Differentiated thyroid carcinoma (DTC) in the elderly: disease outcome, therapeutic approach, and long-term results in a group of 314 patients.
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Aged↗
Biomedical subjects
D Rubello
Publications and source records attributed to D Rubello.
Neuroendocrine tumor imaging: can 18F-fluorodeoxyglucose positron emission tomography detect tumors with poor prognosis and aggressive behavior?
We evaluated the clinical value of positron emission tomography (PET) using 18F-fluorodeoxyglucose (FDG) for neuroendocrine tumor (NET) detection. Sixteen patients with cytologically or histologically proved NETs were investigated. Patients were divided in two groups of eight patients each according to the clinicopathologic features related to prognosis: slow-growing NETs and aggressive NETs. Results of FDG tumor uptake as detected by PET were compared with computed tomography (CT) scans and with scans obtained with 111In-octreotide scintigraphy (n = 13). Tumor FDG uptake was increased in the primary lesion of all eight aggressive NETs; the tracer was shown also in lymph nodes, liver metastases, or both in five of six of them (83%). In four cases, additional unknown tumor sites undetected by CT scan were identified. A slight positivity was found in only one of eight cases with a slow-growing NET. The overall octreotide scintiscan sensitivity was 85%, but in the aggressive NETs it failed to detect the primary lesion in two of seven cases. Uptake of the tracer in some but not all tumor lesions in the same patient was seen by both FDG-PET and octreotide scintiscans. From our limited experience 18F-FDG PET seems to be useful for identifying NETs characterized by rapid growth or aggressive behavior. Uptake of the FDG tracer by the tumor may be related to a worse prognosis. Despite the heterogeneity of tracer uptake in the various lesions of NETs with multiple tumor sites, FDG-PET was able to detect unsuspected distant metastases, contributing to better staging of advanced disease.
Adult↗
Unusual association between a thyrotropin-secreting pituitary adenoma and a papillary thyroid carcinoma.
We report here an unusual case of association between thyrotropin (TSH)-secreting pituitary adenoma and papillary thyroid carcinoma in a young female patient. Serum TSH levels did not significantly change after both stimulatory (thyrotropin-releasing hormone [TRH], domperidone) and inhibitory (bromocriptine levotriiodothyronine, [LT3], levothyroxine [LT4], LT4 plus LT3) tests, while a 67% decrease of serum TSH levels was obtained after acute administration of a somatostatin analog (SMS 201-995, 100 microg s.c.). Serum alpha-subunit levels and the alpha-subunit/TSH molar ratio were clearly elevated. Magnetic resonance imaging (MRI) revealed the presence of a pituitary adenoma (1 cm in diameter). Pitfalls arising from the failure to inhibit TSH secretion in a patient thyroidectomized for papillary cancer are discussed.
Adenoma↗
[Positron emission tomography (PET) with 18-fluorodeoxyglucose (FDG) in the diagnosis and preoperative staging of head and neck tumors: a prospective study].
To evaluate the effectiveness of PET with FDG in the preoperative identification of loco-regional lymph node metastases in patients with head and neck tumors a total of 24 consecutive patients coming to the E.N.T. Center were studied. In all cases staging was made using CT and/or MRI and by PET with FDG. All patients then underwent surgery performed by one single team and the histopathological findings were evaluated every time by the same pathologists. The sensitivity (87.5% vs. 53.1%), specificity (99% vs. 87.8%) and diagnostic precision (98.2% vs. 85.3) achieved by PET with FDG proved significantly better than the radiological imaging methods. In particular, given that in the present study PET showed a negative predictive value of 99%, when planning a functional lymphadenectomy this technique can be suggested as a preoperative guide in mapping out lymph node metastases.
Adult↗
Potential role of fluorine-18-deoxyglucose (FDG) positron emission tomography (PET) in the staging of primitive and recurrent medullary thyroid carcinoma.
