Thyroid lobectomy for indeterminate FNA: not without consequences

Background

Thyroid nodules are exceedingly common, and the cytologic interpretation of fine needle aspiration (FNA) findings has been the reference standard for diagnosing nodules as benign, atypia or a follicular lesion of undetermined significance, suspicious for follicular or Hürthle cell neoplasm, suspicious for malignancy, or malignant. Many patients undergo thyroid lobectomy for indeterminate FNA findings (atypia or a follicular lesion of undetermined significance or suspicious for follicular or Hürthle cell neoplasm), although the risk of malignancy is low. The general data have quoted a 20% risk of hypothyroidism after lobectomy. The purpose of the present study was to determine the risk of hypothyroidism after lobectomy in our diverse population.

Methods

The pathology records from a large county hospital were reviewed to identify patients with indeterminate FNA findings. The incidence of hypothyroidism was determined by the need for thyroid hormone replacement therapy. Categorical variables were compared using the chi-square and continuous variables using the Mann-Whitney U test.

Results

A total of 655 FNAs were performed during the study period, and 60 resulted in indeterminate cases. Of these 60 patients, 17 subsequently underwent diagnostic lobectomy. The mean age was 52.8 ± 16.5 years, 88% were women, and 67% were Hispanic and 22% were African American. Only 6% had a final diagnosis of cancer, and eight patients (47%) became hypothyroid postoperatively.

Conclusions

The incidence of hypothyroidism after diagnostic thyroid lobectomy in our patient population was much higher than previously reported. It is necessary to preoperatively counsel patients about this increased risk, in addition to the usual risks of nerve palsy and bleeding, with thyroid lobectomy. As testing of thyroid nodules evolves, the expense of preoperative testing should be weighed against the increased incidence for lifelong thyroid hormone replacement.     

Thyroid hormone replacement therapy for primary hypothyroidism leads to significant improvement of renal function in chronic kidney disease patients

Background

The interactions between kidney and thyroid functions have been known for many years; however, there are few studies on the extent of the improvements and long-term changes of renal function after thyroid hormone replacement therapy (THRT) in chronic kidney disease (CKD) patients. The purpose of this study was to determine how THRT affects the estimated glomerular filtration rate (eGFR) in CKD patients with primary hypothyroidism.

Methods

A retrospective investigation was performed on 51 Japanese patients (15 men and 36 women) with primary hypothyroidism. The changes in eGFR after THRT were examined according to the existence of CKD and severity of thyroid function.

Results

eGFR increased rapidly over the first 6 months after THRT in CKD patents, which was followed by a plateau. There was a correlation between eGFR and the severity of hypothyroidism, which was independent of age, and eGFR in severely hypothyroid patients significantly increased up to levels that were similar to mildly hypothyroid patients after THRT. eGFR improved more in the lower initial eGFR group and increased about 30 % in CKD patients (47.5 ± 7.7 vs. 62.1 ± 9.5 ml/min/1.73 m², P < 0.01). Moreover, eGFR in CKD patients with mild to moderate hypothyroidism was significantly increased compared to that in non-CKD patients.

Conclusion

Our data suggested that hypothyroidism contributed to the reduction in eGFR, especially in CKD patients; therefore, patients with CKD should positively be examined for thyroid function, and appropriate THRT should be started if needed.     

Conservative management of giant omphalocele with topical povidone-iodine and its effect on thyroid function

Purpose

The aim of the study was to evaluate topical povidone-iodine as a bridge to delayed fascial closure of giant omphaloceles with emphasis on its effect on thyroid function.

Methods

Newborns from a single institution with giant omphaloceles treated with topical povidone-iodine for a 10-year period were reviewed. Recorded data included sex, associated anomalies, length of stay, frequency of povidone-iodine application, thyroid function tests, frequency of laboratory draws, and thyroid supplementation administration.

Results

Six neonates with giant omphaloceles were treated with povidone-iodine. Thyroid function testing occurred weekly as inpatients and monthly as outpatients, with abnormal values normalized by the subsequent laboratory draw. One patient demonstrated persistent hypothyroidism and subsequently died secondary to cardiac complications, but this infant's newborn thyroid screening suggested congenital hypothyroidism. Five patients remained euthyroid and ultimately achieved fascial closure without the need for a prosthetic implant. None of these patients had abnormal outpatient thyroid tests nor did they require thyroid hormone supplementation.

