Cytological Results of Ultrasound-Guided Fine-Needle Aspiration Cytology for Thyroid Nodules: Emphasis on Correlation with Sonographic Findings

PURPOSE: To compare the cytological results of ultrasound-guided fine-needle aspiration (US-FNA) cytology of thyroid nodules to sonographic findings and determine whether US findings are helpful in the interpretation of cytological results. MATERIALS AND METHODS: Among the thyroid nodules that underwent US-FNA cytology, we included the 819 nodules which had a conclusive diagnosis. Final diagnosis was based on pathology from surgery, repeated FNA cytology or follow-up of more than one year. Cytological results were divided into five groups: benign, indeterminate (follicular or Hurthle cell neoplasm), suspicious for malignancy, malignant, and inadequate. US findings were categorized as benign or suspicious. Cytological results and US categories were analyzed. RESULTS: Final diagnosis was concluded upon in 819 nodules based on pathology (n=311), repeated FNA cytology (n=204) and follow-up (n=304), of which 634 were benign and 185 were malignant. There were 560 benign nodules, 141 malignant nodules, 49 nodules with inadequate results, 21 with indeterminate results, and 48 that were suspicious for malignancy. The positive and negative predictive values of the US categories were 59.1% and 97.0%, and those of the cytological results were 93.7% and 98.9%. The US categories were significantly correlated with final diagnosis in the benign (p=0.014) and suspicious for malignancy (p<0.001) cytological result groups, but not in the inadequate and indeterminate cytological results groups. The false positive and negative rates of cytological results were 1.9% and 3.2%. CONCLUSION: Sonographic findings can be useful when used alongside cytological results, especially in nodules with cytological results that are benign or suspicious for malignancy.

Clinicopathologic Features and Treatment Outcomes in Differentiated Thyroid Carcinoma Patients with Concurrent Graves' Disease

The clinical behaviors and treatment outcomes of thyroid carcinomas in patients with Graves' disease is a matter of controversy. This study aimed to identify the clinicopathologic features, treatment outcome, and the indicators for predicting recurrence, and to suggest the optimal extent of surgery in these patients. We retrospectively analyzed data of 58 patients who underwent surgical treatment for differentiated thyroid cancer and concurrent Graves' disease. The follow-up period ranged from 23 to 260 months (mean+/-standard devuation, 116.8+/-54.0). In our series, the mean age was 40.8+/-12.7 yr (range, 15-70), with a male-to-female ratio of 1: 6.25. The mean tumor size was 13+/-9 mm (range, 3-62). The surgical methods included 19 cases of total thyroidectomy, 38 cases of subtotal thyroidectomy, and 1 case of completion total thyroidectomy. Locoregional recurrence occurred in four patients (6.9%). The 10-yr overall survival and disease-free survival of patients were 95.8% and 91.1%, respectively. Age over 45 yr (p=0.031), tumor size over 10 mm (p=0.049), multiplicity (p=0.007), extracapsular invasion (p=0.021), and clinical cancer (p=0.035) were significantly more prevalent in patients with locoregional recurrence than in those without recurrence. We recommend that Graves' disease patients should undergo regular ultrasonography screening for early detection of thyroid carcinoma. We also suggest that the choice of extent of surgery should depend on the diagnostic timing (clinical or incidental) and factors for predicting recurrence.

Surgical Aspects of Subacute Thyroiditis / 대한내분비외과학회지

PURPOSE: Subacute thyroiditis (SAT) is an uncommon, self-lemiting inflammatory disorder. If clinicians cannot rule out thyroid cancer in SAT patients with a thyroid nodule, surgical management can be considered. This study was performed to review the clinical characteristics of patients who were treated surgically for SAT presenting with thyroid nodule. METHODS: We retrospectively reviewed the clinical features of 14 cases who underwent an operation for SAT with a thyroid nodule between January 1986 and May 2006 at our institution. RESULTS: There were 3 male and 11 female patients, with a mean age of 47 years. All patients underwent surgical management prior to 1998. Twelve patients had thyroidal pain, 6 had viral prodromal symptoms, and 5 had hyperthyroidisms. Preoperative erythrocyte sedimentation rates (ESRs) (n=4) were elevated in 3 patients. Decreased uptake of radioiodine was reported in all 6 patients for whom scans were performed (n=6). Fine needle aspiration biopsy (FNAB) was performed in 4. In this study, the operative indications were clinically indeterminate thyroid nodule (n=14); lobectomy in 8, lobectomy with partial thyroidectomy in 2, lobectomy with near total thyroidectomy in 2, and bilateral total thyroidectomy in 2. Hoarseness occurred in one patient. CONCLUSION: SAT is usually managed clinically, but patients presenting with an indeterminate thyroid nodule will require surgical management even though they may have more benign characteristics. Most surgeons have to wait for the results of frozen biopsy because limited resectioning can be performed if the results are benign.

