[Goiter and nodular thyroid disease: clinical guidelines for diagnosis and treatment. (Waiting? Hormone therapy? Surgery? radioiodine?)]

Nodular thyroid disease is a common problem. We present clinical guidelines for the management of patients with thyroid nodules, multinodular goiters and thyroid cysts for use by primary physicians. In the initial evaluation ultrasonography of the thyroid and fine-needle aspiration biopsy (FNAB) is recommended. FNAB has become the cornerstone in the evaluation of solitary thyroid nodules, cysts and dominant nodules within multinodular goiters. If the procedure is done properly, it should have a false-negative rate of less than 5% and a false-positive rate of not more than 1%. Thyroid radionuclide scans are less frequently used in the initial evaluation of a nodular goiter. Surgery is the primary therapy for patients with nodular thyroid disease. Other available treatment options are radioiodine and TSH-suppression with thyroxine. The main indications for surgery in euthyroid patients with thyroid nodule or with nontoxic multinodular goiter are recently documented or suspected malignancy, compression of the trachea and esophagus, significant growth of the nodule, recurrence of a cyst after aspiration, neck discomfort and cosmetic concern.

Approach to and Treatment of Goiters

The main causes of simple diffuse goiter (SDG) and multinodular goiter (MNG) are iodine deficiency, increase in serum thyroid-stimulating hormone (TSH) level, natural goitrogens, smoking, chronic malnutrition, and lack of selenium, iron, and zinc. Increasing evidence suggests that heredity is equally important. Treatment of SDG and MNG still focuses on L-thyroxine-suppressive therapy surgery. Radioiodine alone or preceded by recombinant human TSH stimulation is widely used in Europe and other countries. Each of these therapeutic options has advantages and disadvantages, with acute and long-term side effects.

Cytogenetic analysis of a multinodular thyroid goiter

Short-term cultures of a collagenase disaggregated multinodular goiter was shown by cytogenetic analysis to have the mosaic karyotype 47,XX,+7/48,XX,+7,+17/49,XX,+7,+10,+17. No cytogenetic data on goiter are available for comparison with the present case.

Tireóide ectópica cervical lateral: Relato de caso e revisão da literatura

Tireóide ectópica é qualquer tecido tireoideano localizado fora de sua topografia habitual, podendo apresentar-se na linha mediana do pescoço ou, mais raramente, na região cervical lateral. Algumas teorias tentam explicar a origem do tecido tireoideano ectópico: 1. falha na descida da glândula; 2. seqüestro de nódulos tireoideanos; 3. presença de tecido tireoideano na cápsula de linfonodos cervicais; 4. formação teratomatosa; 5. Secundário a anomalias branquiais. Na abordagem diagnóstica, diversos exames têm sido utilizados, sendo o diagnóstico definitivo algumas vezes fornecido apenas pelo estudo histopatológico. Apesar das controvérsias em relação às abordagens terapêuticas apresentadas na literatura, é necessário um planejamento rigoroso para evitar iatrogenias. Conclui-se que a presença de tecido tireoideano ectópico deve ser lembrada no diagnóstico diferencial de massas cervicais laterais, e sua origem histológica considerada, sendo na maioria das vezes metástase de um carcinoma tireoideano oculto. Os autores relatam um caso de tecido tireoideano ectópico lateral no pescoço, em paciente do sexo feminino com bócio colóide mergulhante. Foram realizadas considerações importantes sobre dismorfogênese tireoideana, métodos diagnósticos e opções de tratamento, com revisão da literatura das últimas cinco décadas.

Avalição ecocardiográfica do ventrículo direito e da pressão arterial pulmonar em portadoresde hipertireoidismo

Pós-graduação em Fisiopatologia em Clínica Médica - FMB

Extended resection for thyroid disease has less operative morbidity than limited resection

BACKGROUND: Theodor Kocher, surgeon and Nobel laureate, has influenced thyroid surgery all over the world: his treatment for multinodular goiter-subtotal thyroidectomy-has been the "Gold Standard" for more than a century. However, based on a new understanding of molecular growth mechanisms in goitrogenesis, we set out to evaluate if a more extended resection yields better results. METHODS: Four thousand three hundred and ninety-four thyroid gland operations with 5,785 "nerves at risk" were prospectively analyzed between 1972 and 2002. From 1972 to 1990, the limited Kocher resections were performed, and from 1991 to 2002 a more radical resection involving at least a hemithyroidectomy was performed. RESULTS: The incidence of postoperative nerve palsy was 3.6%; in the first study period and 0.9%; in the second (P < 0.001, Fisher's exact). Postoperative hypoparathyroidism decreased from 3.2%; in the first period to 0.64%; in the second (P < 0.01). The rate of reoperation for recurrent disease was 11.1%; from 1972 to 1990 and 8.5%; from 1991 to 2002 (P < 0.01). CONCLUSIONS: Extended resection for multinodular goiter not only significantly reduced morbidity, but also decreased the incidence of operations for recurrent disease. Our findings in a large cohort corroborate the suggestions that Kocher's approach should be replaced by a more radical resection, which actually was his original intention more than 130 years ago.

