Antithyroid drugs in Graves' hyperthyroidism: differences between "block and replace" and "titration" regimes in frequency of euthyroidism and Graves' orbitopathy during treatment.

PURPOSE: Whereas antithyroid drugs (ATD) are the preferred treatment modality for Graves' hyperthyroidism (GH), there is still controversy about the optimal regimen for delivering ATD. To evaluate whether 'Block and Replace' (B + R) and 'Titration' (T) regimes are equivalent in terms of frequency of euthyroidism and Graves' Orbitopathy (GO) during ATD therapy. METHODS: A prospective multicentre observational cohort study of 344 patients with GH but no GO at baseline. Patients were treated with ATD for 18 months according to B + R or T regimen in line with their institution's policy. RESULTS: Baseline characteristics were similar in both groups. In the treatment period between 6 and 18 months thyrotropin (TSH) slightly increased in both groups, but TSH was on average 0.59 mU/L (95% CI 0.27-0.85) lower in the B + R group at all time points (p = 0.026). Serum free thyroxine (FT4) remained stable during the same interval, with a tendency to higher values in the B + R group. The point-prevalence of euthyroidism (TSH and FT4 within their reference ranges) increased with longer duration of ATD in both groups; it was always higher in the T group than in the B + R group: 48 and 24%, respectively, at 6 months, 81 and 58% at 12 months, and 87 and 63% at 18 months (p < 0.002). There were no significant differences between the B + R and T regimens with respect to the fall in thyrotropin binding inhibiting immunoglobulins (TBII) or thyroid peroxidase antibodies (TPO-Ab). GO developed in 15.9% of all patients: 9.1 and 17.8% in B + R group and T group, respectively, (p = 0.096). GO was mild in 13% and moderate-to-severe in 2%. CONCLUSION: The prevalence of biochemical euthyroidism during treatment with antithyroid drugs is higher during T compared to B + R regimen. De novo development of GO did not differ significantly between the two regimens, although it tended to be higher in the T group. Whether one regimen is clinically more advantageous than the other remains unclear.

Asymmetry indicates more severe and active disease in Graves' orbitopathy: results from a prospective cross-sectional multicentre study.

PURPOSE: Patients with Graves' orbitopathy can present with asymmetric disease. The aim of this study was to identify clinical characteristics that distinguish asymmetric from unilateral and symmetric Graves' orbitopathy. METHODS: This was a multi-centre study of new referrals to 13 European Group on Graves' Orbitopathy (EUGOGO) tertiary centres. New patients presenting over a 4 month period with a diagnosis of Graves' orbitopathy were included. Patient demographics were collected and a clinical examination was performed based on a previously published protocol. Patients were categorized as having asymmetric, symmetric, and unilateral Graves' orbitopathy. The distribution of clinical characteristics among the three groups was documented. RESULTS: The asymmetric group (n = 83), was older than the symmetric (n = 157) group [mean age 50.9 years (SD 13.9) vs 45.8 (SD 13.5), p = 0.019], had a lower female to male ratio than the symmetric and unilateral (n = 29) groups (1.6 vs 5.0 vs 8.7, p < 0.001), had more active disease than the symmetric and unilateral groups [mean linical Activity Score 3.0 (SD 1.6) vs 1.7 (SD 1.7), p < 0.001 vs 1.3 (SD 1.4), p < 0.001] and significantly more severe disease than the symmetric and unilateral groups, as measured by the Total Eye Score [mean 8.8 (SD 6.6) vs 5.3 (SD 4.4), p < 0.001, vs 2.7 (SD 2.1), p < 0.001]. CONCLUSION: Older age, lower female to male ratio, more severe, and more active disease cluster around asymmetric Graves' orbitopathy. Asymmetry appears to be a marker of more severe and more active disease than other presentations. This simple clinical parameter present at first presentation to tertiary centres may be valuable to clinicians who manage such patients.

Does early response to intravenous glucocorticoids predict the final outcome in patients with moderate-to-severe and active Graves' orbitopathy?

