Medición rutinaria de calcitonina sérica en nódulos tiroideos / Routine serum calcitonin measurement in thyroid nodules

Existe mucha controversia sobre los beneficios de la medición de la calcitonina sérica (CT) durante la evaluación inicial de pacientes con nódulos tiroideos. El objetivo del estudio fue evaluar la identificación temprana del carcinoma medular de tiroides (CMT) a través de la medición rutinaria de CT sérica en una cohorte de Buenos Aires, Argentina. Se estudiaron consecutivamente a los pacientes con enfermedad nodular de la tiroides (n=1017). La CT se midió por quimioluminiscencia (valor normal: hasta 18 pg/ml en hombres y 12 pg/ml en mujeres). En dos pacientes, la hipercalcitoninemia se confirmó en mediciones repetidas. La aspiración con aguja fina con medición de CT en el líquido obtenido identificó la presencia del CMT. El estudio genético fue positivo en uno (mutación exón 14, Val804Met, CMT familiar). El otro presentó un polimorfismo (heterocigoto exón 13 L769L - heterocigoto exón 15 S904S). En ambos casos, la CT se normalizó 3 meses después de la cirugía y se mantuvo en valores normales después de 6 años de seguimiento. La medición rutinaria de la CT en nódulos tiroideos fue útil para detectar dos casos de CMT, uno de ellos esporádico y el otro familiar en la cohorte seguida. La prevalencia de CMT fue de 0.2%.

There is much controversy about the benefits of the use of serum calcitonin (CT) in the initial evaluation of patients with thyroid nodules. The objective of the study was to early identify medullary thyroid carcinoma (MTC) through the routine measurement of CT in thyroid nodular pathology in a large cohort of patients from Buenos Aires, Argentina. Consecutive patients with nodular thyroid disease (n=1017) were studied. CT was measured by chemiluminescence, normal value: up to 18 pg/ml in men and 12 pg/ml in women. In two patients, hypercalcitoninemia was confirmed in repeated measurements. Fine needle aspiration with CT measurement in the needle wash fluid identified MTC in nodules with citology abnormalities. The genetic study was positive in one patient (mutation exon 14, Val804Met, MTC familiar). The other presented a polymorphism (exon 13 L769L heterozygous - exon 15 S904S heterozygous). In both cases, CT was normalized 3 months after surgery and remained normal after 6 years of follow-up. The routine measurement of CT in thyroid nodular pathology was useful to detect two cases of MTC, one of them sporadic and the other familiar in this cohort. The prevalence of MTC was 0.2%.

Serum PTH reference values in an adult Brazilian population: implications for the diagnosis of hyperparathyroidism

ABSTRACT Objective: To define serum parathyroid hormone (PTH) reference values in carefully selected subjects following the recommended pre-analytical guidelines. Subjects and methods: First, 676 adults who would be submitted to thyroidectomy were evaluated. Patients using interfering medications or with malabsorption syndrome, hypomagnesemia, hyper- or hypophosphatemia, hypo- or hypercalcemia, 25-hydroxyvitamin D < 30 ng/dL, estimated glomerular filtration rate < 60 mL/min/1.73 m2, urinary calcium/creatinine ratio ≥ 0.25, thyroid dysfunction, parathyroid adenoma detected during surgery were excluded. The sample consisted of 312 subjects. Results: The median, minimum, maximum, and 2.5th and 97.5th percentiles of the PTH values obtained were 30, 7.2, 78, 10.1, and 52 pg/mL, respectively. Thus, the reference range was 10 to 52 pg/mL. PTH > 65 pg/mL, the upper limit of normal according to the manufacturer of the kit, was observed in only one subject (0.3%). Considering the upper limit proposed by the kit's manufacturer, 1/6 hypercalcemic patients and 4/8 normocalcemic patients with PHPT had normal PTH. Using the upper limit established in this study, only one normocalcemic patient had normal PTH. Thus, the sensitivity of PTH in detecting asymptomatic primary hyperparathyroidism (PHPT) using the values recommended by the kit and established in this study was 64% and 93%, respectively (50% versus 87.5% for normocalcemic PHPT). Conclusion: The upper reference limit of PTH obtained for a rigorously selected sample was 20% lower than that provided by the assay, which increased its sensitivity in detecting PHPT.

