Surgical treatment of Hashimoto's thyroiditis. Personal experience

BACKGROUND: To report personal experience in the surgical treatment of Hashimoto's thyroiditis. METHODS. Eight patients (7 females, 1 male, mean age 48 years old) referred to our Institution with diagnosis of Hashimoto's thyroiditis have been studied. All patients were evaluated by determination of serum thyroid hormones and of anti-thyreoglobulin and anti-microsomal antibodies; ultrasound and scintigraphic scans of the gland were performed in all cases and a cytological examination of fine needle aspiration (FNAC) of the nodules was evaluated. Diagnosis of Hashimoto's thyroiditis was suspected on the basis of clinical and laboratory data and was confirmed by cytology and histology on surgical specimens. Preoperative FNAC showed a Hashimoto's thyroiditis with thyroid differentiated carcinoma in 3 cases (37.5%), Hashimoto's thyroiditis in 1 case and chronic thyroiditis in 4 cases (50%). Seven patients underwent surgery, while 1 patient received a medical treatment; we performed 6 total thyroidectomies and 1 hemithyroidectomy. Histology on surgical specimens confirmed the diagnosis of Hashimoto's thyroiditis in all cases; in 3 patients an associated papillary thyroid carcinoma was found. RESULTS: Postoperative mortality was absent; no major postoperative complications (laryngeal nerve paralysis or permanent hypocalcemia) were recorded. Only 2 mild transient hypocalcemias have been observed. CONCLUSIONS: Total thyroidectomy is the technique of choice in surgical treatment of Hashimoto's thyroiditis, a self-immune pathology which involves the whole gland and has a high correlation with differentiated thyroid carcinoma (37.5%). Total thyroidectomy warrants a radical and definitive control of the disease, without risk of relapse, with a low incidence of major complications, in experienced hands, and anyway lower than the morbility due to reinterventions.     

Coexisting Hashimoto's thyroiditis with differentiated thyroid cancer and benign thyroid diseases: indications for thyroidectomy

Hashimoto's thyroiditis is a medical disease that affects about 5% of the population. In cases of goitre, hashitoxicosis or associated differentiated thyroid cancer, surgical treatment is recommended. The aim of this study was to evaluate the indications for thyroidectomy in Hashimoto's thyroiditis, the frequency of coexistence of Hashimoto's thyroiditis and differentiated thyroid cancer, and the impact of Hashimoto's thyroiditis on the management of differentiated thyroid cancer. From January 1998 to May 2002, 344 patients underwent thyroidectomy in our department. Among 44 patients with HT, the authors carried out a retrospective comparative study of 33 patients with a cytological diagnosis of differentiated thyroid cancer (group A) and 11 patients with non-neoplastic conditions (group B). Surgical indications based on cytological findings and management characteristics were considered. The frequency of the association of Hashimoto's thyroiditis and differentiated thyroid cancer was 23.8% as compared to a 6.7% frequency of coexisting Hashimoto's thyroiditis and benign thyroid diseases (P = 0.000). The sensitivity of cytology in the diagnosis of papillary carcinoma in Hashimoto's thyroiditis was 92%. Cytological diagnosis of hyperplastic follicular and hyperplastic Hürthle cell nodules in Hashimoto's thyroiditis was impossible in some cases. Intraoperatively distinguishing between chronic lymph-node reactivity and tumour involvement was difficult, but the morbidity rate was not increased very much by Hashimoto's thyroiditis. In conclusion, an adequate follow up of patients with Hashimoto's thyroiditis may permit an early diagnosis of differentiated thyroid cancer and its appropriate management.     

多灶性甲状腺乳头状癌的生物学特性及治疗分析

目的 探讨多灶性甲状腺乳头状癌的临床特性及治疗.方法 回顾性分析1995-1997年间在天津市肿瘤医院手术治疗并经病理证实的86例多灶性甲状腺乳头状癌的临床资料,研究其临床生物学特征.结果 多灶性甲状腺乳头状癌者共86例,占同期甲状腺乳头状癌的23.4%.病灶位于单侧12例,位于双侧74例;颈部淋巴结转移51例(59.3%);病灶中含微小癌者46例(53.5%);合并桥本甲状腺炎者23例(26.7%);周围组织侵犯19例(22.1%);发生远处转移者1例(1.2%);10年生存率95.3%.美国癌症联合会(AJCC)分期与预后相关(x2=63.395,P=0.000).结论 多灶性甲状腺乳头状癌多发生于双侧甲状腺,病灶中含微小癌者及合并桥本甲状腺炎者较多,AJCC分期是多灶性甲状腺乳头状癌的重要预后因素.     

