Treatment of benign nodular goitre with mildly suppressive doses of L-thyroxine: effects on bone mineral density and on nodule size

OBJECTIVES: To evaluate (i) the demineralizing effect of L-thyroxine (LT4) therapy at doses mildly inhibiting serum thyroid stimulating hormone (TSH) in patients with benign nodular goitre; (ii) the efficacy of treatment on nodule size. DESIGN: Cross-sectional study comparing euthyroid women with nodular goitre treated with LT4 for > or = 2 years (52 +/- 32 months, range 24-138, median 42) and a matched group with untreated goitre. SUBJECTS: A total of 89 female outpatients (53.3 +/- 9 years; 36 pre- and 53 postmenopausal), 43 treated and 46 untreated. MAIN OUTCOME MEASURES: Bone mineralization was measured with total body and regional mineralometry [dual energy X-ray absorptiometry (DEXA)], and indirectly evaluated with biochemical parameters (alkaline phosphatase, osteocalcin). Efficacy of LT4 therapy was assessed by measuring the nodule size during ultrasonography. The adequacy of the treatment was evaluated on the basis of serum TSH levels. RESULTS: No significant differences were found at DEXA for total body and regional mineralization (P > 0.05 for all comparisons) in treated and untreated patients, both in pre- and postmenopausal states. Evaluation of the nodule size during the ultrasound scan showed a reduction of > or = 30% in 11 of 43 treated patients (26%) versus none of the untreated, an unchanged size in 29 treated patients (67%) versus 18 untreated, an increase of nodules and/or new nodule development in three treated patients (7%) versus 28 untreated (61%). CONCLUSIONS: L-thyroxine (LT4) treatment at doses slightly suppressing TSH does not significantly affect bone mineralization, nor does it represent a risk factor for osteoporosis, even in postmenopausal patients. The efficacy of this therapeutic schedule on goitre size is comparable with the effects previously reported with suppressive doses.     

Total and age-specific incidence of Graves' thyrotoxicosis,toxic nodular goitre and solitary toxic adenoma in Malmö 1970–74

During a 5-year period, 333 new cases of thyrotoxicosis were diagnosed in a well-defined urban population of 258,000 inhabitants in southern Sweden without a history of endemic goitre. This corresponds to a mean annual incidence of thyrotoxicosis of 25.8/100,000. The incidence of Graves' disease was 17.7, the incidence of toxic nodular goitre was 5.4 and that of solitary toxic adenoma was 2.7/100,000/year. The peak age-specific incidence of Graves' disease was 32.6/100,000/year (age group 60-69 years), and that of toxic nodular goitre and solitary toxic adenoma was 31.5/100,000/year (age group over 80 years).     

Prevalence of iodine deficiency disorders and goitre in Chad

A nationwide sample survey was conducted in Chad to establish the prevalence of iodine deficiency disorders (IDD). The country was stratified into the Sahel zone and the Sudan zone, the latter including the city of N'Djamena. The analysis followed a stratification whereby the city of N'Djamena was also separately analysed. A total of 1171 people between 10 and 20 years of age were included in the survey. The overall weighted prevalence of goitre, evaluated by a clinical examination, was 63%. In the Sudan zone the prevalence was 70%, in the Sahel zone 64% and for the capital, N'Djamena, 25%. There were significant differences in the frequency of goitre between the three zones. Females - as established in surveys from other areas and countries—had goitre significantly more often. The prevalence of cretinism varied between o and 1.2%, and was highest in the Sahel zone. Amongst the sampled population of the Sudan zone, 33% had less than 20 μg/l of urinary iodine, indicating severe iodine deficiency. In the Sahel zone and in N'Djamena the figures reached 8 and 1%. There were high levels of thiocyanate anions in urine reaching medians between 21 and 27 mg/l in the geographical stratas. This probably decreases the bio-availability of iodine. These data show that there is a high endemicity of goitre in Chad and provide a basis for interventions as part of a national action plan against IDD, which will be adapted to the social, cultural and economic situation of the country and to available health services.     