Percutaneous laser ablation of benign thyroid nodules: a one year follow-up study / Ablação percutânea com laser de nódulos benignos de tireoide: um estudo de acompanhamento de um ano

ABSTRACT Objective To evaluate safety and effectiveness of nodule volume reduction and thyroid function after percutaneous laser ablation treatment in patients with benign nonfunctioning thyroid nodules. Methods Prospective single-center study, from January 2011 to October 2012, which evaluated 30 euthyroid and thyroid antibodies negative patients with benign solitary or dominant nodule with indication of treatment due to compressive symptoms and aesthetic disturbances. The clinical and laboratory (thyroid ultrasound, TSH, FT4, TG, TG-Ab, TPO-Ab and TRAb levels) evaluations were performed before the procedure, and periodically 1 week, 3 months and 6 months after. The ablation technique was performed under local anesthesia and sedation. In each treatment, one to three 21G spinal needle were inserted into the thyroid nodule. The laser fiber was positioned through the needle, which was then withdrawn 10mm to leave the tip in direct contact with the nodule tissue. Patients were treated with a ND: Yag-laser output power of 4W and 1,500 to 2,000J per fiber per treatment. The entire procedure was performed under US guidance. Results Thirty patients, with a total of 31 nodules submitted to laser ablation were evaluated. The median volumetric reduction of the nodule was approximately 60% after 12 months. No statistical significance was observed on thyroid function and antibodies levels. There was a peak on the level of thyroglobulin after the procedure due to tissue destruction (p<0.0001). No adverse effects were observed. Conclusion Percutaneous laser ablation is a promising outpatient minimally invasive treatment of benign thyroid nodule.

RESUMO Objetivo Avaliar a segurança e a efetividade da redução de volume nodular e função tireoidiana após tratamento com ablação percutânea por laser em pacientes com nódulos tireoidianos benignos não funcionantes. Métodos Estudo unicêntrico prospectivo, de janeiro de 2011 a outubro de 2012, que avaliou 30 pacientes eutireoideos (com anticorpos antitireoide negativos), com nódulo solitário ou dominante benigno, com indicação de tratamento devido a sintomas de compressão e distúrbios estéticos. As avaliações clínica e laboratorial (ultrassonografia de tireoide, TSH, FT4, TG, TG-Ab, TPO-Ab e TRAb) foram realizada antes do procedimento e periodicamente − 1 semana, 3 meses e 6 meses depois. A técnica de ablação consistiu em procedimento realizado sob a anestesia local e sedação. Em cada tratamento, uma a três agulhas espinhais 21G foram inseridas no nódulo tireoidiano. A fibra laser foi posicionada através da agulha que foi, então, retirada 10mm, para deixar a ponta em contato direto com o nódulo. Os pacientes foram tratados com uma potência de saída ND: Yag-laser de 4W e 1.500 a 2.000J por fibra por tratamento. Todo o procedimento foi guiado por ultrassonografia. Resultados Foram avaliados 30 pacientes, com total de 31 nódulos submetidos à ablação a laser. A redução média volumétrica do nódulo foi de aproximadamente 60% após 12 meses. Não foi observada significância estatística na função da tireoide e nem nos níveis de anticorpos. Houve pico no nível de tiroglobulina após o procedimento devido à destruição do tecido (p<0,0001). Nenhum efeito adverso foi observado. Conclusão A ablação com laser é um tratamento minimamente invasivo promissor para tratamento do nódulo benigno da tireoide.

Relationship between metabolic syndrome and thyroid nodules in healthy Koreans

BACKGROUND/AIMS: This study evaluated the relationship between thyroid nodules and metabolic syndrome (MS) and its components in apparently healthy Koreans. METHODS: We reviewed the records of 3,298 subjects with no noticeable symptoms who underwent thyroid ultrasound imaging as part of a routine check-up between July 2009 and June 2010; of these, 1,308 were excluded based upon predefined criteria. Among the remaining 1,990 patients, we examined the association between MS and its components and the incidence of thyroid nodules. RESULTS: Of the 1,990 subjects included in this study, 38.4% (n = 764) had thyroid nodules and 12.7% (n = 253) had MS. Female sex, older age, higher body mass index, larger waist circumference, higher glycated hemoglobin level, lower thyroid stimulating hormone level, and presence of MS were all closely related with the presence of thyroid nodules (all p < 0.05). Furthermore, the relevant number of MS components showed a positive linear correlation with the occurrence of thyroid nodules (p < 0.001). Evidence of MS alone was not independently associated with thyroid nodules after adjusting for sex and age in a multivariate binary logistic regression analysis; however, glycated hemoglobin for females and waist circumference for males, as well as both age and thyroid stimulating hormone for all patients, were identified as independent predictors for the existence of thyroid nodules (all p < 0.05). CONCLUSIONS: This study suggests a positive relationship between the components of MS and thyroid nodules in an ostensibly healthy Korean population. Our data support the idea that the recent increase in thyroid nodules is partly due to increases in both MS and obesity.

