12-month efficacy of a single radiofrequency ablation on autonomously functioning thyroid nodules.

PURPOSE: Radiofrequency ablation has been advocated as an alternative to radioiodine and/or surgery for the treatment of autonomously functioning benign thyroid nodules. However, only a few studies have measured radiofrequency ablation efficacy on autonomously functioning benign thyroid nodules. The aim of this work was to evaluate the 12-month efficacy of a single session of radiofrequency ablation (performed with the moving shot technique) on solitary autonomously functioning benign thyroid nodules. METHODS: Thirty patients with a single, benign autonomously functioning benign thyroid nodules, who were either unwilling or ineligible to undergo surgery and radioiodine, were treated with radiofrequency ablation between April 2012 and May 2015. All the patients underwent a single radiofrequency ablation, performed with the 18-gauge needle and the moving shot technique. Clinical, laboratory, and ultrasound evaluations were scheduled at baseline, and after 1, 3, 6, and 12 months from the procedure. RESULTS: A single radiofrequency ablation reduced thyroid nodule volume by 51, 63, 69, and 75 % after 1, 3, 6, and 12 months, respectively. This was associated with a significant improvement of local cervical discomfort and cosmetic score. As for thyroid function, 33 % of the patients went into remission after 3 months, 43 % after 6 months, and 50 % after 12 months from the procedure. This study demonstrates that a single radiofrequency ablation allowed us to withdraw anti-thyroid medication in 50 % of the patients, who remained euthyroid afterwards. CONCLUSION: This study shows that a single radiofrequency ablation was effective in 50 % of patients with autonomously functioning benign thyroid nodules. Patients responded gradually to the treatment. It is possible that longer follow-up studies might show greater response rates.

Management of a pregnant woman with thyrotropinoma: a case report and review of the literature.

INTRODUCTION: Pituitary disorders during pregnancy are uncommon. The approach should include a close follow-up in order to reduce maternal and fetal risks associated with physiological changes during pregnancy or treatment side effects. MATERIALS AND METHODS: We report a 21-year-old woman with a thyroid-stimulating hormone-secreting pituitary macroadenoma and positive antithyroid antibodies. She was initially treated using transsphenoidal pituitary surgery. The patient relapsed 17-month post-surgery. Somatostatin analog therapy was started which rapidly controlled the hyperthyroidism. Eleven months later, while receiving octreotide, the patient reported to be pregnant and the medication was stopped. Gestation and delivery went well with a healthy full-term newborn. The patient developed a postpartum thyroiditis 15 weeks after giving birth. Twenty-eight months postpartum the patient remains euthyroid without medication. CONCLUSIONS: The overall positive outcomes of the four cases reported in literature, including this new case, suggest that pregnancy should not be absolutely contraindicated in women with thyrotropinomas. We emphasize the effectiveness of octreotide to control hyperthyroidism, as well as stopping medication when a patient is found to be pregnant. In our case, close observation following octreotide cessation had a positive outcome.

Early detection of biochemically occult autonomous thyroid nodules.

OBJECTIVE: Autonomously functioning thyroid areas may be associated with subclinical or overt hyperthyroidism, but may exist even in the presence of normal TSH. This study was aimed at comparing the rate of autonomously functioning areas and their cardiac sequelae in patients with nodular goitre studied with the usual and a novel approach. DESIGN AND METHODS: In total 490 adult outpatients with thyroid nodular goitre, living in a mild iodine-deficient area, were selected in our referral centre for thyroid diseases from 2009 to 2014 on the basis of a suspicion of thyroid functional autonomy. They were divided in three groups according to a non-conventional approach (excessive response to thyroxine treatment: group 1) or conventional approach (low/normal TSH with clinical suspicion or low TSH: groups 2 and 3). All patients of the study with the suspicion of thyroid functional autonomy underwent thyroid scan with radioactive iodine (I131) uptake (RAIU). RESULTS: The percentage of confirmed thyroid functional autonomy was 319/490, being significantly higher in group 3 than in groups 1 and 2 (81.5 vs 64.7 vs 52.6%; chi-square P < 0.0001). However, the diagnosis with non-conventional approach was made at a significant earlier age (P < 0.0001). Cardiac arrhythmias as well as atrial fibrillation were similarly detected by conventional and non-conventional approaches (chi-square test: P = 0.2537; P = 0.8425). CONCLUSIONS: The hyper-responsiveness to thyroxine treatment should induce the suspicion of thyroid functional autonomy at an early stage, allowing to detect autonomous functioning areas in apparently euthyroid patients.