Risk factors in reoperative thyroid surgery for recurrent goitre. Our experience

Aim. Reoperative thyroid surgery is an uncommon operation associated with a higher complication rate; we reviewed our series of patients on whom reoperative thyroid surgery was performed.Method. 106 patients had a thyroid reoperation for recurrent multinodular goiter (93 patients), recurrent thyrotoxicosis (3) or suspected malignancy (10); bilateral completion thyroidectomy was performed in 68 cases, lobectomy in 36, removal of a mediastinal recurrence and of a pyramidal remnant in 1 patient respectively. Results. Temporary hypoparathyroidism occurred in 41 patients (38.67%), definitive in 7 (6.6%), transient recurrent laryngeal nerve palsy in 5 (4.71%), permanent nerve palsy in 1 (0.94%); in 3 cases (2.83%) surgical revision of haemostasis was necessary for postoperative haemorrhage. After monolateral surgery we had 13 cases of transient hypoparathyroidism (34.21%), 2 of definitive (5.26%) and 1 transient recurrent laryngeal nerve palsy (2.63%); after bilateral surgery we had 29 cases of transient hypoparathyroidism (42.64%), 5 of definitive (7.35%), 4 of transient recurrent laryngeal nerve palsy (5.88%), 1 of definitive (1.47%) and 3 of postoperative bleeding (4.41%). Conclusions. Reoperative thyroid surgery is a technical challenge with a high incidence of complications. Scarring, edema and friability of the tissues together with distortion of the landmarks make reoperative surgery azardous. A higher risk of complications is described when previous surgery has been performed on both sides. Total thyroidectomy should be considered the procedure of choice for benign multinodular goiter eliminating the potential of a reoperation. Whenever necessary, reoperative hyroidectomy may be performed safely with little morbidity in experienced hands.

Humoral and cell-mediated immunity in large non-toxic multinodular goitre

Humoral and cell-mediated immunity was investigated in fourteen patients with non-toxic multinodular goitre and ten healthy controls by in vitro methods. These included determination of sheep erythrocyte and complement rosette-forming cells in the peripheral blood, immunoglobulin levels, titres of thyroglobulin and microsomal antibodies and migration inhibition test using thyroid extract and phytohemagglutinin. When compared with controls the patients showed high IgA levels and positive response to thyroid antigen in the leucocyte migration inhibition test. There was no correlation between the leucocyte migration results and the presence of auto-antibodies. These findings indicate a possible role of cell-mediated immunity in non-toxic multinodular goitre.

Immunological disturbances in toxic multinodular goitre and active Graves' disease

Cell-mediated and humoral immunity were studied in seventeen patients with toxic multinodular goitre, ten with active Graves' disease and fourteen healthy controls. The study included determination of sheep erythrocyte and complement rosette-forming cells in peripheral blood, immunoglobulin levels, titres of microsomal antibodies and migration inhibition test using thyroid extract and phytohaemagglutinin. When compared with controls the patients showed a positive response to thyroid antigen in the leucocyte migration inhibition test. Microsomal antibodies were detected in seven out of ten active Graves' disease patients against two out of seventeen of those with toxic multinodular goitre. Significantly increased IgG and IgA and decreased IgM levels were found only in the toxic multinodular group. These data provide further evidence for immunological disturbances in toxic multinodular goitre.

Incidental cancer in patients surgically treated for benign thyroid disease. Our experience at a single institution

Increased incidence of incidental cancer in patients operated for benign thyroid disease has been reported. We report our experience about incidental thyroid cancer (ITC) in order to better characterize this nosologic entity. Between 2001 and 2009 a total of 568 patients underwent surgery for benign thyroid disease. Patients with preoperative cytology undetermined or positive for malignancy were excluded. The most frequent indication for surgery was multinodular or diffuse nontoxic goiter. We performed total thyroidectomy in 499 cases and emithyroidectomy in 69 cases. Final histology revealed ITC in 53 patients (9.3%): 44 had papillary carcinoma (20 classic variant and 24 follicular variant), 4 follicular carcinoma, 4 medullary carcinoma and 1 primitive thyroid paraganglioma. The preoperative diagnosis was multinodular or diffuse goiter in 45 cases of ITC and uninodular goiter in 8 cases. We performed total thyroidectomy in 46 case, emithyroidectomy in 4 patients with past history of lobectomy, emithyroidectomy in 3 patients with following radicalization and central neck dissection. In 14 patients the tumor was multifocal and in 12 of these patients the tumor foci were bilateral. The lesion was a microcarcinoma in 34 cases. Mean diameter of the ITC was 1.14 cm. We retrospectively reconsidered the results of preoperative ultrasound examinations in relation to the exact position of the tumor in the specimens and we found a statistically significant association between echogenicity and papillary histotype. Twenty-six patients were followed up at our Hospital. The mean follow-up period was 38.2 months. A relapse was observed in 3/26 patients. Incidental thyroid cancer in patients operated for benign disease has its own surgical and oncological relevance. A correct preoperative assessment, with a careful selection of nodules for fine-needle aspiration cytology on the basis of ultrasound pattern, could better address the choice of surgical procedure. The non irrelevant incidence of incidental thyroid cancer, the eventuality of multifocality and bilaterality and the possible occurrence of relapse, support that total thyroidectomy without residuum is a valuable option for treating benign thyroid conditions such as multinodular goitre. When an incidental cancer is diagnosed after emithyroidectomy, a radicalization with central neck dissection could be considered. We suggest that natural history of papillary microtumors and the correct surgical approach for these lesions could be better defined with a more extensive use of “Porto proposal” criteria. Incidental thyroid cancer, Papillary microcarcinoma, Papillary microtumors, Total thyroidectomy.

