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PubMed2002

Iodine deficiency in Calabria: characterization of endemic goiter and analysis of different indicators of iodine status region-wide.

The distribution of goiter prevalence in schoolchildren (no.=13,984, age 6-14 yr), the neonatal TSH results obtained from the congenital hypothyroidism screening program and the urinary iodine excretion values (no.=284) were employed for the assessment of iodine deficiency in Calabria, a Southern Italy region. Data were collected during the years 1990-1996. In the inland territory, goiter prevalence ranged from 19 to 64%. At sea level, there was a great variability of goiter prevalence, with values varying from 5.3 to 25.7%. The analysis of the neonatal hypothyroidism screening program data (no.=21,078) showed a 14.8% frequency of TSH levels >5 microU/ml whole blood in newborns from the inland territory and a 14.1% frequency at sea level. Urinary iodine excretion resulted (mean+/-SD) 53.8+/-43.4 microg/l (range: <20 to 189 microg/l) in the inland territory and 89.6+/-59.8 microg/l (range: 26 to 333 microg/l) at sea level. Median urinary iodine excretion values in 13 villages or small towns of the inland territory ranged from 31 to 57 microg/l. In 2 major towns located at sea level, the median iodine excretion values were 72 microg/l in Crotone main city and 94 microg/l in Reggio Calabria main city. The data indicated that moderate, with pockets of severe iodine deficiency is present in the inland region while iodine supply varies from sufficient to marginally low in the coastal areas. Mild iodine deficiency was found in a major town located at sea level.

Adolescent↗
PubMed2003

Relapses of hyperthyroidism in patients treated with radioiodine for nodular toxic goiter: relation to thyroid autoimmunity.

Relapses of hyperthyroidism after treatment with radioiodine for uni- or multi-nodular goiter may be accompanied by the appearance of TSAb. However, this phenomenon has only emerged from one retrospective study on Northern European patients, in which it was not possible to determine whether TSAb also appeared in treated patients who did not relapse. The present study aimed to assess the appearance, immunogenic nature and clinical characteristics of hyperthyroidism relapse after treatment with 131I for nodular toxic goiter in patients from the Mediterranean area. A retrospective study was performed on 76 consecutive patients, born and resident in Sicily and aged 56-80 yr at diagnosis, who were treated with radioiodine. Serum aliquots obtained from the patients before 131I treatment and during a follow-up of 36-144 months were assayed for TSAb and TPOAb. The clinical charts of the patients were also re-examined. Twenty-six out of 76 patients (36.8%) had a hyperthyroidism relapse after a first treatment with 131I. Eight of the 26 (30.7%) also relapsed after the second treatment. Three out of 26 (11.5%) relapsed after a third treatment. The 50 patients who required only one treatment and the 18 who relapsed only once were all TSAb-negative at baseline, while 3/8 (37.5%) who relapsed also after the second treatment were already TSAb-positive at baseline. TSAb became positive in 3/18 patients (16.7%) who relapsed once, and in 4/8 (50.0%) of those who relapsed after a second treatment. One of these 7 TSAb-positive relapsers was also already TPOAb-positive at baseline and another became TPOAb-positive after treatment. The presence of circulating TSAb in 3/76 (3.9%) patients before treatment for toxic goiter more probably points to a diagnosis of Marine-Lenhart's syndrome. In contrast, the de novo appearance of TSAb in the presence of hyperthyroidism relapse in 4/76 (5.3%) patients suggests the development of a Graves'-like disease after radioiodine treatment. This occurrence does not seem to have precise ethnic grounds, since the incidence we observed in Mediterranean patients was similar to that previously reported in Northern European patients.

Aged↗
PubMed1993

Endemic goiter in Morocco (Skoura-Toundoute areas in the high atlas).

Endemic goiter in Morocco is localized in the Rif and Atlas mountains. In this study, performed in the Skoura-Toundoute areas (high Atlas), we demonstrate that iodine deficiency is the main factor involved in the development of endemic goiter. However it may not constitute the only etiological factor. The median urinary iodine excretion, measured on untimed samples, was low both in goitrous patients, m = 18 micrograms/l (n = 109) and in non goitrous subjects, m = 24 micrograms/l (n = 47). The value found in a nonendemic region (Casablanca) was much higher m = 117 micrograms/l (n = 67). Another approach to evaluate iodine intake per day was the analysis of iodine content of some samples of cereals (barley, wheat and corn), drinking water, sea and rock salt, cow and breast milk. Iodine content is low, specially in the endemic area: barley = 90 micrograms/kg (n = 1); wheat = 227 micrograms/kg (n = 1); corn = 91 micrograms/kg (n = 1); water = 0.92 to 1.30 micrograms/l (n = 3); cow milk = 6 to 33 micrograms/l (n = 10) breast milk = 10 to 55 micrograms/l (n = 14); rock salt = 420 to 660 micrograms/kg (n = 8); sea salt = 90 to 160 micrograms/kg (n = 4). Sodium chloride intake per day, estimated by the measurement of sodium and chloride urinary excretion, is normal both in the Skoura-Toundoute areas (10.7 g and 9.8 g for goitrous and nongoitrous subjects, respectively) and in Casablanca (10.9 g for control persons). Altogether the results demonstrate the importance of introducing the practice of iodinated salt in the prophylaxis of endemic goiter in this area.

