Primary lymphoma of the thyroid, the association with Hashimoto's thyroiditis.

This paper reviews the cases of thyroid lymphoma seen at one centre to assess the relationship between autoimmune thyroiditis and the subsequent development of thyroid lymphoma. Twenty two cases of thyroid lymphoma were seen over a 10 year period; 5/22 (23%) had previously been diagnosed as having Hashimoto's thyroiditis. The series comprised 18 women and four men; mean (range) age at presentation was 64 (26-85) years. All patients presented with a rapidly enlarging goitre and 13/22 (59%) underwent surgical excision prior to diagnosis of lymphoma. Nineteen of 22 (86%) patients underwent radiotherapy. The 5-year mortality for stage IE disease was 43%, survival appeared to be unrelated to previous Hashimoto's thyroiditis or to surgical resectability. The histological differentiation between pre-existing thyroiditis and thyroid lymphoma is often difficult and may lead to an underestimate in the reporting of the association. A prospective study of serial autoantibody assays in patients with Hashimoto's thyroiditis may be useful in predicting the onset of lymphomatous change in this condition.

The use of computed tomography in the evaluation of large multinodular goitres.

This study reports one unit's experience of the value of computed tomography (CT) in the evaluation of 24 patients with large cervical and retrosternal goitres. Of these patients, 17 were thought clinically to have symptoms of tracheal compression, but the CT demonstrated significant narrowing in only 12 cases. In the other five patients, surgery was deferred and other causes for their symptoms sought and treated. Seven patients were asymptomatic and CT failed to reveal any evidence of tracheal compression in six. In the remaining patient, however, CT revealed gross narrowing and urgent surgery was performed. When compared with CT, chest/thoracic inlet radiographs were misleading in 48% of patients, with tracheal narrowing being overestimated and underestimated. We conclude that CT gives useful information about tracheal compression in patients with large multinodular goitres, and is more accurate than chest/thoracic inlet radiographs.

The association between thyroid neoplasia and intestinal polyps.

Recent reports have suggested an association between familial adenomatous polyposis and papillary carcinoma of the thyroid. This report describes four patients, each with intestinal polyps and thyroid or thyroglossal cyst carcinoma. One patient had a medullary rather than papillary carcinoma of the thyroid and in another the intestinal polyps were due to Peutz-Jeghers syndrome. This may indicate a wider association between thyroid carcinoma and intestinal polyps than has previously been recognised.

Thyroidectomy for Graves' disease: is hypothyroidism inevitable?

The outcome of 234 patients with Graves' disease treated by subtotal thyroidectomy over a 12-year period is analysed with specific reference to hypothyroidism. Of definite hypothyroid cases, 98% occurred within 2 years. Failure to develop hypothyroidism was statistically related to large remnant size and a large goitre preoperatively. Histological review showed that any degree of lymphocytic infiltration was associated with the development of hypothyroidism (50% vs 22%). Late onset hypothyroidism occurred rarely and is not an inevitable outcome of thyroid surgery in our hands.

Assessment of thallium-pertechnetate subtraction scintigraphy in hyperparathyroidism.

Reliable techniques for detecting and localising abnormal parathyroid tissue have been a persistent problem. We have evaluated thallium-pertechnetate subtraction scintigraphy in a prospective study of 40 patients with clinical and biochemical evidence of hyperparathyroidism prior to parathyroid surgery. Four patients were excluded as they were shown to have goitre, making subtraction scanning non-diagnostic. 89% of parathyroid adenomas (totalling 27 glands in 26 patients) and 41% of hyperplastic glands (17 glands in 6 patients) were accurately localised prior to surgery. These included three retrosternal glands, four patients with renal failure and tertiary hyperparathyroidism and five patients who had previously undergone neck exploration. The apparent discrepancy between detecting hyperplastic and adenomatous glands was associated with the smaller size of the former. For both types of gland, scintigraphy successfully located parathyroids 0.6 g or more in weight. These results suggest that this simple and non-invasive method is a useful technique for locating parathyroid tissue before parathyroid surgery.

Surgery for thyrotoxicosis.

Recent reports have suggested the use of radio-iodine for the treatment of all cases of thyrotoxicosis. This paper evaluates the results of 627 patients undergoing subtotal thyroidectomy with a mean follow-up of 5 X 8 years. The most common complications were hypothyroidism (26 X 6 per cent) and recurrent thyrotoxicosis (2 X 6 per cent). Permanent hypocalcaemia occurred in 8 cases (1 X 4 per cent) and one patient developed a permanent, though asymptomatic, unilateral cord palsy (0 X 2 per cent). Ultimately all patients receiving radio-iodine appear to become hypothyroid and there is continued worry about possible thyroid malignancy. Almost 70 per cent of our cases were free of complications and euthyroid and we therefore believe that surgery remains the treatment of choice for thyrotoxicosis. We also discuss the difference in results between Graves disease and toxic multinodular goitre.

Treatment of thyroid carcinoma in 107 cases.

One hundred and seven patients with thyroid carcinoma were treated. Thirty-one per cent of the tumours were papillary, 27% were follicular, 28% anaplastic, 4% medullary, and 10% were lymphomas. In the differentiated group of tumours, lobectomy followed by suppressive doses of thyroxine was the commonest surgical treatment. This series confirms that in the absence of extrathyroid dissemination, lobectomy is a safe and effective treatment.

The treatment of autonomous functioning thyroid nodules.

The clinical features and management of 90 thyrotoxic and 11 euthyroid patients with a single autonomous hot nodule in the thyroid have been reviewed to assess the results of surgery and radio-iodine therapy. Symptoms and signs of thyrotoxicosis were often minimal but histories were frequently long with cardiac complications predominating. Thyrotoxicosis was permanently eradicated in the 60 patients treated surgically, although hypothyroidism occurred in 6.6 per cent. Twelve of the 37 (32 per cent thyrotoxic patients receiving radio-iodine needed further definitive treatment for persistent or recurrent thyrotoxicosis, but only 2 patients (5 per cent) became hypothyroid. Early surgery for the autonomous toxic thyroid nodule ensures control of the thyroid overactivity and minimizes the risk of permanent cardiac damage. The absence of morbidity justifies surgical excision of autonomous hot nodules in patients who are euthyroid to eliminate the risk of thyrotoxicosis supervening.

The effect of partial thyroidectomy for Graves' disease on serum long-acting thyroid stimulator protector (LATS-P).

The effect of partial thyroidectomy on serum LATS-P has been investigated in twenty-one consecutive patients. Before surgery, LATS-P was detectable in seventeen (81%) but 1 year after operation only five (24%) had activity. The activity did not fall immediately after surgery but declined progressively throughout the year. In no patient was an increase in activity demonstrated; nor did LATS-P appear in those patients who did not have activity before operation.

Solitary toxic adenoma of the thyroid gland.

The incidence of solitary toxic adenoma of the thyroid in a general surgical unit with an interest in thyroid disease has been reviewed over a 15-year period. Six hundred and thirty thyrotoxic cases were treated surgically, 35 (5.6 per cent) having a solitary toxic adenoma. Thyroid enlargement or toxicity had been present for more than 5 years in 7 patients (20.0 per cent). Cardiovascular complications were present in 6 cases (17.1 per cent). Thyroid lobectomy resulted in 30 (85.7 per cent) euthyroid and 5 (143.3 per cent) hypothyroid patients. One toxic adenoma contained a focus of carcinoma. The clinical features, diagnosis and management of solitary toxic adenoma, and the management of symptomatic nodules which are 'hot' but not biochemically toxic, are discussed.