[Hyperthyroidism in the elderly]. / L'ipertiroidismo nell'anziano.

UNLABELLED: Hyperthyroidism in elderly patients is not to be under-evaluated, since it is characterized in such age range by particular clinical and prognostic features. Based upon literature survey and their clinical experience, the authors discuss in the present paper clinical, diagnostic and therapeutic problems of hyperthyroidism in geriatric patients. MATERIAL AND METHOD: In the period between 1978-2003 out of 1804 patients surgically treated for thyroid disease (non neoplastic in 1470 pts.), 180 subjects presented hyperthyroidism (17%). 36 were in geriatric age-range (mean age 76 yr.; 29 females and 7 males). 26 presented a Multinodular Toxic Goiter (72.2%), whereas 9 patients complained of Plummer Adenoma (25%); only 1 patient showed Basedow disease (2.7%). RESULTS: As far as ASA classification, there were 7 ASA I, 27 ASA II and 2 ASA III. Compression of digestive tract and/or respiratory airway represented a surgical indication in 15 patients (41.6%). 12 (33.4%) were operated due to predominant cardiac symptoms (tachycardia, atrial fibrillation). The remaining 9 patients (25%) were treated for the concomitance of atypical symptoms of hyperthyroidism. We performed 15 total thyroidectomy, 7 "near totally", 8 sub-total, 6 hemithyroidectomy in case of Plummer adenoma. Postoperative mortality was nihil; p.o. morbidity was 5.5% for medical conditions (pneumonia) and surgery-related (1 laryngeal recurrent paralysis and 1 hypoparathyroidism) in 5.5%. Post-operative follow-up, conducted at 6 and 12 months from the operation, showed regression of hyperthyroidism and regression or improvement of all clinical symptoms complained by the patient. CONCLUSION: Surgical treatment seems to be the only immediate and definitive cure for hyperthyroidism. Geriatric age does not seem to be a surgical contraindication.

A tele-injector for large doses of radionuclides in diagnostics and therapy.

The risks and the inconveniences of the oral administration of radionuclides for therapeutic purposes are examined. A remotely operated injector which permits the direct injection of the radioactive dose from the sealed bottle to the vein of the patient to lower the exposure dose to the operator is illustrated. The tele-injector can be also used each time a large dose of radioactive substance needs to be injected for diagnostic purposes, or if subdivision of the mother solution into other sterilised bottles is necessary.

Immunohistochemical assessment of peroxidase-like immunoreactivity in the thyroid gland and its correlation with biochemical assay.

BACKGROUND: Peroxidase content has been recently evaluated in normal thyroid and in different thyroid disorders by biochemical, histochemical, ultrastructural and immunocytochemical methods. Nevertheless immunocytochemical detection of thyroid peroxidase in thyroid samples conventionally processed for histology has never been done using a commercially available antibody, neither its correlation with the biochemical activity on adjacent samples. METHODS: In this study we have analyzed normal thyroid tissue (3 patients), follicular adenoma (2 patients) and multinodular goiter (2 patients) conventionally processed for histology and stained by immunocytochemistry (Avidin Biotin System) using a polyclonal (rabbit) antibody for horseradish peroxidase (Serotec). Biochemical assay was performed on adjacent samples according to Hosoya method. RESULTS: Normal thyroid showed peroxidase immunoreactivity in the majority of follicular cells; neoplastic cells of adenomas were variably stained. Biochemical assay showed positive correlation with ICC ranging from 20.4 micrograms/mg/prot a in multinodular goiter to 42.12 in normal thyroid, up to 122 of follicular adenoma. CONCLUSIONS: Peroxidase content in the thyroid gland may be of clinical interest in several thyroid diseases, and in this study we have demonstrated that thyroid peroxidase can be detected by ICC in routinely processed thyroid samples using a commercially available antibody.

[Sclerotherapy of thyroid cysts with tetracycline hydrochloride]. / Sclerosi delle cisti tiroidee mediante tetraciclina cloridrato.

In order to verify sclerotherapy efficiency in solitary thyroid cysts, needle aspiration of the cyst followed by instillation of tetracycline hydrochloride into the cyst cavity was performed in 110 patients; in thirty of these the aspirations was ultrasonically guided. A tight dressing on the neck was applied for 48 hours in order to maintain pressure on the cyst cavity. All patients were treated with L-T4 in TSH-suppressive doses. In a few patients (< 155), the tetracycline instillation caused local pain, lasting less than two hours. In no case, did cytological examination of the sediment of the aspirated fluid reveal any evidence of malignant cells. In 82 patients (84.54% of the 97 controlled patients), the last ultrasonic follow-up (performed at 3, 6, 9, 12 or 24 months) showed a decrease in lesion size. In particular, 16 patients (16.50%) had a complete cyst disappearance, 41 patients (42.17%) had a volume reduction of the cyst between 85 and 65%, and in 25 patients (25.77%) the reduction was more than 25%. In the remaining 15 patients (15.46%) a second treatment was performed, 3 of them also required a third treatment but in all these cases, the results seemed to be less satisfactory. The distinction in cyst size seemed to indicate that in the case of a large cyst (> 36 mm diameter), the treatment gives better results (92% success rate against 82% of the other patients). In conclusion, we are able to affirm that needle aspiration of the thyroid cyst with instillation of tetracycline hydrochloride is a simple, well tolerated and low cost technique.(ABSTRACT TRUNCATED AT 250 WORDS)

Three-phase radionuclide bone imaging and magnetic resonance imaging detection of occult knee fractures in athletes.