Adolescent↗
PubMed1996

Treatment by iodized oil (Lipiodol UF) of a population in Mali suffering from endemic goiter.

In order to reduce the prevalence of goiter in a village of Mali liable to iodine deficiency, an iodized product (Lipiodol Ultra Fluide) was orally administered to their inhabitants. Taking into account a series of demographic variables and goiter types, a protocol was conducted using Lipiodol at three different dosage levels. Six months after the treatment, the hormone levels regained normal values, whereas only the smallest dose reduces the volume of goiters significantly.

Female↗
PubMed1992

Recurrence of hyperthyroidism in multinodular goiter after long-term drug therapy: a comparison with Graves' disease.

The chance of permanent remission after prolonged drug therapy was investigated in 41 patients with toxic multinodular goiter. For purposes of comparison a group of 41 patients with Graves' disease was also studied. After euthyroidism was achieved all patients received a combination of thionamide and thyroxine for at least 12 months. The minimum follow-up period was 2 yr. Relapse of thyrotoxicosis occurred in 95.1% of patients with toxic multinodular goiter and 34.1% of patients with Graves' disease (p < 0.001). It is concluded that for patients with toxic multinodular goiter early radioiodine therapy or surgery is preferred since prolonged drug therapy seldom produces permanent remission.

Adolescent↗
PubMed1994

Endemic goiter in Calabria: etiopathogenesis and thyroid function.

An endemic goiter study was carried out in a vast territory of the Calabria region, including the provinces of Catanzaro and Cosenza. About 50% of 7231 school-children, aged between 6 and 12 years, examined in 34 villages, presented a thyroid enlargement. The high prevalence of goiter seems to be related to a moderate iodine deficiency intake indicated by a mild urinary iodine excretion (lower than 100 micrograms/g creatinine). In a few villages, in which a two year voluntary iodine prophylaxis was carried out, an increase in the urinary iodine excretion with a decreased goiter prevalence was observed. A slight increase in TT3, FT3 and TSH in one endemic area studied, compared to the control area, was also observed. These data suggest that an effective program of iodoprophylaxis is fundamental in this region as well.

Child↗
PubMedDate not supplied

Thyroid blood flow rate in man. Electromagnetic flowmetry during operation in euthyroid normal gland, nontoxic goiter, and hyperthyroidism.

Human thyroid blood flow rate (TBF) was measured during operations by electromagnetic flowmetry in 75 euthyroid patients with normal thyroid tissue, nodular goiter, or solitary adenoma, and in 22 hyperthyroid patients with diffuse or nodular goiter. Blood flow rate was measured in one to four of the thyroid arteries. No difference in blood flow rate was seen between the left and right lobes. The slight difference found between the inferior and superior arteries was not significant. In each subject, total TBF was calculated as 4 times the mean of the recorded blood flow in the single arteries. The total TBF was 31 (9-109) ml/min (inner 95 percentile range) in euthyroid patients, similar in all 3 groups. This is less than in most earlier reports. The relative TBF was 1.2 (0.4-3.8) ml/min/g thyroid tissue in normal thyroid tissue and 0.6 (0.1-3.7) ml/min/g in nontoxic nodular goiter (p less than 0.01). Patients with hyperthyroidism had a higher total TBF 54 (15-197) ml/Min (p less than 0.001), despite preoperative treatment giving euthyroidism, Similar TBF rates were found in 3 hyperthyroid patients given propranolol preoperatively. Electromagnetic flowmetry is applicable to study thyroid blood flow rate. Human TBF shows considerable interindividual variations, which must be kept in mind when studying directly the rate of thyroid hormone secretion from arteriovenous gradients.

Adult↗
PubMed1989

Amyloid goiter. Diagnosis by fine-needle aspiration biopsy of the thyroid.

