Journal of Thyroid Research最新文献

Background: The primary hyperparathyroidism (PHPT) is a common disease for the endocrinologist. The concomitant thyroid disease and differentiated thyroid cancer (DTC) appear to be more frequent in patients with PHPT than in the general population. The aim of this study was to characterize patients with symptomatic PHPT with and without DTC and analyze frequency and risk factors.

Methods: We consecutively studied patients with symptomatic PHPT diagnosed and treated at our center between 2013 and 2015. Patients with subclinical and syndromic forms of PHPT were excluded. Clinical and biochemical characteristics of patients with and without DTC were compared and risk factors were determined. All patients were studied with thyroid ultrasound and thyroid gammagraphy with TC-MIBI. Two expert surgeons performed all the surgical procedures.

Results: In 59 patients included, we found 12 cases of PTC (20.3%). The final histopathological report of the PTC was 7 cases of follicular variant, 2 cases of oncocytic variant, 2 cases of classic variant, and 1 case of columnar cells variant of PTC. Patients with thyroid cancer were older than patients without thyroid cancer (62 ± 9.5 versus 52 ± 15.8, p = 0.03). Higher preoperative levels of iPTH were associated with PTC (p=0.03) [OR 5.16 (95% CI: 1.08-24.7)].

Conclusion: PTC is frequent in patients with symptomatic PHPT. Thyroid nodules in patients with symptomatic PHPT must be studied before parathyroidectomy. In symptomatic PHPT, higher level concentration of parathormone (PTH) was associated with higher risk of DTC.

Background: Optimal neck lymphadenectomy in patients with papillary thyroid cancer (PTC) and microscopic lymph node metastasis needs to be defined in order to aid surgeons in their decision about the best way to proceed in these cases.

Methods: Patients who underwent total thyroidectomy and lymphadenectomy at levels IIa to VI were divided into two groups: Group 1 (G1) with macroscopic metastasis detected before surgery and Group 2 (G2) with microscopic metastasis detected in sentinel node during surgery. Odds ratio (OR) was computed for age, sex, tumor size, multicentricity, capsular invasion, vascular/lymphatic permeation, and nodes with metastasis.

Results: Primary tumor size was (G1 versus G2, respectively) 3.8 cm versus 1.98 cm (P<0.001); only lymphatic permeation was correlated to an increase in metastasis in lymph nodes 65.4% versus 25% (OR=5.6, p<0.001); metastatic frequency by region was IIa 18.5% versus 1.5%, III 24.3% versus 9.9%, IV 17.4% versus 18.1%, and VI 25.9% versus 71,2%. Metastasis to level V was found only in G1.

Conclusion: Selective lymphadenectomy at levels III, IV, and VI is optimal for PTC patients without preoperative evidence of lymph node disease, but who present with lymph node microscopic metastasis in an intraoperative assessment.

Scarless (in the neck) endoscopic thyroidectomy (SET) has evolved into a cosmetically preferred alternative to conventional thyroidectomy (ConT). Recently many of our patients are demanding SET; however their goitres are larger than the recommended size of 4-6 cm. Our aim was to compare the outcomes of ET for small (<6 cm) vs large (≥6 cm) goitres and determine its feasibility in such cases. This is a retrospective analysis of prospectively maintained database of patients undergoing ET. Patients were divided into 2 groups: I, small (<6 cm) and II, large goitres (≥6 cm). Their demographic and clinicopathological profiles, operation time, conversion and complication rates, and hospital stay were compared. 99 patients (101 procedures) were included: group I, 60 patients (61 procedures), and group II, 39 patients (40 procedures). Mean tumor size (± SD) was 4.4 ± 0.9 cm and 6.7 ± 1.1 cm in groups I and II, respectively. The groups were comparable with respect to demographic and clinical profile except for mean duration of goiter [30.1 ± 32.6 months (group I) vs 60.5 ± 102.4 months (group I), p = 0.03] and gland weight [21.5 ± 15.3 grams (group I) vs 62.3 ± 51.3 grams (group II), p = 0.001]. Although there was no significant difference between mean operating times, long term perioperative outcomes, and conversion rates, temporary hypocalcaemia and length of stay were longer in group II. One patient had permanent vocal cord palsy (~1%, 1/101); none had permanent hypoparathyroidism. Our results indicate that ET can be offered to a subset of patients with larger goitres desirous of SET with no significant difference in mean operation time, conversions, and long term postoperative complications in experienced hands.