PURPOSE: Intravenous glucocorticoids (ivGCs) given as 12-weekly infusions are the first-line treatment for moderate-to-severe and active Graves' orbitopathy (GO), but they are not always effective. In this study, we evaluated whether response at 6 weeks correlated with outcomes at 12 (end of intervention) and 24 (follow-up) weeks, particularly in patients initially unresponsive. METHODS: Our database (Bartalena et al. J Clin Endocrinol Metab 97:4454-4463, 10), comprising 159 patients given three different cumulative doses of methylprednisolone (2.25, 4.98, 7.47 g) was analyzed, pooling data for analyses. Responses at 6 weeks were compared with those at 12 and 24 weeks using three outcomes: overall ophthalmic involvement [composite index (CI)]; quality of life (QoL); Clinical Activity Score (CAS). Responses were classified as "Improved", "Unchanged", "Deteriorated", compared to baseline. RESULTS: Deteriorated patients at 6 weeks for CI (n = 8) remained in the same category at 12 weeks and 7/8 at 24 weeks. Improved patients at 6 weeks for CI (n = 51) remained in the same category in 63% and 53% of cases at 12 and 24 weeks, respectively. Unchanged patients at 6 weeks (n = 100) eventually improved in 28% of cases (CI), 58% (CAS), 32% (QoL). There was no glucocorticoid dose-dependent difference in the influence of early response on later outcomes. CONCLUSIONS: Patients who deteriorate at 6 weeks after ivGCs are unlikely to benefit from continuing ivGCs. Patients unresponsive at 6 weeks still have a significant possibility of improvement later. Accordingly, they may continue ivGC treatment, or, alternatively, possibly stop ivGCs and be switched to a second-line treatment.

Update on a new controversy in endocrinology: isolated maternal hypothyroxinemia.

Isolated hypothyroxinemia (IH) is defined as a thyroxine level in the lower 5th (severe IH) or 10th percentile (mild IH) of the pregnancy-related reference range and a normal TSH. The etiology of IH remains unknown. This review aims to evaluate the biochemical criteria used to define IH in different published studies and to discuss potential maternal as well as fetal outcomes and whether treatment during early pregnancy can prevent the eventual adverse effects. For the current literature a better standardization of free thyroxine assays is needed, as well as the use of appropriated trimester-specific reference intervals for thyroid function tests. Today no study demonstrates a benefit from treating early pregnant IH women on perinatal and fetal outcomes.

Efficacy and safety of three different cumulative doses of intravenous methylprednisolone for moderate to severe and active Graves' orbitopathy.

BACKGROUND: Optimal doses of i.v. glucocorticoids for Graves' orbitopathy (GO) are undefined. METHODS: We carried out a multicenter, randomized, double-blind trial to determine efficacy and safety of three doses of i.v. methylprednisolone in 159 patients with moderate to severe and active GO. Patients were randomized to receive a cumulative dose of 2.25, 4.98, or 7.47 g in 12 weekly infusions. Efficacy was evaluated objectively at 12 wk by blinded ophthalmologists and subjectively by blinded patients (using a GO specific quality of life questionnaire). Adverse events were recorded at each visit. RESULTS: Overall ophthalmic improvement was more common using 7.47 g (52%) than 4.98 g (35%; P = 0.03) or 2.25 g (28%; P = 0.01). Compared with lower doses, the high-dose regimen led to the most improvement in objective measurement of ocular motility and in the Clinical Activity Score. The Clinical Activity Score decreased in all groups and to the least extent with 2.25 g. Quality of life improved most in the 7.47-g group, although not reaching statistical significance. No significant differences occurred in exophthalmos, palpebral aperture, soft tissue changes, and subjective diplopia score. Dysthyroid optic neuropathy developed in several patients in all groups. Because of this, differences among the three groups were no longer apparent at the exploratory 24-wk visit. Major adverse events were slightly more frequent using the highest dose but occurred also using the lowest dose. Among patients whose GO improved at 12 wk, 33% in the 7.47-group, 21% in the 4.98-group, and 40% in the 2.25-group had relapsing orbitopathy after glucocorticoid withdrawal at the exploratory 24-wk visit. CONCLUSIONS: The 7.47-g dose provides short-term advantages over lower doses. However, this benefit is transient and associated with slightly greater toxicity. The use of a cumulative dose of 7.47 g of methylprednisolone provides short-term advantage over lower doses. This may suggest that an intermediate-dose regimen be used in most cases and the high-dose regimen be reserved to most severe cases of GO.