Huge Cavernous Hemangioma of the Thyroid Gland / 대한내분비외과학회지

Cavernous hemangioma is a benign congenital vascular malformation that can affect any part of the body. However, primary hemangioma of the thyroid gland is extremely rare with only six cases reported in the literature. We report here on a case of a cavernous hemangioma of the thyroid gland in a 66-year-old man. Magnetic resonance imaging (MRI) showed a huge exophytic mass measuring 17 cm, which had replaced the left lobe of the thyroid. The histologic examination of the surgical specimen revealed a huge cavernous hemangioma.

RET/PTC and CK19 Expression in Papillary Thyroid Carcinoma and Its Clinicopathologic Correlation

Recently, the rearrangement of RET proto-oncogene has been reported to be the most common genetic change in papillary thyroid carcinoma (PTC). However, its prevalence has been reported variably and its relation to clinical outcome has been controversial. The characteristic nuclear features of PTC usually render the diagnosis, but problem arises with equivocal cytologic features that are present focally. Although there remains some controversy, CK19 has been reported to be a useful ancillary tool for diagnosis of PTC. To evaluate the expression rate of RET/PTC rearrangement and CK19 in PTCs in a Korean population, we studied 115 papillary thyroid carcinomas in 3 mm-core tissue microarray based immunohistochemical analysis. The prevalence of Ret protein expression was 62.6% and the CK19 immunoreactivity was 80.9%. There was no statistically significant asso-ciation between the Ret positivity and CK19 immunoreactivity, although the percent agreement of the two was relatively high. The clinicopathological variables did not correlate with the expression of Ret. In conclusion, the prevalence of Ret protein expression and its clinicopathological implications in a Korean population are not much different from those reported in previous studies. However, its detection via immunohistochemistry can be a useful diagnostic tool for diagnosing papillary thyroid carcinoma in conjunction with CK19.

New Promising Therapeutic Modalities for Thyroid Cancers: Histone Deacetylase Inhibitor, PPAR-gamma Agonist, and Retinoic Acid / 대한내분비외과학회지

Most patients with thyroid cancer have well differentiated tumors that usually respond to conventional therapy including total or near total thyroidectomy, radioiodine ablation and TSH suppression. About 10% of patients, however, have aggressive cancers as a consequence of de-differentiation. During de-differentiation, thyroid cancers not only show more mitosis, fibrosis, and altered cell structure, they also lose thyroid-specific functions (iodine uptake, TSH receptor expression, and thyroglobulin production). These poorly differentiated or undifferentiated tumors mostly fail to take up radioiodine and are responsible for most deaths from thyroid cancer. New therapies need to be developed for patients with these types of tumors. Among the most promising antineoplastic therapies for these poorly differentiated and undifferentiated thyroid cancers are the histone deacetylase inhibitors, the PPAR-gamma agonist and retinoic acids. These drugs have therapeutic effects for thyroid cancers in inhibiting growth and inducing apoptosis and redifferentiation, in vivo and in vitro studies. And, clinical trials in patients with refractory thyroid cancers have been initiated. Further laboratory investigation of these drugs is necessary to understand molecular mechanisms and demonstrate therapeutic efficacy for thyroid cancers.