Background: The association between subclinical thyroid dysfunction (defined by no symptoms or clinical features of hypothyroidism but biochemically TSH level in the range of above 5 miu/ml but below 10 miu/ml with normal FT4 level) and Acute Coronary Syndrome (ACS) is not known so far. This study was done to calculate the prevalence of subclinical thyroid dysfunction in patients with ACS.

Methods: A retrospective chart review of 1100 consecutive patients was done who presented to Emergency Department with symptoms suggestive of ACS and admitted. They were later classified in 3 categories that includes Acute ST Elevated Myocardial Infarction (STEMI), Unstable Angina (UA), and Acute Non-ST Elevated Myocardial Infarction (NSTEMI). Thyroid function test (FT4, TSH) and antithyroid peroxidase (TPO) were done and evaluated properly.

Results: Of 1100 consecutive patients 168 (15.27%) patients had the biochemical features of subclinical thyroid dysfunction. These 168 patients include 60 STEMI, 66 NSTEMI, and 42 Unstable Angina patients. There were no statistically significant differences in terms of left ventricular ejection fraction (LVEF) and catheterisation results considering thyroid dysfunction.

Conclusions: Subclinical thyroid dysfunction is quite prevalent in ACS patients. There are no significant associations between STEMI, Unstable Angina, or NSTEMI patients in terms of thyroid dysfunction neither in single vessel versus multivessel disease involvement. The causative role and outcomes of treatment are still uncertain and need further follow-up.

Both type 2 diabetes and hypothyroidism are highly prevalent disorders in the community. The existing data regarding prevalence of hypothyroidism in patients with diabetes comes mostly from small studies. There are only two studies with a sample size of more than 1000 diabetic patients, none of which have been done in South Asians. The present study evaluated patients with type 2 diabetes for presence of hypothyroidism and the clinical factors associated with it. The demographic, anthropometric, clinical, and biochemical parameters of consecutively enrolled patients with diabetes were systematically collected and analyzed. A total of 1152 middle aged patients with type 2 diabetes with a mean duration of diabetes of around 10 years were enrolled. Nearly 40 percent of the patients were obese and overweight, respectively, for South Asian standards and abdominal obesity was seen in around 90% patients. Clinical hypothyroidism (TSH>10 mIU/ml) was present in 113 of patients (9.83%) and another 68 patients (5.9%) had subclinical hypothyroidism (TSH 5-10 mIU/ml). Anemia (odds ratio : 2.19), overweight/obese status (odds ratio 2.07), and known dyslipidemia (odds ratio : 1.99) were found to have independent association with clinical hypothyroidism. HbA1c, abdominal obesity, poor control of hypertension, lipid parameters, microalbuminuria, and renal dysfunction showed no difference among patients with hypothyroidism when compared with euthyroid patients. Subclinical hypothyroid patients had no difference in any of the above analyzed parameters when compared to the euthyroid patients. This study shows that a significant proportion of type 2 diabetes patients suffer from clinical or subclinical hypothyroidism and screening for the same may be appropriate.

Introduction: The concept of short stay thyroidectomy has been tested and in practice in the developed world; the same has not been replicated in countries with limited resources due to lack of organized healthcare system. So, in this study, we tried to analyze if short stay thyroid surgery can be performed in a cost-effective way in developing countries and also if the endocrine surgical trainee can deliver these services safely.

