Radioiodine therapy in non-toxic multinodular goitre. The possibility of effect-amplification with recombinant human TSH (rhTSH)

There is no consensus regarding the optimum treatment of benign non-toxic goitre. L-thyroxine suppressive therapy is widely used, but there is poor evidence of its efficacy, and it may have serious adverse effects on health. Surgery is first choice in large goitres or if malignancy is suspected. ¹³¹I therapy results in a one-year goitre reduction of around 40% in multinodular goitres, usually with a high degree of patient satisfaction and improvement of the inspiratory capacity. The effect is attenuated with increasing goitre size. The risk of hypothyroidism is 22-58% within 5-8 years. A sufficient thyroid ¹³¹I uptake is mandatory for ¹³¹I therapy to be feasible and pre-stimulation with recombinant human TSH (rhTSH) increases this considerably. This leads to an increased absorbed thyroid dose by approx.75%, mainly in those patients with the lowest thyroid ¹³¹I uptake, and a more homogeneous intrathyroidal isotope distribution. Pre-stimulation with even a small dose of rhTSH seems to allow a reduction of the ¹³¹I activity while still achieving a mean goitre reduction of approximately 40% within a year. A significantly lower extrathyroidal radiation is achieved by this approach. With an unchanged ¹³¹I activity, rhTSH pre-stimulation improves the goitre reduction by 30-50%. However, this is at the expense of a higher rate of hypothyroidism, cervical pain and transient thyrotoxicosis. Of particular concern is the observation made in healthy persons, that rhTSH results in a transient average thyroid volume increase of 35%. A similar goitre swelling may cause problems in susceptible patients during rhTSH-augmented ¹³¹I therapy. Thus, this concept still needs a closer evaluation before routine use.     

Mammography phototimer technique chart

A phototimer technique chart for mammography is presented along with the methodology used to design it. The chart is based on accurate measurement of breast thickness and helps overcome the inability of the phototimer to track as breast thickness varies. In clinical practice, the chart results in the consistent attainment of optimally exposed films and decreased number of retakes.     

An automatic algorithm for detecting stent endothelialization from volumetric optical coherence tomography datasets

Recent research has suggested that endothelialization of vascular stents is crucial to reducing the risk of late stent thrombosis. With a resolution of approximately 10 microm, optical coherence tomography (OCT) may be an appropriate imaging modality for visualizing the vascular response to a stent and measuring the percentage of struts covered with an anti-thrombogenic cellular lining. We developed an image analysis program to locate covered and uncovered stent struts in OCT images of tissue-engineered blood vessels. The struts were found by exploiting the highly reflective and shadowing characteristics of the metallic stent material. Coverage was evaluated by comparing the luminal surface with the depth of the strut reflection. Strut coverage calculations were compared to manual assessment of OCT images and epi-fluorescence analysis of the stented grafts. Based on the manual assessment, the strut identification algorithm operated with a sensitivity of 93% and a specificity of 99%. The strut coverage algorithm was 81% sensitive and 96% specific. The present study indicates that the program can automatically determine percent cellular coverage from volumetric OCT datasets of blood vessel mimics. The program could potentially be extended to assessments of stent endothelialization in native stented arteries.     

Cost of care in a randomised trial of early hospital discharge after surgery for breast cancer

The aim of this study was to determine the effect of the reduction of the length of hospital stay after surgery for breast cancer on the rate of care consumption and the cost of care. Patients with operable breast cancer were randomised to a short or long postoperative hospital stay. Data on care consumption were collected for a period of 4 months in diaries administered by patients, and socioeconomic status was evaluated by questionnaires. A cost minimisation analysis using the 'societal' perspective was performed and savings were compared with the savings of hospital charges. The use of professional home care was higher for the short stay group during the first month (7.2 versus 1.3 h, P < 0.0001). The number of out-patient consultations, the intensity of informal home care and patient's expenses did not increase after early discharge. The total cost of care was reduced by US$1320 by introducing the short stay programme (P = 0.0007), but the savings were substantially lower than the savings in hospital charges (US$2680).     