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB): past, present, and future

Endoscopic ultrasound (EUS) is a combination of endoscopy and intraluminal ultrasonography. EUS also enables ultrasonographic images of high resolution to be obtained. However, whether a lesion is malignant or benign cannot be diagnosed solely from the findings of EUS. Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) was developed to enhance the diagnostic capabilities of EUS by providing additional pathological findings. Though more than 10 years have passed since EUS-FNAB was first used for pancreatic disease, EUS FNAB has not been widely accepted in Japan. This may be due to the technical difficulties, relatively low sensitivity for the detection of malignancies, and Japanese gastroenterologists' and surgeons' inherent conservative way of thinking. We describe here a short history of EUS-FNAB, with details of technical tips, current indications and contraindications, diagnostic accuracy, and complications. The clinical utility of EUS-FNAB has been gradually understood and EUS-FNAB procedures have been increasing in number in Japan. So in the near future, EUS followed by EUS-FNAB will be routinely performed in the same manner as gastrointestinal endoscopy, followed by biopsy under direct vision. Also, therapeutic EUS procedures, such as EUS-guided celiac plexus neurolysis, pancreatic tumor ablation, drainage of pancreatic pseudocysts, and the development of an anastomosis may become feasible as less invasive and safer techniques than those used at present.     

Endoscopic ultrasound guided fine-needle aspiration and biopsy of pancreatic cysts

Pancreatic cystic lesions (PCLs) are often incidentally found on cross-sectional imaging. Long strides have been made in the past decade with improved quality and optics of cross-sectional imaging and endoscopic ultrasound (EUS), but a singular reliable test to appropriately characterize and risk-stratify PCLs has still eluded us. EUS allows high-resolution imaging of the pancreatic parenchyma and the ductal system, for assessment of PCL characteristics, with features concerning for malignancy and additionally provides an opportunity to sample the cyst to obtain fluid or cells for further diagnostic testing. This presents new sets of challenges, which include devising suitable equipment or needles and techniques for reliable and safe tissue acquisition, as well as provision of an adequate cytology or tissue sample to the pathologist, in order to arrive at an accurate diagnosis. This article will review the current role of EUS in the diagnosis and characterization of PCLs, with a focus on available strategies and pitfalls of cytology, cyst-fluid biomarkers, and biopsy acquisition techniques; and future directions to increase the yield and accuracy.     

细胞块结合免疫组化在内镜超声引导下穿刺诊断胰腺实性占位中的应用价值

目的探讨超声内镜引导下细针穿刺（EUS—FNA）物行不同细胞学检查方法对胰腺占位性病变的诊断价值。方法前瞻性研究广西医科大学第一附属医院2012年3月至2013年6月收治的胰腺实性占位性病变72例,均行超声内镜引导下细针穿刺活检取材,分别行常规涂片、液基涂片及细胞块结合免疫组化检查。结果72例患者中,最终确诊胰腺肿瘤61例,包括胰腺癌55例、胰腺假乳头状瘤2例、胰腺内分泌肿瘤4例;良性病变11例,包括慢性胰腺炎4例、胰腺结核2例、胰腺炎4例、黏液性囊腺瘤1例。常规涂片、液基涂片和细胞块结合免疫组化对胰腺肿瘤的诊断敏感度分别为68．9％（42／61）、75．4％（46／61）和90．2％（55／61）,特异度均为100．0％,准确率分别为73．6％（53／72）、79．2％（57／72）和91．7％（66／72）,细胞块结合免疫组化诊断准确率高于常规涂片细胞学及液基细胞学（P均〈0．05）。术后患者均无出血、感染、急性胰腺炎等并发症。结论EUS—FNA是一种安全有效的诊断胰腺占位病变的方法,具有高敏感度和特异度。EUS—FNA细胞块结合免疫组化有助于胰腺实性占位病变的定性诊断和组织学分型诊断,对治疗方案的选择有较大的临床应用价值。     

乳腺癌患者术前雌、孕激素受体的表达及意义

术前对68例乳腺癌患者行细针穿刺(FNA)涂片,用免疫细胞化学(ICA)检测(ABC法)雌激素受体(ER)、孕激素受体(PR)在涂片上的表达;同时应用免疫组化检测相应术后组织切片上ER、PR的表达.结果FNA涂片ICA检测ER阳性率为64.7%(44/68),PR的阳性率为39.7%(27/68);在组织切片上ER的阳性率为58.8%(40/68),PR的阳性率为36.7%(25/68).ER、PR在FNA涂片上的表达与组织切片上的表达无显著差别(P＞0.05).ER在FNA涂片上的表达情况与组织学分级、临床分期呈显著负相关(P＜0.05),腋淋巴结阴性者显著高于腋淋巴结阳性者(P＜0.05),与肿瘤大小无关;PR的表达与组织学分级明显负相关(P＜0.05),与其它指标无关.认为FNA与ICA相结合,对于乳腺癌的早期诊断、指导治疗和判断预后具有重要意义.     