Change of maternal thyroid function in twin-twin transfusion syndrome.

Human chorionic gonadotropin (hCG) has weak thyroid-stimulating activity because of its homology with thyroid stimulating hormone (TSH). In twin-twin transfusion syndrome (TTTS), which is a severe complication of monochorionic twin pregnancies, a close association between maternal serum hCG concentration and TTTS has been reported. And, TTTS can be treated by fetoscopic laser coagulation of the communicating vessels. To clarify the relationship between maternal serum hCG and maternal thyroid function in TTTS, the present study investigated the change in thyroid hormone and hCG levels after laser therapy. The protocol included collection of serial maternal blood samples in TTTS before laser therapy, and at two and four weeks after laser therapy. For 131 cases of TTTS, the following parameters were determined at each point: hCG, TSH, free triiodothyronine (fT3), and free thyroxine (fT4). The multiple of the median (MoM) of pre-operative hCG concentration in TTTS was 5.39 MoM (interquartile range, 2.83 - 8.64). There was a moderate positive correlation between hCG and fT3 in TTTS pre-operatively (R = 0.22, P = 0.030). fT4 was also positively correlated with hCG (R = 0.33, P < 0.001). Some cases showed very high concentration in fT3. When laser therapy for TTTS was effective, the hCG concentration significantly decreased, and fT3 and fT4 decreased progressively in concert with the decrease in hCG. The relationship between hCG and thyroid function in TTTS supports the finding of TTTS as a novel etiology of hCG-mediated hyperthyroidism during pregnancy.

Iodine deficiency and thyroid disorders.

Iodine deficiency early in life impairs cognition and growth, but iodine status is also a key determinant of thyroid disorders in adults. Severe iodine deficiency causes goitre and hypothyroidism because, despite an increase in thyroid activity to maximise iodine uptake and recycling in this setting, iodine concentrations are still too low to enable production of thyroid hormone. In mild-to-moderate iodine deficiency, increased thyroid activity can compensate for low iodine intake and maintain euthyroidism in most individuals, but at a price: chronic thyroid stimulation results in an increase in the prevalence of toxic nodular goitre and hyperthyroidism in populations. This high prevalence of nodular autonomy usually results in a further increase in the prevalence of hyperthyroidism if iodine intake is subsequently increased by salt iodisation. However, this increase is transient because iodine sufficiency normalises thyroid activity which, in the long term, reduces nodular autonomy. Increased iodine intake in an iodine-deficient population is associated with a small increase in the prevalence of subclinical hypothyroidism and thyroid autoimmunity; whether these increases are also transient is unclear. Variations in population iodine intake do not affect risk for Graves' disease or thyroid cancer, but correction of iodine deficiency might shift thyroid cancer subtypes toward less malignant forms. Thus, optimisation of population iodine intake is an important component of preventive health care to reduce the prevalence of thyroid disorders.

A critical review of food-associated factors proposed in the etiology of feline hyperthyroidism.

Since the first description of feline hyperthyroidism (HT) in 1979, several studies have been undertaken to define the etiology of the disease. Epidemiologic studies, after investigating non-food- and food-associated factors, suggest a multifactorial etiology. However, in the absence of prospective cohort studies that can confirm a cause-and-effect relationship between HT and associated risk factors, no causative factor for HT has been identified to date. Feline HT resembles toxic nodular goiter in humans, with autonomously functioning upregulated iodide uptake systems. Contribution of the diet to HT development remains controversial. The purpose of this paper is to review critically the reported food-associated risk factors for HT.

[Maternal autoimmune thyroid disease: relevance for the newborn]. / Enfermedad tiroidea autoinmunitaria materna: repercusión en el recién nacido.