The majority of Danish nontoxic goitre patients are ineligible for Levothyroxine suppressive therapy

Objective Levothyroxine suppressive therapy (LT4‐therapy), aimed at shrinking thyroid nodules is controversial. Despite evidence of limited effect and long‐term side‐effects, questionnaire surveys indicate widespread use. Our aim was to determine, in consecutive nontoxic goitre patients, the proportion ineligible for LT4‐therapy. Exclusion criteria were set up in agreement with recent guidelines. Setting Secondary/tertiary referral centre at University Clinic. Subjects and methods During 1997–2001, 822 patients were referred to our endocrine unit on suspicion of nontoxic goitre. Patients were evaluated clinically including fine needle aspiration biopsy, thyroid scintigraphy and ultrasound. Seven‐hundred and forty‐five patients (627 women and 118 men; median age 47 years, range 11–90) were potential candidates for LT4‐therapy. Based on guidelines we defined conditions where LT4‐therapy is contraindicated. Exclusion criteria included (1) Serum TSH < 1·0 mIU/l, (2) Post‐menopausal status, or males older than 60 years, (3) Thyroid volume above 100 ml, (4) Intrathoracic goitre, (5) Clinical suspicion of malignancy, (6) Dominant thyroid cyst, (7) Nondiagnostic FNA, (8) Previous ineffective LT4‐therapy, (9) Elevated serum calcitonin, (10) Osteoporosis or cardiovascular disease. Results Of patients 84% were ineligible for LT4‐therapy. In diffuse goitre (n = 35) 63%, in uninodular goitre (n = 320) 77% and in multinodular goitre (n = 390) 91% were ineligible. Main ineligibility reasons were a low serum TSH, post‐menopausal status, a large goitre or clinical suspicion of malignancy. Conclusion The vast majority of consecutive Danish nontoxic goitre patients (84%) were ineligible for LT4‐therapy. Due to low efficacy and potential long‐term adverse effects on the skeleton and cardiovascular system we strongly advocate against LT4‐therapy for nontoxic goitre.     

The feasibility of high dose iodine 131 treatment as an alternative to surgery in patients with a very large goiter: effect on thyroid function and size and pulmonary function.

Some patients with very large goiters (>150 mL) are not candidates for surgery. We evaluated the feasibility of high dose 131I in such patients. Twenty-three patients (2 men and 21 women; median age, 67 yr; range, 42-86 yr) with very large goiter (8 toxic) were treated with calculated high dose 131I [median, 2281 megabecquerels (61.6 mCi); range, 988-4620 megabecquerels (26.7-124.9 mCi)]. During the 12-month observation period, goiter reduction and tracheal anatomy were monitored by magnetic resonance imaging, and the respiratory capacity was monitored by pulmonary function tests. Five patients (22%) developed hypothyroidism. Thyroid volumes were at baseline, after 1 week, and after 1 yr [mean +/- SEM, 311 +/- 28, 314 +/- 26 (P = NS), and 215 +/- 26 (P < 0.01) mL]. The relative changes 1 week after therapy ranged from -14.1% to 15.3%. After 1 yr the mean size was reduced by 33.9% (range, 13.5-61.4%). Only the initial goiter size showed a significant negative correlation to the percent reduction. The smallest cross-sectional area of the trachea decreased 9.2% within 1 week after treatment, but eventually emerged with a 17.9% larger area [mean +/- SEM, 84.3 +/- 4.8, 75.5 +/- 5.1 (P < 0.01), and 98.2 +/- 6.0 (P < 0.01) mm2]. The inspiratory parameter, FIF50%, improved after an initial insignificant decline [baseline therapy, after 1 week, after 3 months, and after 1 yr (mean +/- SEM), 2.37 +/- 0.24, 2.20 +/- 0.21 (P = NS), 2.51 +/- 0.23 (P = NS), and 2.76 +/- 0.25 (P = 0.01) L/s]. FIF50% correlated significantly with the smallest cross-sectional tracheal area (baseline, 1 week, and 1 yr: r = 0.74; P < 0.001, r = 0.63; P < 0.005, and r = 0.46; P < 0.05). Changes in tracheal anatomy did not correlate with changes in either lung dynamics or goiter size. In conclusion, very large goiters can be reduced by a third, on the average, with high dose 131I therapy without any initial clinically significant tracheal compression. Tracheal cross-sectional area as well as pulmonary inspiratory capacity improve. No serious adverse effects are seen.