The value of thyroid parenchymal echogenicity as an indicator of pathology using the sternomastoid muscle for comparison

This study was undertaken to evaluate the diagnostic accuracy of comparison of the echogenicity of the thyroid gland with the sternomastoid muscle in diagnosis of thyroid disorders. Fifty healthy subjects underwent a thyroid ultrasound, and 80 patients with archived thyroid ultrasound examinations (50 thyrotoxicosis and 30 thyroiditis) were reviewed. Images were measured for the image density of the thyroid gland and the sternomastoid muscle, using a transmission densitometer. Healthy thyroid was relatively hyperechoic when compared with the sternomastoid muscle (100%). Of the thyrotoxic patients, 70% showed a relatively hyperechoic thyroid compared to 47% of the thyroiditis patients. Mean image density difference in healthy thyroid, thyrotoxicosis and thyroiditis ranged from 0.1 to 1, -0.42 to 0.83, and -0.55 to 0.58, respectively. In conclusion, the relative echogenicity of the thyroid gland when compared with the sternomastoid muscle may be useful to differentiate healthy thyroid from thyrotoxicosis and thyroiditis, but does not help to distinguish thyrotoxicosis from thyroiditis. An image density difference of less than 0.1 may be considered to be abnormal, whereas a value greater than 0.83 may be considered to be normal.     

Antigoitrogenic effect of combined supplementation with dl-alpha-tocopherol, ascorbic acid and beta-carotene and of dl-alpha-tocopherol alone in the rat

The effects of the vitamins dl-alpha-tocopherol, ascorbic acid and beta-carotene, free radical scavengers and lipid peroxidation inhibitors, were analyzed in male Wistar rats made goitrous by feeding a low iodine diet (< 20 micrograms iodine/kg) and perchlorate (1% in drinking water) for 4, 8, 16, and 32 days. Groups of control or goitrous rats received for at least 16 days before killing a diet containing 0.6% vitamin E (as dl-alpha-tocopherol acetate), 1.2% vitamin C (ascorbic acid) and 0.48% beta-carotene, either simultaneously (vitamin cocktail) or separately. This treatment led to a 5-fold increase of vitamin E in the thyroid gland, a 24-fold increase in the liver and a 3-fold increase in the plasma. In control rats, vitamin cocktail administration increased slightly the thyroid weight with little changes in thyroid function parameters. During iodine deficiency, administration of the vitamin cocktail or vitamin E alone reduced significantly the rate of increase in thyroid weight, and DNA and protein contents, as well as the proportion of [3H]thymidine labeled thyroid follicular cells, but not that of labeled endothelial cells. Plasma tri-iodothyronine, thyroxine, TSH levels, thyroid iodine content and concentration as well as relative volumes of glandular compartments were not modified. The proportion of necrotic cells rose from 0.5% in normal animals to about 2% after 16 days of goiter development. No significant protective effect of the vitamins was observed. These results suggest that these vitamins, particularly vitamin E, modulate one of the regulatory cascades involved in the control of thyroid follicular cell growth, without interfering with the proliferation of endothelial cells.     

Exophthalmometry and thyroid disease. The value of the Hertel measurement evaluated by a group of patients with thyroid diseases and a control group

Exophthalmometry values from routine referrals to a hospital eye clinic are analysed, including adult patients with and without thyroid disease. In thyroid disease without eye motility complaints (n = 90) the median exophthalmometry value was 18 mm (range 12-28 mm). Thyroid patients with eye muscle involvement (diplopia, n = 47) had significantly higher values (median 22 mm, range 15-31 mm) but did not differ significantly from a subgroup of 51 patients without thyroid disease, but with "big eyes" as a (presumably) physiological finding (median value 20 mm, range 16-25 mm). The above three categories were all excluded from the control group (n = 203) which had 16 mm as median value, range 11-23 mm. Mean values were 16.0 +/- 1.8 mm in the females and 16.5 +/- 2.3 mm in the male controls. A side difference in exophthalmometry value > or = 2 mm appeared in 34% of thyroid patients with eye muscle involvement. This appeared in only a few per cent in the three other groups. Due to the wide overlap between groups, the solitary exophthalmometry reading is of limited diagnostic value, while the importance of exophthalmometry is evident when following the individual patient with orbital disease.     