The optically clear nucleus. A reliable sign of papillary carcinoma of the thyroid?

The clear ("Orphan Annie Eye") nucleus has been accepted as one of the important microscopic features of papillary carcinoma of the thyroid. This study undertook an examination of 100 consecutive thyroid lesions exclusive of papillary, mixed, and follicular carcinomas for the presence of these nuclei. Only two lesions (2%), a follicular adenoma and diffuse hyperplasia, had such nuclear morphology but as focal changes. Thirty-seven cases of papillary, mixed, and follicular carcinoma were also studied. Clear or empty nuclei were present in 83% of papillary carcinomas. One carcinoma of follicular type had clear nuclei in a diffuse distribution. "Pseudoclear" nuclei were noted in a variety of situations ranging from normal thyroids to diffuse hyperplasia, where they were present in 65% of cases. We conclude that clear nuclei when present as a diffuse changes in a thyroid tumor are a reliable sign of papillary carcinoma but are not pathognomonic. If the character of the clear nuclei is questionable, other histologic features of papillary carcinoma should be looked for, such as papillae with overlapping nuclei, psammoma bodies and multicocality. It was also fould that frozen sections and imprints do not demonstrate the nuclei; they appear only in fixed tissues.     

The incidence of thyroid carcinoma in Hashimoto's thyroiditis

The incidence of thyroid carcinoma in Hashimoto's thyroiditis has been a widely debated issue. Previous authors have reported on this topic by analyzing series of patients with Hashimoto's thyroiditis or patients with thyroid carcinoma, but not both of those populations in the same series. The population consists of a consecutive series of 800 patients operated on for thyroid nodules not associated with a radiation history. Among 161 patients with the diagnosis of thyroid carcinoma, 61 (38%) had coexistent Hashimoto's thyroiditis. In comparison, among 161 sex- and age-matched patients with colloid nodules in the same population, 18 (11%) had Hashimoto's thyroiditis. Furthermore, in the series as a whole, the incidence of Hashimoto's thyroiditis in 423 patients with colloid nodules was 10 per cent. From the perspective of the Hashimoto's thyroiditis population in the same series of 800 thyroidectomies, among 267 patients with Hashimoto's thyroiditis 61 (23%) had coexistent carcinoma. In comparison, among 267 age- and sex-matched patients with colloid nodules there were only ten coexistent carcinomas for an incidence of 4 per cent. The high incidence of carcinoma of the thyroid in Hashimoto's thyroiditis lends credence to the hypothesis that Hashimoto's thyroiditis is a predisposing factor in the development of thyroid carcinoma.     

Hashimoto's thyroiditis and carcinoma of the thyroid gland

Seven cases of Hashimoto's disease (HT) occurring in association with carcinoma of the thyroid gland are presented. The diagnosis of HT was not reached before surgery in any of the cases; it was an incidental histopathological finding. There was no case of pure papillary cancer: two specimens showed mixed papillary and follicular cancers, four revealed follicular carcinomas (one of them with anaplastic areas) and one medullary neoplasm. Other authors, however, have reported that pure papillary carcinoma occurred with significantly greater frequency in thyroids also displaying Hashimoto's disease. Total thyroidectomy was performed in all seven patients and one patient with anaplastic follicular cancer also received external irradiation. TSH suppressive therapy was given postoperatively. All these patients are alive with no evidence of further disease after seven to 17 years of follow-up study, whereas the mortality in our total series of thyroid cancers, even in patients with low-grade malignancy, was about 9%. Thus the prognosis of patients with carcinoma of the thyroid gland with coexisting Hashimoto's disease is better than that of patients with carcinoma of the thyroid gland alone. Hashimoto's thyroiditis does not seem to be a premalignant lesion. There was no evidence suggesting that thyroid carcinoma originated in the proliferating epithelium of Hashimoto's thyroiditis. It would appear that thyroid carcinoma stimulates the development of HT in some patients and that the presence of the autoimmune inflammatory reaction and the circulating antibodies retard growth and dissemination of carcinoma of the thyroid gland.     

Hashimoto's thyroiditis with medullary carcinoma.

The association of Hashimoto's thyroiditis with lymphoma and papillary carcinoma has been recognized, but there have been few reports of an association between Hashimoto's thyroiditis and medullary carcinoma of the thyroid gland, especially in Canada. The authors report three cases, seen in an 18-month period, of Hashimoto's thyroiditis and medullary carcinoma in patients whose relatives had multiple endocrine neoplasia type II. The findings support the view that the thyroiditis occurred in response to the tumour process and not vice versa.     

