Color Duplex Doppler US can Follow up the Response of Radioiodine in Graves' Disease by Evaluating the Thyroid Volume and Peak Systolic Velocity.

PURPOSE: The objective of this study was to prove the efficacy of Doppler ultrasonography (US-Doppler) in the follow-up of patients with GD treated with radioactive iodine. METHODS: 97 patients (77 female and 20 male) with a mean age of 42 years (SD ±â€Š15) and with prior diagnosis of GD were treated with radioiodine. In total, 88.5 % achieved euthyroidism or hypothyroidism after treatment. The study was documented before treatment and one, three, and six months after treatment with radioactive iodine (131I) by a single investigator. The volume, echogenicity, echotexture and vascularization of the glands as well as the peak systolic velocity (PSV) of the inferior thyroid arteries were evaluated and compared with the laboratory data. RESULTS: Thyroid volume and PSV had a statistically significant correlation with hormone levels (p < 0.05). The mean pre-dose therapeutic thyroid volume was 43.01 ±â€Š3.88 cm3 and was 11.58 ±â€Š11.26 cm3 6 months after treatment. The mean PSV before 131I was 90.06 ±â€Š44.13 cm/s and decreased significantly over time (p < 0.001). Six months after the therapeutic dose, the mean PSV was 32.95 ±â€Š16.36 cm/s. However, the subjective parameters did not have a significant correlation with the normalization of the thyroid hormones. CONCLUSION: Doppler US was useful for monitoring the therapeutic response of GD patients after treatment with radioiodine by evaluating the thyroid volume and peak systolic velocity.

Comparison between peak systolic velocity of the inferior thyroid artery and technetium-99m pertechnetate thyroid uptake in differentiating Graves' disease from thyroiditis

ABSTRACT Objectives The differentiation between the various etiologies of thyrotoxicosis, including those with hyperthyroidism (especially Graves' disease [GD], the most common cause of hyperthyroidism) and without hyperthyroidism (like thyroiditis), is an important step in planning specific therapy. Technetium-99m (99mTc) pertechnetate thyroid scanning is the gold standard in differentiating GD from thyroiditis. However, this technique has limited availability, is contraindicated in pregnancy and lactation, and is not helpful in cases with history of recent exposure to excess iodine. The aim of this study was to identify the diagnostic value of the peak systolic velocity of the inferior thyroid artery (PSV-ITA) assessed by color-flow Doppler ultrasound (CFDU) and compare the sensitivity and specificity of this method versus 99mTc pertechnetate thyroid uptake. Subjects and methods We prospectively analyzed 65 patients (46 with GD and 19 with thyroiditis). All patients were evaluated with clinical history and physical examination and underwent 99mTc pertechnetate scanning and measurement of TRAb levels and PSV-ITA values by CFDU. The diagnosis was based on findings from signs and symptoms, physical examination, and 99mTc pertechnetate uptake. Results Patients with GD had significantly higher mean PSV-ITA values than those with thyroiditis. At a mean PSV-ITA cutoff value of 30 cm/sec, PSV-ITA discriminated GD from thyroiditis with a sensitivity of 91% and specificity of 89%. Conclusion Measurement of PSV-ITA by CFDU is a good diagnostic approach to discriminate between GD and thyroiditis, with sensitivity and specificity values comparable to those of 99mTc pertechnetate thyroid uptake.

Comparison between peak systolic velocity of the inferior thyroid artery and technetium-99m pertechnetate thyroid uptake in differentiating Graves' disease from thyroiditis.