Diagnosis of occult thyroid carcinoma by thyroid ultrasonography with fine needle aspiration cytology

OBJECTIVE: To assess the role of ultrasonography and fine needle aspiration cytology (FNAC) in preoperative diagnosis of patients with occult thyroid carcinoma (OTC). STUDY DESIGN: Data on 768 thyroid carcinoma patients receiving primary treatment at Chang Gung Medical Center were retrospectively reviewed. Of these patients, 97 had OTC. To detect small thyroid nodules early and define the characteristics of clinically palpable nodules, thyroid ultrasonography with FNAC were performed on 67 histopathologically proven OTC patients. Analysis for diagnostic value was done for ultrasonography and FNAC. RESULTS: In the 67 patients receiving ultrasonography with FNAC, 23 were preoperatively diagnosed as having papillary thyroid carcinoma and 1 as having follicular carcinoma. The tumor size of these 24 preoperative FNAC-proven OTC was 0.81 +/- 0.23 cm (mean +/- SD). In the remaining patients, 10 presented pictures suspicious for malignancy, with a mean tumor size 0.63 +/- 0.24 cm, and 33 (49.3%) were diagnosed as having benign thyroid lesions in preoperative FNAC. The tumor size in these 33 lesions was 0.58 +/- 0.24 cm. Fifty-seven of the 67 OTC patients received frozen sections. Thirty-eight papillary thyroid carcinomas and four follicular carcinomas were correctly diagnosed on frozen sections. CONCLUSION: Although the rate is not high, high-resolution ultrasonography and FNAC is the best approach to preoperative diagnosis for OTC patients today.     

Interdisciplinary treatment of the malignant lymphoma of the thyroid

720 patients with malignant tumor of the thyroid were treated at our department between 1950 and 1996. Histological examination revealed 15 cases (2%) of malignant lymphoma (14 female, 1 male mean age: 69.8 year). In 8 cases Hashimoto thyroiditis, in 1 case chronic lymphocytic thyroiditis was verified beyond the lymphoma. According to Ann Arbor staging, 9 patients were stage I E, 3 II E, 1 III E, and 2 IV E. Radical surgical treatment was performed in 7, palliative in also 7, and only biopsy in one case. Irradiation was administered in 9, chemotherapy in 8 patients. In 5 out of the 7 palliative operated patients tracheostomy was performed. 10 patients were lost. The therapy of the non-Hodgkin lymphoma of the thyroid is debated in the literature. There are some authors, who question the role of surgery. Our experience, based on the longer survival of the patients, who underwent radical operation, support those, who consider the possible surgical treatment as the initial part of the multimodal therapy.     

Expression of glutathione-peroxidase (GSH-PO) in the rat ventral prostate--effect of castration and administration of testosterone

This series retrospectively reviewed 3657 patients who received thyroid ultrasonography with fine-needle aspiration cytological (FNAC) examinations at Chang Gung Memorial Hospital during the period from January 1, 1993 to December 31, 1993. Thyroid ultrasonography studies were performed using a real-time ultrasonographic machine with a 10 MHz transducer. The aspirates were air dried and stained by the Romanowsky-based Liu method. Three hundred seventy-eight cases (10.3%) received surgical treatment after the ultrasonographic and FNAC examinations. Benign lesions were diagnosed in 269 patients. Thyroid malignancy was confirmed histopathologically in 109 cases including 76 papillary thyroid carcinomas, 17 follicular carcinomas, 5 medullary thyroid carcinomas, 3 anaplastic carcinomas, 3 Hürthle cell carcinomas, and 3 lymphomas. Another 2 cases were metastatic cancer to thyroid. The results demonstrated that 28.8% of the surgically treated patients had histopathologically proven malignancies. The incidence of thyroid malignancy was 2.98% in this study. The sensitivity of the cytological diagnosis was 79.80% and the specificity was 98.66%. The positive predictive value was 96.34%. Negative predictive value was 91.70%. The false negative index was 20.20%. The diagnostic accuracy was 92.89%. Thyroid ultrasonography with the FNAC can provide high specificity and sensitivity in differentiating malignant lesions from benign.     