Surgically treated Hashimoto's thyroiditis

The primary way to treat Hashimoto's thyroiditis is conservative. However, it has a relatively high occurrence in operated patients, up to 13% in the literature. Indications for surgery are suspicion of malignancy, and/or trachea/esophagus compression. 2818 thyroid operations were performed at our department between 1986 and 1995. 279 patients suffered from thyroid cancer and 2539 had benign disease. Histology revealed Hashimoto's thyroiditis in 118 cases. Coexisting malignant thyroid tumor was found in 14 cases (11.8%): 9 papillary, 2 follicular, 1 anaplastic cancer, and 2 non-Hodgkin lymphoma. Postoperative recurrent laryngeal nerve paralysis occurred in 8 cases, of which 6 remained permanent. This relatively high incidence supports the importance to identify the laryngeal nerve during every operation for Hashimoto's thyroiditis. Four patients had temporary and one had permanent hypoparathyroidism. Coexistence of Hashimoto's thyroiditis and thyroid carcinoma, the increased risk for the development of non-Hodgkin's lymphoma in chronic lymphocytic thyroiditis and the need for thyroxin supplementation in many cases justify a careful, long-term follow-up of patients with Hashimoto's disease.     

桥本氏病合并甲状腺恶性肿瘤(附10例报告)

本文报告86例桥本氏病,发现同时合并甲状腺恶性肿瘤10例。男1例,女9例,年龄31～69岁,平均46岁;其中乳头状癌5例,滤泡状癌1例,恶性淋巴瘤3例,肉瘤变1例。术后随访1～5年,存活8例,2例死于其它疾病。作者强调术前甲状腺同位素扫描,主张对桥本氏病合并发结节者应积极手术探查。     

Differentiated thyroid cancer--peculiar morphological and clinical forms

The most common clinical presentation of differentiated thyroid cancer (DTC), consisting of papillary and follicular adenocarcinoma (with their histological variants), is the solitary thyroid nodule. A review of the literature is performed in order to describe particular forms of DTC, in terms of incidence, diagnosis and treatment: occult carcinoma, carcinoma on aberrant thyroid tissue, "functional" thyroid carcinoma and familial non-medullary carcinoma. A particular interest is shown to the coexistence of malignancy with benign thyroid diseases, such as goiter, hyperthyroidism and Hashimoto's thyroiditis, as well as parathyroid adenoma. In conclusion, the authors emphasize that the association of carcinoma with benign thyroid conditions is not rare and it substantiate an aggressive approach in regard to diagnosis and treatment, increasing the indication for surgery and, moreover, for total thyroidectomy.     

桥本病及其共存病的诊断和处理

目的 探讨桥本病及与其共存病的诊断和外科处理原则。方法 回顾性分析５４例桥本病患者的临床资料。结果 甲组２５例经临床检查、小针穿刺细胞学检查及免疫抗体测定拟诊桥本病,采用药物诊断性治疗,２４例治愈,１例后发现共存癌中转手术;乙组２９例因非典型表现误诊为外科病施行甲状腺切除术,术后均经病理切片明确诊断,并发现１４例与甲状腺其它良、恶性疾病共存（甲亢３例,甲状腺癌４例,恶性淋巴瘤２例,甲状腺腺瘤５例）     

415例结节型桥本氏甲状腺炎的诊断和外科治疗的经验和教训

【摘要】 目的 探讨结节型桥本氏甲状腺炎的诊断、手术适应证及术式选择。方法〓资料来源于2005年1月至2014年1月在我院接受诊治的415例桥本氏甲状腺炎的完整病案病例。诊断方法通过检测甲状腺抗体;超声、CT查、同位素扫描;细针或粗针穿刺活检联合检查。所有患者均表现为甲状腺结节而进行手术治疗,根据患者结节的病变范围,主要采取甲状腺全切、患侧腺叶+峡部切除及双侧腺叶次全切除术进行治疗。结果〓415例中:单纯桥本氏甲状腺炎157例,桥本氏甲状腺炎合并毒性甲状腺肿18例,合并结节性甲状腺肿146例,合并甲状腺腺瘤31例,合并甲状腺癌63例。结论〓桥本氏甲状腺炎临床表现缺乏特异性,应采用采取多种检查手段提高诊断的准确性,避免手术不必要手术,但疑有恶变或产生压迫症状者应积极手术。以往诊断出现结节即采取手术的方法不符合当前治疗指南。     