OBJECTIVES: The differentiation between the various etiologies of thyrotoxicosis, including those with hyperthyroidism (especially Graves' disease [GD], the most common cause of hyperthyroidism) and without hyperthyroidism (like thyroiditis), is an important step in planning specific therapy. Technetium-99m (99mTc) pertechnetate thyroid scanning is the gold standard in differentiating GD from thyroiditis. However, this technique has limited availability, is contraindicated in pregnancy and lactation, and is not helpful in cases with history of recent exposure to excess iodine. The aim of this study was to identify the diagnostic value of the peak systolic velocity of the inferior thyroid artery (PSV-ITA) assessed by color-flow Doppler ultrasound (CFDU) and compare the sensitivity and specificity of this method versus 99mTc pertechnetate thyroid uptake. SUBJECTS AND METHODS: We prospectively analyzed 65 patients (46 with GD and 19 with thyroiditis). All patients were evaluated with clinical history and physical examination and underwent 99mTc pertechnetate scanning and measurement of TRAb levels and PSV-ITA values by CFDU. The diagnosis was based on findings from signs and symptoms, physical examination, and 99mTc pertechnetate uptake. RESULTS: Patients with GD had significantly higher mean PSV-ITA values than those with thyroiditis. At a mean PSV-ITA cutoff value of 30 cm/sec, PSV-ITA discriminated GD from thyroiditis with a sensitivity of 91% and specificity of 89%. CONCLUSION: Measurement of PSV-ITA by CFDU is a good diagnostic approach to discriminate between GD and thyroiditis, with sensitivity and specificity values comparable to those of 99mTc pertechnetate thyroid uptake.

Severe cholestatic syndrome secondary to Graves' disease

This paper reports a case of severe cholestasis as an atypical manifestation of Graves' disease. It discusses the pathophysiology, the diagnosis and the investigation of this complication of hyperthyroidism as well as the impact of this finding on the therapeutic options for managing the disease. (AU)

Thyroid nodules and thyroid cancer in Graves' disease.

OBJECTIVE: The frequency of thyroid nodules accompanying Graves' disease and the risk of thyroid cancer in presence of accompanying nodules are controversial. The aim of this study was to evaluate the frequency of thyroid nodules and the risk of thyroid cancer in patients operated because of graves' disease. SUBJECTS AND METHODS: Five hundred and twenty-six patients in whom thyroidectomy was performed because of Graves' disease between 2006 and 2013 were evaluated retrospectively. Patients who had received radioactive iodine treatment and external irradiation treatment in the neck region and who had had thyroid surgery previously were not included in the study. RESULTS: While accompanying thyroid nodule was present in 177 (33.6%) of 526 Graves' patients, thyroid nodule was absent in 349 (66.4%) patients. Forty-two (8%) patients had thyroid cancer. The rate of thyroid cancer was 5.4% (n = 19) in the Graves' patients who had no nodule, whereas it was 13% (n = 23) in the patients who had nodule. The risk of thyroid cancer increased significantly in presence of nodule (p = 0.003). Three patients had recurrence. No patient had distant metastasis. No patient died during the follow-up period. CONCLUSIONS: Especially Graves' patients who have been decided to be followed up should be evaluated carefully during the follow-up in terms of thyroid cancer which may accompany.

Radioiodine therapy for Graves disease: thyroid absorbed dose of 300 Gy-tuning the target for therapy planning.

PURPOSES: Based on the committed thyroid absorbed dose, the aim was to compare the efficiency of I therapy against Graves disease (GD) within 1 year after treatment and, by exploring the dose-response relationship, indicate an absorbed dose to be targeted into patient therapeutic planning. METHODS: Thyroid-absorbed doses were calculated to 196 patients with GD by applying Medical Internal Radiation Dose formalism and taking into account administered I activity, thyroid radioiodine uptake, effective half-life, and gland tissue mass. Statistical analysis was applied to assess the relationship between absorbed doses and the patient's clinical response. RESULTS: Overall, successful therapy was achieved in 167 patients, whereas in 29 the disease persisted, even though 64.8% and 89.3% of all the treated patients had received, respectively, thyroid absorbed dose and activity superior to 300 Gy and 11.1 MBq/g (300 µCi/g) of thyroid tissue. Among those in whom the disease persisted, 24 (83%) had a 6- to 24-hour I uptake ratio equal or superior to 0.9, whereas only 5 (17%) presented a lower ratio. According to statistical analysis, there was no difference in cure rate between the groups that received 300 Gy or less and that which received more (84.1% vs 85.8%, P = 0.8336). CONCLUSIONS: A thyroid absorbed dose of 300 Gy is plausible as a targeted therapeutic dose in GD therapy planning, because statistical analysis has proven there to be no advantage in treating patients with doses above this level. On the other hand, numerous efforts should be made to develop an optimized and easily applicable protocol of patient-specific dosimetry and to provide data that show its clinical impact on patient management.