Possible relation of osteopontin to development of psammoma bodies in human papillary thyroid cancer

Fine-needle aspiration cytology (FNAC) is the most useful procedure for the evaluation of thyroid nodules. The requirement for repeated aspirations in the follow-up of benign nodular thyroid disease, however, is controversial. To determine the value of re-aspirations in benign nodular thyroid disease, we studied 457 fine-needle reaspirations performed on 216 patients (197 female, 19 male) aged 42.9+/-12 years with uninodular (n = 65) and multinodular (n = 151) thyroid disease. Two hundred fifty-seven of these were second, 137 were third, 46 were fourth, and 17 were fifth re-aspirations of the same nodule, performed in a mean follow-up time of 43.9+/-31 (3-156) months. FNAC results were benign in 407 (89%), insufficient for diagnosis in 31 (6.8%), suspicious in 16 (3.5%), and papillary carcinoma (PC) in 3 (0.7%). An initial benign diagnosis did not change after multiple aspirations in 213 (98.61%) of the cases. Three patients with initial aspirations read as benign had a diagnosis of PC from their second biopsies, (diagnosis confirmed at surgery). Re-examination of the initial FNAC revealed atypical features in 1 of the 3 patients. These 3 patients likely represent a false-negative result of the initial FNAC rather than benign nodular disease transformed to a malignant one during the follow-up period. In conclusion, a second aspiration of clinically suspicious nodules may correct a few initial false-negative results, but routine additional re-aspirations are not useful for clinically stable disease.     

Lymph node excision in thyroid carcinoma

The prognostic value of lymph node metastases in thyroid cancer has been a matter of controversy for many years. However, during the past decade most multivariate analyses have shown a prognostic influence of lymph node metastases in papillary as well as medullary thyroid carcinoma constituting the basis for a standardized concept of lymphadenectomy oriented to the lymph node classification of the UICC (1993). Due to the frequency of lymph node metastases in the ipsilateral cervicocentral compartment (42-86%), in the ipsilateral cervicolateral compartment (32-68%), in the contralateral cervicolateral compartment (12-24%), and in the mediastinal compartment (3-20%), these compartments can be defined as the lymph node regions of the first, second, third and fourth order, respectively. Cervicocentral systematic lymphadenectomy should be part of the en bloc resection of the thyroid gland and the first lymph node region in any thyroid cancer. Cervicolateral as well as mediastinal lymphadenectomy should be performed according to the extent of lymph node involvement, i.e. systematically when multiple lymph node metastases are present, otherwise selectively. One exception is in medullary thyroid carcinoma, where a four-compartment lymphadenectomy is recommended in any patient with positive lymph nodes. Performing a gentle technique using magnifying glasses and bipolar coagulation forceps, systematic lymphadenectomy does not increase the rate of complications, can decrease the recurrence rate and improve survival.     

Identification of immunodominant regions within the C-terminal cell binding domain of intimin alpha and intimin beta from enteropathogenic Escherichia coli

Enteropathogenic Escherichia coli (EPEC) strains are a common cause of infantile diarrhea in developing countries. EPEC strains induce a characteristic attaching and effacing (A/E) lesion on epithelial cells. A/E lesion formation requires intimin, an outer membrane adhesin protein. The cell-binding activity of intimin is localized at the C-terminal 280 amino acids of the polypeptide (Int280). So far, four distinct Int280 types (alpha, beta, gamma, and delta) have been identified. The aim of this study was to identify immunodominant regions within the Int280alpha and Int280beta domains. Recombinant DNA was used to construct and express overlapping polypeptides spanning these domains. Rabbit anti-Int280 antisera and human colostral immunoglobulin A were reacted with these polypeptides in Western blots and enzyme-linked immunosorbent assays. The results obtained with the rabbit antisera showed the presence of two separate immunodominant regions which are common to both Int280alpha and Int280beta. The first localized within the N-terminal region of Int280, and the second localized between amino acids 80 and 130. The results with the human colostra revealed one reactivity pattern against the Int280alpha fragments but two different reactivity patterns against the Int280beta domain.     