Conclusion

Topical povidone-iodine promotes escharification and epithelialization of the omphalocele sac. Because transient hypothyroidism may occur, thyroid function studies may guide inpatient therapy. After sac desiccation, systemic effects of iodine are minimal and thyroid supplementation is not necessary. Topical povidone-iodine is an effective initial strategy for giant omphaloceles and does not produce clinically significant hypothyroidism.     

Thyrotropin Level and Thyroid Volume for Prediction of Hypothyroidism Following Hemithyroidectomy in an Asian Patient Cohort

Background  As more patients undergo diagnostic thyroid surgery, the development of posthemithyroidectomy hypothyroidism is becoming a major concern. We hypothesized that the preoperative thyrotropin (thyroid-stimulating hormone, TSH) level and ultrasonographically measured thyroid volume, both commonly available in thyroid nodule patients, may predict the development of posthemithyroidectomy hypothyroidism. Method  Among the 132 patients who underwent hemithyroidectomy from January 2004 to January 2006, a total of 101 patients who were followed for more than a year were included in the analysis. Results  Biochemical hypothyroidism developed in 37 patients (36.6%). Patients who developed postoperative hypothyroidism showed higher TSH levels (P < 0.001) and smaller remnant thyroid volumes (P = 0.014). Logistic regression analysis showed that the TSH level and remnant thyroid volume were independent predictors of posthemithyroidectomy hypothyroidism (P < 0.001 and P = 0.04, respectively). A risk scoring system using these two factors was created based on the results of logistic regression analyses. The incidences of hypothyroidism were 5.3%, 12.1%, 51.7%, and 85.0% according to the risk scores of 0, 1, 2, and 3, respectively. Conclusions  Patients with a high preoperative TSH level and small thyroid volume are at high risk of developing hypothyroidism following hemithyroidectomy. Potential risk of postoperative hypothyroidism should be discussed with these patients when thyroid surgery is being considered for a diagnostic purpose.     

Relationship between subclinical thyroid dysfunction and the risk of fracture: a meta-analysis of prospective cohort studies

Summary

To identify the relationship between subclinical thyroid dysfunction and the risk of fracture, we conducted a meta-analysis of prospective cohort studies. Results showed that subclinical hyperthyroidism is associated with an increased risk of fracture, especially in elder.

Introduction

There are conflicting data on the association between subclinical thyroid dysfunction and the risk of fracture. This study is aimed at providing a summary of prospective evidence of the relationship between subclinical thyroid dysfunction and the risk of fracture.

Methods

We systematically searched the MEDLINE, EMBASE, and the Chinese Biomedical literature database (CBM) from 1974 to August 2014 to identify prospective cohort studies which have studied the risk of fracture in patients with subclinical thyroid dysfunction. Various fractures were reported as the sole outcome.

Results

Five population-based cohort studies including 314,146 participants with relationship of endogenous or exogenous subclinical thyroid dysfunction or euthyroidism and fractures were identified as eligible for the meta-analysis. In an unadjusted model, the relative risk (RR) of subclinical hypothyroidism for fracture was 1.30 (CI 1.08–1.56). Risk estimates were lower in a multivariable-adjusted model (RR?=?1.20, CI 0.70–2.04) and when higher quality studies (RR?=?0.95, CI 0.58–1.57) were analyzed. For subclinical hyperthyroidism, the RR was 1.52 (CI 1.33–1.73) in unadjusted model and 1.25 (CI 1.11–1.41) in a multivariable-adjusted model. An analysis of higher quality studies revealed a RR 1.18 (CI 1.07–1.29). Subgroup analysis indicated that the RR for risk of fracture was higher in the endogenous group than the exogenous group, taking thyroid-altering medicine in subclinical hyperthyroidism. Similar finding was also demonstrated in subclinical hypothyroidism.