Is the measurement of inferior thyroid artery blood flow velocity by color-flow Doppler ultrasonography useful for differential diagnosis between gestational transient thyrotoxicosis and Graves' disease? A prospective study.

OBJECTIVE: To determine the role of peak systolic velocity, end-diastolic velocity and resistance indices of both the right and left inferior thyroid arteries measured by color-flow Doppler ultrasonography for a differential diagnosis between gestational transient thyrotoxicosis and Graves' disease during pregnancy. METHODS: The right and left inferior thyroid artery-peak systolic velocity, end-diastolic velocity and resistance indices of 96 patients with thyrotoxicosis (41 with gestational transient thyrotoxicosis, 31 age-matched pregnant patients with Graves' disease and 24 age- and sex-matched non-pregnant patients with Graves' disease) and 25 age and sex-matched healthy euthyroid subjects were assessed with color-flow Doppler ultrasonography. RESULTS: The right and left inferior thyroid artery-peak systolic and end-diastolic velocities in patients with gestational transient thyrotoxicosis were found to be significantly lower than those of pregnant patients with Graves' disease and higher than those of healthy euthyroid subjects. However, the right and left inferior thyroid artery peak systolic and end-diastolic velocities in pregnant patients with Graves' disease were significantly lower than those of non-pregnant patients with Graves' disease. The right and left inferior thyroid artery peak systolic and end-diastolic velocities were positively correlated with TSH-receptor antibody levels. We found an overlap between the inferior thyroid artery-blood flow velocities in a considerable number of patients with gestational transient thyrotoxicosis and pregnant patients with Graves' disease. CONCLUSIONS: This study suggests that the measurement of inferior thyroid artery-blood flow velocities with color-flow Doppler ultrasonography does not have sufficient sensitivity and specificity to be recommended as an initial diagnostic test for a differential diagnosis between gestational transient thyrotoxicosis and Graves' disease during pregnancy.

Espessamento do tendão muscular na oftalmopatia de Graves / Muscle tendon enlargment in Graves´ophthalmopathy

OBJETIVO: Estudar a frequência do espessamento do tendão muscular em pacientes com oftalmopatia de Graves buscando estabelecer correlações com as diferentes formas clínicas da doença. A diversidade clínica e laboratorial na oftalmopatia de Graves pode levar à confusão quanto ao diagnóstico, conduta e prognóstico. Os achados radiológicos variam desde o aumento isolado do tecido adiposo até o espessamento da musculatura extraocular, caracteristicamente poupando os tendões. Em 2004,no entanto, Ben Simon descreveu o espessamento do tendão muscular na oftalmopatia de Graves. MÉTODOS: Foram avaliados 20 pacientes, de ambos os sexos, com idades entre 20 e 80 anos, com formas clínicas designadas como :forma benigna (retração palpebral),forma intermediária (diplopia na posição primária do olhar) e forma maligna ou infiltrativa (sinais de comprometimento do nervo óptico).Todos os pacientes foram submetidos à tomografias computadorizadas de órbita. Os pacientes estavam eutiroideanos, há pelo menos um ano. Os padrões tomográficos foram estudados e divididos em dois grupos: com e sem espessamento dos tendões da musculatura extraocular. RESULTADOS: Uma relação estatisticamente significativa entre espessamento do tendão e a forma clínica intermediária foi encontrada (p <0,012). CONCLUSÃO: O espessamento do tendão extraocular, encontrado em 30 por cento dos pacientes com oftalmopatia de Graves, relaciona-se positivamente com a forma intermediária da doença, caracterizada pela presença de diplopia e que constitui um achado de grande valor clínico.

PURPOSE: The aim is therefore to study the frequency of tendon enlargment in Graves' ophthalmopathy, seeking to estabilish its clinical correlations. Clinical and laboratory diversity in Graves' Ophthalmopathy sometimes may mislead its diagnosis. Radiological findings are more reliable for the diagnosis of Graves' Ophthalmopathy. Since then, a number of patterns have been described. Extraocular muscle involvement in this pathology is considered as always sparing the tendons. In 2004, Ben Simon described extraocular muscles tendon enlargment in some patients with diplopia in Graves' orbitopathy. METHODS: 20 patients, aged between 20 and 80 years, of both sexes, designated as benign (eyelid retraction), intermediate(diplopia in primary sight position) and malignant or infiltrative(signs of optic nerve compromise) forms were evaluated by orbital tomography. All patients had already been euthyroidean for at least one year. Tomographic patterns were studied and divided into two groups: with or without extraocular muscle tendons enlargment. RESULTS: Statistically significant relationship was found between tendon enlargment and intermediate form (p<0.012). CONCLUSION: Extraocular tendon involvement present in 30 percent of the patients with Graves' ophthalmopathy, and is positively correlated to intermediary form of the disease, characterized by diplopia, a very important clinical landmark.

