Favorable Surgical Results in 433 Elderly Patients with Papillary Thyroid Cancer

Papillary thyroid cancer (PTC) has a good prognosis among patients younger than 45 years old, but the prognosis in elder is worse and treatment strategy is not well established. We retrospectively analyzed the clinical features and outcomes of 433 patients with PTC aged 70 years or older. The patients consisted of three groups: group A (n = 327); patients receiving surgical treatment, group B (n = 51); patients with microcancer (maximal diameter, ≤ 1.0 cm) who did not undergo surgical treatment, group C (n = 55); patients in whom surgery was contraindicated due to age, high surgical risk or complication by other illnesses. In group A, the mean tumor size was 2.6 ± 1.5 cm, and 218 patients (66.7%) had pathologically confirmed lymph node metastasis; 110 patients (33.6%) had extrathyroidal invasion. The 5- and 10-year overall survival rates (OSR) in group A were 97.2% and 85%, respectively, which was significantly higher than the 5-year OSR in group C (62.6%). The 5- and 10-year disease-specific survival rates (DSSR) in group A were 98.5% and 91.3%, respectively, which was also significantly higher than the 5-year DSSR in group C (81.8%). Although the patients in group B did not receive any treatment, none of them demonstrated cause-specific death or progression of disease. Papillary thyroid cancer in elderly patients, except for microcancers, may be biologically aggressive. Thus surgery is recommended for these patients, if their general status is judged able to tolerate the stress of anesthesia and surgery.     

Correlation between the pituitary size and function in patients with asthenia

To explore the relationship between pituitary morphology and function, we performed mid-sagittal MRI and endocrinological evaluation in 38 patients with asthenia. Six patients were diagnosed as having complete empty sella (ES) and 16 patients partial empty sella (PES). BMI, blood pressure, serum Na, ACTH, cortisol, TSH and T(4) were lower in ES group and PES group than in the group with normal pituitary size. Age in the patients with ES was oldest. Multiple regression analysis revealed that serum cortisol level was independently correlated with the size of the pituitary (beta = 0.586, p = 0.0069). Other variables, including age, BMI, blood pressure, serum Na, ACTH, TSH and T(4), were not correlated with the pituitary size when multivariate analysis was employed. In conclusion, there is a close relationship between the reduction of size of pituitary gland and the degree of adrenocortical dysfunction in asthenic patients. It is suggested that the pituitary-adrenal axis is especially vulnerable in empty sella syndrome, and therefore, meticulous evaluation of the hypophysial adrenal axis is recommended in subjects with reduced pituitary size even in elderly population.     

Platypnea-orthodeoxia syndrome combined with multiple congenital heart anomalies

A 71-year-old woman was admitted for paralysis on the left side of her body. She developed dyspnea and hypoxemia after admission. Although pulmonary embolism was suspected, hypoxemia and dyspnea occurred repeatedly in spite of anticoagulation therapy. Transesophageal echocardiography revealed a patent foramen ovale (PFO), an atrial septal aneurysm (ASA), and a right-to-left shunt that appeared in an upright position. She was diagnosed with platypnea-orthodeoxia syndrome. Moreover, cardiac catheterization showed congenital anomalies, such as unroofed coronary sinus, partial anomalous pulmonary venous return and persistent left superior vena cava. Simple surgical closure of the ASA and PFO improved all of her symptoms.     

