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PubMed1987

Differential diagnosis of goiter.

Goiters can be detected in about 5 per cent of school-aged children. Goiters appearing during childhood are the result of distinct diseases and should be investigated rather than attributed to "physiologic hyperplasia." The etiology of the diffuse goiter can often be established by clinical evaluation, performing thyroid function tests, and measurement of serum thyroid antibodies. Unlike diffuse goiters, thyroid nodules frequently require tissue examination to exclude malignancy. The goal in evaluating children with nodular goiters is to be as selective as possible in submitting children to surgery without missing cases of cancer. The decision to perform an open biopsy should be based on detecting increased risk for cancer in the medical history, physical examination, or laboratory tests as outlined in Figure 1. Ultrasonography and fine-needle aspiration of nodules are two new methods that aid in the selection of patients for surgery or a trial of thyroid hormone suppression.

Adolescent↗
PubMed1978

Increased serum thyroglobulin levels in patients with nontoxic goiter.

Thyroglobulin (Tg) levels were found to be elevated in 30 to 35 patients with euthyroid sporadic goiter and in 15 of 37 patients with euthyroid endemic goiter. The elevated Tg levels in the goitrous patients did not correlate with either goiter size, TSH levels, or urinary iodine excretion, but did correlate with the triiodothyronine to thyroxine ratio. It was concluded, therefore, that in both sporadic and endemic euthyroid goiters, factors other than goiter size and TSH, such as hypoiodination of Tg may be responsible for the elevated Tg secretion.

Adult↗
PubMedDate not supplied

Nodular goiter and thyroid carcinoma in children and adolescents in a moderate endemic area (lower Silesia-Sudeten endemia) in the last twelve years.

Although thyroid carcinoma is more common in the adult population, the risk of a nodule being malignant is greater in children. The aim of our present investigation was to ascertain the percentage of malignancy in nodular goiter observed in patients from the Lower Silesia region in the last 12 years. The examination included 60 children (12 boys and 48 girls) treated in our clinic from 1987 to June 1998. Age varied from 7 to 18 years (mean 14.8 +/- 2.4), most of them in the age group between 13 and 18 years. The following investigations were performed: TSH, T3, T4, thyroid ultrasonography, fine needle aspiration biopsy and Tc99 scintigraphy of the thyroid. Most of the patients were euthyroid; two children demonstrated pressure symptoms. All the patients were treated by operation. Histological examinations revealed the following: nodular goiter in 19 patients, cystic nodular goiter in 5, follicular adenoma in 20, fetal adenoma in 3, nodular goiter and follicular adenoma in 6, papillary carcinoma in 6, and follicular carcinoma in 1 patient. We concluded that an increased incidence of thyroid cancer has been noted in children with nodular goiter in Lower Silesia during the last 12 years. Thyroid cancer was observed mostly in patients with single nodules and was associated with a high risk of malignancy.

Adolescent↗
PubMed1992

[Ultrasonographic pattern and levels of thyrotropin and antithyroid antibodies in patients with recurrent neutral goiter after subtotal thyroidectomy].

The study comprised 65 women (mean age 43 years) with the recurrent goiter after subtotal strumectomy. All patients were subjected to ultrasonographic examination using a sonograph Sonoline LM (Siemens) with 7.5 MHz head. The study was aimed at: 1) assessment of etiology of goiter recurrence, 2) assessment of changes in the thyroid parenchyma, 3) detection of the occurrence of heterogeneous structures, such as nodules, cysts and calcifications. It was found that goiter recurrence appeared mainly in the patients subjected to surgery because of neutral nodular goiter. The observed changes in the thyroid stump, such as heterogeneous structure of parenchyma, generalized cyst-like spaces and nodular structures mainly of mixed type or of solid, normo-echogenic or hyper-echogenic type, were associated with high levels of THS and the presence of antithyroid antibodies in blood serum. In patients with evidently high TSH levels and positive with respect to occurrence of antithyroid antibodies, the nodular structures were more numerous and of larger size. In can be concluded that ultrasonography provides a valuable noninvasive tool for the evaluation of morphological structure of the recurrent goiter.

Adult↗
PubMed2006

[Current views on the etiopathogenesis of goiter in children].