We investigated 5 MTC patients, 3 preoperatively for staging purpose, and 2 after surgery, during the follow-up, because of the persistence of elevated serum tumoral markers. FDG PET results were compared with conventional radiologic (US, CT scan, MRI) and scintigraphic non-invasive techniques (99mTc-MIBI and 99mTc-MDP scans). In all the 3 patients preoperatively studied, PET, as well as the other imaging modalities, detected the primitive tumor and the loco-regional lymphnode metastases. Furthermore, in one case, PET was the only technique that revealed an additional localization to the lungs. One false negative result was recorded with PET, as well as with the conventional imaging, in a MTC patient with a MEN II syndrome and with some liver micrometastases, 2 to 5 mm sized, showed only at laparotomy. PET was the only method capable of early visualizing a mediastinal relapse of the tumor in one of the 2 patients studied during the follow-up. This patient was re-operated and serum calcitonin levels became undetectable. On the basis of our preliminary results on MTC, PET with FDG seems to be an accurate, non-invasive technique, for staging purpose before surgery, and, during the follow-up for visualizing tumoral spread in patients with increased serum tumoral markers.
Adult↗
Three-phase bone scan pattern in asymptomatic uncemented total knee arthroplasty.
In this study we investigated the bone scan pattern in a homogeneous group of asymptomatic patients implanted with the same type of total knee arthroplasty (TKA) and with a minimum follow-up of 2 years. Twenty-nine patients (21 females, 8 males, mean age 62 years), with a total of 30 uncemented Hofmann TKAs, were entered in the study. The time interval from surgery to scintigraphic evaluation ranged from 2 to 4 years. Bone scan was performed using the three-phase technique and images were interpreted by visual analysis using a three-point scale for the dynamic and blood pool phases and a five-point scale for the bone phase. Areas of increased periprosthetic technetium-99m methylene diphosphonate (MDP) uptake were observed until 4 years after surgery. However, comparing the TKAs implanted 2, 3 and 4 years previously, a decreasing pattern in tracer uptake intensity was noted this being more evident in the femoral and lateral tibial components. In some cases, a persistently elevated tracer uptake, not exceeding a moderate grade, was found in the medial tibial component. In conclusion, increased periprosthetic 99mTc-MDP uptake is a common finding in asymptomatic uncemented Hofmann TKAs for a prolonged period after surgery, but the uptake intensity is generally mild or moderate and shows a characteristic decreasing pattern over time. Furthermore, in contrast with other types of asymptomatic knee implants previously investigated, no case of high or very high bone uptake was recorded with this type of implant. We may speculate that scintigraphic parameters of normality, and pathology, should be determined for each type of TKA. It is likely that, with the uncemented Hofmann TKA, a high or very high tracer uptake or a progressive increase in the uptake intensity is suggestive of the presence of complications.
Female↗
Functional meaning of scintigraphic and echographic patterns, and of circulating anti-peroxidase antibodies in asymptomatic chronic thyroiditis.
Asymptomatic chronic thyroiditis (ACT) is a variant of the autoimmune thyroiditis characterized by the presence of circulating anti-thyroid antibodies and the absence of palpable goiter. Thyroid function can be normal but a considerable percentage of ACT patients tend to develop subclinical hypothyroidism over time and thus periodical controls of thyroid hormones and TSH levels are needed. At present, useful parameters for predicting the functional outcome of ACT patients are lacking. To investigate this aspect, we evaluated 57 consecutive ACT patients (51 females, 6 males, aged 22-56 years) by means of thyroid 99mTc-pertechnetate scintigraphy and echography, and by measuring the serum level of anti-peroxidase antibodies (TPOAbs), FT4, T3 and TSH. At first observation, 30 patients were euthyroid whereas 27 had subclinical hypothyroidism. No patient had been previously treated with thyroid hormones. Thyroid scan showed a normal pattern or a diffuse and mild irregular uptake, without differences between euthyroid and subclinical hypothyroid patients. TPOAb levels tend to be higher in patients with subclinical hypothyroidism in comparison to the euthyroid patients (5893 +/- 1423 and 3943 +/- 912 UI/mL, respectively) but the difference was not statistically significant by using Student's "t"-test. Echography showed a normal pattern in 14 patients, while a diffuse hypoechoic pattern in the other cases, mild in 12, moderate in 19 and marked in 12, was found. A significantly higher prevalence of subclinical hypothyroidism was observed in the group of patients with a moderate or marked hypoechoic pattern in comparison to the group with a normo-echoic or mild hypoechoic pattern (70.4% versus 23.0%, Fisher's exact test p = 0.00003). Furthermore, the 3 patients who developed thyroid failure during a one-year follow-up also presented a moderate or marked hypoechoic pattern. Our data suggest that the echo-pattern can be a useful predictor of thyroid failure in ACT patients and thus the echographic evaluation should be included in the diagnostic protocol of these patients.