Is Recombinant Human TSH a Trigger for Graves' Orbitopathy?

The pathogenesis of Graves' orbitopathy (GO) remains unknown. The hypothesis of a causal relationship between autoimmunity against the TSH receptor (TSHR) and GO is supported by clinical studies. Radioiodine treatment is associated with worsening or new onset of GO, possibly via antigen shedding or by inducing hypothyroidism. The coexistence of thyroid cancer with Graves' disease (GD) and GO is rare. Here we report 3 cases of reactivation of GO in patients who underwent treatment with recombinant human TSH (rhTSH) and radioiodine ablation. In each case, a thyroidectomy was performed to treat the GD, and an incidental thyroid cancer was discovered. In all 3 cases, reactivation of GO was observed 3-6 weeks after administration of rhTSH, despite maintaining euthyroidism, which was unaccompanied by a rise in serum TSHR antibodies after radioiodine and despite steroids in 1 of the 3 patients. These observations suggest that binding of either TSH or TSHR antibodies to the TSHR, independently of thyroid status, may be causally related to deterioration of GO. Clinicians should be aware of a possible association between rhTSH administration and reactivation of GO, which should be taken into account before prescribing rhTSH in patients with GO. Prophylactic steroids may need to be considered for patients at high risk of exacerbation of GO.

To treat or not to treat euthyroid autoimmune disorder during pregnancy?

BACKGROUND: Subclinical autoimmune hypothyroidism during pregnancy is associated with an increased risk of miscarriage and has a deleterious effect on fetal development. The aim of this study was to evaluate a screening and treatment strategy of subclinical hypothyroidism, and to establish normal ranges of thyroid-stimulating hormone (TSH) and thyroxine (T(4)) during pregnancy. METHODS: A retrospective study was carried out on 784 consecutive files of pregnant women; the files were systematically searched for thyroid function and antithyroid antibodies in order to determine the effect and the prevalence of anti-thyroid peroxidase antibodies (TPO-Ab) during pregnancy, and to evaluate treatment with levothyroxin (LT(4)) in TPO-Ab carriers. RESULTS: Among the 75 TPO-Ab-positive patients, 42 received LT(4) treatment during pregnancy. Although the range of TSH serum levels was wide, the mean TSH level was significantly higher in TPO-Ab-positive women (3 vs. 1 mIU/l, p < 0.01). No significant difference in the obstetrical complications rate was observed between TPO-Ab-positive and TPO-Ab-negative populations. CONCLUSIONS: Our study provides information on normal ranges of serum TSH and free T(4) for Belgian pregnant women receiving iodide supplementation. Based on our results, we suggest supplementation of TPO-Ab-positive pregnant women with 50 microg/day of LT(4), unless their TSH levels are lower than 1 mIU/l, to avoid the risk of hypothyroidism during pregnancy.

Is there an increased incidence of surgically removed thyroid carcinoma in Belgium ten years after Chernobyl? A study of hospital discharge data.

In order to provide some answers to the much debated subject of the consequences of the Chernobyl accident, this study attempts to measure the incidence of surgically removed thyroid cancers in Belgium ten years following the explosion. The analysis was made from the hospital discharge data between 1993 and 1998. It offers the advantage of national coverage in spite of certain validity limits. The results show an increase in surgically removed thyroid cancers, which is not, however, evident in the more susceptible younger generation who were involved at the time of the accident. Furthermore, the geographic distribution of the incidence is more marked in the south of the country, unaffected by the radioactive iodine contamination of 1986, which was more prevalent in the east of the country. The study of the type of surgery involved shows a rise in the proportion of total thyroidectomies. These findings are in favour of the hypothesis of a causal effect linking the increased incidence of thyroid cancers to medical practice and surgery in particular and not to the consequence of the possible contamination.