BACKGROUND AND OBJECTIVE: Autoimmune thyroid disease is amongst the most frequent endocrine disorders during pregnancy. It is associated with an increase in perinatal morbidity, congenital defects, neurological damage, fetal and neonatal thyroid dysfunction. Maternal thyroid hormones play a key role in child neurodevelopment. We aimed to evaluate the thyroid function and the clinical course of neonates born from mothers with autoimmune thyroid disease during the first months of life in order to define the follow-up. PATIENTS AND METHOD: We monitored thyroid function and clinical status during the first months in 81 newborns of mothers with autoimmune thyroid disease; 16 had Graves disease and 65 autoimmune thyroiditis. RESULTS: A percentage of 4.93 newborns had congenital defects, and 8.64% neonates showed an increase in thyrotropin (TSH) (>9.5 µUI/mL 2 times) and required thyroxin within the first month of life. A 85.7% of these showed a negative newborn screening (due to a later increase of TSH). A higher TSH value in the newborn was related to an older age of the mother, higher levels of thyroid peroxidase (TPO) antibody during pregnancy and lower birth weight. A higher free thyroxine (FT4) value in the newborn was related to fewer days of life and mothers with Graves disease. CONCLUSIONS: We recommend the evaluation of TSH, T4 and TPO antibodies before 10 weeks in all pregnant women with follow-up if maternal thyroid autoimmunity or disorders is detected. It is also recommended to test children's serum TSH and FT4 at 48 h of life in newborns of mothers with autoimmune thyroid disease and repeat them between the 2nd and 4th week in children with TSH>6 µUI/mL. Careful endocrine follow-up is advised in pregnant women and children if hyperthyroidism is detected.

Adenoma tóxico de Plummer: relato de caso / Toxic adenoma of Plummer: case report

O termo hipertireoidismo refere-se ao aumento da síntese e liberação dos hormônios tireoidianos pela glândula tireoide. O bócio multinodular toxico e o adenoma toxico constituem as principais causas do hipertireoidismo no paciente idoso e são frequentes em regiões com ingestão insuficiente de iodo...

[Total thyroidectomy in patients with amiodarone-induced hyperthyroidism: when does the risk of conservative treatment exceed the risk of surgery?]. / Totale Thyreoidektomie bei amiodaroninduzierter Hyperthyreose: Wann übersteigt das Risiko der konservativen Therapie das Risiko der chirurgischen Behandlung?

Amiodarone plays a pivotal role in the treatment of ventricular and supraventricular arrhythmias. However, amiodarone-induced hyperthyroidism (AIH) is one of the most feared complications, which necessitates interdisciplinary treatment and careful balancing of the risks of conservative treatment against those of total thyroidectomy. In this article we discuss the pharmacological aspects of amiodarone and its diverse effects on the thyroid. Furthermore, we present diagnostic and therapeutic strategies and report our positive experiences with total thyroidectomy in patients with AIH. Particularly in patients for whom continuation of amiodarone treatment is compulsory, a well-timed total thyroidectomy is a reliable therapeutic option, with minimal complication rates and immediate amelioration of symptoms.

Interventions for hyperthyroidism pre-pregnancy and during pregnancy.

BACKGROUND: Women with hyperthyroidism in pregnancy have increased risks of miscarriage, stillbirth, preterm birth, and intrauterine growth restriction; and they can develop severe pre-eclampsia or placental abruption. OBJECTIVES: To identify interventions used in the management of hyperthyroidism pre-pregnancy or during pregnancy and to ascertain the impact of these interventions on important maternal, fetal, neonatal and childhood outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2013). SELECTION CRITERIA: We planned to include randomised controlled trials, quasi-randomised controlled trials, and cluster-randomised trials comparing antithyroid interventions for hyperthyroidism pre-pregnancy or during pregnancy with another intervention or no intervention (placebo or no treatment). DATA COLLECTION AND ANALYSIS: Two review authors assessed trial eligibility and planned to assess trial quality and extract the data independently. MAIN RESULTS: No trials were included in the review. AUTHORS' CONCLUSIONS: As we did not identify any eligible trials, we are unable to comment on implications for practice, although early identification of hyperthyroidism before pregnancy may allow a woman to choose radioactive iodine therapy or surgery before planning to have a child. Designing and conducting a trial of antithyroid interventions for pregnant women with hyperthyroidism presents formidable challenges. Not only is hyperthyroidism a relatively rare condition, both of the two main drugs used have potential for harm, one for the mother and the other for the child. More observational research is required about the potential harms of methimazole in early pregnancy and about the potential liver damage from propylthiouracil.