Usefulness of preoperative serum calcitonin in patients with nodular thyroid disease without suspicious history or cytology for medullary thyroid carcinoma / Utilidade da calcitonina sérica pré-operatória em pacientes com doença nodular tireoidiana sem história ou citologia suspeitas para carcinoma medular de tireoide

OBJECTIVE: To evaluate the usefulness of preoperative serum calcitonin (sCT) in patients with nodular disease without suspicion of medullary thyroid carcinoma (MTC) in history or cytology. PATIENTS AND METHODS: sCT was measured before thyroidectomy in 494 patients with nodular disease who had no family history of MTC or multiple endocrine neoplasia type 2, and no cytological suspicion of MTC. RESULTS: Basal sCT was < 10 ng/mL in 482 patients and none of them had MTC. One patient with basal sCT > 100 pg/mL had MTC. Among the 11 patients with basal sCT between 10 and 100 pg/mL, MTC was diagnosed in only one. The two patients with MTC were submitted to total thyroidectomy, combined with elective lymph node dissection indicated exclusively based on hypercalcitoninemia, and sCT was undetectable after six months. CONCLUSIONS: Preoperative sCT is useful for the detection of sporadic MTC in patients with nodular disease, even in the absence of suspicious history or cytology.

OBJETIVO: Avaliar a utilidade da calcitonina sérica (sCT) pré-operatória em pacientes com doença nodular sem suspeita de carcinoma medular de tireoide (CMT) pela história e citologia. PACIENTES E MÉTODOS: Antes da tireoidectomia, sCT foi dosada em 494 pacientes com doença nodular, sem história familiar de CMT ou neoplasia endócrina múltipla tipo 2 e sem citologia suspeita para CMT. RESULTADOS: sCT basal foi < 10 ng/ml em 482 pacientes e nenhum possuía CMT. Um paciente com sCT basal > 100 pg/ml realmente possuía CMT. Dos 11 pacientes com sCT basal entre 10 e 100 pg/ml, CMT foi diagnosticado em apenas um. Os dois pacientes com CMT foram submetidos à tireoidectomia total com dissecção eletiva de linfonodos, indicada exclusivamente pela hipercalcitoninemia, e após seis meses apresentaram sCT indetectável. CONCLUSÕES: Em pacientes com doença nodular, mesmo sem história ou citologia suspeitas, a sCT pré-operatória é útil para detecção do CMT esporádico.

Hyperfunction Thyroid Nodules: Their Risk for Becoming or Being Associated with Thyroid Cancers

OBJECTIVE: To retrospectively evaluate the risk of thyroid cancer in patients with hyperfunctioning thyroid nodules through ultrasonographic-pathologic analysis. MATERIALS AND METHODS: Institutional review board approval was obtained and informed consent was waived. From 2003 to 2007, 107 patients consecutively presented with hot spots on thyroid scans and low serum thyroid-stimulating hormone levels. Among them, 32 patients who had undergone thyroid ultrasonography were analyzed in this study. Thyroid nodules depicted on ultrasonography were classified based on size and categorized as benign, indeterminate, or suspicious malignant nodules according to ultrasonographic findings. The thyroid nodules were determined as either hyperfunctioning or coexisting nodules and were then correlated with pathologic results. RESULTS: In 32 patients, 42 hyperfunctioning nodules (mean number per patient, 1.31; range, 1-6) were observed on thyroid scans and 68 coexisting nodules (mean, 2.13; range, 0-7) were observed on ultrasonography. Twenty-five patients (78.1%) had at least one hyperfunctioning (n = 17, 53.1%) or coexisting (n = 16, 50.0%) nodule that showed a suspicious malignant feature larger than 5 mm (n = 8, 25.0%), or an indeterminate feature 1 cm or greater (n = 20, 62.5%) in diameter, which could have been indicated by using fine needle aspiration (FNA). Seven patients were proven to have 11 thyroid cancers in 3 hyperfunctioning and 8 coexisting nodules. All of these had at least one thyroid cancer, which could have been indicated by using FNA. The estimated minimal risk of thyroid cancer was 6.5% (7/107). CONCLUSION: Patients with hyperfunctioning nodules may not be safe from thyroid cancer because hyperfunctioning nodules can coexist with thyroid cancer nodules. To screen out these cancers, ultrasonography should be performed.