The most frequent cause of goiter in children is a deficit of iodine, leading to endemia of goiter in the regions with insufficient supplementation of this element. Goiter occurs also in the course of autoimmunological diseases of the thyroid gland (Hashimoto disease, Graves' disease), genetically-related disorders of thyroid hormones, biosynthesis/impaired biosynthesis of thyroid hormones. According to the theory of goiter pathogenesis, excessive enlargement of the thyroid gland is due to adaptation of follicle cells of the gland aiming at neutralizing the impaired synthesis of the thyroid hormones caused by various intrathyroid, environmental and genetic factors/agents. The mechanisms stimulating thyrocytes to hyperplasia or hypertrophy are very complex and still unknown in spite of having identified many physiological and pathogenetic factors connected with goiter.

Child↗
PubMed1988

[The role of goitrogenic factors distinct from iodine deficiency in the etiology of goiter].

The main cause of endemic and sporadic goiter is a deficiency in the dietary supply of iodine. However, iodine deficiency is not the only cause of goiter. This paper reviews present knowledge on the role of naturally occurring goitrogens in the etiology of goiter. Vegetables from the Cruciferae family, chronic consumption of poorly detoxified cassava containing large amounts of cyanogenic glucosides, flavonoids, humic substances originating from the organic residues in the soil are clearly involved in the etiology of endemic goiter. Iodine excess, especially in the newborn infants, lithium and thiocyanate overload resulting from smoking habits can be responsible for the development of goiter in non endemic areas.

Goiter↗
PubMed1980

[Hormone picture in female patients with diffuse and nodular goiter].

Concentration of total thyroxine, normalized thyroxine ratio, T3-RIA, and Serum TSH before and 30 minutes after stimulation with 0,2 mg TRH i.v. in various forms of euthyroid goiter were determined. There were no significant differences between the three clinical groups of goiter patients. We draw the conclusion that the dependence on TSH, as one important factor in pathogenesis, can on the one hand lead to a diffuse goiter and, on the other hand lead to a nodous goiter. That means, that different developments of goiter are determined by specific thyroid tissue factors.

Adult↗
PubMedDate not supplied

[A case of forgotten giant goiter].

The forgotten goiter is most often the consequence of the incomplete removal of a "plunging" goiter, but it can sometimes be attributed to a concomitant, unrecognised mediastinal goiter which is not connected to the thyroid. Differential diagnosis must be made with other mediastinal masses and with plunging relapses of a previously operated struma. Radiological analysis of persisting mediastinal involvement before and immediately after surgery is the only decisive means of diagnosis, but this is not always available in practice. In this paper the authors report a case of considerable size observed in a series of 346 mediastinal goiters operated between 1967 and 1994. They examine the pathogenetic aspects and the nosological, diagnostic and therapeutic problems related to forgotten goiter, and lastly they list the recommendations that several surgeons have made in an attempt to reduce the incidence. In conclusion, the systematic use of CAT or NMR in the diagnosis of mediastinal opacity may help to reduce the risk of forgetting glandular residue in the mediastinum.

Diagnosis, Differential↗
PubMed2003

Spread of goiters outside the thyroid bed: a review of 190 cases and an analysis of the incidence of the various extensions.

OBJECTIVES: To analyze the distribution of thyroid goiters into the mediastinum and/or behind or along the sides of the pharynx, and to review the anatomy of the spaces in the neck that explains these extensions. METHODS: We used a 28-month period, to retrospectively identify 190 cases of neck goiters that underwent computed tomographic imaging. The maximal size of a normal thyroid gland and the limits of the normal thyroid bed were defined on the basis of established anatomic measurements. Standard definitions of the mediastinum and its compartments were also used. Each case was reviewed by 3 radiologists, and extension of the thyroid gland into the mediastinum or cranially behind or along the sides of the pharynx was noted. All cases were correlated with clinical observations. RESULTS: Of the 190 goiters, 106 (55.8%) were confined to the thyroid bed, 70 (36.8%) extended into the mediastinum, and 14 (7.4%) extended behind or along the sides of the pharynx. All 70 cases that extended into the mediastinum involved the anterior mediastinum, and 5 (7.1%) of these extended into the posterior mediastinum. CONCLUSIONS: Goiterous extension outside of the thyroid bed occurred in 84 (44.2%) of cases. Although extension cranially behind the pharynx is uncommon, the physician should be aware of this diagnosis and the fascial anatomy that explains its occurrence. All of the goiters that were in the posterior mediastinum also had a component in the anterior mediastinum.

Adult↗
PubMed2005

Surgical management of multinodular goiter with compression symptoms.