Conclusions

Despite heterogeneity across the studies, data suggest that subclinical hyperthyroidism is associated with an increased risk of fracture in the population older than 60 years. No evidence could prove a definite association between subclinical hypothyroidism and the risk of fracture yet.

     

Surveillance and Intervention After Thyroid Lobectomy

Background

After thyroid lobectomy, many patients require ongoing care. This study sought to quantify the rates of surveillance and intervention after thyroid lobectomy.

Methods

One hundred one consecutive patients who underwent a thyroid lobectomy for nodular disease were evaluated. Clinical and follow-up data were obtained by a review of patient charts and included an evaluation of resource utilization related to thyroid disease.

Results

Nineteen patients required completion thyroidectomy for thyroid cancer, and 11 had hypothyroidism before lobectomy. Of the remaining evaluable patients, 30 (42.2%) of 71 required thyroid hormone replacement after lobectomy, with 24 patients having elevated thyroid-stimulating hormone and 6 suppression of nodules in the contralateral lobe. The likelihood of thyroid hormone replacement demonstrated a trend with a contralateral nodule (9 of 14 vs. 21 of 57, P = 0.06) and a significant association with thyroiditis on surgical pathology (10 of 11 vs. 20 of 60, P < 0.001). Of the 82 patients who did not undergo completion lobectomy, 10 (12%) of 82 underwent postoperative fine-needle aspiration of the contralateral lobe, and 25 (30%) of 82 were followed with ultrasound surveillance. Only 27% of patients treated with lobectomy required no further surveillance or intervention. There were no instances of permanent recurrent laryngeal nerve injury.

Conclusions

After thyroid lobectomy, most patients require continued surveillance and intervention. With a near-zero complication rate, total thyroidectomy may be a more effective and efficient option for management of nodular thyroid disease.     

Comparison of video-assisted thyroidectomy and traditional thyroidectomy for the treatment of papillary thyroid carcinoma

Background  

There is concern regarding the oncological effectiveness of minimally invasive video-assisted thyroidectomy (VAT) for thyroid carcinoma. This study compared the surgical results of VAT and traditional thyroidectomy in patients with small papillary thyroid carcinomas (PTC).     

Frozen section and fine needle aspiration biopsy in thyroid surgery — needles and sections

Purpose  

To review our own experience with fine needle aspiration biopsy (FNAB) and frozen section (FS) in thyroid surgery and to assess the value of FNAB and FS in predicting malignancy in patient with thyroid disease.     

Surgeon-Performed Ultrasound can Predict Differentiated Thyroid Cancer in Patients with Solitary Thyroid Nodules

Introduction  

Certain surgeon-performed ultrasound (SUS) features may predict differentiated thyroid cancer (DTC). The purpose of this study was to determine the SUS characteristics that are strongly associated with DTC in patients with solitary thyroid nodules.     

The Role of BRAFV600E Mutation and Ultrasonography for the Surgical Management of a Thyroid Nodule Suspicious for Papillary Thyroid Carcinoma on Cytology

Background  

This study was designed to investigate the role of BRAF^V600E mutation status in cytology specimens and ultrasonography (US) when planning surgery for thyroid nodules with cytologic results suspicious for papillary thyroid carcinoma (PTC).     

The false-negative rate of fine-needle aspiration cytology for diagnosing thyroid carcinoma in thyroid nodules

Purpose  

Our aim was to define the false-negative rate of fine-needle aspiration cytology (FNAC) for diagnosing thyroid carcinoma in thyroid nodules <4 cm versus ≥4 cm.     

Hypothyroidism Increases 90-Day Complications and Costs Following Primary Total Knee Arthroplasty

Background

Thyroid disease is common and often remains undetected in the US population. Thyroid hormone has an array of metabolic, immunologic, and musculoskeletal functions crucial to well-being. The influence of thyroid disease on perioperative outcomes following primary total knee arthroplasty (TKA) is poorly understood. We hypothesized that hypothyroidism was associated with a higher risk of postoperative complications and 90-day costs following primary TKA.

