Incidentally discovered papillary carcinoma of the thyroid: value of ultrasonographic follow-up. A case-report.

Incidentalomas of the thyroid are common small nodules found occasionally during imaging procedures. Their pathological nature is generally benign, but about 4% may harbour malignant tissue. Most current studies only suggest clinical follow-up, but there are no data about the natural history of malignant incidentalomas. The authors describe a patient with multiple incidentaloma of the thyroid submitted to fine-needle aspiration biopsy because his larger nodule grew 50% in 3 months at ultrasonographic follow-up. The cytological examination suggested thyroid malignancy in this nodule and surgical pathology showed multicentric papillary carcinoma. This case suggests that the larger diameter of a malignant incidentaloma may change rapidly. If more time had been spent before repeating the ultrasonography, the volume could have changed even more and the prognosis could have been changed as indicated by most prognostic score indexes.

[The use of helium-oxygen mixture in the ventilation study of children with chronic obstructive lung disease] / Uso da mistura de hélio e oxigênio no estudo da ventilação de crianças com doença pulmonar obstrutiva crônica.

OBJECTIVE: To study the distribution of Tc-99m DTPA radioaerosol when heliox or oxygen are used in the nebulization of children and adolescents with chronic obstructive pulmonary disease during pulmonary ventilation scintigraphy. MATERIAL AND METHODS: Clinical randomized and controlled trial. Patients with chronic obstructive pulmonary disease (5 to 18 years old) who required pulmonary scintigraphy between March 1996 and September 1998 were included. Obstruction of the lower airway was measured by spirometry. Patients were randomized into two groups according to the gas used for nebulization during scintigraphy: heliox (80% helium and 20% oxygen) or oxygen. Scintigraphy studies were expressed as slope of the cumulative pulmonary radioactivity uptake curve and as the maximal cumulative radioactivity in the lung. The mean diameter of the Tc-99m DTPA particles generated by heliox and oxygen was measured by laser diffraction. RESULTS: Ten patients were allocated in each group. There were no statistical differences (P>0.05) in terms of gender, main diagnosis, signs of malnutrition, mean values of weight, height, body area, or spirometry results. The mean slope in the heliox group (5,039-/+1,652) was significantly different (P=0.018) from the mean slope of the oxygen group (3,410-/+1,100). The mean slope of patients with severe airflow obstruction in the heliox group was statically different (P=0.017) from the mean slope of patients with airflow obstruction in the oxygen group. In both groups, patients without evidence of airflow obstruction were similar in terms of mean slopes (P=0.507) and mean cumulative radiation in the lung (P=0.507). The mean diameter of heliox-generated Tc-99m DTPA particles was 2.13 m (-/+0.62). This was statistically different (P=0.004) from the mean diameter of oxygen-generated particles (0.88-/+0.99 m). CONCLUSIONS: Nebulization with heliox was more efficacious than nebulization with oxygen for distribution and dispersion of Tc-99m DTPA radioaerosol in the lungs of children and adolescents with chronic obstructive pulmonary disease submitted to ventilation scintigraphy. The benefits of heliox over oxygen are more evident in the presence of lower airway obstruction. Without airway obstruction, we did not observe any difference in the distribution and dispersion of radioaerosol in the lungs. Although the mean diameter of the Tc-99m DTPA particles generated by heliox and oxygen was significantly different, the particles generated by both gases were still within the recommended range (between 1 and 5 m). Therefore, this difference does not account for the effects of heliox observed in this study.

Suppressive therapy with levothyroxine for solitary thyroid nodules: a double-blind controlled clinical study and cumulative meta-analyses.