HYPOTHESIS: Multinodular goiter (MG) with compression symptoms has a clinical profile different from that of goiter without these symptoms. The surgical treatment of MG with compression symptoms has a high rate of sternotomy and morbidity. DESIGN: Retrospective study conducted between 1970 and 1999. SETTING: Tertiary referral center. PATIENTS: One hundred fifty-seven patients with MG with compression symptoms were reviewed from 672 patients with MG undergoing surgery in our department. We used 515 patients with MG without compression symptoms as a control group. INTERVENTION: All 157 patients underwent programmed surgery for thyroidectomy. MAIN OUTCOME MEASURES: General patient data, history and symptoms, exploration (both physical and with complementary techniques), data on the surgery and surgeon, and postsurgery morbidity and evolution. The chi2 test, the t test, and a logistic regression test were applied. RESULTS: Multinodular goiter with compression symptoms is characterized by its appearance in persons older than 55 years, a preoperative evolution of more than 10 years, and an intrathoracic component in more than 75% (P<.001). All the patients underwent surgery, with 6 (4%) requiring a sternotomy. Twenty-four percent had complications (n = 37), 3% of which corresponded to 4 cases of permanent recurrent laryngeal nerve injury. Eleven patients (7%) had an associated thyroid carcinoma, 9 of them corresponding to microcarcinomas. However, 5 were multifocal, and there was 1 anaplastic carcinoma, from which the patient died. All the papillary carcinomas are currently asymptomatic. The symptoms were remitted after surgery in all the cases except 1 dysphonia. Of the 32 patients receiving partial surgery, 9 (28%) had recurrence, of whom 6 underwent reoperation to complete the thyroidectomy. CONCLUSIONS: Multinodular goiter with compression symptoms occurs in long-evolving goiters with an intrathoracic component. Surgery is the definitive treatment, as it excludes malignancy, involves low rates of permanent morbidity and mortality, and, if the technique is total thyroidectomy, avoids recurrences.

Chi-Square Distribution↗
PubMedDate not supplied

Operative treatment of substernal goiters.

This report describes the operative experience in 72 patients with substernal goiters treated over the past 5.5 years. Even though the incidence of multinodular goiter has decreased in the United States due to the routine use of iodized salt, we continue to see a large number of patients with massive goiters, predominantly from Caribbean Islands. The diagnosis of substernal goiter was made on clinical examination augmented by such radiologic studies, as chest x-ray, barium esophagograms, airway films, and CT scans. Computed tomographic (CT) scanning was particularly helpful in evaluating the extent of substernal extension. Confirmation of the extent of disease was made at the time of operation. Ninety percent of the patients had tracheal deviation and 85% were symptomatic from airway compression. Esophageal compression was noted in 60% of the patients. All patients had a long history of goiter with recent onset of pressure symptoms. Flow-volume-loop studies were performed in 44% of the patients and were useful in the evaluation of pressure symptoms. However, the decision for operation was made primarily based on clinical evaluation of signs and symptoms. Sixteen patients in this group were admitted with acute airway distress requiring airway intubation or semi-emergency decompression. Only 1 patient required mediastinal splitting, while all others were operated by the cervical approach. The decision as to the extent of thyroidectomy was made at the time of operation. Drains were routinely used because of the large dead space. One patient developed a hematoma in the recovery room and required re-exploration.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Effectiveness of prophylactic therapy on goiter recurrence in an area with low iodine intake--a sonographic follow-up study.

There is no agreement as to whether or not drug treatment after surgery for nodular goiter is effective in preventing recurrence of goiter. Data about recurrences in areas of marginally low iodine intake (like Germany) vary widely. Therefore, we performed a retrospective study in 104 patients who had been treated surgically because of benign uninodular or multinodular goiter. The mean follow-up period was 6.4 years (minimal 1 year) with at least three examinations. Thyroid ultrasound with volumetric analysis was recorded in each patient. Thirty-two patients did not receive any prophylaxis, 50 patients were treated with L-thyroxine, 17 patients with a combination of L-thyroxine and iodine and 5 patients with iodine alone. Recurrence of goiter was documented in 28.0% of the untreated patients and in 8.9% of the patients on prophylaxis (P < 0.05). The mean increase of thyroid volume was 7.3 ml versus 3.1 ml in patients without versus with prophylactic drug treatment (not significant). No significant correlation was found between the increase of thyroid volume and age of the patients, follow-up time, or initial thyroid volume, respectively. These data clearly demonstrate the effectiveness of prophylactic drug therapy to prevent recurrence of goiter after thyroid surgery in an iodine-deficient area.

