Approach to management of the patient with primary or secondary intrathoracic goiter.

Intrathoracic (substernal) goiter, depending on definition, is seen in up to 45% of all patients operated for goiter. It can either be primary (ectopic thyroid tissue detached from a cervical thyroid mass), which is very rare (1%), or (more commonly) secondary, where a portion of the goiter extends retrosternally. There is no consensus on diagnostic or therapeutic management, partly because many are asymptomatic. Classification involves functional characterization with serum TSH and morphological characterization with diagnostic imaging and cytology to rule out malignancy, which is not more common than in cervical goiters. Pulmonary function is often affected in asymptomatic individuals also. Therefore, but also because natural history is continuous growth and evolution from euthyroidism to hyperthyroidism, most experts recommend therapy. In primary as well as secondary intrathoracic goiter, the therapy of choice is total/near-total thyroidectomy and subsequent levothyroxine substitution. Data suggest that complications are only slightly more prevalent than in cervical goiters. Although levothyroxine is not recommended for goiter shrinkage, there is increasing focus on radioactive iodine as an alternative to surgery in secondary intrathoracic goiters. Here it can reduce thyroid size by on average 40% after 1 yr and improve respiratory function and quality of life. Recent studies show that recombinant human TSH, currently used off-label, can augment the radioiodine-related goiter shrinkage by 30-50%. With currently used doses of recombinant human TSH, the side effects, besides hypothyroidism, are rare and mild. Future studies should also explore the use of radioiodine in primary intrathoracic goiter and compare surgery and radioiodine, head to head.

Terapêutica actínica do bócio multinodular precedida de dose única de hormônio estimulante da tireóide humano recombinante (rhTSH) / The actinic treatment of multinodular goiter preceeded by a single dose of recombinant human thyroid-stimulating hormone (rhTSH)

Bócios multinodulares podem causar sintomas compressivos e hipertireoidismo subclínico.O tratamento actínico é uma alternativa ao tratamento cirúrgico.Porém com TSH suprimido e captação baixa , a resposta ao tratamento é variável.Com o objetivo de elevar a captação e aumentar a eficácia do tratamento actínico foi utilizado TSH humano recombinante.Os trinta e quatro pacientes selecionados, com bócio / Multinodular goiters, often present pressure symptoms and subclinical hyperthyroidism. Actinic treatment has been alternatively used to surgical treatment, moreover suppresssed TSH and low radioiodine uptake, the response to I131 is variable To increase the goiter uptake of radioiodine, was used recombinant human thyroid stimulating hormone Thirty four patients presenting multinodular goiter...(

Bilateral external laryngoceles following radioiodine ablation for Graves disease.

A 28-year-old trumpet player underwent multiple treatments with radioactive iodine for Graves disease associated with an unusually large goiter. Following his second treatment, the patient developed acute neck pain and swelling. Radiographic studies and a laryngoscopy demonstrated bilateral symptomatic external laryngoceles, a very rare entity, not previously known to be associated with radioiodine treatment or Graves disease. The patient's profession placed him at risk for the development of a laryngocele, but the temporal relationship to goiter regression following radioiodine therapy suggests that this occurred as a result of this treatment. The patient's disease was managed nonsurgically, and he has subsequently done well. This represents the first known association of symptomatic laryngocele with radioiodine treatment for Graves disease.