Oral triiodothyronine normalizes triiodothyronine levels after surgery for pediatric congenital heart disease*.

OBJECTIVES: This study was conducted to determine if oral triiodothyronine supplementation could prevent the decrease of serum triiodothyronine levels that commonly occurs after cardiopulmonary bypass for pediatric congenital heart surgery. Secondary objectives included identifying any significant adverse effects of oral triiodothyronine supplementation, including any effects on the thyroid/pituitary axis. DESIGN: Randomized, placebo-controlled, doubleblind clinical trial SETTING: Operating room and ICU. SUBJECTS: Infants and children younger than 2 years of age undergoing congenital heart surgery using cardiopulmonary bypass (n = 43). INTERVENTIONS: Subjects were assigned to placebo (n = 15, group A) or one of two treatment groups: a low-dose group (group B, n = 14, 0.5 mcg/kg triiodothyronine orally every 24 hr for 3 d) or a high-dose group (group C, n = 14, 0.5 mcg/kg triiodothyronine orally every 12 hr for 3 d). MEASUREMENTS AND MAIN RESULTS: Thyroid hormone, including total and free triiodothyronine levels at predetermined time points, potential side effects indicating hyperthyroidism, indicators of the thyroid-pituitary axis, and clinical endpoints. Oral triiodothyronine supplementation twice-daily maintained serum triiodothyronine levels within normal limits in group C, whereas serum levels progressively declined in groups A and B. A statistically significant difference in triiodothyronine levels between the treatment groups occurred between 18 and 36 hours post cross-clamp release, with the largest difference in serum levels between group C and group A noted at 36 hours post cross-clamp release (total triiodothyronine, 0.71 ± 0.15 [0.34-1.08] ng/mL [p < 0.01]; free triiodothyronine, 2.56 ± 0.49 [1.33-3.79] pg/mL [p < 0.01]). There was no evidence of hyperthyroidism or suppression of the pituitary-thyroid axis in either treatment group CONCLUSIONS: Oral triiodothyronine supplementation at a dose of 0.5 mcg/kg every 12 hours for 3 days can maintain total and free triiodothyronine levels within normal limits after open-heart surgery using cardiopulmonary bypass for congenital heart disease.

Hyperthyroidism due to thyroid-stimulating hormone secretion after surgery for Cushing's syndrome: a novel cause of the syndrome of inappropriate secretion of thyroid-stimulating hormone.

CONTEXT: Hyperthyroidism with the syndrome of inappropriate secretion of TSH (SITSH) occurred by a decrease in hydrocortisone dose after surgery for Cushing's syndrome. This is a novel cause of SITSH. OBJECTIVE: The aim of this study was to describe and discuss 2 cases of SITSH patients that were found after surgery for Cushing's syndrome. We also checked whether SITSH occurred in 7 consecutive patients with Cushing's syndrome after surgery. PATIENTS AND METHODS: A 45-year-old Japanese woman with ACTH-independent Cushing's syndrome and a 37-year-old Japanese man with ACTH-dependent Cushing's syndrome presented SITSH caused by insufficient replacement of hydrocortisone for postoperative adrenal insufficiency. When the dose of hydrocortisone was reduced to less than 20 mg/d within 18 days after surgery, SITSH occurred in both cases. We examined whether the change of the hydrocortisone dose induced the secretion of TSH. Free T3 and TSH were normalized by the hydrocortisone dose increase of 30 mg/d, and these were elevated by the dose decrease of 10 mg/d. We also checked TSH and thyroid hormone levels of the 7 consecutive patients with Cushing's syndrome after surgery. Six (66.6 %) of 9 patients showed SITSH. CONCLUSIONS: This is the first report that insufficient replacement of hydrocortisone after surgery for Cushing's syndrome caused SITSH. Hyperthyroidism by SITSH as well as adrenal insufficiency can contribute to withdrawal symptoms of hydrocortisone replacement. We need to consider the possibility of SITSH for the pathological evaluation of withdrawal syndrome of hydrocortisone replacement.

Beneficial effects of adequate iodine supply on characteristics of thyroid autonomy.