Is the management of thyroid nodules and differentiated thyroid cancer in accordance with recent consensus guidelines? - Results of a national survey.

OBJECTIVE: To assess approaches to patients with a potentially malignant thyroid nodule and patients with differentiated thyroid carcinoma and compare them with the European Consensus and Guidelines by the American Thyroid Association. DESIGN: A survey of the 388 active members of the Belgian Thyroid Club. METHODS: A questionnaire addressing the management of an index case and four clinical variations (including variations in the size of the tumour and histological type). The index case was a 40-year-old euthyroid woman with a 3-cm solitary thyroid nodule. Fine-needle aspiration (FNA) cytology showed cellular aspirates with numerous follicular cells and no colloid. RESULTS: The overall response rate was 41%. For the index case, respondents favoured a right lobectomy. Variations in size and histopathology of the nodule altered the management. In the case of a papillary thyroid carcinoma (PTC) of 3 cm in diameter, a total thyroidectomy and prophylactic central lymph node dissection was preferred. After a lobectomy showing a 3.5-cm follicular thyroid carcinoma (FTC), completion surgery followed by radioiodine administration was the most frequent proposal. For the follow-up of the index case with a low-risk disease, determination of serum thyroglobulin (Tg) after recombinant human TSH (rhTSH) administration was considered by the majority of respondents. For the follow-up of a clinical variation with residual disease, immediate planning of a new treatment was (mistakenly) not considered by a majority of respondents. CONCLUSIONS: In most cases, respondents were in accordance with the guidelines, although there were some unexpected variations.

Propylthiouracyl-induced severe liver toxicity: an indication for alanine aminotransferase monitoring?

Propylthiouracyl (PTU)-related liver toxicity is likely to occur in about 1% of treated patients. In case of acute or subacute hepatitis, liver failure may occur in about one third. We report two further cases of PTU-induced subacute hepatitis, in whom the delay between occurrence of liver damage after the initiation of treatment, the underestimation of its severity and the delayed withdrawal of the drug were all likely responsible for liver failure. The high incidence of liver toxicity related to PTU, its potential severity and delayed occurrence after initiation of treatment are in favor of monthly alanine aminotransferase monitoring, at least during the first six months of therapy.

Hypothyroidism and major depression: a common executive dysfunction?

Little is known about the possible link between the cognitive disorders associated with hypothyroidism and those encountered in depression. This study examines attentional and executive functions as well as the intensity of anxiety and depressive symptoms in hypothyroidism and major depression and the possible link between these symptoms and cognitive disturbances. This study confirms the existence of psychomotor slowing associated with attentional and executive disturbance in major depression as well as in hypothyroidism. However, while depressed subjects manifested a conscious bias with material of negative emotional valence, no such bias was found in the hypothyroid subjects. While the hypothyroid state is accompanied by anxiety/depressive symptoms, it seems that the latter are too discrete for an attentional bias to be observed with material with a negative emotional valence.

Anxiety and depression, attention, and executive functions in hypothyroidism.