Amyloid goiter is a rare condition. We could not find more than 90 cases from an extensive review of world literature. We report here two patients in whom that diagnosis was made, prior to surgery, by fine-needle aspiration biopsy of the thyroid. We review the major clinic and histopathologic characteristics of amyloid goiter and we stand out the usefulness of the fine-needle aspiration biopsy of the thyroid to diagnose the amyloid goiter and amyloidosis, in general.

Aged↗
PubMed2006

Need for an individualized and aggressive management of multinodular goiters of endemic zones by specially trained surgeons: experience in western Nepal.

BACKGROUND: The goals of the present study were to explore the presentation of multinodular goiter (MNG) and solitary thyroid nodules (STN) in the sub-Himalayan belt, including the risk of malignancy, and to evaluate whether specialized surgeon training in endocrine surgery has an effect on reducing complications. METHODS: This retrospective study (1998-2003) analyzed 624 patients with thyroid disorders seen in the thyroid clinic of a tertiary care hospital in western Nepal. The findings included 67.7% (n = 423: euthyroid, 297, toxic, 126) multinodular goiters (MNG) and 18.5% (n = 116) STN. Rest of patients of other thyroid disorders were excluded from the study. Ultrasonography and fine-needle aspiration cytology (FNAC) were the available diagnostic adjuncts. To evaluate the role of surgeon training, outcomes were compared between patients cared for by surgeons specially trained in endocrine surgery and those who were not. Prognostic markers indicated aggressiveness of cancers. RESULTS: Of the 539 MNG and STN patients in this series, 236 underwent operation. Of these, 25.7% (139/539) were toxic, and 11.31% had associated carcinoma. Aggressive cancers, like poorly differentiated (4.9%) and anaplastic types (18%), were more common than in series of patients from iodine-sufficient regions. Patients 40-55 years of age were more likely to have toxicity, and those > 60 years of age were more likely to have aggressive cancers. Postoperative complication rates were lower in the group treated by surgeons who had special training in endocrine surgery. CONCLUSIONS: There is a higher incidence of toxicity and malignancy in MNG in an endemic goiter zone. The limited diagnostic and therapeutic facilities in the region under study warrant a high degree of clinical suspicion and judgment, sound knowledge of thyroid physiology, thorough interpretation of hormone test results, and meticulous surgical techniques. The treatment must be individualized with consideration of humanitarian and socioeconomic factors, without compromising the quality of care and its long-term consequences. Aggressive management of malignancy and toxicity with total thyroidectomy is needed as primary therapy in many instances. However, subtotal excision is more useful in carefully selected cases with a small remnant. Specialized training in thyroid surgery appears to be valuable in reducing complications.

Adolescent↗
PubMed2006

Subtotal thyroidectomy for benign multinodular goiter: a 6-month postoperative study of the remnant's function and sonographic aspect.

BACKGROUND: The purpose was to evaluate the thyroid function after subtotal thyroidectomy. METHODS: One hundred and nineteen patients operated on for multinodular benign goiter were included in this prospective study. Results of the surgical treatment were evaluated 6 months after operation by thyroid-stimulating hormone (TSH) assay and cervical echography. RESULTS: Thyroid-stimulating hormone levels correlated inversely (r=-0.78) with the thyroid remnant volumes. Forty-seven patients presented with a hypoechoic aspect of the remnant. Isoechoic and hypoechoic remnant volumes were similar; however, 46 of the 47 patients with a hypoechoic remnant (97.9%) had TSH levels higher than 5 mU/l vs. 39 of the 72 patients (54.2%) with an isoechoic aspect. No predictive factor for the occurrence of this hypoechoic feature was found. CONCLUSIONS: After sub-total thyroidectomy for benign multinodular goiter, the volume of the remnant is not the only determinant of the occurrence of postoperative hypothyroidism. The appearance of a hypoechoic aspect of the remnant is also a strong predictive factor for such an outcome. In this case the occurrence of hypothyroidism is quite constant whatever the volume of the thyroid remnant. Since this evolution toward a hypoechoic aspect of the remnant is unpredictable, our results are an additional argument in favor of total thyroidectomy for benign multinodular goiter.

Adult↗
PubMedDate not supplied

Long-term observation of serum thyroglobulin after resection of nontoxic goiter and relation to ultrasonographically demonstrated relapse.