Levothyroxine suppressive treatment of solitary thyroid nodules is controversial. A 1-yr prospective randomized placebo-controlled trial was conducted to evaluate the effect of T4 on nodule volume and bone mineral density, and meta-analyses were performed to examine the quantitative synthesis of data from similar designed controlled trials. Forty-five euthyroid patients (42 females, age range: 19-73 yr) with single, colloid nodules were randomized to T4 (21 patients, 2.7 +/- 0.3 microg/kg, TSH < 0.3 microIU/mL) and placebo. Ultrasonography and densitometry were performed at baseline and repeated after treatment. Mean nodule volume or bone mineral density did not change. Nodule reduction more than 50% was observed in 6 of 21 treated patients and 2 of 24 placebo patients (P = 0.12). This study and another 6 prospective controlled trials (minimum 6 months, ultrasonographic nodule evaluation) were included in cumulative meta-analyses (risk-difference method). Nodule volume decreased more than 50% in a significantly higher percentage of patients in the T4 groups (risk difference, 16.7%; 95% confidence intervals, 5.8-27.6%). Four trials evaluated nodule growth with homogeneous results (Q = 0.42). Nodule volume increased more than 50% in a significantly smaller percentage of patients treated with T4 (risk difference, 9.7%; 95% confidence intervals, 2.0-17.4%). In conclusion, T4 treatment is associated with decreased nodule volume in 17% of patients and may inhibit growth in another 10%.

Cytopathological findings from fine-needle aspiration biopsy are accurate predictors of thyroid pathology in patients with functioning thyroid nodules.

The cytopathological findings after fine-needle aspiration biopsy (FNAB) of functioning solitary thyroid nodules (FSTN) are not well defined. This is an important issue, once this procedure is the first step in nodule evaluation. This study evaluated FNAB findings and correlated these findings with histopathology in patients subjected to thyroidectomy. Eleven clinically euthyroid female patients (age range: 19 to 47 years) with FSTN, satisfactory specimens from FNAB and negative antithyroid antibodies were studied. Seven patients had autonomous nodules. The cytopathological findings were of follicular pattern suggestive of neoplasia in one case where the histopathological examination confirmed a follicular adenoma. In all other 6 autonomous cases, the smears were suggestive of colloid goiter and they had surgery due to compressive symptoms (n=4) or subclinical hyperthyroidism (n=2). The histopathological results confirmed colloid goiter in all except one who presented a follicular adenoma. Four patients had functioning thyroid nodules that suppressed their 1311 uptake after receiving T3. The cytopathological findings were considered malignant in one case surgically confirmed to be a papillary carcinoma. In all other 3 non-autonomous cases, the smears were suggestive of colloid goiter and they had surgery due to compressive symptoms (n=1), aesthetic reasons (n=11) or increase in nodule volume (n=1). The histopathological results confirmed colloid goiter. In conclusion, FNAB was an accurate predictor of thyroid pathology in FSTN without false-positive results in the present study.

Análise de fatores associados à recorrência de bócio pós-tiroidectomia / Analysis of the factors associated to recurrence of post-thyroidectomy goiter

Os fatores associados à recidiva de bócio pós-tiroidectomia por doença benigna da tiróoide ainda näo estäo completamente definidos, especialmente o uso profilático de hormônio tiroidiano. Objetivo. Determinar a prevalência, características e fatores associados à recorrência de bócio em pacientes submetidos à tiroidectomia por doença benigna. Métodos. Foram incluídos 66 pacientes, 53 mulheres e 13 homens (idade média = 51 anos, variaçäo = 20-82 anos) submetidos previamente (5,6 + or - 1 anos) à tiroidectomia (lobectomia, n = 50; nodulectomia, n = 5; tiroidectomia subtotal, n = 11). Na ocasiäo do estudo foi realizada ecografia de tiróide e dosagens séricas de T3, T4, TSH e anticorpos antimicrossomal. Definiu-se como recorrência de bócio a presença de volume residual >20mL e/ou novos nódulos >0,5mL à ecografia e näo previamente detectados durante a cirurgia. Resultados. SEte pacientes (10 por cento) apresentaram recorrência de bócio. O tempo de acompanhamento foi mais longo no grupo com recorrência (p < 0,5) e näo foi observada diferença em relaçäo a idade, sexo presença de história familiar de tiropatia e diagnóstico pré-operatório entre os dois grupos. Na análise de regressäo múltipla, apenas o tmepo de acompanhamento pós-tiroidectomia foi significativamente associado à recorrência de bócio (ß = 0,02;//2 = 0,16; p < 0,05), influenciando em 14 por cento a taxa de recorrência. História familiar de tiropatia, uso de hormônio tiroidiano e níveis séricos de T4 e TSE näo influenciaram a recorrência. Conclusäo. A recorrência de bócio pós-tiroidectomia por doença benigna de tiróide ocorre numa minoria de pacientes e estáa relacionada com o maior tempo de acompanhamento após a cirurgia. O uso de hormônio tiroidiano em doses näo supressiva após a cirurgia näo se relaciona à prevençäo de recorrência