Utility of colour Doppler sonography in patients with Graves' disease.

OBJECTIVE: Assessment of thyroid blood flow gives valuable information about underlying functional status. Colour Flow Doppler Sonography (CFDS) is a powerful tool which displays tissue blood flow and vascularity. Colour Flow Doppler Sonography of the thyroid gland in different subsets of patients with Graves' disease was studied to define its role in initial diagnosis and management. METHODS: Eighty consecutive patients with Graves' disease (both treated and untreated) presented to hospital between August 2007 and February 2008. All patients were evaluated with CFDS of the thyroid for size, vascularity and peak systolic velocity (PSV) of the Inferior Thyroid Artery (ITA). Pertechnate scan and thyroidal autoantibody levels were done in selected cases. The patients were divided into Untreated Graves' disease (n = 31), Graves' disease on treatment but hyperthyroid (n = 26) and euthyroid Graves' disease on therapy (n = 23). Mann-Whitney U-test was used for statistical analysis and a p-value of less than 0.05 was considered significant. RESULTS: Thyroid blood flow, as assessed by PSV of ITA, was significantly higher in untreated Graves' disease than in Graves disease on treatment but hyperthyroid and euthyroid Graves respectively (61.5 +/- 19.5 versus 42.9 +/- 24.7 versus 32.2 +/- 12.9 cm/s, p < 0.05). Parenchymal vascularity of the thyroid gland was higher in hyperthyroid patients than in euthyroid patients irrespective of therapy. In both groups on therapy, the dose of carbimazole correlated with the vascularity of the gland (r = 0.492 versus 0.564, p < 0.05). Colour Flow Doppler Sonography parameters correlated significantly with pertechnate scan results giving comparable sensitivity and specificity. CONCLUSION: Assessment of thyroid blood flow by CFDS is an effective marker in the initial diagnosis of Graves' disease. Vascularity of the gland can predict long term disease course while on medical therapy.

[The effect of propylthiouracil on the efficacy of radioiodine (I-131) therapy in graves hyperthyroidism]. / Efeito do propiltiouracil sobre a eficácia da dose terapêutica de iodo radioativo (I-131) no hipertiroidismo por doença de graves.

Aiming at evaluating the effect of antithyroid drugs on the efficacy of radioiodine treatment (RAI) we retrospectively analyzed 226 patients with Graves disease hyperthyroidism submitted to RAI between 1990 and 2001: 58 patients without any antithyroid drug (ATD) prior to RAI, 119 patients using propylthiouracil (PTU) and 49 patients using methimazole (MMI) prior to RAI. Clinical and laboratory parameters 1 year after RAI defined their clinical status (cured or not cured). High serum free T4 and 131-iodine uptake were negatively related with cure as well as lower RAI doses (mCi) and larger goiters (p< 0.05). The percentage of cured patients on PTU prior to RAI was 70.2% (84/119), while those on MMI was 85.7% (42/49), and 84.5% (49/58) of those without ATD prior to RAI (p= 0.034). On logistic regression analysis, free T4 > 4 ng/dl, large goiter, RAI dose < 10 mCi and PTU prior to RAI were related to lower cure rates. Compared to patients with no ATD prior to RAI, we concluded that the previous use of PTU implies in higher failure rates after RAI (OR= 3.13), an effect not observed in patients on MMI (OR= 1.28).

High pre-therapy [99mTc]pertechnetate thyroid uptake, thyroid size and thyrostatic drugs: predictive factors of failure in [131I]iodide therapy in Graves' disease.