Adult↗
Myocardial technetium-99m sestamibi single-photon emission tomography as a prognostic tool in coronary artery disease: multivariate analysis in a long-term prospective study.
To date several studies have evaluated the accuracy of thallium-201 myocardial scan in risk stratification of coronary artery disease (CAD), while reports using technetium-99m methoxyisobutylisonitrile (MIBI), a tracer particularly suited to single-photon emission tomographic (SPET) imaging, are lacking. To rectify this omission, a prospective study was started in 1988 and at present 176 consecutive, and thus unselected, patients have been enrolled. All of them have been submitted to stress-rest MIBI SPET for the diagnosis or evaluation of CAD; 147 patients (121 males and 26 females, aged 53 +/- 9 years) have completed a surveillance period of at least 36 months following the scintigraphic study (range 36-60 months, mean 43). Sixty-one patients had a documented previous myocardial infarction. The mean pre-test likelihood of CAD was 44% in the patients without prior infarction. The main anamnestic, clinical, EKG and scintigraphic findings were evaluated and statistically correlated with the incidence of ensuing cardiac events using both univariate (chi-square test) and multivariate analysis (logistic regression model). Twenty-nine patients suffered from a cardiac event during the follow-up period (i.e. three cardiac deaths, six myocardial infarctions and 20 cases of unstable angina). Statistical multivariate analysis identified MIBI scan as the only highly significant and independent prognostic predictor [P = 0.006, relative risk (RR) = 17.62]. In detail, the most important scintigraphic parameters were the presence of a reversible defect (P = 0.0089, RR = 5.11) and the extension of the stress perfusion defect (P = 0.0255, RR = 3.27). The presence of typical angina proved to be a slightly significant predictor (P = 0.051, RR = 2.45), while no other examined parameter showed a significant correlation with a bad prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)
Angina, Unstable↗
Three-phase bone scintigraphy pattern of loosening in uncemented hip prostheses.
The three-phase bone scintigraphy pattern of loosening in uncemented hip prostheses (UHPs) has not previously been elucidated. We evaluated 28 patients with complicated UHPs who had undergone total hip arthroplasty a very long time previously (range 3-20 years, mean 8.4). All the patients were surgically reviewed: 26 UHPs were found to be loosened and two infected. Nine asymptomatic UHPs were taken as controls. The dynamic phase was invariably negative in both loosened and asymptomatic UHPs while markedly positive in the infected ones. The blood pool phase was positive to various degrees in 16 of the 26 loosened UHPs as well as in the infected UHPs, but was invariably negative in painless replacements. In the bone phase, areas of significantly (discrete to marked) increased uptake were observed in all the loosened prostheses as well as in two-thirds of the asymptomatic ones. However, the regions of the lesser trochanter and/or tip and/or shaft were involved exclusively in the case of the loosened UHPs, and diffuse periprosthetic uptake was found only with loosened or infected implants. Areas of slight methylene diphosphonate (MDP) uptake were found at every periprosthetic site and areas of discrete to marked MDP uptake were commonly found in the acetabulum and/or the greater trochanter with both loosened and painless prostheses and are thus considered to be nonspecific findings.
Bone Cements↗
Natural course of subclinical hypothyroidism in Down's syndrome: prospective study results and therapeutic considerations.
