a mutation in the MEN1 gene may eventually help clarify this uncommon familial condition.

The role of ultrasonography in the evaluation of primary hyperparathyroidism.

Ultrasonography was used preoperatively in 21 patients with primary hyperparathyroidism in an effort to locate enlarged parathyroid glands. It indicated the presence of a solitary mass compatible with a parathyroid adenoma in 14 patients. At operation, adenomas were found at the location indicated by ultrasonography in 13 of the 14 patients (93 per cent). In seven patients, ultrasonography failed to reveal evidence of a mass of the parathyroid gland. At operation, three had diffuse parathyroid hyperplasia and four had a solitary adenoma. Of the four patients with adenomas undetected by ultrasonography, one patient had an adenoma which had undergone infarction and three had coexisting nodular thyroid gland disease. We concluded that ultrasonography is valuable in the preoperative assessment of patients with primary hyperparathyroidism. This is especially so in the absence of coexisting nodular thyroid gland disease. When positive, ultrasonography accurately locates adenomas, and when negative, it strongly suggests the presence of hyperplasia. This may have clinical application in limiting the extent of dissection and, thereby, reducing the morbidity of parathyroid gland exploration.