BACKGROUND AND OBJECTIVE: Several factors may interfere with the success rate of radioiodine therapy (RIT) in Graves' disease. Our aim was to evaluate, retrospectively, some of these factors in the outcome of RIT. METHODS: Patient gender, age at diagnosis, ophthalmopathy, disease duration, thyroid size, drug used as clinical treatment, thionamide withdrawal period during RIT preparation, FT4, TSH and [99mTc]pertechnetate thyroid uptake prior to RIT were studied as potential interference factors for RIT success. Eighty-two Graves' disease patients were submitted to RIT after thionamide treatment failure. Prior to RIT, 67 patients were receiving methimazole and 15 propylthiouracil. Thirty-three patients received thionamides during RIT; in 49 patients the medication was withdrawn for 2-30 days. [99mTc]pertechnetate thyroid uptake was determined before RIT. Fixed doses of 370 MBq of [131I]iodide were administered to all patients. RESULTS: Eleven patients became euthyroid; 40 became hypothyroid and 31 remained hyperthyroid. There was no association between outcome and age at diagnosis, gender, ophthalmopathy, pre-RIT FT4, TSH, antithyroid antibodies or thyrostatic drug. Multiple logistic regression showed higher probability of treatment success in patients with thyroid mass <53 g (odds ratio (OR)=8.9), with pre-RIT thyroid uptake <12.5% (OR=4.1) and in patients who withdrew thionamide before RIT (OR=4.9). CONCLUSIONS: Fixed doses of 370 MBq of radioiodine seem to be practical and effective for treating Graves' disease patients with [99mTc]pertechnetate uptake <12.5% and thyroid mass <53 g. This treatment is clearly not recommended for patients with large goitre. In contrast to what could be expected, patients with a high pre-RIT thyroid uptake presented a higher rate of RIT failure.

Ultrasound parameters and markers of bone turnover in hyperthyroidism: a longitudinal study.

Hyperthyroid patients are characterized by accelerated bone turnover leading to bone mass loss. The aim of this study was to assess changes in quantitative ultrasound [QUS] parameters, bone mineral density (BMD), and biochemical markers of bone turnover in patients prior to and after the onset of hyperthyroid treatment. A 2-yr longitudinal study was performed on 10 women recently diagnosed with Grave's disease after starting antithyroid therapy. Six patients were postmenopausal. All patients showed evidence of thyrotoxicosis as indicated by suppressed serum TSH and high levels of total serum thyroxine. They received antithyroid therapy (methimazole and/or 131I radiodine). QUS parameters were measured using an Achilles ultrasound unit and BMD was assessed by dual-energy X-ray absorptiometry (DXA). Thyroid hormones and markers of bone turnover were determined at baseline and 6, 12, and 24 mo after the onset of treatment.Stiffness, broadband ultrasound attenuation (BUA), and speed of sound (SOS) were low at baseline compared to normal values for the same age range and increased after 2 yr of treatment. A significant increase in BMD of the lumbar spine, total skeleton, and skeletal regions (legs) was also observed after treatment. Recovery of stiffness was almost complete at 12 mo. No significant elevation was observed between 12 and 24 mo. Stiffness increased 7.6%, 10.4%, and 10.4% after 6 mo (p < 0.02), after 1 yr (p < 0.02), and after 2 yr, respectively. No significant increase in SOS and BUA was observed between 12 and 24 mo. Furthermore, recovery of total skeleton and lumbar spine BMD continued throughout the study. Successful antithyroid therapy produced a rapid increase in QUS parameters (Stiffness) and spine BMD and femoral neck during the first year of treatment and a slower increment in total skeleton (up to 24 mo). Overall, ad integrum restitution was not observed in QUS or BMD.

[Cerebral vasculitis and Basedow-Graves disease: report of two cases]. / Vasculite cerebral e doença de Basedow-Graves: relato de dois casos.