Adult↗
PubMed2005

Prevalence of goiter among schoolchildren from Gorgan, Iran, a decade after national iodine supplementation: association with age, gender, and thyroperoxidase antibodies.

BACKGROUND: One decade after universal salt iodization in Iran, goiter prevalence, urinary iodine concentration (UIC) and thyroperoxidase antibody (TPOAb) values were assessed among schoolchildren in Gorgan, Iran. METHODS: From 2003-2004, 500 girls and 900 boys aged 7-11 yr were evaluated for goiter by palpation. UIC was measured in 183 randomly-selected goitrous children. Serum TSH, T4, and TPOAb were measured in 53 goitrous and 30 non-goitrous children with adequate UIC. RESULTS: Goiter was detected in 370 (26.4%) children. Goiter was present in 31% of girls and 17% of boys age 9 (p<0.012); 37% of girls and 20% of boys age 10 (p<0.003); and 52% of girls and 19% of boys age 11 (p<0.0001). Median (range) UIC for all goitrous children sampled was 190 (20-600) microg/l; 220 (30590) in boys and 170 (20-600) in girls (p=0.001). Eight point seven percent of goitrous children and 22% of goitrous girls aged 10-11 had UIC<100 microg/l, while 47% of the goitrous children had UIC> or =200 microg/ l. TPOAb was present in 52.8% of goitrous children and 10% of non-goitrous children (p=0.0001). TPOAb was present in 53.9% of 10-11 and 22.7% of 7-9 yr old goitrous and non-goitrous children (p=0.003) with adequate UIC. Median (range) TSH was 2.9 (0.3-10.9) mlU/I in TPO-positive and 1.8 (0.5-4.1) in TPO-negative children (p=0.001). CONCLUSIONS: Gorgan, Iran, is an iodine-sufficient area and almost half of schoolchildren have more than adequate UIC. TPOAb is associated with endemic goiter. Despite sufficient UIC overall, some school-aged girls remain at risk of iodine deficiency.

Age Factors↗
PubMed1984

Thiocyanates and iodine in endemic goiter in Italy.

Urinary iodine (I) and serum and urinary thiocyanates (SCN-) were determined in sample groups from 12 areas of endemic goiter in Italy. The mean urinary I level of 637 subjects with thyroid 0 was 67 +/- 31 (mean +/- SD) microgram/liter, that of 648 with goiter 54 +/- 29 micrograms/liter. Mean serum and urinary SCN- were 2.44 +/- 1.36 mg/liter and 2.58 +/- 1.36 mg/liter in 887 and 1531 subjects, respectively. The thiocyanates data enabled a distinction to be drawn between two groups (populations). Population I included 73% of the adults and 92% of the school-children (6-16 yr). Its thiocyanate values were logarithmically spread around means of 1.24 +/- 0.6 mg/liter (serum) and 1.24 +/- 0.57 mg/liter (urine), whereas those of population II were widely dispersed around means of 6.1 +/- 3.0 mg/liter and 8.08 +/- 5.5 mg/liter respectively. The boundary between the two populations was set at 3 mg/liter urine SCN-. This distinction was substantiated by the fact that 90% of those in population II smoked 10 or more cigarettes a day, whereas population I comprised occasionally smokers only. It is believed that only the values in population I can be regarded as representative of thiocyanates either endogenous or due to dietary dietary intake: these values never differed more than 60% regardless of the areas, seasons, or dietary habits. As urinary SCN- levels rose, there was also an increase in urinary iodine excretion within certain limits. This, however, did not interfere with thyroid secretion. The urinary I/SCN- ratio was lower in subjects with goiter. This was because their iodine levels were lower, whereas SCN- values were much the same in subjects with and without goiter. We have found no correlation between thiocyanate itself and goiter.

Adolescent↗
PubMed1996

Current status of endemic goiter in Croatia: the results of a nationwide study (1995).

In the beginning of the nineties, 40 years after introduction of iodine prophylaxis in Croatia, on a basis of a frequent reports coming from general practitioners about the presence of a rather high prevalence of goiter among schoolchildren, a nationwide study was initiated with the aim to determine the real prevalence of goiter in the country. A total of 2856 schoolchildren of both sexes, aged 7-15 years, were included into the study. Investigations were designed in a way to cover most of geographical regions in Croatia and subjects were randomly selected. The prevalence of goiter in schoolchildren was assessed by palpation and in part by ultrasonography of the neck. At the same time urinary iodine excretion was measured and iodine content in salt samples was determined. The results have revealed the persistence of mild endemic goiter in inland parts of Croatia with the prevalence of 6-29% in the age group 7-11 years and those of 10-43% among the age group 12-15 years. The overall goiter prevalence in schoolchildren in Croatia fluctuates from 8% to 35%. Such prevalence, most probably due to less than optimum iodine intake, is unlikely to change until iodine content of the salt is increased from its present level of 10 mg of Kl per kg of salt.