BACKGROUND: Divergences in cognitive disturbances in hypothyroidism reported in the literature are a result of a methodological bias. METHODS: By using a precise methodology, we examined attention and executive functions in hypothyroidism, verified the presence of anxiety and depressive symptoms in hypothyroidism, and examined the possible link between these symptoms and the cognitive disturbances (searching for attentional bias for words with a negative emotional valence). We administered a battery of cognitive tests to 23 participants who had undergone thyroidectomy for thyroid carcinoma: for the first time in an euthyroid state, then 3 weeks later (still in the euthyroid state) to assess the test/retest effect, and finally 4 weeks later in an hypothyroid state. We compared their performance with that of a group of 26 control participants who were also administered the same cognitive tests, also 3 times. RESULTS: In hypothyroidism, the thyroid participants were more anxious and depressed than the controls and presented attentional and executive disturbances that reflected general slowing and difficulties in using their capacities of inhibition. However, they did not exhibit an attentional bias for words with a negative emotional valence. CONCLUSIONS: Contrary to what was expected, symptoms of anxiety and not symptoms of depression interfered with the cognitive performance of participants in hypothyroidism.

Intense 18-fluorodeoxyglucose uptake by the thymus on PET scan does not necessarily herald recurrence of thyroid carcinoma.

This is the first report of intense fluorodeoxyglucose positron emission tomography (FDG-PET) uptake secondary to thymic hyperplasia during follow-up for thyroid carcinoma. A 36-yr-old woman underwent thyroidectomy for a papillary carcinoma measuring 4 cm in diameter. After two doses of radioiodine, thyroglobulin (Tg) remained detectable following recombinant human TSH (rhTSH) stimulation. A whole body scan (WBS) was negative. On computed tomography (CT) scan, a slightly lobulated thymus was visualized. PET scan showed intense thymic uptake. Following resection, anatomo-pathological analysis showed homogenous hyperplastic thymic gland without neoplastic cells. Two months later, under levothyroxin (L-T4) substitution, Tg was no longer detectable and PET scanning did not show any 18-FDG uptake. This observation suggests that thymic FDG uptake does not necessarily herald recurrence of thyroid carcinoma and must be interpreted with caution in such a setting. Other conditions associated with abnormal uptake by hyperplastic thymus must also be envisaged.

Predictive factors of thyroid carcinoma in non-toxic multinodular goitre.

The management of nontoxic multinodular goitre (NMNG) remains controversial. The challenge for the clinician is to identify the small proportion of NMNG patients with associated thyroid carcinoma who would thus benefit from surgery. We studied retrospectively the medical records of 80 patients with NMNG and coexisting thyroid carcinoma who underwent total thyroidectomy. Eighty total thyroidectomy patients with NMNG whose histology was benign were then randomnly chosen as controls. In univariate analysis, the following parameters were significantly more frequent in the carcinoma group: rapid growth of the goitre (p = 0.002), presence of microcalcifications (p = 0.01), hypoechogenicity (p = 0.02), firm consistency of a nodule (p = 0.03), and presence of a dominant cold nodule on scintigraphy (p = 0.03). In the multiple regression analysis, the variables significantly associated with carcinoma were rapid growth (Odds ratio (OR) = 4.13, 95% confidence interval(CI): 1.72-9.89), hypo-echogenicity (OR = 3.11, 95% CI: 1.13-8.51) and the presence of a dominant nodule (OR = 2.26, 95% CI: 1.06-4.79)). In the cancer group, tumour size was positively correlated with compression signs (p = 0.01), age (p = 0.02), the presence of a dominant nodule on scintigraphy (p = 0.02), and with rapid growth (p = 0.04). Concerning nodule size estimated on US (ultrasound), the majority (65%) of patients without carcinoma had nodules < 3 cm, whereas 73% of patients with clinical thyroid carcinoma (> or = 1 cm on histology) had nodules with a diameter of > or = 3 cm on US (p = 0.02). In conclusion, our study suggests that surgical treatment of NMNG should be proposed in the presence of rapid nodular growth, compression signs, dominant nodule on scintigraphy, nodule size > or 3 cm and hypo-echogenicity.

Correlation between the loss of thyroglobulin iodination and the expression of thyroid-specific proteins involved in iodine metabolism in thyroid carcinomas.