Pathogenesis, natural course and therapeutic management of subclinical hypothyroidism (SH) in Down's syndrome (DS) remain object of debate in literature. In the present study thyroid function, antithyroid antibody (ATA) prevalence and serum lipid concentrations were investigated in a group of 344 Down patients (DP) and data were compared with those obtained from a control group of 257 age and sex matched healthy subjects. Thyroid function and ATA prevalence were also studied in 120 parents of DP. SH prevalence was clearly higher in DP (32.5% of cases) than in controls (1.1%) and parents (0%). Similarly, ATA prevalence was higher in DP (18% of cases) than in controls (5.8%) and parents (6.6%). In spite of this, no correlation was found in DP between SH and ATA prevalences, since ATA were detected in 18.7% of SH-DP and in 15.8% of euthyroid DP. Thus, circulating ATA were not detected in the majority of SH-DP. No significant differences regarding T4, FT4, T3 and serum lipid levels among SH and euthyroid DP and controls were found. Moreover, TSH levels were only slightly increased, generally less than 10 microU/ml, in most cases of SH-DP. Follow-up was longer than 24 months (range 2-7 years, mean 3.1) in a group of 201 DP: two different patterns of SH course were observed, mainly depending on the presence or the absence of circulating ATA. In particular, 35.7% of ATA-positive SH-DP developed a clinically evident thyroid disease (overt hypothyroidism or hyperthyroidism), while no similar case was recorded among ATA-negative SH-DP.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Usefulness of 99mTc-MIBI stress myocardial SPECT bull's-eye quantification in coronary artery disease.
99mTc-methoxy-isobutyl isonitrile (MIBI) myocardial SPECT quantification performed using a Bull's-eye polar map, was evaluated and compared with visual analysis in 120 patients with proven or suspected CAD. The study series comprised 106 men and 14 women, age 37-75 years (mean 51 +/- 6), 68 of whom had had a prior myocardial infarction. Coronary angiography was taken as the gold standard: one-vessel disease was present in 24 patients, two-vessel disease in 39, and three-vessel disease in 44, whereas no significant stenosis was documented in 13 cases. Forty age-matched subjects (26 men, 14 women), with less than a 5% chance of having CAD, were enrolled to establish the normal database for males and females. ROC analysis was used to calculate the optimal thresholds for the definition of the disease extension in each vascular territory of the Bull's-eye polar map: 10% for LAD, 8% for LCX, and 20% for RCA territory. The sensitivity/specificity ratio of the scintigraphy was: 75/82% with the visual and 78/74% with the quantitative analysis for LAD; 60/90% with visual and 72/64% with visual and 70/62% with quantitative analysis for RCA territory. The sensitivity/specificity ratios for the CAD diagnosis were similar with the visual and the Bull's-eye analysis in 92/61% and 93/61% respectively. Bull's-eye analysis agreed with visual analysis in 296/360 vessels. Two and three-vessel disease were most frequently observed using the Bull's-eye approach.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
The role of 111In-octreotide scintigraphy in the detection of APUD tumours: our experience in eighteen patients.
111In-Octreotide scintigraphy has been recently proposed as a sensitive technique for the detection of neuroendocrine tumours, based on the high radiotracer affinity towards the somatostatin receptors expressed by the APUD-system cells. In the present study, a group of 18 patients with carcinoid tumours and gastrointestinal (GI) apudomas was investigated to assess the accuracy of Octreotide scintigraphy in localizing primitive, recurrent or metastatic lesions. Both planar and SPECT studies were obtained 4 hours after the i.v. injection of 111In-Octreotide (111 MBq); planar images were also carried out 24 hours later. In accordance with other authors, the sensitivity of the method was found to be very high (94%) in our group of patients; only in one case of nesidioblastosis was the scintigraphy negative. No differences in sensitivity were observed between the planar and SPECT studies, but the latter provided a better topographic localization of the neoplastic foci. It should be pointed out that in 7 cases (3 primitive, 1 recurrent and 3 metastatic lesions) scintigraphy correctly localized the tumour, when the other morphological techniques, such as echography, computed tomography or magnetic resonance, failed. On the basis of our data, we believe that Octreotide scintigraphy should be the first study performed in the evaluation of patients affected by APUD tumours.
Angiography↗
Pregnancy after high therapeutic doses of iodine-131 in differentiated thyroid cancer: potential risks and recommendations.