The object was to carry out a prospective study of the changes in serum thyroid hormones and thyroglobulin (Tg) following resection of nontoxic goiter and to investigate if there was a correlation to the pattern of relapse. A group of 39 consecutive patients, mainly with nodular, nontoxic goiter, were studied for 13 years following thyroidectomy. No thyroid hormone replacement therapy was given after surgery. The preoperative serum Tg level was elevated. After operation the mean serum Tg declined to a nadir of 43 micrograms/L at 1 year and subsequently increased to 90 micrograms/L at 10 years, with large individual differences. In 19 patients the serum Tg increased, in 1 it decreased, and in 19 no significant alteration was observed. Serum free thyroxine and triiodothyronine indices decreased following resection but achieved normal levels within 6 to 12 months. Serum thyroid-stimulating hormone increased after resection, with a peak level 1 month after surgery, but it returned to normal levels at 1 year and remained stable for the rest of the period. At 13 years after resection the thyroid volume was determined by ultrasonography in 30 of the patients. In 10 patients the thyroid volume was enlarged (>/= 28 ml). In this group a rise of average serum Tg after resection [DeltaTg(10-1 year)] of 133 micrograms/L was observed, compared to 26 micrograms/L in the 20 patients without sonographic relapse (volume < 28 ml). A positive correlation was demonstrated between serum DeltaTg(10-1 year) postsurgically and thyroid volume 13 years after surgery. However, an overlap was observed between the groups with and without ultrasonographic relapse, probably in part due to large differences in the Tg synthesis activity of different follicle cell clones. It is concluded that repeated serum Tg determinations may provide biochemical evidence of increased growth activity of thyroid remnants monitored after goiter resection.

Adult↗
PubMed1998

Thyroid carcinoma in intrathoracic goiter.

INTRODUCTION: Most cases of intrathoracic goiter can be managed by cervical incision alone. A thoracic approach may be needed when adhesions or an anomalous blood supply are present or carcinoma is suspected. PATIENTS AND METHODS: Only 44 patients out of 5263 operated on for goiter needed a thoracic incision. A sternotomy was performed in 29 cases and a thoracotomy in 15; a malignancy was present in 9 cases. Symptoms, surgical approach, histology, survival and pTN staging of these 9 patients were reviewed and discussed; no perioperative mortality was observed. DISCUSSION: A thoracic approach is more frequently needed for treatment of intrathoracic thyroid carcinoma as it offers a greater chance of radical excision and better control of intraoperative bleeding. Histologically, thyroid carcinoma in intrathoracic goiter is often anaplastic or rare and has a poor long-term survival rate when compared to cervical forms.

Adult↗
PubMed2005

Results of surgery for toxic multinodular goiter.

PURPOSE: We analyzed the clinical and histological features of patients operated on for toxic multinodular goiter (TMG) to determine the clinical profile and evaluate the surgical results. METHODS: We reviewed 672 patients who underwent surgery for multinodular goiter (MG), 112 (17%) of whom had hyperthyroidism, and analyzed the epidemiological, clinical, and surgical variables. RESULTS: The patients with TMG tended to be older than those with nontoxic MG, with a greater evolution time of the goiter and a higher rate of positive antithyroid antibodies. In the multivariate analysis, the only feature characteristic of TMG, as opposed to nontoxic MG, was the evolution time. Morbidity was 34%, representative of the fact that that most of the patients were seen before the establishment of our endocrine surgical unit. The hyperthyroid symptoms resolved in all patients, but 4 of 17 patients who underwent partial surgical resection showed signs of relapse within a follow-up period of 98 +/- 71 months. CONCLUSIONS: TMG is characterized by a long evolution time and is most effectively treated by total thyroidectomy, which achieves complete remission from symptoms, without relapse, and is necessary if there is associated carcinoma. However, the incidence of complications may be high if this procedure is not carried out by surgeons with experience in endocrine surgery.

Female↗
PubMed2000

Management of nodular goiters and their operative indications.

It remains controversial whether or not nodular goiters should be treated surgically or conservatively. This report reviews our 9-year experience of treating nodular goiters in 334 patients, 44 of whom underwent surgery, and compares the methods of treatment employed from 1990 to 1999 with those employed from 1971 to 1989 when 171 operations were carried out. In accordance with diagnoses made using fine-needle aspiration biopsy (FNAB) and ultrasonography, patients were treated as follows. Those with cysts were given percutaneous ethanol injection therapy (PEIT), and those with solid tumors underwent surgery if cancer of >class 3 was suspected or if the tumors were >3 cm. Consequently, 44 patients with solid tumors underwent surgery and 72 with cysts were treated by PEIT. The number of operations performed annually decreased to half of the pre-1990 figure. During the follow-up of those patients who did not undergo surgery, four with solid tumors and two with cysts later required surgery due to suspected carcinoma of >class 3 in 3 patients or as a result of personal choice in 3 patients. The growth of solid tumors was not able to be measured in most cases. These results indicate that the number of operations performed for nodular goiters can be reduced by PEIT. An accurate cytological diagnosis supports this therapeutic strategy.