Utilidad e interpretación de la biopsia tiroidea por punción con aguja fina / Use and interpretation of fine needle aspiration biopsy of thyroid nodules

Fine needle thyroid biopsy is a safe and cost effective diagnostic method for thyroid nodules. Its use has reduced the number of unnecessary thyroidectomies, performed to excise thyroid nodules. Since it is an invasive diagnostic method, its indications should be specified according to ultrasonographic criteria. The massive use of fine needle biopsies increase the number of unsatisfactory samples and indeterminate results. Although it is possible to obtain biopsies from exceedingly small nodules, the clinical significance of these small carcinomas is not yet defined. Ultrasonography, mmunohistochemical markers such as citokeratin, 19, HBME-1, galectin 3) and genetic determinants such as oncogene RET/PTC, 1, 2, 3, RAS oncogene and BRAF V600E mutation along with clinical follow up, will readily identify those patients that are benefited with fine needle biopsies.

Nódulos de tireóide e câncer diferenciado de tireóide: consenso brasileiro / Thyroid nodules and differentiated thyroid cancer: brazilian consensus

Os nódulos tireoidianos constituem a principal manifestação clínica de uma série de doenças da tireóide com uma prevalência de aproximadamente 10 por cento na população adulta. O maior desafio é excluir o câncer da tireóide, que ocorre em 5 a 10 por cento dos casos. Os carcinomas diferenciados respondem por 90 por cento dos casos de todas as neoplasias malignas da tireóide. A maioria dos pacientes com carcinoma diferenciado apresenta, geralmente, um bom prognóstico quando tratada adequadamente, com índices de mortalidade similares à população geral. No entanto, alguns indivíduos apresentam doença agressiva, desafiando o conhecimento atual e ilustrando a complexidade do manejo dessa neoplasia. No presente trabalho, reunimos 8 membros do Departamento de Tireóide da Sociedade Brasileira de Endocrinologia & Metabologia, para elaborarmos, por consenso, as diretrizes brasileiras no manejo dos nódulos tireoidianos e do câncer diferenciado da tireóide. Os membros participantes representam diferentes Centros Universitários do Brasil, refletindo diferentes abordagens diagnósticas e terapêuticas. Inicialmente, cada participante ficou responsável pela redação de determinado tema a ser enviado ao Coordenador, que, após revisão editorial e elaboração da primeira versão do manuscrito, enviou ao grupo para sugestões e aperfeiçoamentos. Quando concluído, o manuscrito foi novamente enviado e revisado por todos. A elaboração dessas diretrizes foi baseada na experiência dos participantes e revisão pertinente da literatura.

Thyroid nodules are a common manifestation of thyroid diseases. It is estimated that ~10 percent of adults have palpable thyroid nodules with the frequency increasing throughout life. The major concern on nodule evaluation is the risk of malignancy (5-10 percent). Differentiated thyroid carcinoma accounts for 90 percent of all thyroid malignant neoplasias. Although most patients with cancer have a favorable outcome, some individuals present an aggressive form of the disease and poor prognostic despite recent advances in diagnosis and treatment. Here, a set of clinical guidelines for the evaluation and management of patients with thyroid nodules or differentiated thyroid cancer was developed through consensus by 8 member of the Department of Thyroid, Sociedade Brasileira de Endocrinologia e Metabologia. The participants are from different reference medical centers within Brazil, to reflect different practice patterns. Each committee participant was initially assigned to write a section of the document and to submit it to the chairperson, who revised and assembled the sections into a complete draft document, which was then circulated among all committee members for further revision. All committee members further revised and refined the document. The guidelines were developed based on the expert opinion of the committee participants, as well as on previously published information.