Equine multinodular pulmonary fibrosis in three horses in Australia

Background Equine multinodular pulmonary fibrosis (EMPF) is a recently described form of interstitial pneumonia associated with the presence of equine herpesvirus type 5 (EHV-5). Since 2007, several case reports from America, Europe and the United Kingdom have further characterised the clinical presentation and laboratory findings of this disease. Case reports Three Thoroughbred broodmares were diagnosed with EMPF. Diagnosis was based on lung histopathology and positive identification of EHV-5 using PCR DNA amplification. There was multiple organ involvement in all three cases, including identification of EHV-5 in hepatic tissue in one case. Two of the three horses died. Treatment with acyclovir was unsuccessful in one horse and one horse survived without antiviral or corticosteroid treatment. Conclusion This case series is, to the authors' knowledge, the first report of EMPF in Australia and adds to the clinical description of the disease.

The sequence and structure of snake gourd (Trichosanthes anguina) seed lectin, a three-chain nontoxic homologue of type II RIPs

The sequence and structure of snake gourd seed lectin (SGSL), a nontoxic homologue of type II ribosome-inactivating proteins (RIPs), have been determined by mass spectrometry and X-ray crystallography, respectively. As in type II RIPs, the molecule consists of a lectin chain made up of two beta-trefoil domains. The catalytic chain, which is connected through a disulfide bridge to the lectin chain in type II RIPs, is cleaved into two in SGSL. However, the integrity of the three-dimensional structure of the catalytic component of the molecule is preserved. This is the first time that a three-chain RIP or RIP homologue has been observed. A thorough examination of the sequence and structure of the protein and of its interactions with the bound methyl-alpha-galactose indicate that the nontoxicity of SGSL results from a combination of changes in the catalytic and the carbohydrate-binding sites. Detailed analyses of the sequences of type II RIPs of known structure and their homologues with unknown structure provide valuable insights into the evolution of this class of proteins. They also indicate some variability in carbohydrate-binding sites, which appears to contribute to the different levels of toxicity exhibited by lectins from various sources.

Nontoxic electrodes of solid amalgams

This is a review of electrodes based on nontoxic solid amalgams (MeSAE) (prepared by amalgamation of soft metal powders) in connection with some other kinds of voltammetric electrodes is given. Information is summarized on various types of MeSAEs (esp. AgSAE, CuSAE, AuSAE), pretreatment of their surfaces, their hydrogen overvoltage in aqueous solutions, conditions for their testing, electroanalytical parameters and use, in compared with the hanging mercury drop electrode (HMDE). Although the solid amalgam electrodes do not reach the quality of the HMDE, in many cases they represent its possible alternative. The broad range of voltammetric applications of the MeSAEs, especially of the AgSAEs, their good mechanical stability, simple handling, and new aspects of their use in electrochemical techniques are documented by numerous examples.

Nicotinic acid as a nontoxic corrosion inhibitor for hot dipped Zn and Zn-Al alloy coatings on steels in diluted hydrochloric acid

The inhibition effect of nicotinic acid for corrosion of hot dipped Zn and Zn-Al alloy coatings in diluted hydrochloric acid was investigated using quantum chemistry analysis, weight loss test, electrochemical measurement, and scanning electronic microscope (SEM) analysis. Quantum chemistry calculation results showed that nicotinic acid possessed planar structure with a number of active centers, and the populations of the Mulliken charge, the highest occupied molecular orbital (HOMO), and the lowest unoccupied molecular orbital (LUMO) were found mainly focused around oxygen and nitrogen atoms, and the cyclic of the benzene as well. The results of weight loss test and electrochemical measurement indicated that inhibition efficiency (IE%) increased with inhibitor concentration, and the highest inhibition efficiency was up to 96.7%. The corrosion inhibition of these coatings was discussed in terms of blocking the electrode reaction by adsorption of the molecules at the active centers on the electrode surface. It was found that the adsorption of nicotinic acid on coating surface followed Langmuir adsorption isotherm with single molecular layer, and nicotinic acid adsorbed on the coating surface probably by chemisorption. Nicotinic acid, therefore, can act as a good nontoxic corrosion inhibitor for hot dipped Zn and Zn-Al alloy coatings in diluted hydrochloric acid solution. (c) 2007 Elsevier Ltd. All rights reserved.