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Between 1976 and 1994, 139 cases of diving goiter were operated. Hyperthyroidism is a factor in compression. Morbidity is low for surgery for diving goiters, but increases if performed in emergency situations. Cervicotomy was used alone in more than 99% of the cases.
UNLABELLED: In patients with a large, multinodular goiter (> 100 g), radiation absorbed doses in the thyroid, surrounding tissues and remainder of the body were estimated after therapeutic administration of 131I(3.7 MBq or 100 microCi/g of thyroid tissue retained at 24 hr). METHODS: Thermoluminescent dosimeter (TLD) measurements were performed on 23 patients (12 euthyroid and 1I hyperthyroid; thyroid weight 222 +/- 72 g; 2.1 +/- 0.9 GBq 131I) on the skin over the thyroid, over the submandibular gland and over the parotid gland. Thyroid radioactivity measurements were done daily in 6 euthyroid and 6 hyperthyroid patients (thyroid weight 204 +/- 69 g; 1.9 +/- 0.9 GBq 131I). An iodine biokinetic model and the MIRD methodology were used to estimate absorbed doses in organs. Cancer risks were calculated using ICRP Publication 60. RESULTS: Cumulated absorbed doses on the skin (TLD measurements) were 4.2 +/- 1.4 Gy (thyroid), 1.2 +/- 0.6 Gy (submandibular) and 0.4 +/- 0.2 Gy (parotid). All these values were significantly correlated with the amount of radioiodine retained in the thyroid at 24 hr (euthyroid versus hyperthyroid not significant). Absorbed doses in the thyroid of 94 +/- 25 Gy for euthyroid and 93 +/- 17 Gy for hyperthyroid patients were calculated (thyroid radioactivity measurements). Extrathyroidal absorbed doses (means of 12 patients) were 0.88 Gy in the urinary bladder, 0.57 Gy in the small intestine, 0.38 Gy in the stomach, and ranged from 0.05 to 0.30 Gy in other organs (euthyroid versus hyperthyroid not significant). A 1.6% life-time risk of development of cancer outside the thyroid gland was calculated. When applied to people of 65 yr and older the estimated risk is approximately 0.5%. CONCLUSION: These data may help in choosing the treatment regimen for individual patients with a large, multinodular goiter, who have to be treated for hyperthyroidism or compressive problems. In younger patients, surgery may be preferred. However, for elderly patients and patients with cardiopulmonary disease, the advantages of noninvasive radioiodine treatment will outweight the life-time risk of this mode of therapy.
We report two cases of amyloid goiter which clinical appearance had evoked a neoplastic lesion. The diagnosis was made by histologic examination. The nature of the amyloid precursor, determined by immunohistochemistry, has allowed to evoke primitive amyloidosis in one case and to attribute amyloid goiter to renal insufficiency in the second case.
Histochemical studies were carried out of the content and localization of neutral and acid lipids, cholesterol and its ethers, phospholipids, free fatty acids and soaps in various forms of goiter (96 of the thyroid glands removed during during the operation in connection with goiter). It was shown that thyreo-toxic strumas were characterized by a very small amount of neutral lipids in the apical part of thyreocytes and some small amount in the stroma. The greatest amount of lipids (predominantly acid ones, free fatty acids and soaps) were identified in euthyroid macro-microfollicular strumas which were characterized by cystic degeneration of the glandular parenchyma and by a marked process of desquamation of the follicular epithelium. Histochemically, the desquamated Kulesh-Lauer's cells were found to contain moderate and insignificant amounts of neutral lipids, cholesterol and its ethers, with the help of the reaction with Nile bleu sulphate a great amount of acid lipids was identified, by Fischer's method--a great amount of free fatty acids. The results obtained also showed that Ashkinazi's cells were free from lipids. C-cells, which hardly identifiable in thyreotoxic colloid-parenchymatous strumas, were found to be rich in phospholipids, whereas in other cellular elements of the thyroid gland they were not detected, which in the authors' opinion, may serve as a histochemical test of C-cells.
An ectopic thyroid goiter was found in a 58-year-old woman who presented with abdominal and low back pain, diarrhea, and generalized weakness. Initial workup, including abdominal CT scan, revealed a mass extending from the duodenum to the porta hepatis. After resection and upon pathologic examination of the tissue, nodular arrangement of thyroid follicles and colloid lakes with focal hyperplastic and nodular goiter changes were identified.
Preoperative thyroid isotope scan would influence the operative procedure and the perioperative management in patients with nontoxic goiter only if it raises suspicion of malignancy. However, the scintigram shows significantly lower sensitivity and specificity in the detection and prediction of malignant nodules in the thyroid gland than the ultrasound examination. Thyroid isotope scan is more expensive than ultrasonography, and its routine use in the investigation of nontoxic nodular goiter should be abandoned.
The authors present a case of large posterior mediastinal cystadenomatous goiter in an elderly man. The resection performed utilised a combined cervical and thoracic approach. The diagnostic and operative handicaps in deep and fixed mediastinal goiters are discussed.