Systemic lupus erythematosus is associated with increased auto-antibody titers against calreticulin and grp94, but calreticulin is not the Ro/SS-A antigen

Auto-antibodies against purified human calreticulin were determined by an ELISA in sera from patients with systemic lupus erythematosus (SLE) and from healthy persons or patients without an autoimmune disease. More than 80% of patients with SLE had titers exceeding the highest value obtained in the group without SLE. Almost 30% of the patients had also elevated auto-antibody titers against purified rat grp94, another resident ER-protein of the KDEL-protein family, but not against rat ERp72 (CaBP2), an ER-resident protein of the proteindisulfide isomerase family. It could, however, be excluded that calreticulin is the Ro/SS-A antigen on the basis of the following observations: 1) Calreticulin purified from rat, bovine or human liver contained far less than 1 mol of phosphate per mol of calreticulin, showed an E280/E260-absorption ratio of about 2.0, and did not contain extractable RNA; 2) Sera from patients with SLE did not react with or precipitate endogenous calreticulin from Hep G2 cells; they did, however, precipitate hY-RNA from these cells; 3) Sera from SLE-patients, but not anti-calreticulin antisera precipitated [32P]-hY-RNA from [32P]-labelled Hep G2 cells.     

Maternal and neonatal plasma inorganic fluoride levels after methoxyflurane analgesia for labor and delivery

At the time of the experiment, lean animals weighed 226-235 gm and the fatty rats 330-440 gm. On Day 5 after castration, rats received injections of estradiol-17beta (E2) for a 3-day period. Doses were .01-100 mcg/100 gm of body weight. Radioiodine uptake was determined by injecting 50 microCi of iodine-125 ip 24 hours before sacrifice. Beginning 12 hours after the last dose of E2, pairs of rats including a fatty and lean rat were sacrificed until all had been killed. Ovaries (at castration or autopsy), pituitary, and thyroid were removed and weighed. Uteri in obese rats were significantly smaller than in lean rats. There was a close dose-response relationship between E2 and the weight of the uteri; this was more marked in the obese rats. The radioactivity of the thyroid was increased more in the lean rats. Fatty rats ate more food than lean rats. The highest dose of E2 did not increase the food intake of obese rats but did increase that of the lean animals. It is concluded that the small uteri in the fatty rats may be due to decreased estrogenization and that this may also partly account for the small pituitary and low thyroid uptake of radioiodine.     

Acute necrotizing encephalopathy of childhood (infantile bilateral thalamic necrosis): two non-Japanese cases

Graves' disease is increasing in incidence amongst urban black South Africans. The pathogenic role of thyrotropin receptor antibodies (TRAb), crucial in other populations, has not been formally evaluated in African communities. We therefore prospectively investigated the prevalence of TRAb in 30 consecutive urban black South African patients with classical Graves' disease at the onset of their illness. This was compared with the frequency of thyroid microsomal and thyroglobulin antibodies in the same patients. Ten patients with euthyroid goitres unrelated to Graves' disease and 10 healthy controls were also studied. Twenty of the hyperthyroid patients were retested 4-6 months after starting carbimazole therapy and ten of them again after 1 year. Initially 83% of patients were positive for TRAb as against 54% for thyroid microsomal and 1 7% for thyroglobulin antibodies. After 4-6 months of treatment, 65% of patients still had elevated (>15% inhibition of binding) TRAb titres, while at 1 year this had dropped to 40% (4 out of 10 patients). All positive patients had relapsed biochemically, while TRAb negative patients were all in remission. We conclude that TRAb are a sensitive and specific marker of Graves' disease in black South Africans and closely parallels the response to medical therapy at 1 year. However, their predictive value for delayed relapse requires the study of a larger cohort of patients over a longer time-frame.     