Cribriform-morular Variant Papillary Carcinoma associated with Familial Adenomatous Polyposis / 대한내분비외과학회지

Cribriform-morular variant (CMV) is a rare histologic subtype of papillary thyroid carcinoma (PTC). Patients with familial adenomatous polyposis (FAP) could be associated with several comorbid diseases including thyroid cancer. Most thyroid cancers in them are PTCs, but infrequently CMV types can occur. The FAP concomitant CMV-PTCs are found predominantly in young women and reveals lower recurrence rate. Moreover, this variant shows circumscribed morphology and rarely metastasizes to node. Because the incidence of thyroid carcinoma is higher than that in general population, comprehensive evaluation of thyroid gland should be performed for the patients with FAP. Because thyroid cancer could be first manifestation of FAP, colonic screening should be considered in CMV-PTC patient. We report two cases of CMV-PTCs concurrent with FAP.

Forgotten Mediastinal Goiter / 대한내분비외과학회지

Forgotten mediastinal goiter is an extremely rare disease. It is most often the consequence of the incomplete removal of a ‘ plunging’ goiter, but it can sometimes be attributed to a concomitant, unrecongnized primary mediastinal goiter which is not connected to the thyroid. A primary mediastinal goiter(autonomous intrathoracic goiter) essentially caused by an abnormal embryonic development of the thyroid gland and a thyroid gland formation located in the thorax or the mediastinum. The differential diagnosis with ordinary recurrence was based on the absence of parenchymatous or vascular connections with the cervical thyroid gland. It is fed by local intrathoracic vessels and observed in the absence of previous thyroidectomy. Nevertheless, for primary mediastinal goiter, sternum-splitting incision will be required in most cases as troublesome mediastinal bleeding may occur which is difficult to control from a cervical collar incision. In this study we report a case of forgotten mediastinal goiter and review the various diagnostic and therapeutic problems posed by the condition. A number of possible solutions that can be implemented for this diasease are identified.

Anaplastic Thyroid Carcinoma: A Therapeutic Dilemma

Anaplastic thyroid carcinoma (ATC) is one of the most malignant human neoplasms and has a grave prognosis. This study gives an update on our experience with this unusual neoplasm, with specific focus on the response to various treatment modalities. Forty-seven patients with histologically proven ATCs were enrolled (19 men, 28 women; mean age, 62.8 years). This number represents 1.5% among a total of 3, 088 thyroid cancers treated between 1977 and 2002. The mean tumor diameter was 8.8 cm, and 22 patients had distant metastasis. Extrathyroidal extension was seen in 26 (89.7%) of the cases that underwent surgery. Treatment modalities adopted could be classified into 5 groups: Group 1, biopsy only; Group 2, biopsy and chemoradiotherapy; Group 3, debulking only; Goup 4, debulking and chemoradiotherapy; Group 5, complete excision and chemoradiotherapy. Survival was calculated from the time of diagnosis, and comparisons of survival were done by log-rank analysis. The mean survival was 4.3 months (range, 1.0-21 months). The mean survival based on treatment modalities were as follows: Group 1 (n = 10), 2.1 months, Group 2 (n = 8) ; 3.6 months; Group 3 (n = 7), 3.0 months; Group 4 (n = 14), 3.5 months, Group 5 (n = 8), 9.4 months. There was no significant difference in survival time between the various types of treatment modalities. Even though a small improvement in survival was observed with complete excision and aggressive multimodality therapy, nearly all ATCs remain unresponsive to ongoing treatment modalities and as such, present a therapeutic dilemma. A more effective treatment regimen should be sought in order to improve survival.