Twelve athletes presenting acute knee injury with normal radiological findings underwent both three-phase radionuclide bone imaging (TPBI) and magnetic resonance imaging (MRI). The association of these highly sensitive diagnostic procedures detected occult fractures in all patients. The areas of signal intensity alterations on MRI corresponded to those of increased radionuclide uptake in blood pool images. However, the same areas seemed to be more extended on delayed TPB images. TPBI yielded early diagnostic information about lesion sites and functional activities, while MRI provided better anatomical definition and specific information about associated soft tissue lesions and served to establish the correct therapeutic approach and follow-up.

Can iodine-131 whole-body scan be replaced by thyroglobulin measurement in the post-surgical follow-up of differentiated thyroid carcinoma?

This study compared serum thyroglobulin measurement and whole-body scans in the post-surgical follow-up of patients with differentiated thyroid carcinoma. Thyroglobulin levels were measured in 61 patients receiving L-thyroxine therapy after thyroidectomy, and again after suspension of therapy, before performing a whole-body scan with iodine-131. The sensitivity, specificity, and accuracy of thyroglobulin levels, measured during L-thyroxine therapy, for diagnosis of tumor residue or metastases were then calculated and compared with results obtained by diagnostic whole-body scanning. Our data show that neither thyroglobulin levels nor whole-body scans alone can discriminate between patients with or without metastases. Sensitivity reached 95.7%, specificity 100%, and accuracy 96.7% if results of both procedures were also taken into consideration. We conclude that in the management and follow-up of patients with differentiated thyroid carcinoma both parameters need to be evaluated.

Thyroid carcinoma with biphasic clinical course and evolution in medullary carcinoma-follicular variant. A case report and an immunocytochemical demonstration of calcitonin and thyroglobulin in the same neoplastic cells.

The authors present an unusual case of thyroid neoplasia firstly diagnosed as an anaplastic carcinoma with no rise in plasma thyroglobulin (Tg) and treated with total thyroidectomy and radioiodine administration. After 18 months regional lymph node metastases were present with a rise in plasma calcitonin (Ct) (8000-14000 pg/ml); lymphectomy and external radiation were performed and histology revealed a metastasis from thyroid medullary carcinoma. After 3 years, mediastinal and right supraclavicular masses were present with a concomitant rise in plasma calcitonin (from 700 to 3400 pg/ml); all neoplastic lesions showed radioiodine uptake and plasma Tg was 8.9 ng/ml. A biopsy of the supraclavicular region was taken and 131I therapy was attempted, but the patient died after 6 months. Immunocytochemistry of the biopsy revealed the presence of a medullary carcinoma-follicular variant: the neoplastic cells were variably reacting with anti-Ct and anti Tg, and, moreover, the two antigens were sometimes observed in the same cell bodies. The metabolic pattern and the clinical course of this tumour are discussed, and the authors propose that Ct and Tg plasma levels be evaluated and a total body scan (WBS) with radioiodine be performed in all cases of medullary or poorly differentiated thyroid carcinomas.

Identification of serum proteins, thyroglobulin and antithyroid antibodies in the fluid of thyroid cysts.

Fluid from fourteen thyroid cysts has been submitted to electrophoretic and immunochemical procedures in order to describe the biochemical structure of the fluid. Two patterns have been identified: a pattern showing a composition similar to that of normal serum ("serum-like"); thyroglobulin concentration is low, IgG are sometimes above normal and hTg-Abs are frequently detectable. A second pattern shows instead, a picture in which serum protein fractions are largely denatured and not identifiable ("denatured"); thyroglobulin concentration has been found markedly increased. It is suggested that in "serum like" the formation of the cysts occurs in the interstitium, whereas in the "denatured" type cyst the hemorrhagic necrosis appears to be the consequence of a massive damage of the follicular tissue.

TRH test in the follow-up of operated simple goiter: a study of recurrence.

The study was carried out on 46 patients operated for simple goiter. The statistical analysis of data of TRH test on a sample of 57 healthy volunteers has permitted an evaluation of the upper limits of the normal thyrotropin response; the secretory area (As) was shown to be more discriminating. The patients were divided on the basis of response to TRH (evaluated by As) and incidence of recurrence in the group of patients with an abnormal curve with respect to patients with a normal curve was shown to be highly significant (77% v.s. 33%; p less than 0.01). The study underlines the limits of conventional methods of follow-up which should avoid the appearance of recurrence and suggests the validity of TRH test in the screening of subjects to be treated by opotherapy for prevention of recurrence.