Adolescent↗
PubMed1989

Role of smoking in goiter morphology and thyrotropin response to TRH in untreated goitrous women.

Three groups of women were evaluated for TSH response to TRH and for goiter morphology by means of thyroid ultrasonography: group A = goitrous nonsmokers; group B1 = goitrous moderate-smokers; group B2 = goitrous heavy-smokers. They were compared with a control group (group C) made up nongoitrous, nonsmoking women. The size of the goiter was not correlated with the daily consumption of cigarettes, even though in heavy smokers a nodular goiter was prevalent as shown by ultrasonography. The serum values of TT3 showed significant differences between nonsmokers and heavy smokers (p less than (p less than 0.005), whereas the serum values of TT4 and of basal TSH showed no statistically significant differences. On the contrary, the TSH response to TRH showed a significant difference between heavy and nonsmokers (p less than 0.05). In conclusion, it has been demonstrated that goitrous cigarette heavy smokers show: i) A prevalence of statistically significant nodular goiter; ii) A significantly higher TT3 serum levels; iii) A significantly higher re-of TSH to TRH. These data suggest that cigarette smoking favors the development of nodular goiter and can involve the central regulation of the hypothalamus-pituitary-thyroid interaction.

Adult↗
PubMed1983

Nutrition and iodine versus genetic factors in endemic goiter.

Consanguinity has been considered to be the major factor responsible for the high incidence of goiter in the area of Las Hurdes in Spain. However, iodine deficiency was later found to be severe enough to account for endemic goiter, and the presence of cretins in this area. Children from very similar family and socioeconomic backgrounds were found to be on three different nutritional programs, depending on the schools they were attending, and it appeared of interest to determine the effect of nutrition on the goiter incidence in children from the same population. Total iodine, nitrogen and creatinine concentrations were measured in casual urine samples. All three were found to change in parallel in the different subpopulations. They were low in schoolchildren receiving most of their meals at home. Such meals were composed of locally grown food. They were normal in children living in a boarding school, where all of the food is provided from outside the area. They were intermediate in children from a day care center, who received only some meals from an outside source. In the boarding school, goiter incidence was 21%, as opposed to 87% for schoolchildren fed at home. Such results indicate that in this area consanguinity plays a minor role, if any, in the high incidence of goiter.

Adolescent↗
PubMed1998

Thyroid nodules in recurrent multinodular goiters are predominantly polyclonal.

Not only thyroid adenomas and carcinomas, but also the majority of single and well delimited goiter nodules, even if morphologically heterogeneous, are of clonal origin. However, it is still unknown whether the nodules of rapidly growing, recurrent goiters are clonal or polyclonal. We investigated by PCR-based analysis of exon 1 of the human androgen receptor gene clonality of nodules grown in recurrent multinodular goiters (MNG) of 14 female patients. The total goiter volume varied widely between 15 ml and 170 ml. The mean age of patients undergoing surgery for recurrent goiter at the time of their first operation was significantly lower with 34.6 +/- 10.9 yr in comparison to 50 consecutive patients who were operated for MNG for the first time (53.7 +/- 13.5 yr). The interval between first and recurrent operation was 18 +/- 8.5 yr. The mean volume of well circumscribed nodules selected for the present investigation was 3.8 +/- 1.4 ml. Assessment of clonality in at least 2 samples of each lesion revealed a polyclonal pattern in 10 out of 14 nodules, whereas only 3 nodules were clonal and in one case the result remained unclear. The unexpected finding that most nodules within MNG, that had re-grown after a first subtotal thyroidectomy, were of polyclonal rather than clonal composition, suggests that these lesions are generated by de novo-proliferation of cohorts of differing thyrocytes sharing the common trait of an exceedingly high intrinsic growth rate or alternatively, by unknown growth stimulating molecular events acting focally on clusters of cells derived from different ancestors. In addition, the relatively young age of patients with recurrent MNG at the time of their first surgery and the comparatively short interval between first and second operation point to a genetic element in the occurrence of growth-prone thyrocytes.

Adult↗