Incremental threading optimization (TITO) to help alignment and modelling of remote homologues

OBJECTIVE: To evaluate the role of thyroid hormones in maintaining early pregnancy and to examine the association between thyroid physiological functions and immunological parameters. METHODS: Forty-five pregnant women with a clinical diagnosis of threatened abortion and a live fetus and 30 normal pregnant women were included in the study. Blood samples were taken on admission to the hospital. The patients were divided retrospectively into two groups on the basis of outcome: 1) 31 women who did not miscarry (positive outcome) and 2) 14 women who miscarried (negative outcome). Plasma TSH, free triiodothyronine (fT3), free thyroxine (fT4), hCG, immunoglobulin (Ig) G and IgM concentrations and blood counts were determined in each patient. RESULTS: Human chorionic gonadotropin was significantly higher in women who did not abort (39.4 +/- 16.9 IU/mL) than in women who miscarried (17.6 +/- 14.8 IU/mL, P < .001). Free thyroxine but not fT3 was lower in patients with negative outcome (1.25 +/- 0.26 ng/mL compared with 1.98 +/- 0.22 ng/mL, P < .001) and IgG and IgM plasma levels were higher (780 +/- 500 ng/mL compared with 470 +/- 300 ng/mL and 930 +/- 400 ng/mL compared with 650 +/- 280 ng/mL, respectively, P < .05). Plasma TSH levels were higher in patients with negative outcomes (1.72 +/- 0.84 mIU/mL compared to 1.01 +/- 0.41 mIU/mL, P < .001). Plasma concentrations of hCG and thyroid hormones were significantly correlated with peripheral blood lymphocyte and neutrophil counts only in the group of women who aborted. CONCLUSION: Our results indicate that maternal immune response, trophoblast function, and maternal thyroid function are somehow correlated. The presence of low concentrations of hCG and fT4 and high levels of TSH and gamma globulins in women with threatened abortion suggests a negative outcome for the pregnancy.     

Marked restoration of density and total number of mature (knob-bearing) olfactory receptor neurons in rats recovering from early hypothyroid-induced growth retardation

Our recent studies have shown that restoration of thyroid function in developing hypothyroid rats results in upregulation of olfactory neurogenesis and compensatory proliferation of olfactory receptor neurons (ORN) in the olfactory epithelium (OE) (Paternostro and Meisami, Dev. Brain Res., 76 (1993) 151-161; ibid., 83 (1994) 151-162). It was not clear, however, whether the newly forming ORNs undergo complete maturational stages. To determine the effects of restoration of thyroid function on maturation of ORNs, the density and total number of mature ORNs were estimated in the OE of euthyroid and hypothyroid rats at postnatal days 1, 12, 25 and 90 and the results were compared with those in rats allowed to recover from early thyroid deficiency at weaning (day 25). As a marker for mature ORNs, and on the basis of one olfactory dendritic knob per ORN, the density and total number of the olfactory knobs were determined in the entire extent of the OE covering the nasal septum. Hypothyroidism was induced by adding propylthiouracil (PTU) to the drinking water (1 g/l) from birth until days 12, 25 or 90 of age. Recovery from hypothyroidism was induced by withdrawal of PTU at day 25, leading to restoration of thyroid function and somatic growth recovery. The density of olfactory knobs was determined in 1 microm semi-thin sections stained with toluidine blue. In the normal rats, the number of olfactory knobs (= mature ORNs) increased 8.5- and 3-fold during postnatal days 1-25 and 25-90 respectively, reaching a mean value of 4 X 10(6)/septal OE, compared to 2.8- and 1.4-fold, respectively, for the hypothyroid rats. This led to deficits of 51% and 76% in the number of mature ORNs in the 25- and 90-day-old hypothyroid rats. In rats allowed to recover, the number of mature ORNs increased 4.5-fold during postnatal days 25-90 (3 X > hypothyroid rats and 1.5 X > controls). The results indicate marked upregulation of the maturational process of the ORNs and their compensatory accretion within the OE of the recovery group. The recovery process was not complete however, as indicated by a remaining deficit of about 25% in the total number of mature ORN, compared to normal 90-day controls. Thus thyroid hormones are essential for accretion of new mature ORNs in both the suckling and postweaning rats. Also, the ORNs show a remarkable ability to recover from severe early hypothyroid-induced growth retardation and attain normal mature state.     