[Analysis of the factors associated with recurrence of post-thyroidectomy goiter]. / Análise de fatores associados à recorrência de bócio pós-tiroidectomia.

The factors associated with post-thyroidectomy goiter recurrence in benign thyroid disease are not clearly defined, especially prophylactic thyroxine treatment. PURPOSE--To determine the prevalence, characteristics and associated factors of recurrence of goiter post-thyroidectomy in patients submitted to surgery for benign disease. METHODS--Sixty-six patients, 53 female and 13 male (mean age = 51 yrs., range 20-82 yrs.), previously (5.6 +/- 6.1 yrs.) submitted to thyroidectomy (lobectomy, n = 50; nodulectomy, n = 5; subtotal thyroidectomy, n = 11) for benign thyroid disease were included. Measurements of T3, T4, TSH, thyroid microsomal autoantibody titers and thyroid ultrasonography were performed at the time of the study. Recurrence of goiter post-thyroidectomy was defined on ultrasonography as the presence of residual thyroid volume > 20mL and/or new nodules > 0.5mL not detected at surgery. RESULTS--Seven patients (10%) developed recurrence of goiter. The post-operative follow-up period was longer in the recurrence group and there was no difference between the two groups as to age, sex, familial history of thyropathy and preoperative goiter diagnosis. In multiple regression analysis only the following post-operative period was significantly associated to goiter recurrence (beta = 0.02; R2 = 0.16; p < 0.05) and influenced the goiter recurrence rate by 14%. Familial history of thyropathy, thyroxine treatment in non-supressible doses after thyroidectomy and seric T4 and TSH levels did not influence the recurrence. CONCLUSION--Recurrence of goiter post-thyroidectomy occurs in a small number of patients and is related to longer post-operative follow-up time. Thyroxine treatment in non-supressible doses after surgery is not related to goiter recurrence prevention.

Riedel's thyroiditis associated with high titers of antimicrosomal and antithyroglobulin antibodies and hypothyroidism.

Riedel's thyroiditis is a rare, chronic inflammatory disease of the thyroid gland. The aggressive fibrosis with extension beyond the thyroid into adjacent tissues contrasts with the diffuse, but intracapsular fibrosis of Hashimoto's thyroiditis. Most current studies refute the possibility of progression from a highly fibrosing form of Hashimoto's thyroiditis to a Riedel's thyroiditis based on the distinct clinical and laboratory data, although an unknown immunological basis is suggested for both diseases. The authors describe a patient with Riedel's thyroiditis, probably associated with Hashimoto's thyroiditis, sent to surgery because her cytological examination suggested thyroid malignancy. This patient had clinical and laboratory features of hypothyroidism and very high titers of antimicrosomal and antithyroglobulin antibodies, which decreased after surgery. Pathology studies disclosed Riedel's thyroiditis with intense lymphocytic infiltration suggestive of Hashimoto's thyroiditis. Quantitative immunohistochemical studies were not able to distinguish between both diseases.