OBJECTIVE: Our aim was to establish the characteristics of thyroid autonomy (TA) in Slovenian patients and the required therapeutic dose of radioiodine before and ten years after the increase in mandatory salt iodization from previous 10 mg of potassium iodide to 25 mg per kg in 1999 because almost no data about TA and radioiodine treatment with respect to iodine supply are available. DESIGN: Retrospective clinical study. PATIENTS: We reviewed records of all patients referred for the first time in 1998 and 2009 to the Thyroid Department at the University Medical Centre Ljubljana which is a tertiary referral centre with a stable catchment area for more than 20 years. METHODS: TA was diagnosed by thyroid function, ultrasound, scintigraphy and negative TSH receptor antibodies. Demographic characteristics and the applied dose of radioiodine were evaluated. RESULTS: In 1998, significantly more patients presented with TA than in 2009 (383 of 3243, 11·8% and 333 of 4546, 7·3%, respectively, P < 0·001). In 1998, the ratio between hyperthyroid and euthyroid patients was higher than in 2009 (6:1 and 2·1:1, respectively, P < 0·001). In 1998, patients were younger than in 2009 (mean 63·8 ± 13·9 and 66·8 ± 14·9 years, respectively, P < 0·004). Hyperthyroid patients were older than euthyroid in both years (P < 0·001). In 1998, mean applied dose of radioiodine was significantly lower than in 2009 (713 ± 306 and 791 ± 194 MBq, respectively, P = 0·003). CONCLUSIONS: In adequate iodine supply, TA is less frequent, patients are less often hyperthyroid, they are older and cured with higher doses of radioiodine than in mild iodine deficiency.

Hyperthyroidism in cats: what's causing this epidemic of thyroid disease and can we prevent it?

PRACTICAL RELEVANCE: Since first being reported in the late 1970s, there has been a dramatic increase in the prevalence of hyperthyroidism in cats. It is now recognized worldwide as the most common feline endocrine disorder. PATIENT GROUP: Hyperthyroidism is an important cause of morbidity in cats older than 10 years of age. It is estimated that over 10% of all senior cats will develop the disorder. CLINICAL CHALLENGES: Despite its frequency, the underlying cause(s) of this common disease is/are not known, and no one has suggested a means to prevent the disorder. Because of the multiple risk factors that have been described for feline hyperthyroidism, it is likely that more than one factor is involved in its pathogenesis. Continuous, lifelong exposure to environmental thyroid disruptor chemicals or goitrogens in food or water, acting together in an additive or synergistic manner, may first lead to euthyroid goiter and then to autonomous adenomatous hyperplasia, thyroid adenoma and hyperthyroidism. EVIDENCE BASE: This review draws on published research studies to summarize the available evidence about the risk factors for feline hyperthyroidism. Based on the known goitrogens that may be present in the cat's food, drinking water or environment, it proposes measures that cat owners can implement that might prevent, or reduce the prevalence of, thyroid tumors and hyperthyroidism in their cats.

[Hyperthyroidism, eosinophilia, and fever in a 64-year-old patient]. / Hyperthyreose, Eosinophilie und Fieber bei einem 64-jährigen Patienten.

We report on a male patient suffering from loss of weight, fatigue, fever, eosinophilia, and hyperthyreoidism. The echocardiogram revealed a left atrial mass originating from the posterior mitral leaflet. In combination with the constitutional symptoms a left atrial myxoma was diagnosed. The tumor was surgically removed. Postoperatively therapy with corticosteroids and thiamazole was stopped. During follow-up, eosinophilia and hyperthyreodism could no longer be detected.

Time course of Graves' ophthalmopathy after total thyroidectomy alone or followed by radioiodine therapy: a 2-year longitudinal study.