OBJECTIVE: To report two cases of patients with cerebral vasculitis and Basedow-Graves disease. CASE REPORT: Two young female patients presented at emergency with acute neurological picture of hemiparesis and speech distress. The first patient, 22 year-old, has been on clinical treatment for hyperthyroidism for one month. On clinical examination she had an elevated cardiac rate, bilateral exophthalmia and a diffuse goiter. On neurological examination we could observe a mild dysarthria and left hemiparesis. The second patient was a 15 year-old girl, who presented sudden conscious loss, aphasia and right hemiparesis. RESULTS: CT scan and MRI showed areas of cerebral infarcts. Angiographic study showed multiple vascular stenosis similar to an arteritic angiographic pattern. Extensive medical and laboratorial workout disclosed no other risk factor for stroke or for nervous system vasculitis. The antimicrosomal and antithyreoglobulin antibodies were positive and thyroidian hormones confirmed hyperthyroidism. CONCLUSION: The concurrence of cerebral arteritis and Basedow-Graves' disease suggest a possible pathogenic link between Graves' disease and specific cerebral vascular disorders, possibly through a common autoimmune mechanism.

Prospective and controlled study of ophthalmopathy after radioiodine therapy for Graves' hyperthyroidism.

The effects of radioiodine (131I) therapy for hyperthyroidism on the ocular process of Graves' disease is controversial. In order to evaluate the outcome of ophthalmopathy after radioiodine therapy for thyrotoxicosis we studied prospectively 30 Graves' hyperthyroid patients, 22 submitted to radioiodine (131I) treatment (group A) and 8 treated with antithyroid drugs (group B). All patients were evaluated by clinical ophthalmologic examination, and ocular proptosis (OP) was measured with both a Hertel exophthalmometer (HE) and computed tomography (CT) before and 4 to 7 months after therapy. No statistical difference was obtained between pre- and post-treatment OP measurements in each eye in either group, and we did not observe worsening in the ophthalmopathy of patients treated with drugs or radioiodine. After therapy, there was an improvement in the clinical signs of ophthalmopathy in 59% of group A and in 37.5% of group B patients. We found a significant correlation between OP measured by HE and by CT. CT findings showed an increase in orbital fat and/or muscle thickening in all patients at baseline, proving to be a useful procedure for ophthalmologic diagnosis in doubtful cases. No patient in either group developed hypothyroidism or elevated TSH levels during the study period; this may explain our good results in the evolution of Graves' ophthalmopathy after treatment with 131I and antithyroid drugs. Euthyroidism seems to be an important factor in the outcome of ophthalmopathy after therapy, whatever the mode of treatment chosen to achieve it.

Hallazgos tomográficos preliminares acerca del efecto de la terapia del iodo radiactivo sobre la oftalmopatía de Graves / Preliminary tomographic of the effect of the radioactive iodine therapy on Graves ophtalmopathy

Este estudio pretende profundizar la investigación acerca de las modificaciones orbitarias en pacientes con enfermedad de Graves tratados con Iodo radiactivo, objetivada mediante TC y observando su evolución. Se utilizó un protocolo de cortes axiales a menos 10 grados del plano órbitomeatal y coronales perpendiculares al plano órbitomeatal, de 5mm de espesor cada 3 mm de intervalo. Se realizaron treinta tomografías en diez pacientes con enfermedad de Graves, con distinto grado de compromiso ocular. Los mismos recibieron una dosis de Iodo radiactivo. Se tomaron los siguientes parámetros: 1) cambios en los diámetros de la musculatura extrínseca; 2) densitometría de la grasa retroocular y 3) proptosis. En el 80 por ciento de los pacientes hallamos aumento en los diámetros de los músculos extraoculares, no evidencia de cambios cualicuantitativos en la valoración de la grasa retroorbitaria y ausencia de proptosis. Los resultados hasta la fecha no son concluyentes, existiendo escasa literatura referida a estudios prospectivos en este sentido (AU)

[Thyroid nodule in Basedow-Graves disease and thyroid cancer: experience in 6 patients]. / Nódulo tiroideo en enfermedad de Basedow Graves y cáncer tiroideo: experiencia en 6 pacientes.

Traditionally, Basedow-Graves disease was considered a protection against thyroid cancer. However, recent reports suggest that cancer occurs with a higher frequency than expected and is more aggressive in this disease. We report six patients with hyperthyroidism due to a Basedow Graves disease that presented a palpable thyroid nodule, which was cold in the scintiscan and solid in the ultrasound examination. Fine needle cytology disclosed cancer in five cases (two with cytological features of greater aggressiveness) and a nodular hyperplasia in one. The diagnosis was confirmed in the surgical piece in all patients. We conclude that Basedow-Graves disease and thyroid cancer, which can have an increased aggressiveness, may coexist.