Treatment of Anaplastic Thyroid Carcinoma: A Therapeutic Dilemma

PURPOSE: Anaplastic thyroid carcinoma (ATC) is one of the most malignant human neoplasm, with a grave prognosis. This study updates our experience with this unusual neoplasm with specific focus on the response to various treatment modalities. METHODS: Forty-seven patients with histologically proven ATC were enrolled (19 men, 28 women; mean age, 62.8 years). This group represented 1.5% of the 3, 088 thyroid cancers treated between 1977 to 2002. The mean diameter of tumor was 8.8 cm (range, 2.0~20.0 cm), and 22 patients had distant metastasis (10 in the lung, 8 lung and bone, 1 brain, 1 mediastinum, and 2 lung and mediastinum). Extrathyroidal extension was seen in 26 (89.7%) of the cases that underwent surgery. Treatment modalities adopted were classified into 5 groups. Group 1, biopsy only; group 2, biopsy and chemoradiotherapy; group 3, debulking only; group 4 debulking and chemoradiotherapy; and group 5, complete excision and chemoradiotherapy. Survival was calculated from the time of diagnosis, and comparisons of survival were done by log-rank analysis. RESULTS: The mean survival was 4.3 months (range, 1.0~21 months). The mean survival bases of treatment modalities were as follows: group 1 (n=10), 2.1 months (range 1.0~6.0); group 2 (n=8), 3.6 months (range, 2.0~7.0 months); group 3 (n=7), 3.0 months (range, 1.0~11.0 months); group 4 (n=14), 3.5 months (range, 2.0~9.0 months), group 5 (n=8), 9.4 months (range 5.0~21.0 months). CONCLUSION: Even though a small improvement of survival in response was observed with complete excision and aggressive multimodality therapy, nearly all ATC remains ineffective to ongoing treatment modalities and continue to present a therapeutic dilemma. A more effective treatment regimen should be sought for improving the survival rate.

Macrofollicular Variant of Papillary Thyroid Carcinoma with Extensive Hemorrhage / 대한세포병리학회지

BACKGROUND: The macrofollicular variant of papillary thyroid carcinoma (MVPC) is characterized by macrofollicles occupying more than half of the tumor and demonstrating nuclear features of classic papillary carcinoma. It is difficult to recognize on fine needle aspiration (FNA) cytology due to the paucity of aspirated neoplastic cell clusters, especially when the tumor is associated with extensive areas of hemorrhage. CASE: A 34-year-old female presented with a well-demarcated nodule in the thyroid gland, diagnosed as a benign nodule on ultrasonography and computed tomography. FNA cytology smear revealed a few small aggregates of follicular cells with morphological features suspicious for papillary carcinoma, set in a background of hemorrhage, inflammatory cells, and hemosiderin-laden macrophages. Intraoperative frozen section revealed macrofollicular nests filled with hemorrhage and composed of follicular cells demonstrating nuclear clearing and grooves. CONCLUSION: MVPC is a rare but distinctive variant of papillary carcinoma, which is easily mistaken for adenomatous goiter or benign macrofollicular neoplasm on radiologic findings. The cytopathologist should alert oneself on encountering benign radiologic findings and any smear composed of scant numbers of follicular cells with nuclear features suspicious for papillary carcinoma despite the bland-looking background of hemorrhage and hemosiderin-laden macrophages, and recommend intraoperative frozen sections for a definite diagnosis.

Functional Parathyroid Cyst

Parathyroid cysts are uncommon lesions of the neck and superior mediastinum, rarely large enough to be of clinical significance. They frequently present as a clinical diagnostic problem. They may mimic solitary thyroid nodule. They can be classified as either functioning or non-functioning depending on whether or not they are associated with hypercalcemia. Non-functioning or "true" cysts are those associated with normocalcemia (85%), whereas functioning or "pseudocysts" are those associated with hypercalcemia (15%). The presence of a high content of intact parathyroid hormone (iPTH) in the cystic fluid on fine-needle aspiration (FNA), in conjunction with elevated serum levels of calcium and iPTH is diagnostic of a functional parathyroid cyst, which usually requires surgical removal. We report herein two cases of such a functional parathyroid cyst and present a review of the literature.

A Case of Thyroid Cancer Detected with Pet Scan

Although the utility of FDG-PET scan is usually limited to the follow up of a recurrence follow the resection of primary malignant tumors. Its usefulness may be widen to the diagnosis in some malignant neoplasms; that use mostly glucose their energy sources. Thyroid cancers use glucose for their metabolic activities and incidental focal thyroid uptake shown on FDG-PET scans may be representative of a primary tumor. Therefore, increased focal thyroid uptake shown on whole body FDG-PET scans should not be overlooked even when it is not marked, and prompt further investigation should be done to rule out a possible cancer. We present a case of thyroid cancer, incidentally detected with a PET scan in a 60-year-old-man. We also present a review of the literatures regarding the usefulness of PET scan in thyroid cancer.