The findings in hyperthyroid patients with Graves' orbitopathy (GO) of antibodies against antigens shared between the thyroid and orbit, such as the TSH-receptor (TRAb) and a novel protein G2s (G2sAb), suggested a possible common therapeutic strategy. However, the gold therapeutic standard for hyperthyrodism in these patients remains still unsettled and is mainly based on personal experience. Studies on the effect of total thyroidectomy (TT) alone or followed by radioiodine ablation (RAI) of thyroid remnants showed often conflicting results. This longitudinal study was aimed at evaluating the influence of TT alone or followed by post-surgical RAI with respect to methimazole treatment on the activity and severity of GO in patients with hyperthyroidism and GO. Sixty consecutive patients with Graves' disease and mild/moderate GO were studied and grouped as follows: group 1, including 25 patients (16F, 9M) undergoing TT alone; group 2, including 10 patients (8F, 2M) undergoing TT followed by RAI for histological evidence of differentiated thyroid cancer; group 3, including 25 patients (18F, 7M) euthyroid under methimazole therapy, studied as controls. Clinical study of ophthalmopathy and measurements of TRAb and G2sAb were performed in all patients at start of the study (time of TT for group 1 and RAI after TT for group 2 and of the first finding of euthyroidism under methimazole treatment for group 3) and after 6, 12, 24 months. Patients of both groups 1 and 2 showed an early significant decrease and a further progressive reduction of the activity and severity of GO with a disappearance of TRAb and a decrease of G2sAb levels during the follow-up, without statistically significant differences between the two groups. Patients in group 3 showed a much later and less marked improvement of GO with persistence of TRAb and G2sAb positivity, even if with reduction of TRAb levels at 12 and 24 months. Our results suggest that in Graves' patients with large goiter or relapse of hyperthyroidism and mild/moderate GO, TT alone could be an advisable choice to treat hyperthyroidism also improving GO with reduction of cost/benefit ratio.

Striving for euthyroidism in radioiodine therapy of Graves' disease: a 12-year prospective, randomized, open-label blinded end point study.

BACKGROUND: In China, use of radioiodine therapy is problematic because of the need for lifelong levothyroxine substitution. Our aim was to find an optimum dosing strategy for (131)I treatment of hyperthyroidism due to Graves' disease (GD). We attempted to achieve euthyroidism to avoid long-term levothyroxine treatment. METHODS: Six hundred patients with GD were randomized into five groups, each comprising 120 individuals, to receive an individual (131)I activity selected from five different ascending activity ranges. The ranges were modulated according to a clinical score system. Follow-up was extended over a 12-year time frame. The primary outcomes were euthyroidism, hyperthyroidism, hypothyroidism, and recurrent hyperthyroidism. The secondary endpoint was the accumulated (131)I activity needed to achieve euthyroidism. RESULTS: Out of 682 screened patients, 600 entered the study in 1997. Five hundred twenty-nine completed the last follow-up visit at the end of the study in 2009. Group 3 was identified as the study arm that received the optimum radioiodine activity, with 71.8% of the patients maintaining a euthyroid status, 5.8% remaining hyperthyroid, and 22.3% becoming hypothyroid by the end of the study. This group received 1.85-4.07 MBq per gram of thyroid tissue (average administered activity 261 ± 162 MBq). Over the 12-year follow-up period, the recurrence rate was 13.6%. The efficacy of (131)I treatment was related to activities modulated by a clinical score (χ(2) = 82.1, p = 0.000). CONCLUSION: Our protocol effectively treated hyperthyroidism and significantly reduced the hypothyroidism rate. It may be preferable to the intentional induction of permanent hypothyroidism recommended by many experts.

Update on subclinical hyperthyroidism.

Subclinical hyperthyroidism is defined by low or undetectable serum thyroid-stimulating hormone levels, with normal free thyroxine and total or free triiodothyronine levels. It can be caused by increased endogenous production of thyroid hormone (as in Graves disease or toxic nodular goiter), administration of thyroid hormone for treatment of malignant thyroid disease, or unintentional excessive thyroid hormone therapy. The rate of progression to overt hyperthyroidism is higher in persons who have suppressed thyroid-stimulating hormone levels compared with those who have low but detectable levels. Subclinical hyperthyroidism is associated with an increased risk of atrial fibrillation in older adults, and with decreased bone mineral density in postmenopausal women; however, the effectiveness of treatment in preventing these conditions is unknown. There is lesser-quality evidence suggesting an association between subclinical hyperthyroidism and other cardiovascular effects, including increased heart rate and left ventricular mass, and increased bone turnover markers. Possible associations between subclinical hyperthyroidism and quality of life parameters, cognition, and increased mortality rates are controversial. Prospective randomized controlled trials are needed to address the effects of early treatment on potential morbidities to help determine whether screening should be recommended in the asymptomatic general population.