Methods: The study was conducted prospectively from January 2013 to July 2014, at Department of Endocrine Surgery, SGPGIMS, Lucknow, India. Study group included patients undergoing short stay hemithyroidectomy whereas matched patients who qualified for inclusion criteria but did not undergo short stay surgery due to various reasons constituted control group. Outcome in both the groups was compared in terms of complication rates, cost benefit, and patient satisfaction. Subgroup analysis was also done for trainee versus consultant performed short stay thyroid surgery.

Results: A total of 439 patients with surgical thyroid disorders were evaluated at our institute during the study period and out of these 110 patients (58 cases and 52 controls) fulfilled the inclusion criteria. Younger patients with low socioeconomic status who were paying out of pocket were found to be more inclined to short stay thyroid surgery. There was no significant difference between the two groups in terms of postanesthetic discharge score (PADS), complication rates, and patients satisfaction; however there was significant reduction (p <0.001) in hospital cost in short stay group. In subgroup analysis, procedure time was more in trainee performed surgeries; however there was no significant difference in terms of mean PADS and complication rates.

Conclusion: Short stay thyroidectomy can provide a better cost-effective alternative to conventional thyroidectomy in patients undergoing thyroid surgery and can be safely performed by endocrine surgical trainees even in a low resource setting.

Introduction: Subclinical hypothyroidism (ScH) is an endocrine alteration that is related to cardiovascular risk factors, including those categorized as components of the Metabolic Syndrome (MS). However, findings in prior reports regarding an association between these alterations are inconsistent. The purpose of this study was to determine the relationship between both entities in adult subjects from Maracaibo City, Venezuela.

Materials and methods: The Maracaibo City Metabolic Syndrome Prevalence Study is a descriptive, cross-sectional study with random and multistage sampling. In this substudy, 391 individuals of both genders were selected and TSH, free T3, and free T4 tests were performed as well as a complete lipid profile, fasting glycaemia, and insulin blood values. ScH was defined according to the National Health and Nutrition Examination Survey (NHANES) criteria: high TSH (≥4.12mUI/L) and normal free T4 (0.9-1,9 ng/dL) in subjects without personal history of thyroid disease. MS components were defined according to IDF/AHA/NHLBI/WHF/IAS/IASO-2009 criteria. A multiple logistic regression analysis was used to assess the relationship between MS components and ScH diagnosis.

Results: Of the evaluated population, 10.5% (n=41) was diagnosed with ScH, with a higher prevalence in women (female: 13.6% versus male: 7.7%; χ2=3.56, p=0.05). Likewise, 56.1% (n=23) of the subjects with ScH were diagnosed with MS (χ2=4.85; p=0.03), being hyperglycemia the main associated criterion (χ2=11.7; p=0.001). In multivariable analysis, it was observed that the relationship was exclusive with the presence of type 2 diabetes mellitus (T2DM) OR: 3.22 (1.14-9.14); p=0.03.

Conclusion: The relationship between ScH and MS in our population is dependent on the presence of hyperglycemia, specifically T2DM diagnosis, findings that vary from those previously reported in Latin American subjects.

Randomised controlled trials are deemed to be the strongest class of evidence in evidence-based medicine. Failure of trials to prove superiority of T3/T4 combination therapy over standard LT4 monotherapy has greatly influenced guidelines, while not resolving the ongoing debate. Novel studies have recently produced more evidence from the examination of homeostatic equilibria in humans and experimental treatment protocols in animals. This has exacerbated a serious disagreement with evidence from the clinical trials. We contrasted the weight of statistical evidence against strong physiological counterarguments. Revisiting this controversy, we identify areas of improvement for trial design related to validation and sensitivity of QoL instruments, patient selection, statistical power, collider stratification bias, and response heterogeneity to treatment. Given the high individuality expressed by thyroid hormones, their interrelationships, and shifted comfort zones, the response to LT4 treatment produces a statistical amalgamation bias (Simpson's paradox), which has a key influence on interpretation. In addition to drug efficacy, as tested by RCTs, efficiency in clinical practice and safety profiles requires reevaluation. Accordingly, results from RCTs remain ambiguous and should therefore not prevail over physiologically based counterarguments. In giving more weight to other forms of valid evidence which contradict key assumptions of historic trials, current treatment options should remain open and rely on personalised biochemical treatment targets. Optimal treatment choices should be guided by strict requirements of organizations such as the FDA, demanding treatment effects to be estimated under actual conditions of use. Various improvements in design and analysis are recommended for future randomised controlled T3/T4 combination trials.