超声内镜引导下细针穿刺抽吸术的方法和价值

内镜超声引导下细针穿刺抽吸术(EUS-FNA)已被广泛应用于消化壁及其壁外病变的诊断和治疗。不同于CT和腹部超声监视下的穿刺,EUS-FNA可大大缩短穿刺针与病灶的距离,穿刺针通过的穿刺路径气体干扰少、创伤小,并发症亦显著减少。此外,由于采用了高频超声探头,可获得较高的分辨率,EUS-FNA可对微小病变进行穿刺和治疗。本文就EUS-FNA在操作过程中的要点以及在消化道及其壁外疾病中的应用价值做一简要阐述。     

The value of fine-needle aspiration biopsy in subcentimeter thyroid nodules

BACKGROUND: The need to perform fine-needle aspiration biopsy (TFNAB) on subcentimeter thyroid nodules is less clear than for larger nodules. We compared the ultrasonographic features of thyroid nodules less than and greater than one centimeter and correlated this information with the cytological results for TFNAB and the final histopathological diagnosis in selected patients. METHODS: We evaluated 520 thyroid nodules (247 subcentimeter [group 1], 273 supracentimeter [group 2]) in 426 patients. Ultrasonography-guided fine-needle aspiration biopsy was performed on all nodules. Surgery was recommended for patients with TFNAB results that were read as malignant or suspicious. The results of ultrasonography, TFNAB, and histopathology were compared between the groups. RESULTS: Out of 426 patients, 337 had one nodule, 84 had two, and five had three. There was indeterminate cytology in 20 cases, 10 from each group. Inadequate cytology was obtained in 41/247 (16.6%) nodules in group 1 and 61/273 (22.3%) nodules in group 2, and the difference in rate was not significant (p = 0.067). The malignancy rate as determined by TFNAB was 4.9% in group 1 and 1.5% in group 2 (p < 0.025). In patients who underwent surgery for thyroid nodules the malignancy rate was 6% in group 1 and 2.9% in group 2 (p = 0.08). Hypoechoic pattern, microcalcification, and a long axis/short axis ratio (LA/SA) of < 1.5 were associated with malignancy in subcentimeter thyroid nodules (group 1), while only a hypoechoic pattern was associated with malignancy in supracentimeter thyroid nodules (group 2). CONCLUSIONS: The incidence of cancer in thyroid nodules < 1 cm does not appear to be lower than in larger nodules and may even be higher. Physicians should consider obtaining biopsy samples from subcentimeter hypoechoic nodules that contain microcalcification and have a relatively round shape (LA/SA < 1.5).     

The value of sputum cytology

Objective:To assess the value of cytologic examination of expectorated sputum in the diagnosis and management of patients with suspected lung cancer. Design:Retrospective chart review. Setting:Inpatient wards, tertiary care university hospital. Measurements and main results:The charts of 357 patients were reviewed. Two hundred eighty-eight of the 357 patients had had initial sputum cytologic examination prior to other diagnostic procedures, of which 41 (15%) had positive cytologic results. Thirty-six of the 41 were confirmed bistologically or shown to have metastatic spread by noninvasive tests. Of the 222 patients with negative or unsatisfactory sputum tests, 97 went on to bronchoscopy and 35 had needle-aspiration biopsies. In the population of patients whose chest x-rays were highly suggestive of primary or metastatic lung cancer, the positive rate for cytologic examination was 38/94 (40%). There was no false-positive test in this study. Of the 50 patients with positive cytologic results, five (10%) had diseases that were of a different cell type; two of these five (40%) had diseases that involved small-cell cancer. There was an unsatisfactory delay in obtaining these samples for analysis. Conclusions:Sputum cytology was found to be too insensitive and insufficiently accurate to be included in the routine workup of a patient suspected of having lung cancer. The results of the test did not influence further diagnostic procedures. This test should, therefore, be reserved for patients considered on initial assessment to be too sick for further investigations and treatment. Supported by a grant from the Department of Health, Government of Manitoba, Canada.