Minimally Invasive Surgery in Endocrine Surgical Diseases

The concept of minimally invasive endocrine surgery is the newest and most interesting field of surgery. Endocrine surgery is well suited to minimally invasive technique because the nature of most endocrine operations involves a total or partial resection of a gland and reconstructive surgery is rarely necessary. The minimally invasive thyroid procedure can be classified into endoscopic technique with or without constant gas insufflation, video-assisted technique performed under direct and endoscopic vision, and minimally invasive open technique. The endoscopic technique can be subclassified into a neck approach, anterior chest approach, breast approach, and axillary approach. Each of these techniques has its own advantages in terms of cosmetic results, invasiveness, safety, and ease of use. With experience and more advanced devices, minimally invasive thyroid surgery can replace the traditional procedure for most patients. The advances in diseased parathyroid gland and removal make surgical removal for primary hyperparathyroidism simpler and faster. Various types of minimally invasive parathyroid surgery (endoscopic technique, video-assisted technique, radio-guidance technique, and focused parathyroidectomy) are now performed and have replaced traditional exploration for most patients. The adrenal surgery is well suited for laparoscopic removal due to their relatively small size and the low incidence of malignancy. Since its first description in 1992 by Gagner and associates, the laparoscopic adrenalectomy has become the gold standard for the treatment of most benign adrenal tumors and can give more benefits to the patients with advanced surgical skills and laparoscopic instruments.

Effect of Greater Occipital Nerve Block on the Posterior Headache and Neck Pain after Total Thyroidectomy / 대한마취과학회지

BACKGROUND: During thyroidectomy, the patient's neck is fully extended for good surgical exposure. After thyroidectomy, patients usually complain of posterior headache and posterior neck pain. It has been known that the greater occipital nerve block is a means of effective medical treatment for occipital headache and posterior neck pain. Therefore, we examined the effects of a greater occipital nerve block on postthyroidectomy headache and neck pain. METHODS: This study was randomized and double-blinded. After anesthesia induction, patients were administered greater occipital nerve block by the same anesthesiologist; 0.25% bupivacaine 5 ml was used for each greater occipital nerve block. Patients in the control group did not receive a greater occipital nerve block. After thyroidectomy, another anesthesiologist evaluated patients' headaches and neck pains at 4, 12, and 24 hours postoperatively by using a VAS. RESULTS: Forty four patients were included. The number of patients in the control and the block group were 27 and 17, respectively. VAS scores of occipital headache after 4, 12, and 24 hours in the control group were 3.52+/-2.75, 3.67+/-2.75, and 2.95+/-1.96, respectively. VAS scores of occipital headache after 4, 12, and 24 hours in the block group were 0.05+/-0.65, 0.50+/-0.85, and 0.43+/-0.64, respectively. VAS scores of posterior neck pain after 4, 12, and 24 hours in the control group were 4.09+/-2.79, 3.81+/-2.60, and 3.00+/-2.02. VAS scores of posterior neck pain after 4, 12, and 24 hours in the block group were 1.29+/-2.20, 1.00+/-1.66, and 0.79+/-1.25, respectively. The pain experienced by the block group was significantly lower than that of the control group. CONCLUSIONS: We conclude that greater occipital nerve block is an effective modality for reducing post-thyroidectomy headache and posterior neck pain.

Incidentally Found Thyroid Nodules in Women with no Previous Thyroid Disease: Its Significance

PURPOSE: To determine the prevalence of thyroid nodules discovered incidentally at ultrasonography and to reassess their significance. MATERIALS AND METHODS: During a six-month period and using a high-frequency transducer, 1033 subjects with suspected breast disease underwent a prospective study of the thyroid. We determined the prevalence of thyroid nodules according to age, and the malignancy rate. RESULTS: Focal thyroid nodules were detected in 291 women (28.2%), their prevalence increasing with age (p<0.01). The nodules, totalling 337, were single in 260 cases (89.3%) and multiple in 31 (10.7%); 271 were less than 1 cm in diameter, 53 were 1-2 cm, and 13 were more than 2 cm [mean, 7.1(range, 2-34) mm]; 126 (37.4%) were pure cysts, 62 (18.4%) were mixed, and 149 (44.2%) were solid. Of the 149 solid nodules, 139 were hypoechoic. Eighty women (with 106 nodules) underwent fine-needle aspiration bipsy, and 35 (with 45 nodules) underwent surgery. It was discovered, finally, that 29 women (2.8%) had 35 malignancies, of which 33 were papillary carcinomas and two were carcinomas which had metastasized from a breast malignancy. Eleven women (37.9%) had extrathyroidal invasion and 6 (20.7%) had cervical lymph node metastasis despite incidentaloma. CONCLUSION: The prevalence of incidentally found thyroid nodules was 28.2%. Since the malignancy rate of these was relatively high, at 10.4%, the clinical significance of this finding should be reassessed.