Biopsy, Needle↗
PubMed1979

Hormonal and nutritional status: critical conditions for endemic goiter epidemiology?

Recent advances in protein metabolism and in glycoprotein synthesis bring further insight into endemic goiter epidemiology. Retinol circulates in the blood stream in close parallelism with retinol-binding protein and prealbumin (RBP-PA), a protein complex whose liver secretory rate is dependent upon hormonal and nutritional status. On the other hand, normal glycosylation reaction occurs through the formation of a retinol-linked sugar complex. It is suggested that the relative drop of serum retinol levels, as a result of modified hormonal climate and/or declining protein status, might constitute a critical factor capable of inducing a defective incorporation of mannose into native thyroglobulin, leading to an early depression of the full glycoprotein production. This concept affords a comprehensive explanation of the following unresolved data recorded in goitrous areas: (1) clinical and biochemical discrepancies between subjects living in the same morbid territory, (2) persistence of endemicity in spite of appropriate iodine supplementation, (3) similar prevalence of goiter hypertrophy in male and female prepubertal children, (4) increased frequency of goiter enlargement in the four most vulnerable groups, namely preschool children of both sexes, adolescent girls, pregnant women, and elderly persons, (5) decreased impact of thyroid swelling accompanying improved socio-economic status, even without iodine addition, and (6) resurgence of goitrous hyperplasia as an effect of seasonal or sporadic deterioration of nutritional habits, even when iodine supply remains unchanged.

Adolescent↗
PubMedDate not supplied

Substernal goiter: a clinical review.

Thyroid disease is a very common problem, but indications for surgery are few. We have seen a large number of patients with multinodular goiter. The main indications for surgery in thyroid disease include fear of malignancy, tracheo-esophageal compression, and cosmetic reasons. Tracheo-esophageal compression is most commonly noted in patients with mediastinal goiters. Substernal goiter is defined as those situations in which at least 50% of the gland is in the mediastinal location. Although its incidence has decreased, it remains prevalent in almost every country in the world today. SSG is best diagnosed by a thorough history and physical examination, complemented by airway films, fiberoptic laryngoscopy, and computerized tomography. The most common presenting symptoms are those produced secondary to compression effects. SSG show a poor response to medical treatment. Moreover, given their propensity to cause acute airway symptoms, surgical treatment should be considered in most cases. Extirpation of the gland is best performed through a collar incision, with the addition of a median sternotomy in select few and difficult cases. Median sternotomy is necessary in only 1% to 2% of cases. Operative mortality is negligible, and the incidence of complication is minimized by following strict surgical principles.

Diagnostic Imaging↗
PubMedDate not supplied

Report of an obstructive goiter and its surgical treatment during delivery.

We report a case of a morbidly obese young woman in her third trimester of pregnancy presenting with a history of goiter and respiratory disease. The recent history of this patient was significant for worsening respiratory symptoms over a period of 2 weeks, and, on presentation at 36 weeks gestation, she was stridorous, dyspneic at rest, and had a hoarse voice. Evaluation revealed a morbidly obese individual with a large goiter. She was biochemically euthyroid. Fiberoptic laryngoscopy revealed a left true vocal cord paresis, and ultrasound evaluation was significant for diffuse multinodular enlargement, with each lobe measuring greater than 10 cm and the isthmus measuring 5. Pulmonary function testing revealed a significant degree of upper airway obstruction without significant lower airway disease. Given the patient's clinical signs and symptoms, her tenuous airway, poor candidacy for urgent tracheotomy, and her proximity to delivery, it was agreed that the patient should undergo elective cesarean section and at its completion undergo subtotal thyroidectomy for the obstructive goiter.

Adult↗
PubMed2004

A case of mediastinal goiter.

A case of mediastinal goiter in a 51-year-old female is reported. She demonstrated an abnormal shadow on chest X-ray but there were no clinical symptoms. Tumors were recognized in the isthmus of the thyroid and mediastinum on CT scan and MRI. These two tumors were resected via standard neck skin incision and sternotomy. At surgery, we found no communication between the two tumors. Following Rives' classification, the mediastinal tumor in this case was diagnosed as aberrant mediastinal goiter. Pathological diagnoses of both tumors were adenomatous goiter.

Adenoma↗