Progress in biotechnology has provided useful tools for tracing proteins involved in thyroid hormone synthesis in vivo. Mono- or polyclonal antibodies are now available to detect on histological sections the Na(+)/I(-) symporter (NIS) at the basolateral pole of the cell, the putative iodide channel (pendrin) at the apical plasma membrane, thyroperoxidase (TPO), and members of the NADPH-oxidase family, thyroid oxidase 1 and 2 (ThOXs), part of the H(2)O(2)-generating system. The aim of this study was to correlate thyroglobulin (Tg) iodination with the presence of these proteins. Tg, T(4)-containing Tg, NIS, pendrin, TPO, ThOXs, and TSH receptor (TSHr) were detected by immunohistochemistry on tissue sections of normal thyroids and various benign and malignant thyroid disorders. Tg was present in all cases. T(4)-containing Tg was found in the adenomas, except in Hurthle cell adenomas. It was never detected in carcinomas. NIS was reduced in all types of carcinomas, whereas it was detected in noncancerous tissues. Pendrin was not expressed in carcinomas, except in follicular carcinomas, where weak staining persisted. TPO expression was present in insular, follicular carcinomas and in follicular variants of papillary carcinomas, but in a reduced percentage of cells. It was below the level of detection in papillary carcinomas. The H(2)O(2)-generating system, ThOXs, was found in all carcinomas and was even increased in papillary carcinomas. Its staining was apical in normal thyroids, whereas it was cytoplasmic in carcinomas. The TSHr was expressed in all cases, but the intensity of the staining was decreased in insular carcinomas. In conclusion, our work shows that all types of carcinomas lose the capacity to synthesize T(4)-rich, iodinated Tg. In follicular carcinomas, this might be due to a defect in iodide transport at the basolateral pole of the cell. In papillary carcinomas, this defect seems to be coupled to an altered apical transport of iodide and probably TPO activity. The TSHr persists in virtually all cases.

Metastatic liposarcoma of the thyroid gland.

Metastatic liposarcoma of the thyroid gland is exceptionally rare. A case of pleomorphic liposarcoma, which manifested as a soft tissue lump in the neck, is described in a 30-year-old woman. Fine needle aspiration cytology permitted prompt diagnosis. The ultrasound and CT appearance of this type of thyroid metastasis is described which has not been previously reported in the literature.

Is the black thyroid really an innocuous pathological finding?

We report the case of a 24-year-old euthyroid woman in whom the discovery of a cold nodule in the left thyroid lobe led to a thyroidectomy. The surgical specimen was characterized by a diffuse black discoloration. Optical examination revealed brown granules within the apical portion of the follicular cells whereas ultrastructural studies showed intralysosomal lipofuscin-like deposits, all findings consistent with pathological descriptions reported in black thyroids associated with the intake of minocycline. Retrospectively, we were told that the patient had received this antibiotic for at least three years for the treatment of acne vulgaris. As experimental models have demonstrated potential antithyroid effects of the drug, it appears relevant to monitor thyroid tests in patients receiving long-term minocycline therapy.

Structural changes in the angiofollicular units between active and hypofunctioning follicles align with differences in the epithelial expression of newly discovered proteins involved in iodine transport and organification.

In animals, as well as in humans, the thyroid gland is made of active follicles, with cuboidal cells and hypofunctioning follicles, with flattened cells. In this study, the functional status of human follicles was dissected out, based on immunohistochemical detection of TSH receptor, Na(+)/I(-) symporter, pendrin, thyroperoxidase (TPO), thyroid oxidases (ThOXs), and T(4)-containing iodinated Tg (Tg-I). To ascertain that angiofollicular units exist in the human, we studied the microvascular bed of each follicle, in correlation with detection of vascular endothelial growth factor (VEGF), of nitric oxide synthase III, and of endothelin in normal and goitrous thyroids. In hypofunctioning follicles, pendrin, TPO, and ThOXs were not detected, and there was no Tg-I in the colloid. At the opposite, in active follicles, pendrin, TPO, and ThOXs were detected in thyrocytes, and Tg-I was present in the colloid. In normal and goitrous thyroids, the capillary networks surrounding active follicles were larger than those surrounding hypofunctioning follicles. Immunoreactivity for nitric oxide synthase III and endothelin was solely detected in active follicles. Only a few follicles in normal thyroids were immunostained for VEGF, regardless of their functional status. In multinodular goiters, VEGF was detected in contact with the extracellular matrix at the basal pole of the cells. In conclusion, the present study endorses the likelihood of angiofollicular units in the human thyroids. Vascular changes are related to the functional status of thyrocytes.