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??Clinical significance of calcification in Hashimoto's thyroiditis with thyroid cancer LONG Guan-bao, ZHANG Chun-xia, ZHENG Jian-wei, et al. Department of Biliary-pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030,China
Correspondence author: SHEN Ming, E-mail:shen_ming75@yahoo.com.cn
Abstract Objective To investigate the clinical significance of calcification in Hashimoto's thyroiditis with thyroid cancer. Methods The clinical data of 184 cases of Hashimoto's thyroiditis asscciated with thyroid cancer treated between January 2001 and December 2011 in Department of Biliary-pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (excluding cases with a history of thyroid surgery) were analyzed retrospectively. Results Hashimoto's thyroiditis associated with thyroid cancer was in 43 cases??23.4%??43/184??, with calcification in 26 cases. Among 141 cases of Hashimoto's thyroiditis and Hashimoto's thyroiditis associated with benign thyroid diseases, 13 cases had calcifications. The ratio of calcification in Hashimoto's thyroiditis associated with thyroid cancerthe was higher than that in Hashimoto's thyroiditis associated with benign thyroid diseases (P<0.05). There were 22 cases of microcalcifications in 26 cases of malignant calcification while coarse calcifications were 3 cases. The specificity of microcalcifications ratio in Hashimoto's thyroiditis with thyroid cancer was 84.6%??22/26??.The diagnosis rate of Hashimoto's thyroiditis associated with thyroid cancer performed FNAC was 67.6%(25/37). Conclusion Microcalcification has the high specificity for the diagnosis of Hashimoto's thyroiditis associated with thyroid cancer. Prompted Hashimoto's thyroiditis patients with microcalcifications on ultrasonography should be positive surgical exploration combined with intraoperative rapid pathological examination, which can improve the rate of early diagnosis of Hashimoto's thyroiditis associated with thyroid cancer effectively.     

Hashimoto's thyroiditis and thyroid cancer: a report of a clinical case and a review of the literature

Considerable controversy exists concerning the existence of statistically significant relationship between Hashimoto's disease and thyroid cancer, since there is very discordance in the incidence reported in literature, ranging from 0.5% by Crile and Hazard (5) to as high as 22.5% by Hirabayashi and Lindsay (9). Within this context, the authors present a clinical case of a patient who previously underwent lobectomy for a nodular papillary cancer of the thyroid. The histological diagnosis after "totalization" procedure proved to be Hashimoto's thyroiditis on a previous cancer. Starting from this case, an accurate review of the existing literature is carried out and some pathogenetic theories are proposed on the correlation between this two lesions.     

Sclerosing mucoepidermoid thyroid carcinoma with eosinophilia. A distinctive low-grade malignancy arising from the metaplastic follicles of Hashimoto's thyroiditis

Eight cases of a distinctive low-grade carcinoma of the thyroid gland occurring in a background of Hashimoto's thyroiditis are reported. The patients were women presenting with a painless thyroid mass. Grossly, the tumors were white, homogeneous, firm, and usually ill defined. Histologically, strands and small nests of squamoid tumor cells exhibiting mild to moderate nuclear pleomorphism, distinct nucleoli, and pale cytoplasm infiltrated an abundant, dense fibrohyaline stroma. Foci of definite squamous differentiation and small pools of mucin were often found within the tumor nests. The neoplastic cells were immunoreactive for cytokeratin, but not for thyroglobulin or calcitonin. The stroma and many of the tumor islands were infiltrated by eosinophils in all cases. Extrathyroidal extension occurred in five cases and lymph node metastases in one. This tumor seems to arise from the benign squamous nests sometimes associated with mucin deposition found in Hashimoto's thyroiditis and thought to be the result of metaplastic changes of the follicular epithelium. It shares several morphologic features with cases previously reported as mucoepidermoid carcinoma of the thyroid, but it differs from them in other respects. The differential diagnosis includes undifferentiated/squamous cell carcinoma, intrathyroidal thymic carcinoma, and direct extension or metastasis of carcinoma from other organs.     