Ferulic acid dehydrodimers from wheat bran: isolation, purification and antioxidant properties of 8-O-4-diferulic acid

Wheat bran contains several ester-linked dehydrodimers of ferulic acid, which were detected and quantified after sequential alkaline hydrolysis. The major dimers released were: trans-5-[(E)-2-carboxyvinyl]-2-(4-hydroxy-3-methoxy-phenyl)-7-methoxy-2, 3- dihydrobenzofuran-3-carboxylic acid (5-8-BendiFA), (Z)-beta-[4-[(E)-2-carboxyvinyl]-2-methoxyphenoxy]-4-hydroxy-3-methox ycinnamic acid (8-O-4-diFA) and (E,E)-4,4'-dihydroxy-5,5'-dimethoxy-3,3'-bicinnamic acid (5-5-diFA). trans-7-hydroxy-1-(4-hydroxy-3methoxyphenyl)-6-methoxy-1,2-dihydro - naphthalene-2,3-dicarboxylic acid (8-8-diFA cyclic form) and 4,4'-dihydroxy-3,3'-dimethoxy-beta,beta'-bicinnamic acid (8-8-diFA non cyclic form) were not detected. One of the most abundant dimers, 8-O-4-diFA, was purified from de-starched wheat bran after alkaline hydrolysis and preparative HPLC. The resultant product was identical to the chemically synthesised 8-O-4-dimer by TLC and HPLC as confirmed by 1H-NMR and mass spectrometry. The absorption maxima and absorption coefficients for the synthetic compound in ethanol were: lambda max: 323 nm, lambda min: 258 nm, epsilon lambda max (M-1 cm-1): 24,800 +/- 2100 and epsilon 280 (M-1 cm-1): 19,700 +/- 1100. The antioxidant properties of 8-O-4-diFA were assessed using: (a) inhibition of ascorbate/iron-induced peroxidation of phosphatidylcholine liposomes and; (b) scavenging of the radical cation of 2,2'-azinobis (3-ethyl-benzothiazoline-6-sulphonate) (ABTS) relative to the water-soluble vitamin E analogue, Trolox C. The 8-O-4-diFA was a better antioxidant than ferulic acid in both lipid and aqueous phases. This is the first report of the antioxidant activity of a natural diferulate obtained from a plant.     

Prospective study on thyroid autoimmunity and dysfunction related to chronic hepatitis C and interferon therapy

This study was designed to assess patients with chronic hepatitis C (CHC) for the presence of thyroid autoimmunity and dysfunction, to evaluate the risk of thyroid disorders associated with interferon (IFN) therapy, and to survey the outcome of possible treatment-related thyroid injury. Out of 104 consecutive untreated patients (30 women and 74 men; mean age, 52.7 years), 8 (7.7%) were found seropositive for thyroid autoantibodies (ThyAb), whereas seropositivity in healthy controls was 1/98 (1.3%). The relative increase in risk of developing thyroid autoimmunity associated with CHC was 760% (95% CI, 220-1300%). No patients had abnormalities of thyroid function tests, but on IFN treatment, 3/3 patients showed a rapid over-range rise in circulating thyrotropin, which returned to normal after therapy discontinuation. In the other 5 seropositive patients who refused treatment, thyroid function remained normal. Out of the 58 initially seronegative patients who consented to IFN treatment, 9 (15.5%) developed thyroid autoimmunity. Seven of them (77.7%) had thyroid dysfunction: hypothyroidism in 4 cases, transient thyrotoxicosis in 2 cases. The last patient developed TSH-receptor antibodies and Graves' disease, requiring methimazole therapy. Thyroid function recovered in the former 6 cases following IFN discontinuation. In the 28 initially seronegative patients who refused IFN and participated in a preliminary tauroursodeoxycholic acid trial, antithyroglobulin antibodies alone appeared in one case, but no thyroid dysfunction was observed. The relative risk of thyroid autoimmune disorder associated with IFN therapy was 342% (28-636%). The patients with CHC were unlikely to develop thyroid dysfunction in the absence of IFN therapy, in spite of being ThyAb seropositive. Moreover, a considerable proportion of seronegative patients, when IFN-treated, developed thyroid autoimmunity and then thyroid dysfunction. Both in seropositive and seronegative patients immediate IFN discontinuation normalized thyroid function and hormone replacement therapy was not necessary.     