Seventy female patients who had been treated with high doses of iodine-131 for differentiated thyroid cancer (DTC) and who had a subsequent pregnancy were evaluated. The total 131I dose ranged from 1.85 to 16.55 GBq (mean +/- SD = 4.39 +/- 25.20 GBq). Age at first therapy ranged from 15 to 36 years (mean +/- SD = 24.3 +/- 5.0 years) and the interval from 131I therapy to pregnancy varied from 2 to 10 years (mean +/- SD = 5.3 +/- 2.8 years). The estimated radiation dose to the gonads ranged from 10 to 63 cGy (mean +/- SD = 24.0 +/- 13.5 cGy). All patients were treated with L-thyroxine at doses capable of suppressing thyroid-stimulating hormone. Seventy-three children were followed-up and seven pregnancies are still in progress. One child was affected by Fallot's trilogy and three had a low birth weight through with subsequent normal growth; the others were healthy with subsequent normal growth. No newborn with clinical or biochemical thyroid dysfunctions was found. Two spontaneous abortions during the second month of pregnancy were recorded. One of two patients in question subsequently had two healthy children. On the basis of these data, previous administration of high 131I doses does not appear to be a valid reason for dissuading young female DTC patients from considering pregnancy. However, patients should be advised to avoid pregnancy after 131I administration for a period sufficient to ensure complete elimination of the radionuclide and to permit confirmation of complete disease remission, i.e. at least 1 year in our opinion.
Adenocarcinoma↗
Metastatic thyroid carcinoma of the adrenal gland.
Follicular thyroid carcinoma may spread distant metastases in sites such as bone, lung and brain. In our series of 448 patients with follicular thyroid carcinoma, distant metastases were present in 25% of cases. We report here a case of follicular thyroid carcinoma with a single metastasis at the right adrenal gland, that was found 12 years after total thyroidectomy and radioiodine therapy. Chest X ray, neck and liver echography and total body scan (TBS), performed after radioiodine therapy, were negative. During hormone therapy, serum thyroglobulin (Tg) levels were less than 1 ng/ml until 1990, and then Tg progressively increased in eighteen months up to 149 ng/ml. A new TBS was negative. At computer tomography a node at the right adrenal gland was found. The patient underwent adrenalectomy and histology showed a metastatic follicular thyroid cancer with Hurthle cells. After 1 and 5 months from surgery Tg serum levels were 0.9 ng/ml. This case shows once again the importance of Tg serum levels during follow-up of differentiated thyroid cancer.
Adenocarcinoma↗
TSH-receptor antibody (TSH-R Ab) variations in patients undergoing subtotal thyroidectomy for Graves' disease: a prospective study.
Variations in circulating TSH-R Ab were correlated to the thyroid function outcome in a group of 43 patients who received subtotal thyroidectomy for Graves' disease. There were 36 females and 7 males, ranging in age from 18 to 63 years (mean +/- SD = 41.3 +/- 9.5 years). All patients were operated on by the same surgeon, with the same surgical technique, leaving a remnant of 4-5 grams of thyroid. When a condition of subclinical hypothyroidism was found after surgery, thyroid function was tested again within 2-3 months. Thus, in cases with persisting elevated TSH levels, L-thyroxine was administered. During follow-up a progressive decrease in the prevalence of euthyroid patients was documented (51.2% at 3 months, 30.2% at 2 years, 28% at 4 years), with a parallel increase in cases of subclinical and overt hypothyroidism. Two patients with persisting detectable TSH-R Abs showed recurrent disease within 2 years after surgery. No case of relapse was observed among patients who became TSH-R Ab negative. TSH-R Abs remained detectable in 68% of euthyroid and in 63.6% of subclinical hypothyroid patients before L-thyroxine administration, whereas TSH-R Abs remained positive in only 30% of patients with overt hypothyroidism, and became undetectable in most patients with subclinical hypothyroidism after L-thyroxine was begun. The persistence of TSH-R Abs in patients who have undergone surgery for Graves' disease should be considered a risk condition for relapse. These patients must be carefully followed-up.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Different features of pulmonary metastases in differentiated thyroid cancer: natural history and multivariate statistical analysis of prognostic variables.