Thyroid evaluation in patients with primary hyperparathyroidism

We evaluated the efficacy of preoperative high-resolution ultrasonography (US) for diagnosing possible concomitant thyroid disease which affects the surgical management in patients with primary hyperparathyroidism (pHPT). One hundred and nine patients with sporadic pHPT underwent US with or without ultrasound-guided fine-needle aspiration biopsy (US-FNAB). Diagnosis of concomitant thyroid nodules by US and US-FNAB were compared with the histopathological findings. Of the 109 patients, 19 (17.4%) had malignant thyroid nodules, 26 (23.9%) had benign thyroid nodules alone, and 12 (11.0%) had diffuse goiter. The sensitivity, specificity, and accuracy of diagnosing 72 thyroid nodules were 91.3%, 91.8%, and 91.7% for US, 57.9%, 94.3%, and 81.5% for US-FNAB, and 95.7%, 91.8%, and 93.1% for combined US and US-FNAB, respectively. True positive/false negative ratio of US-FNAB diagnosis was significantly lower in nodules of 5-9 mm than nodules of 10 mm or more. Four unexpected thyroid cancers existed at a different site in 3 of the 39 patients with palpable thyroid disease. Five thyroid cancers were histopathologically confirmed in 5 (7.1%) of 70 patients without palpable thyroid disease. Eight (88.9%) of the 9 non-palpable thyroid cancers were accurately diagnosed by combined US and US-FNAB. Preoperative US is useful for evaluation of possible concomitant thyroid disease, especially for prediction of malignancy.     

Reevaluation of stringent low iodine diet in outpatient preparation for radioiodine examination and therapy

To decrease total body iodine is a key point in preparation for radioiodine study and therapy. We introduced a stringent self-managed low iodine diet (LID) and compared the outcome to that of the conventional restricted iodine diet (RID) for outpatients. We measured urine iodine to creatinine ratios (I/Cr) in patients prepared with RID for one week, LID for one week, or LID for two weeks. Mean urinary iodine excretion after RID for one week (n = 210) was 182.2 microg/gCr (range, 13-986 microg/gCr; standard deviation (SD) = 158.5) not reaching below the recommended level (I/Cr<100 microg/gCr). Urinary iodine excretion after LID for one week (n = 15) showed a lower mean urinary iodine level (I/Cr 119.4 microg/gCr; range, 23-218 microg/gCr; SD = 55.9) than RID for one-week, and two-week LID (n = 17) showed an even lower mean level (I/Cr 63.1 microg/gCr; range, 7-134 microg/gCr; SD = 38.7). The one-week LID period adequately (recommended level of I/Cr being less than 100 microg/gCr) prepared 26% of the patients, while two-weeks on the diet adequately prepared 70% of the patients. Furthermore, none of the two-week LID patients had I/Cr>150 microg/gCr, although a significantly greater number of one-week LID patients (19%) did. Our self-managed, outpatient LID successfully induced iodine deficiency, and two-week LID may be recommended for preparation in radioiodine study and therapy for thyroid cancer.     

Evaluation of the relationship between periapical lesions/sclerotic bone and general bone density as a possible gauge of general health among 80-year-olds

OBJECTIVES: To evaluate the incidence among 80-year-olds of periapical lesions as detected on panoramic radiographs and to determine the relationship between sclerotic bone around the periapical lesions to heel bone density, body height, and hand-grip strength. STUDY DESIGN: Six hundred fifty-nine panoramic radiographs (262 males, 397 females), obtained from 80-year-old residents of Fukuoka Prefecture, Japan, were used for evaluation of periapical lesions. These findings were correlated with physical examination results to determine the relationship to general health. RESULTS: Of 659 panoramic radiographs, 31 (5%) were noted to have periapical lesions. Average size of the 31 periapical lesions was 6.1 +/- 2.2 mm. Of the 31 periapical lesions, 21 (68%) were accompanied by linear or diffuse types of sclerotic bone. Of the 21 sclerotic bones, 10 (48%) were of a linear type of sclerotic bone and 11 (52%) of a diffuse type of sclerotic bone. Of the 11 diffuse types of sclerotic bone, 10 (91%) were in the mandible and 1 (9%) in the maxilla. Periapical lesions in the mandible were more frequently accompanied by a diffuse type of sclerotic bone than those in the maxilla (P < .01). The hand-grip strength of those having periapical lesions, accompanied by a diffuse type of sclerotic bone, was stronger than those having no periapical lesions (P < .01) and those accompanied by a linear type of sclerotic bone (P < .03). However, there was no relationship between presence of sclerotic bone and heel bone density or body height. CONCLUSIONS: Periapical lesions accompanied by a diffuse type of sclerotic bone were more frequently seen in the mandible of 80-year-olds. To evaluate the clinical significance of sclerotic bone around periapical lesions in 80-year-olds, further study to evaluate the significance of endodontic treatment needs to be done.