Evidence for thyrotropin receptor immunoreactivity in pretibial connective tissue from patients with thyroid-associated dermopathy.

Pretibial myxedema (PTM), mainly characterized by the accumulation of glycosaminoglycans in the dermis and subcutaneous tissue, is an extrathyroidal manifestation of autoimmune Graves' disease (GD), almost always associated with Graves' ophthalmopathy (GO). The thyrotropin receptor (TSH-R) has been proposed as the common target antigen in GD, GO and PTM, with evidence for receptor transcripts and/or protein in these locations. The aim of this study has been to investigate whether receptor protein is present in the pretibial tissues. Skin biopsies were obtained from two patients with PTM and two normal subjects without thyroid disease. A portion of each sample was fixed to produce semi-thin sections for Toluidine Blue or Periodic Acid Schiff (PAS) staining. The remainder was snap frozen to generate cryostat sections for immunohistochemical analysis using three monoclonal antibodies against TSH-R. In the skin from the two patients suffering from PTM, the dermis was infiltrated by inflammatory cells (lymphocytes, B cells, macrophages, mast cells) and adipocytes. The collagen fibers were dissociated by edema and by the accumulation of a PAS-positive material. Immunodetection of TSH-R produced positive staining on cells localized in the dermis, beneath the epidermis or close to the hypodermis. These cells were elongated and resembled fibroblasts. No immunoreactivity was observed in the dermis from control patients without thyroid disease. In conclusion, we have evidence for TSH-R immunoreactivity in the pretibium of patients with GD, GO and PTM. Further studies are needed to unambiguously identify the positive cells and determine whether the reactivity is due to the receptor itself or to a cross-reacting protein.

Minimally invasive video-assisted approach for partial and total thyroidectomy: initial experience.

BACKGROUND: We report our initial experience with partial and total thyroidectomy using a video-assisted approach. The feasibility, safety, and potential benefits of this technique are examined. METHODS: Between January and May 2000, 28 patients were select to undergo a thyroid lobectomy (n = 17) or total thyroidectomy (n = 11) by a video-assisted cervical approach. Patient selection was based on clinical examination and preoperative ultrasonography. The surgical procedures were conducted under general anesthesia through a minimal substernal skin incision. Frozen sections were examined peroperatively in all cases. RESULTS: The initial diagnosis was solitary nodule in 19 patients and multinodular goiter in 8 patients. One patient was treated for hyperthyroidism. The mean cranio-caudal axis and transverse diameter of the resected specimen were 4.9 +/- 0.9 and 2.7 +/- 0.5 cm, respectively, and the mean total lobar weight was 11.9 +/- 5.5 g. Conversion to conventional surgery was required in three patients (10.7%), due to local bleeding in all cases. The mean operative times were 150 +/- 8.2 and 102.5 +/- 17 min for total and partial thyroidectomy, respectively. The laryngeal nerve was identified in 94.8% of cases. The mean length of skin incision was 25.4 +/- 2 mm. There was one case of postoperative hypocalcemia and one case of postoperative hoarseness. One patient had a transient vocal cord palsy. The postoperative hospital stay was 1 day for 66.7% of patients. The pain intensity evaluation, performed on postoperative day 1 using the visual analogue scale (VAS) method, was 1.9 +/- 1.4. CONCLUSION: Video-assisted thyroidectomy is feasible, safe, and effective in selected cases. Benefits for the patients in terms of postoperative pain, hospital stay, and cosmesis still need to be assessed in a prospective trial comparing standard open and video-assisted approaches.