We studied 134 patients with differentiated thyroid cancer and pulmonary metastases. All were treated with total or near total thyroidectomy, radioiodine and L-thyroxine. The prognostic value of the following variables in three groups of patients were evaluated by univariate and multivariate analysis: age at diagnosis, sex, histologic type, tumor extension, cervical lymph node metastases, mediastinic metastases, presence of metastases in distant sites other than lungs (multiple distant metastases) and morphological (chest x-rays) and functional (131I uptake) features of lung metastases. Univariate analysis identified patient age (p < 0.0001), morphological and functional features of lung metastases (p < 0.0001), presence of multiple distant metastases (p < 0.0001) and histologic type (p = 0.04) as significant prognostic factors. Multivariate analysis showed only morphological (p = 0.0014) and functional (p < 0.0001) features of lung metastases and the presence of multiple distant metastases (p = 0.01) as significant and independent variables. The data show that early (pre-radiological) scintigraphic diagnosis and 131I therapy of lung metastases appear to be the most important elements in obtaining both a significant improvement in survival rate and a prolonged disease-free time interval in these patients.
Adenocarcinoma, Follicular↗
Differentiated thyroid carcinoma in the elderly.
Prognostic factors and therapeutic results in a group of 268 patients with differentiated thyroid cancer (DTC) aged over 60 years are reported. These cases were selected from a total of 1457 DTC-patients seen at our Center from 1967 to 1987. All elderly patients underwent total thyroidectomy, and were treated with 131I therapy and suppressive hormonal therapy. Moreover, external radiotherapy was performed in 20% and chemotherapy in 3.8% of all cases. Follow-up included periodical clinical examination, serum Thyroglobulin (Tg) determination, 131I total body scan (TBS), and echographic and radiologic survey. Several unfavorable prognostic factors were identified in elderly patients with DTC. In comparison with data obtained in a group of patients under 60 years of age, 1) the follicular histologic type was increased, papillary/follicular ratio was 1.1 vs 2.6; 2) the F/M ratio was decreased, 1.5 vs 2.8 for papillary tumors, and 1.7 vs 3.6 for follicular tumors; 3) the rate of cases with local extrathyroid tumor growth and distant metastases was higher, and 4) rates of metastases to bone and metastases with low 131I uptake were increased. Moreover, the 10-year survival rate in elderly patients with lymph node and distant metastases was significantly reduced compared to younger patients, both for papillary and follicular cancer. The finding of detectable serum Tg levels was well correlated with the presence of metastatic disease. Moreover, Tg sensitivity was higher than TBS in showing the presence of metastatic foci. DTC in elderly people must be considered an aggressive tumor both for follicular and papillary histologic types. A radical approach is recommended: total thyroidectomy, 131I administration, and suppressive hormonal therapy.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Acute and chronic effects of high glucocorticoid levels on hypothalamic-pituitary-thyroid axis in man.
It is known that glucocorticoids can influence anterior pituitary hormones other than ACTH. Their effects on the hypothalamic-pituitary-thyroid axis are controversial. To further investigate this issue, the acute and chronic effects of high plasma cortisol levels on TSH secretion were evaluated in 20 normal subjects and in 14 patients with Cushing's syndrome. In normals, high plasma cortisol levels were obtained by giving ACTH 250 micrograms or CRH 100 micrograms iv as a bolus or by an hydrocortisone 500 mg infusion over 1 h. Acute cortisol increase produced no effect both on basal and TRH-stimulated TSH secretion. In patients with Cushing's syndrome, basal TSH levels, low or suppressed, showed an impaired response to TRH, inversely correlated with urinary cortisol values. After successful surgery, TSH and its response to TRH became normal in concomitance with the normalization of plasma and urinary cortisol levels. Our data show the lack of an acute inhibitory effect of high plasma cortisol levels on TRH-TSH axis. However, after long-term exposure to high plasma cortisol levels, i.e. Cushing's syndrome, inhibition of both basal and TRH-stimulated TSH secretion was demonstrated. These findings indicate that only prolonged hypercortisolism does interfere with pituitary TSH secretion. The underlying mechanisms are still unclear.
Adrenocorticotropic Hormone↗