Five-Year Follow-up of a Randomized Clinical Trial of Unilateral Thyroid Lobectomy with or Without Postoperative Levothyroxine Treatment

Background  

The aim of this study was to compare the prevalence of recurrent nodular goiter in the contralateral thyroid lobe among patients after unilateral thyroid lobectomy for unilateral multinodular goiter (MNG) receiving versus not receiving postoperative prophylactic levothyroxine (LT4) treatment.     

Thyroid Tuberculosis in Southeastern Turkey: Is This the Resurgence of a Stubborn Disease?

Background  

While tuberculosis (TB) has been found in many parts of the body, involvement of the thyroid gland is rare. In this study we describe the clinicopathological characteristics of seven patients with primary thyroid tuberculosis (TTB).     

Diagnostic Utility of Fine-Needle Aspiration Cytology in Pediatric Differentiated Thyroid Cancer

Background  

Pediatric patients present with thyroid nodules less often than adults, but the rate of malignancy is much higher. This study was designed to determine the ability of fine-needle aspiration cytology (FNA) to diagnose accurately and facilitate management of thyroid neoplasms in pediatric patients.     

Inoperable Symptomatic Recurrent Thyroid Cancers: Preliminary Result of Radiofrequency Ablation

Purpose  

To determine the role of radiofrequency ablation (RFA) in patients with inoperable symptomatic recurrent thyroid cancers.     

Pituitary tumorous hyperplasia due to primary hypothyroidism

Background  

To study the diagnostic and therapeutic features of pituitary tumorous hyperplasia due to primary hypothyroidism.     

Five-year Follow-up of a Randomized Clinical Trial of Total Thyroidectomy versus Dunhill Operation versus Bilateral Subtotal Thyroidectomy for Multinodular Nontoxic Goiter

Background  

The extent of thyroid resection in multinodular nontoxic goiter (MNG) is controversial. The aim of the present study was to evaluate results of various thyroid resection modes, with special emphasis put on the recurrence rate and morbidity rate, in a 5-year follow-up.     

Impact of pathognomonic genetic alterations on the prognosis of papillary thyroid carcinoma

Introduction  

BRAF mutations and RET or NTRK1 rearrangements were identified as causing events that drive the malignant transformation of the thyroid follicular cell. The impact of these alterations on the course of papillary thyroid carcinoma (PTC) is still unsettled.     

Role of cervical ultrasound in detecting thyroid pathology in primary hyperparathyroidism

Background

Minimally invasive parathyroidectomy for primary hyperparathyroidism is made possible with accurate preoperative imaging. In addition to the detection of parathyroid adenomas, cervical ultrasound also provides concomitant assessment of the thyroid gland, and many surgeons believe that it is essential. However, the incidental identification of thyroid nodules may then subject patients to further workup and potentially invasive thyroid procedures. We sought to determine the long-term consequence of omitting preoperative ultrasound on the development of thyroid pathology and cancer.

Methods

At our institution, 222 patients with primary hyperparathyroidism underwent parathyroidectomy without preoperative cervical ultrasound from 1990–2001. Thyroid pathology discovered by follow-up after parathyroidectomy, subsequent biopsy, and surgical interventions were analyzed.

Results

Of the 222 patients who underwent parathyroidectomy, the mean age was 55 ± 1 y and 149 were female (67%). In the course of their follow-up after parathyroidectomy, 13 patients (6%) received a cervical ultrasound, and seven of 13 (3%) underwent fine needle aspiration of a thyroid nodule. Only one of seven (0.4% of all patients) was ultimately diagnosed with thyroid cancer. Four additional patients were discovered to have thyroid malignancies as a result of intraoperative decision making. All five patients are currently alive with an average follow-up time of 14.9 ± 1.6 y. No patients in this series had an unnecessary thyroid intervention.

Conclusions

In patients who underwent parathyroidectomy without a preoperative ultrasound, only a small number (0.4%) were subsequently diagnosed with thyroid cancer. Furthermore, omission of ultrasound during the localization of parathyroid glands does not have a negative impact on the diagnosis of thyroid pathology as all patients who had thyroid cancer had good outcomes, and in fact, may prevent unnecessary thyroid interventions. Therefore, the use of cervical ultrasound for parathyroid localization should be considered optional rather than essential.