Thyroid nodule: first manifestation of chronic lymphocytic leukaemia

The presence of chronic lymphocytic leukaemia (CLL) cells in the thyroid gland is most likely due to a secondary involvement by a systemic disease. The reported incidence of CLL involving the thyroid is extremely low, representing about 3–4% of all thyroid lymphoproliferative neoplasm. We report a rare case of CLL presenting initially in the thyroid gland. Systemic disease was detected as a result of thyroid investigation. An 85 years old woman, with multinodular goiter without adenophaties, was referred to our department, carrying a fine needle aspiration biopsy (FNAB) report of a private institution referring “lymphoid monomorphic proliferation” and suggesting a “Core-needle biopsy” for further investigation. She was euthyroid (TSH–0.5 uU/mL (0.4-4.0), thyroid antibodies negative, including TRab). The patient denied systemic symptoms and at physical examination there were no adenophaties or organomegalies. FNAB analysis was repeated. Although the patient denied constitutional symptoms and there were no relevant findings in physical examination, technetium 99m thyroid gamagraphy (GG) and blood count were additionally asked. FNAB analysis concluded lymphocytic tiroiditis, but thyroid GG revelled global hypocaptation and blood count showed 173.4 x 109 leukocyte/L with 94% lymphocyte. An ecoguided FNAB with flow cytometry identified thyroid infiltration by monotonous population of blasts with phenotype consistent with CLL/malignancy of mature B-cells. CLL/malignancy of mature B-cells was also detected in peripheral blood analysis, suggesting systemic disease with secondary thyroid involvement. The patient started chemotherapy with rituximab and chlorambucil with good response. Pos-treatment GG revelled “Increased levels of uptake in the middle third of the right lower lobe, with low uptake of the remaining parenchyma”. In conclusion, good communication with the pathologist can improve diagnostic accuracy and dictate appropriate therapy. The use of techniques such as flow cytometry, immunoglobulin gene rearrangements, and immunohistochemistry has improved diagnostic accuracy and obviated more invasive procedures, such as core needle or open surgery biopsy. Apart from chemotherapy, immunochemotherapy with anti-CD20 and anti-CD52 monoclonal antibodies can be used in the treatment of CLL.

Urine iodine excretion in patients with euthyroid nodular disease

Different nutritional and environmental factors are responsible for the pathogenesis of goiter, but iodine deficiency is the most important factor. However, little is known about the natural course of benign thyroid nodules in euthyroid patients over time. Few studies have used ultrasonographic evaluation to address this issue, especially in iodine-deficient areas. In this study, we present the long-term follow-up of benign thyroid nodules in a iodine-deficient area. Cross-sectional study at a tertiary referral center. This study included 62 randomly selected patients with benign euthyroid nodule. Thyroid volume and nodules were measured with sonography. Iodine intake was estimated by patient diet history and by measuring iodine excretion in spot urine samples. Patients were followed one year. Patients were divided into three groups according to level of urine iodine excretion: Group 1: <50 micro g/L [severe iodine deficiency group], Group 2: 50-100 micro g/L [mild iodine deficiency group], Group 3: >100 micro g/L [iodine sufficient group]. The presence of additional disease [hypertension, diabetes mellitus, coronary heart disease, chronic renal failure and a history of any medication for chronic disorder] and smoking rates were significantly higher in first group compared to the second and third group. Among groups, no significant difference was observed in either right or left thyroid lobe volume after one year. A clinically significant increase in nodule volume was observed in the first group, while there was a significant decrease in the second and third group. In this study, iodine deficiency was associated with an increase in thyroid nodule volumes. Smoking rates were higher in iodine deficient groups. It is thought that smoking impairs iodine intake or absorption consistent with a previous report

Isolated tuberculosis thyroiditis as solitary thyroid nodule

Isolated involvement of the thyroid by tuberculosis is very rare as reported in literature. We are presenting a case of isolated tuberculous thyroiditis presented as a solitary thyroid nodule. The patient was treated with anti-tuberculous regimen and he responded well with disappearance of the nodule and normalization of the thyroid scan

Subclavian steal syndrome as the presenting feature of hypervascular thyroid nodule.

Subclavian steal syndrome (SSS) is a clinical entity characterized by brachial and basilar insufficiency as a result of critical proximal subclavian artery stenosis or occlusion. We report a patient of giant hypervascular thyroid nodule presenting with features of SSS. The left hand ischemia and symptoms of vertebro-basilar artery in our patient were probably related to stealing of blood by the hypervascular thyroid nodule from the subclavian artery. The patient was relieved of the symptoms upon percutaneous subclavian stent placement.

Valoración de la punción biopsia con aguja fina y de la biopsia por congelación en el diagnóstico y tratamiento del nódulo tiroideo / Determine the role of frozen section and fine needle aspiration biopsy of thyroid nodules