Oncogenic emergency and treatment in thyroid disease

The urgent treatment of thyroid disease is mainly considered to be that of thyroid neoplasia, especially malignant thyroid tumors. The clinical symptoms produced by malignant neoplasia are acute respiratory failure caused by tumor compression and/or invasion of the trachea. Massive bleeding caused by tumor invasion of the major vessels also requires emergency therapy. In general, thyroid cancer has a favorable prognosis in patients with well-differentiated papillary carcinoma, which makes up more than 90% of thyroid malignancies. However, anaplastic carcinoma, undifferentiated papillary carcinoma, and malignant lymphoma originating from the thyroid sometimes require urgent therapy to save lives. Anaplastic carcinoma that is basically transformed from well-differentiated papillary carcinoma shows rapid growth and invades the surrounding tissue to produce tracheal obstruction. Repeated postoperative recurrences in patient with papillary carcinoma suggest undifferentiated carcinoma that eventually becomes the same endostage as anaplastic carcinoma. Radical surgery is needed in such cases initially, although making a differential diagnosis between well- and undifferentiated carcinoma is extremely difficult. Urgent treatment of these diseases consists of ensuring that the airway remains open to improve quality of life, but does not include radical treatment. Stent insertion is one adequate method for the urgent treatment of respiratory disturbance caused by tumor compression. Malignant lymphoma frequently develops from Hashimoto's thyroiditis. Immediately after making an accurate pathologic diagnosis, chemotherapy and/or radiation therapy are effective in reducing enlarged goiters rather than surgical management.     

甲状腺炎与甲状腺癌并存的诊断与治疗(附16例临床分析)

目的 探讨甲状腺炎与甲状腺癌并存的诊断要点及手术探查指征。方法 对１６例甲状腺炎与甲状腺癌并存病例的临床资料进行回顾性分析。结果 １６例均行根治性手术治疗，其中亚急性甲状腺炎４例，桥本甲状腺炎１２例。乳头状腺癌１２例，滤泡状腺癌３例，乳头状与滤泡状混合癌１例。１６例术后随访２个月～９年，均无癌复发与转移。结论 强调对有甲状腺结节的甲状腺炎经系统药治疗后，如结节未见缩小、甚或有增大趋势者，或经ＳＰＥ     

Thyroid cancer with coexistent Hashimoto's thyroiditis. Clinical assessment and management

Hashimoto's thyroiditis is a common thyroid disorder. Because of the difficulty of diagnosing a coexisting thyroid cancer, its management remains controversial. We reviewed 120 cases of thyroid cancer seen in our institution during an 11-year period (1976 through 1986) and defined the clinical characteristics of patients with both entities. Thirteen patients had concomitant cancer and Hashimoto's thyroiditis. Six of the 13 patients had a history of thyroiditis before the diagnosis of thyroid cancer. The remaining seven patients had evidence of Hashimoto's thyroiditis on histologic review of the thyroid specimen. The two most common characteristics prompting surgical intervention were the presence of a nonsuppressing dominant nodule and a cold area on thyroid scan. Twelve patients underwent preoperative fine-needle aspiration cytologic examination, but only in three were the results considered to be indicative of cancer. All 13 patients remained disease free. Despite the apparent indolence of thyroid cancer associated with Hashimoto's thyroiditis, selective surgical treatment of patients with clinical thyroiditis is indicated.     

慢性淋巴细胞性甲状腺炎的诊断和治疗

目的:降低慢性淋巴细胞性甲状腺炎的误诊率,选择适宜治疗。方法:回顾性总结1981年—1998年间收治的非典型桥本病64例。结果:64例仅12例未手术,余52例均手术。术后病理结果:单纯桥本病31例,桥本病合并甲状腺腺瘤4例,桥本病合并结节性甲状腺肿12例,桥本病合并甲状腺机能亢进症3例,桥本病合并癌2例。结论:本病误诊率较高,检测TGAB和McAB、细针穿刺活检和甲状腺干制剂诊断性治疗三者结合有助于提高本病的正确诊断率。对有压迫症状或合并其他甲状腺疾病者,可予手术治疗。术中行冰冻病理可明确诊断并确定手术方式,术中应尽量保留正常甲状腺组织,以防术后产生甲状腺功能减低。     

Das insuläre Schilddrüsencarcinom – ein differenziertes Schilddrüsencarcinom mit schlechter Prognose

Insular carcinoma of the thyroid is a low differentiated type constituting about 5% of all thyroid cancers. Higher aggressiveness has been suggested as an important clinical feature. The value of preoperative fine-needle aspiration biopsy is not clearly proven for insular carcinoma. The criteria for histological diagnosis have been outlined by Carcangiu et al. Because of its aggressiveness, radical treatment at primary surgery appears advisable. Its clear distinction from undifferentiated (anaplastic) and medullary (C cell) cancers is important, as thyroglobulin is regularly synthesized by cancer cells. Enrichment of radioactive iodine makes such treatment feasible postoperatively and at relapse. Follow-up should be performed as in highly differentiated papillary and follicular thyroid cancer. A patient series of eight cases is presented. While all cancers were advanced at the initial diagnosis, the observed disease courses were in agreement with the assumption that insular carcinoma is a more aggressive form of differentiated thyroid cancer.