Cáncer de tiroides: estudio descriptivo retrospectivo / Thyroid carcinoma: a descriptive retrospective study

Entre todos los tumores, el carcinoma tiroideo (CT) es poco frecuente, se caracteriza por su lenta evolución y elevado porcentaje de curación. Nuestro objetivo es estudiar las características de los pacientes con CT. Analizamos retrospectivamente a 171 pacientes, edad media al diagnóstico 41.1( ± 14.6 años), que consultaron entre los años 2000-04 por CT. Se evaluaron datos de anamnesis, métodos de diagnóstico, anatomía patológica y evolución. Agrupamos a los tumores por el tamaño y según TNM (tumor-adenopatía-metástasis) en estadios (E). La presencia de tiroglobulina estimulada (Tg) > 2 ng/ml e imagen positiva (con 131I u otro radiotrazador) fueron consideradas como positivas para CT residual. De la población total el 88% fue sexo femenino, el 62% menores de 45 años, y el 77.1% tuvo función tiroidea normal. La punción con aguja fina (PAAF) fue diagnóstica en 78%. El 96% fue carcinoma papilar (CTP), 63% presentaban E I; 14% E II; 19% E III y 4% E IV. Se detectó CT residual en el 90% de los pacientes con Tg entre 2 y 10, y en el 100% con Tg > 10 ng/ml, mientras que con Tg < 2 el 18% mostró imagen positiva. No encontramos correlación significativa con antecedentes patológicos ni con ningún signo relevante en imágenes. En conclusión, en nuestra población el CTP fue predominante. Más frecuente en mujeres, en menores de 45 años y en eutiroideos. El nivel de Tg estimulada es un buen indicador de CT residual, pero no es una prueba suficiente para seleccionar pacientes libres de enfermedad

The thyroid carcinoma (TC) is not very frequent among all cancers. Its course is slow and is high potentially curable. Our aim was to analyse the characteristics in patients with TC. A retrospective analysis on 171 patients, with an average age of 41.1 (±14,6), who asked for TC to our service between the years 2000-04, was performed. From case histories it was evaluated: anamnesis, diagnostic image, histopathology and evolution. Tumours were grouped for size and TNM (tumour-nodule-metastasis) in stages (S). A stimulated serum thyroglobulin level > 2 ng/ml and positive image with 131I or another nuclear marker were considered as positive for residual TC. In the totality of the analyzed patients 88% were female, 62% below 45 years old, and in 77% the thyroid function was normal. The fine needle aspiration (FNA) was diagnostic in 78%. Papillary thyroid carcinoma (PTC) in 96%. The 63% was SI; 14% SII; 19% SIII and 4% SIV. During follow-up, we observed that 90% of patients with Tg between 2 and 10 had evidence of residual TC, and 100% with Tg > 10 ng/ml, whereas 18% of those whose stimulated Tg < 2 presented positive image. There was not found significative correlation with pathologic antecedents or relevant image signs. In conclusion: TCP was the most frequent carcinoma in women, in patients younger than 45 years and in those who have euthyroid function. A stimulated serum thyroglobulin level was a good indicator for residual TC, but failed to select those patients who were disease free

Clinical importance of solitary solid nodule of the thyroid in endemic goiter region.

CONTEXT: Endemic area and iodine supplementation may affect the pathogenesis of the nodule which commonly occurs in endemic thyroid enlargement due to iodine deficiency. AIMS: To establish pathological changes in solitary solid and larger nodule of the thyroid in endemic area. SETTING AND DESIGN: Retrospective study in Surgical Department of University Hospital. METHODS AND MATERIAL: We determined 44 surgically treated patients with solitary solid nodule in endemic goiter area in which the population routinely receives iodinated salt. The thyroid nodule was preoperatively evaluated with blood chemistry, ultrasound, nuclear scanning and FNAC. The results of preoperative evaluation, surgical interventions, and histopathological examination were analyzed. STATISTICAL ANALYSIS: Student t test and Fisher's exact test. RESULTS: Twenty (45%;20/44) patients with hot (autonomous) nodule have received the diagnosis of toxic adenoma. Twenty four patients had solitary solid and cold nodule. Total thyroidectomy was performed on two patients with papillary cancer (PTC) diagnosed by FNAC from cold nodules. Forty two patients have been treated with total excision of the lobe including hyper or hypoactive solitary solid nodule. Pathological examination has reported two more cases of PTC and one case of insular cancer arising from cold nodules. Completion thyroidectomy was performed on these 3 patients. CONCLUSIONS: Solitary solid and large nodule is a common indication for thyroid surgery in endemic goiter area. High incidence of hyperthyroidism due to single autonomous nodule, and high rate of malignant change (mainly papillary cancer) in solitary hypoactive nodule arises from this series in endemic thyroid enlargement.