Antecedentes: el advenimiento de la PBA ha posibilitado una mejor selección de pacientes portadores de patología tiroidea para la cirugía. Objetivo: determinar el rol de la punción y la biopsia por congelación en el manejo quirúrgico de la patología tiroidea. Lugar de aplicación: Servicio de Cirugía General División A; Servicio de Endocrinología y Servicio de Anatomía Patológica del Hospital de Agudos J.M. Ramos Mejía. Diseño: retrospectivo consecutivo. Método: se evaluó la correlación de los hallazgos de la PBA, la congelación y el estudio histopatológico final en el diagnóstico de la patología tiroidea. Población: se analizaron 541 pacientes estudiados con PBA y congelación operados en el Hospital Ramos Mejía. Resultados: de los 541 operados se diagnosticó cáncer en 163 pacientes (30 por ciento). La PBA diagnosticó 111 que fueron confirmados por la congelación e informó 104 casos como dudosos de los cuales 31 fueron cáncer. Dentro del grupo de los "dudosos" hubo mayor prevalencia de carcinoma en los subgrupos "sospechoso de malignidad" y en las "proliferaciones foliculares de alto grado". Conclusiones: se podría prescindir de la utilización de la biopsia por congelación ante una PBA maligna. En cambio ante una benigna o dudosa consideramos completar con la congelación intraoperatoria. Debido a la diferencia de prevalencia de carcinoma en el grupo de los dudosos justificamos mantener separadas las categorías citológicas: SM (sospechoso de malignidad), PFAG (proliferación folicular de alto grado), PFBG (proliferación folicular de bajo grado), PFH (proliferación folicular de Hürthle)

Punción de nódulos tiroideos guiada por ecografía con aguja fina (PAAF): nuestra experiencia / Sonographically guided biopsy of thyroid nodules

El objetivo de éste trabajo es comparar nuestra experiencia sobre las punciones aspirativas de nódulos tiroideos guiada con ecografía con la de otros trabajos publicados. Estudiamos retrospectivamente 183 pacientes sometidos a punciones biópsicas de nódulos tiroides (en un período de 27 meses). Las mismas se realizaron sin anestesia local, sin test de coagulación ni anatomopatológo en la sala. El 9,2 por ciento de los nódulos fueron malignos, 69 por ciento benignos, 14,7 por ciento acelular, sólo material coloide, y el 7,1 por ciento insuficiente. Nuestro trabajo coincide con el resto de la bibliografía en cuanto a que la punción tiroidea guiada por ecografía es un método simple, de bajo costo, con escasas complicaciones y con alta efectividad diagnóstica. Sugerimos punzar los nódulos mixtos ya que el 29,5 por ciento en nuestro estudio fueron malignos. Recomendamos que sea efectuada por personal capacitado, con anatomopatólogo en la sala y sin coagulación previa

Guía ecográfica y punción aspiración de nódulos tiroideos: a propósito de 73 pacientes / Ultrasound-guided percutaneous fine-needle aspiration of thiroid nodules: a 73 patient series

Objetivo: el propósito de ésta comunicación fue comparar nuestra casuítica con la encontrada en la bibliografía sobre hallazgos obtenidos, y complicaciones producidas. Material y métodos: en una serie de 73 pacientes (7 varones y 66 mujeres) con edades comprendidas entre 12 y 77 años (media 43,7 años), se realizaron 73 punciones en nódulos de 6 a 59 mm (con una media de 13,1 mm), obteniéndose material suficiente en todos los casos. Resultados: en 4/73 pacientes la biopsia fue positiva para células neoplásicas. En un caso resultó dudosa, siendo positiva la biopsia por congelación. En consecuencia, 5/73 pacientes presentaron neoplasias malignas. En 5/68 pacientes con lesiones ecográficas no sospechosas de atipía, la biopsia resultó negativa para neoplasia benigna, obteniéndose en los 33 casos restantes un informe más específico indicando bocio (n=10), hiperplasias (n=8), adenomas (n=7), tiroiditis (n=5) y quistes coloides (n=3). No se observaron complicaciones severas; sólo en 2/73 casos (2,7 por ciento) se evidenció un hematoma cervical en el área de punción. Conclusión: el alto índice de efectividad, escasa complicación, unido a que hay un gran porcentaje de nódulos no palpables, hace de la guía ecográfica un método insustituible para la punción de nódulos tiroideos

Follow up study of thyroidectomy.

One hundred thyroidectomized patients were followed up. The male:female ratio was 1:4. Majority (62%) of the patients were in the 4th and 5th decades. Multinodular goiter was the commonest lesion found in 74, diffuse colloid goiter in 12 and carcinoma in 14 cases. After operation, sixty-five patients were relieved of all preoperative symptoms of thyroid disease. Thirteen patients had some persistent symptoms. Rest 22 had developed different types of complication in addition to some preoperative symptoms. Three patients developed hoarseness of voice due to recurrent laryngeal nerve injury. Hypoparathyroidism occurred in 1, hypothyroidism in 4 and recurrent neck swelling in 14 patients. One patient died. It seems that a thorough knowledge of the surgical anatomy and meticulousness during the procedure would reduce the rates of such complications in future.

Nucleolar organizer reglons in the assessment of meoplastic and non-neoplastic thyroid nodules

Forty seven cases of thyroidectomy specimens were selected for this study including 6 cases of anaplastic carcinoma, 9 cases of papillary carcinoma, 6 cases of follicular carcinoma, 8 cases of follicular adenoma and 18 cases of adenomatous goiter. Paraffin section from each case are stained by the one step silver colloid reaction to demonstrate the argyrophilic nucleolar organizer region associated proteins. Anaplastic thyroid carcinoma had mean AgNOR count per cell distinctly and significantly higher than other categories. Mean AgNOR counts of papillary carcinoma, follicular adenoma, follicular carcinoma and adenomatous goiter showed considerable overlap. It is concluded that AgNOR counting has limited value in the differentiation between neoplastic and non-neoplastic thyroid nodules