Generalized resistance to thyroid hormone described by S. Refetoff in 1967 is characterized by the presence of goiter, euthyroidism, increased serum value of thyroid hormones and increased or normal serum TSH concentration. We described four patients treated for nodular goiter, where clinical and biochemical studies before and after triiodothyronine treatment (by increasing doses from 20 micrograms to 100 micrograms daily for 10 days) have made it possible to diagnose the Refetoff syndrome. In each case other causes of the increased T4 level were excluded (i.e. tumour of pituitary gland with the TSH increased, TBG high level syndrome, the presence of anti-T3 and anti-T4).
Prostaglandins (PGE1 and PGE2) induced a hyperplastic microfollicular goiter with a high radioiodine (131I) thyroid uptake, increased endocytosis, a heavy autoradiographic (125I) reaction, and a moderate increase of thyroid hormones (T4, T3), thyroxine-binding globulin (TGB), and thyrotropin (TSH) concentrations in adult rats. Ultrastructurally, both prostaglandins (E1 and E2) markedly stimulated the thyroid cell activity and increased the number of pseudopodia, the size of colloid and dense granule populations, and the number of polysomes. Conversely, a hypofunction of thyroid glands with low radioiodine (131I) thyroid uptake, a decreased autoradiographic (125I) reaction, and a moderate decrease in T4, T3, TGB, and TSH concentrations were observed following prostaglandin F 2alpha. Ultrastructurally, a decrease in size of the colloid and dense granule population and the number of degenerative mitochondria occurred infollicular cells. An intense hyperplasia of parafollicular (C) cells, with abundant population of characteristic dense granules, could be seen in PGF 2alpha-treated rats. A marked decrease of radioiodine (131I) uptake, endocytosis, and autoradiographic (125I) reaction and a sharp decline in T4, T3, and TBG were observed in hypophysectomized and chronically prostaglandin-treated rats. Light and electron microscopy revealed signs of an advanced thyroid hypofunction with flat cuboidal cells, reduced microvilli, scarce endoplasmic reticulum, and few dense droplets. The present findings demonstrate that the chronic administration of prostaglandins exerts significant effects of thyroid gland and goiter formation (goitrogenesis), radioiodine metabolism, and hormone synthesis, and that these effects are mediated by TSH secretion.
The definition, mode of development and symptomatology of cervico-thoracic goiters are described. The treatment of choice is a total thyroidectomy. The indication of each step in the preoperative work-up and the details of the surgical technique specific for cervico-thoracic goiters are reviewed. The choice between a purely cervical and a cervico-thoracic approach remains controversial in function of the morbidity.
Chromosomal-pairing behaviour was studied in the spermatocytes of individual goitered gazelles which were heteromorphic for a 14/15 Robertsonian translocation and which possessed an autosome-to-X translocation. Both translocations exhibited trivalent pairing configurations in pachytene and diakinesis/metaphase I nuclei. Synapsis of the sex chromosomes during pachynema was followed by end-to-end association of the X and Y during diakinesis/metaphase I. The only univalents identified were of the Y chromosome; Y univalency ranged from 15.9% at pachynema to 5.7% at diakinesis/metaphase I. Robertsonian trivalents exhibited evidence of synaptic adjustment in the paracentromeric region. Chiasmata were formed in most bivalents and trivalents; chiasmata were restricted to the autosomal portion of the autosome-to-XY trivalent. Analysis of metaphase II configurations (secondary spermatocytes) revealed no nondisjunction in individuals homozygous or heterozygous for the Robertsonian translocation. These data are consistent with the hypothesis that neither the autosomal nor the gonosomal heteromorphism reduces the meiotic fitness of male goitered gazelles.
A 65-year-old woman presented with an episode of hematemesis and a recurrent cervical goiter due to Graves' disease. The angiogram revealed bleeding esophageal varices which had developed through a drainage vein of the vascular goiter. Total thyroidectomy resulted in eradication of the esophageal varices.
An adult male patient (38 yr old) with a large congenital goiter with hypothyroidism was suspected of having a defective iodide (L) transport mechanism based on low thyroid uptake and a very low salivary/plasma ratio. Moreover the high serum levels of TSH (104 uU/mL) declined to 7.2 uU/mL with a corresponding normalization of serum total T4 concentration, after 40 d of treatment with Lugolts solution (6 mg L/d). Thyroid surgery was performed because a fine-needle aspiration biopsy of a nodule revealed atypical cells associated with the presence of a large compressive goiter (150 g). Pathologic examination indicated histological findings compatible with the hyperplastic pattern with predominant microfollicular aspect. Immunostaining for other specific thyroid proteins thyroid peroxidase (TPO) and Tg, indicated normal expression of both transcripts. Electron microscopy (x13,000) showed the ultrastructural aspects of a hyperactive follicular cell with folding of the basal membrane. Sequencing of the entire sodium/iodide (Na/I) symporter (NIS) cDNA derived from thyroidal mRNA revealed a homozygous substitution of the normal cytosine in nucleotide 1163 with an adenine, resulting in a stop signal at codon 272. This nonsense mutation produces a truncated NIS symporter protein without iodide transport activity. Although the propositus is homozygotic for the NIS-272X expression of one normal allele in the heterozygotic son, mother, and paternal aunt is sufficient to maintain normal thyroid function.