Increased risk of second primary malignancy (SPM) in papillary thyroid cancer (PTC) has been reported. Here, we present the most updated incidence rates of second primary malignancy from original diagnosis of PTC by using the data from the Surveillance, Epidemiology, and End Results. In this cohort, 3,200 patients developed SPM, a substantially higher number than in the reference population of 2,749 with observed to expected ratio (O/E) of 1.16 (95% CI; 1.12-1.21). Bone and joint cancer had the highest O/E ratio of 4.26 (95% confidence interval [CI] 2.33-7.15) followed by salivary gland (O/E 4.15; 95% CI 2.76-6.0) and acute lymphocytic leukemia (O/E 3.98; 95% CI 2.12-6.8). Mean age at the diagnosis of SPM was 64.4 years old. Interestingly, incidence of colorectal cancer was lower in thyroid cancer survivors compared to general population (large intestine O/E 0.3; 95% CI 0.06-0.88, rectum O/E 0.6; 95% CI 0.41-0.85); however, this was not observed in patients who underwent radiation therapy. The incidence of SPM at all sites was higher during 2000-2012 compared to 1992-1999 (O/E 1.24 versus 1.10). Surprisingly, patients with micropapillary cancer had higher incidence of SPM than counterparts with a larger tumor in radiation group (O/E of 1.40 versus 1.15). O/E of all cancers were higher in males compared to females with O/E of 1.41 versus 1.17 during the period of 2000-2012. Diagnosis of PTC before age 50, especially at age 30-34, was associated with higher incidence of overall SPM (age 30-34; O/E 1.43; 95% CI; 1.19-1.71). Efficient monitoring strategies that include age at the time of thyroid cancer diagnosis, exposure to radiation, gender, and genetic susceptibility may successfully detect SPM earlier in the disease course. This is especially important given the excellent prognosis of the initial thyroid cancer itself.

Background: Children and adolescents with papillary thyroid carcinomas (PTCs) have generally excellent prognoses despite their frequent extended disease. The tumor growth of young patients' PTCs might show spontaneous slowing postoperatively. We compared young PTC patients' postoperative thyroglobulin-doubling time (Tg-DT) with their preoperative hypothetical tumor volume-doubling time (hTV-DT).

Methods: Fourteen PTC patients aged ≤18 years who underwent total thyroidectomy at Kuma Hospital in 1998-2016 had biochemically persistent disease postoperatively. We calculated their Tg-DTs and estimated their preoperative TV-DTs with the tumor size and the patient's age at surgery, presuming that a single cancer cell was present at the patient's birth.

Results: Twelve patients had positive Tg-DTs ranging from 2.0 to 147 years, and the remaining two had negative Tg-DTs, indicating slow growth or even regression. The hTV-DTs were 0.3-0.6 years (median 0.5 years), which were significantly shorter than the Tg-DTs (p < 0.001), indicating much faster growth preoperatively. The analyses of the nine patients without radioactive iodine administration (RAI) gave similar results (p < 0.01).

Conclusions: Irrespective of RAI, the patients' postoperative Tg-DTs were significantly longer than their preoperative hTV-DTs and were negative values in two patients, indicating that the growth of these young patients' PTCs had spontaneously slowed or even regressed postoperatively.