Retroperitoneal Bronchogenic Cyst Presenting as Adrenal Tumor / 대한내분비외과학회지

Bronchogenic cyst can be found about everywhere in the mediastinum and rarely in the abdomen. Embriologically, the bronchogenic cyst, one of the primitive foregut-derived developmental anomalies, is composed of any or all of the tissue elements seen in a bronchus including respiratory epithelium, smooth muscle, mixed serous and mucose glands and cartilage. Most bronchogenic cysts are asymptomatic. The diagnosis is therefore made either as an incidental finding or, more usually is secondary to other organic complications such as infection, hemorrhage, compression of adjacent organs. Only a few of subdiaphragmatic bronchogenic cyst have been reported and their occurrence in the retroperitonum is extremely rare. We present a case of retroperitoneal bronchogenic cyst presenting as adrenal tumor which was successfully treated by laparoscopic resection.

Retroperitoneal Bronchogenic Cyst Presenting as Adrenal Tumor / 대한내분비외과학회지

Bronchogenic cyst can be found about everywhere in the mediastinum and rarely in the abdomen. Embriologically, the bronchogenic cyst, one of the primitive foregut-derived developmental anomalies, is composed of any or all of the tissue elements seen in a bronchus including respiratory epithelium, smooth muscle, mixed serous and mucose glands and cartilage. Most bronchogenic cysts are asymptomatic. The diagnosis is therefore made either as an incidental finding or, more usually is secondary to other organic complications such as infection, hemorrhage, compression of adjacent organs. Only a few of subdiaphragmatic bronchogenic cyst have been reported and their occurrence in the retroperitonum is extremely rare. We present a case of retroperitoneal bronchogenic cyst presenting as adrenal tumor which was successfully treated by laparoscopic resection.

Effect of Endogenous Steroids on Human Papillary Thyroid Cancer: Alteration of Urinary Profile in Pre- and Post-operative Cases / 대한내분비외과학회지

No abstract available in English.

Sclerotherapy with OK-432 for recurrent cystic thyroid nodule

We have adopted OK-432 as a sclerosing agent in the treatment of cystic predominant thyroid nodules and have analyzed our findings to assess the efficacy of intralesional instillation of OK-432. From 1992 through 1993, 48 patients with recurrent or progressive cystic thyroid nodules after 2 or 3 aspirations alone, and whom were cytologically negative for malignancy, were used for this study. The OK-432 solution was prepared by dissolving 0.1 mg of OK-432 in 2 ml of physiologic saline and it was instilled in the amount of 1/10-to-1/5 of the aspirated cystic fluid. A repeated course of therapy was given up to 3 times when sufficient resolution was not obtained 4-to-6 weeks after treatment. The mean number of treatment sessions per patient was 1.5. Throughout the follow-up period from 30-to-45 months (mean, 38 months), 32 (66.7%) patients experienced an almost complete disappearance ( 0.5 cm in diameter) of the initial cyst size, and none of these patients required further treatment. The remaining 4 (8.3%) patients showed insufficient resolution despite 3 courses of therapy and 2 of these patients underwent thyroidectomy, in which the lesion proved benign in both cases. All of the patients tolerated the sclerotherapy well. No significant local complications attributed to this treatment were observed. However, a low-grade fever was observed in 26 (54.2%) patients for 2 to 5 days after instillation, which subsided with symptomatic treatment. On the basis of our experience, OK-432 sclerotherapy appears to be safe, simple and effective, and can be a useful alternative treatment for cystic thyroid nodules.