Clinically significant, isolated metastatic disease to the thyroid gland

Despite being second only to the adrenal glands in terms of relative vascular perfusion, the thyroid gland is a rare site of metastatic disease; but when thyroid metastases occur, long-term survival has been reported to be dismal. To determine the incidence and management of isolated, metastatic disease to the thyroid, we reviewed our clinical experience. Between June 1986 and August 1994 ten patients underwent thyroidectomy for isolated, metastatic disease of nonthyroidal origin (mean +/- SD age 58 +/- 6 years, 30% female). The primary tumors were renal cell carcinomas (RCCs) (n = 5), esophageal adenocarcinoma (n = 1), pulmonary squamous cell carcinoma (n = 1), gastric leiomyosarcoma (n = 1), lingual squamous cell carcinoma (n = 1), and parotid gland carcinoma (n = 1). Three patients underwent preoperative fine-needle aspiration (FNA), all of which were suggestive of metastatic disease. The mean time from resection of the primary tumor to thyroid metastases was 3.5 +/- 6.0 years (range 0-19.5 years). Total thyroidectomy (n = 5) or lobectomy (n = 5) was performed without morbidity or mortality. After a median follow-up of 5.2 years six patients are alive and two are free of disease. Moreover, no patients have had recurrent disease in the neck. Thus carcinomas metastatic to the thyroid represent a rare cause of clinically significant thyroid disease, with RCCs comprising 50%. Most thyroid metastases (80%) present within 3 years of primary tumor resection, but with RCC they can occur as late as 19 years. The diagnosis of metastatic disease should be suspected in patients with even a remote history of cancer, especially RCC, and an FNA revealing clear cell or spindle cell carcinoma. Contrary to previous reports, long-term survival can be achieved after resection of the metastatic tumor. Furthermore, thyroidectomy may also palliate/prevent the potential morbidity of tumor recurrence in the neck.     

The role of thyroid resection during reoperation for persistent or recurrent hyperparathyroidism

BACKGROUND: The role of "blind" thyroid lobectomy in the surgical management of patients with persistent or recurrent primary hyperparathyroidism is not known. We reviewed our experience with reoperation for hyperparathyroidism to determine the utility of blind thyroid resection in this setting. METHODS: From 1982 to 1995, 269 patients underwent reoperation for hyperparathyroidism at our institution. All patients had biochemical confirmation of hyperparathyroidism and underwent noninvasive and if necessary invasive localization studies. Patients who underwent thyroid lobectomy in an attempt to extirpate the hyperfunctioning parathyroid gland form the basis of this report. RESULTS: Thirty-two of 269 patients (12%) underwent thyroid lobectomy to remove a parathyroid gland. Intrathyroidal parathyroids were confirmed in 19 of 32 patients (59%). In 18 of 19 patients (94%), preoperative or intraoperative ultrasonography correctly identified an intrathyroidal lesion suspicious or a parathyroid. Only 1 of 6 patients (17%) undergoing a blind thyroidectomy had an intrathyroidal gland identified. Ultrasonography had a sensitivity of 95% and a negative predictive value of 99.5% in detecting an intrathyroidal parathyroid gland. CONCLUSIONS: The prevalence of an intrathyroidal parathyroid gland in our series is low (19 of 269, 7%). Ultrasonography can be used reliably to select patients for thyroid resection, reducing the need to perform a blind thyroid lobectomy and avoiding the potential morbidity of thyroid resection in this clinical setting.     

A multidisciplinary approach in the treatment of endocrine orbitopathy

Despite the knowledge of immunological mechanisms of Graves-Basedow's disease the pathogenesis of endocrine orbitopathy remains obscure. Apart from the most frequent association with GB disease it may occur also in patients with primary hypothyroidism, Hashimoto's thyroiditis or in rare instances in euthyroid patients not suffering from thyroid disease. Endocrine orbitopathy is a typical example of a disease with a multidisciplinary approach to its diagnosis and treatment. In the submitted paper the authors demonstrate the collaboration of four clinics of the Faculty Hospital when dealing with this problem. Complete or almost complete removal of the thyroid gland leads within 1-4 years to regression of the protrusion of the bulbus by 1 mm. In combination with decompression of the orbit by a modification of Ogura's and Walsh's method improvement of visual acuity by 50% was achieved and the mean value of the exophthalmus diminished by 3.5 mm.