Proteins were isolated and characterized in thyroid tissue of six patients from Brazil with endemic goiter. Biochemical studies of these thyroidal proteins included gel filtration, electrophoresis, and amino acid analysis. In addition to thyroglobulin, two of the most abundant proteins found in all goiters studied had molecular weights of 68 and 14 kDa. One protein was identified as albumin based on its immunoreactivity with antibodies to serum albumin. The other protein was identified as a hemoglobin subunit using reverse-phase high-performance liquid chromatography (H PLC). Identification was confirmed by partial N-terminal amino acid sequencing that showed several nonconservative differences in thyroid albumin when compared to human serum albumin (HSA). Biochemical findings were correlated with iodine and hormone contents in serum and thyroglobulin from these patients. Based on these findings, we suggest that hemoglobin and albumin are taken up from the blood by the hyperplastic thyroid tissue. Albumin would be processed by the thyroid follicular cell, becoming iodinated and released into the circulation.
Among 48 Graves' patients treated with antithyroid drugs there were 8 patients with a further growth of an already enlarged goiter and a persistence of thyroid stimulating immunoglobulins (TSI). TSI activity did not persist in a comparison group of patients with less severe initial symptoms and an uncomplicated course during a similar regimen of drug treatment. Thyrotoxicosis was difficult to control in this subgroup of patients as low serum T4 was accompanied by borderline high T3 levels although TSH in serum remained undetectable. In spite of comparable low doses of antithyroid drugs serum T4 in the complicated group remained significantly lower (58 +/= 15 nmol/I SD vs. 97 +/- 19 nmol/I SD, p less than 0,001) and serum T3 stayed significantly higher (3,66 +/- 0,49 nmol/I SD vs. 2,15 +/- 0,50 nmol/I SD, p less than 0,001) than in the group with uncomplicated treatment. It is discussed that the promotion of goiter growth could be due to growth stimulating antibodies, and that a local intrathyroidal iodide depletion during antithyroid drug treatment might cause the shift from T4 to T3 production in this entity of Graves' patients.
BACKGROUND: The aim of this study was to ascertain the utility of echo-Doppler in the analysis of the low resistance thyroid vascularization in diffuse toxic goiter (DTG), and the effectiveness of Lugol's solution (iodine-iodide solution) in patients undergoing thyroidectomy. STUDY DESIGN: Twenty-five patients with diffuse toxic goiter were evaluated and compared with 19 normal subjects. Patients were treated with increasing doses of Lugol's solution 2% for 7 days until a total dose of 75 mg of iodine was given. Echo-Doppler was performed on the last day of treatment, 12 hours before operation. RESULTS: Mean basal Doppler Resistance Index (RI) of intrathyroid arterial flow was significantly lower in patients with DTG compared with normal controls (0.4718 +/- 0.0625 versus 0.55 +/- 0.05, range: 0.472 to 0.643; p = 0.008). Moreover, the RI was significantly increased in patients with DTG after Lugol's solution (+16.46 +/- 10.22%, range: -2.59 to +39.97; p< 0.0005). CONCLUSIONS: Echo-Doppler RI allowed documenting lower arterial resistances within the thyroid gland in patients with DTG. The use of preoperative Lugol's solution therapy induces normalization of those changes for safer thyroidectomy.
A large fetal goiter was detected at 22 weeks of gestation during an antenatal ultrasound scan of a woman with a previous history of Graves' disease treated by partial thyroidectomy. This unsuspected finding initiated maternal investigations and treatment. In untreated cases poor fetal outcome is common and unfortunately fetal thyrotoxicosis/thyroid enlargement frequently remains unrecognized in the first pregnancy. We report the case and its management and discuss the literature emphasizing the importance of screening for antibodies in the 'at-risk' women and the increasing importance of ultrasound in the evaluation and follow-up of these patients. Reports of thyrotoxic fetal goiters are extremely rare and, to our knowledge, there have been no previous reports of this in the second trimester.
One hundred fifty patients with toxic and scintigraphically diffuse goiter were HLA typed (A, B, C, DR). One group consisted of 101 patients with concomitant Graves' ophthalmopathy and/or TSH-binding inhibiting antibodies (TBIAb). Forty nine patients had neither ophthalmopathy nor TBIAb. The former group showed a higher prevalence of HLA-B8 and DR3 compared to a normal control group. The latter group showed a higher frequency of HLA-DR5, whereas the HLA-B8 and DR3 antigens were slightly below normal prevalence. These data indicate an immunogenetic heterogeneity in patients with toxic diffuse goiter. A group of 47 hyperthyroid patients with single autonomous thyroid adenoma had no increased prevalence of any HLA-antigens. Patients with long term remission did not show an altered prevalence of any of the HLA antigens compared to controls. In contrast, patients with Graves' ophthalmopathy and/or TBIAb activity who relapsed had a significantly higher prevalence of HLA-B8 DR3, whereas patients without TBIAb and eye signs who relapsed had a significantly higher prevalence of HLA-DR5 than the control group.