A strategy for the solitary thyroid nodule.
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Adenocarcinoma↗
Biomedical subjects
H Gharib
Publications and source records attributed to H Gharib.
Hyperthyroidism due to inappropriate secretion of thyrotropin in 10 patients.
PURPOSE: The syndrome of inappropriate thyroid-stimulating hormone (TSH) secretion, characterized by elevated serum free thyroxine and triiodothyronine levels in association with measurable serum TSH concentrations, remains an uncommon cause of hyperthyroidism that is being recognized with increasing frequency. The hyperthyroidism may be due to either neoplastic pituitary TSH secretion or selective pituitary resistance to thyroid hormone. In an effort to better understand this rare cause of hyperthyroidism, we undertook a retrospective analysis of our institution's experience with this condition. PATIENTS: We reviewed our cumulative experience (10 patients) with hyperthyroidism due to the syndrome of inappropriate secretion of TSH. RESULTS: Six patients were diagnosed with TSH-secreting pituitary adenomas and four were found to have selective pituitary resistance to thyroid hormone. One patient with tumor had a TSH-secreting pituitary adenoma in the setting of multiple endocrine neoplasia syndrome. In all patients with tumor, hyperthyroidism was successfully treated with transsphenoidal adenomectomy with or without pituitary radiotherapy. All four patients with pituitary resistance had thyroid ablation or resection prior to their correct diagnosis. Therefore, therapy for this group of patients involved thyroid hormone replacement and efforts to suppress TSH hypersecretion. All 10 patients have done well clinically, with follow-up ranging from 2 weeks to 13 years. CONCLUSIONS: Adequate treatment exists for the two primary causes of TSH hypersecretion. TSH-secreting pituitary adenomas are treated with surgery and, if necessary, adjuvant pituitary radiotherapy. The results are generally good if the tumor is diagnosed and treated at an early stage. Primary therapy for hyperthyroidism due to selective pituitary resistance to thyroid hormone is aimed at suppression of pituitary TSH hypersecretion. The evaluation of any patient with hyperthyroidism must be thorough and, in some cases, should include measurement of TSH to determine the presence of inappropriate secretion. Eliminating this diagnosis will help avoid improper and potentially harmful treatment of hyperthyroid patients.
Adenoma↗
Medullary thyroid carcinoma: clinicopathologic features and long-term follow-up of 65 patients treated during 1946 through 1970.
We retrospectively reviewed the medical records of 65 consecutive patients with medullary thyroid carcinoma, who had had their primary surgical treatment at the Mayo Clinic during the years 1946 through 1970. Of these patients, 58 had sporadic and 7 had familial medullary thyroid carcinoma. Thyroid nodules were the most common initial manifestation. Near-total thyroidectomy was the most frequent initial operation. Survival was affected by the following factors: male sex, familial inheritance, size of the tumor, stage of the tumor (American Joint Committee on Cancer), and completeness of initial resection of the tumor. The mean duration of follow-up was 23.5 years, and the maximal follow-up was 36 years. Among 52 patients without initial distant metastatic involvement and with complete resection of the tumor, 20-year survival free of distant metastatic lesions was 81%. Overall 10- and 20-year survival rates were 63% and 44%, respectively. Because of the substantial morbidity and mortality associated with medullary thyroid carcinoma, early diagnosis and thorough initial resection of the tumor are important.
Adolescent↗
Dr. Mohammad Gharib--father of pediatrics in Iran.
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History, 20th Century↗
Multiple endocrine neoplasia type 2B: eighteen-year follow-up of a four-generation family.
Seven members with multiple endocrine neoplasia type 2B from a 15-member family have been followed for 18 years. All affected had the neuroma phenotype in a distribution compatible with autosomal dominant inheritance. The phenotype features have allowed 100% initial and continuing prediction of affected versus nonaffected status in as early as 1.5 years. Among the affected: immunoreactive plasma calcitonin (iCT) concentration was high in 100%; thyroid palpation was false-negative in 71%; and thyroid scintiscan was false-negative in 83%. All had total thyroidectomy, plus lymphadenectomy in three, for bilateral medullary thyroid carcinoma (MTC) or C-cell hyperplasia (in the youngest). None has died directly from MTC. The index case died at age 68 and his son at age 32 years from complications of the syndrome. All but the youngest have continuing high iCT concentrations. No patient has had parathyroid disease. During preoperative calcium infusion, immunoreactive serum parathyroid hormone concentration declined by 35% to 84% of basal. At operation, macroscopically and microscopically normal parathyroid glands were found in all. No patient has had chemical suggestion of pheochromocytomas: at postmortem the index case had no adrenal medullary disease; his son had bilateral nodular adrenal hyperplasia; his daughter has had adrenal medullary hyperplasia and a renin-secreting juxtaglomerular tumor. Initially nonaffected members remain so.
Adolescent↗
Treatment of toxic solitary thyroid nodules: surgery versus radioactive iodine.
BACKGROUND: Because of controversy about the correct treatment of toxic solitary thyroid nodules, we reviewed our experience. METHODS: We retrospectively studied 32 patients (24 women and 8 men) with solitary toxic thyroid nodules who were treated at our institution (1970 to 1985). RESULTS: Median values were as follows: age of patients at initial treatment, 67.6 years (range, 18.9 to 86.2 years); follow-up, 3.8 years; largest diameter of nodules, 3.3 cm (range, 1.5 to 6 cm); and 131I uptake at 24 hours, 31% (range, 7% to 54%). Nine patients had surgical treatment: subtotal thyroid lobectomy in six patients and subtotal thyroidectomy in three patients. Hypothyroidism developed in two of these nine patients (22%) 9 months after operation. No surgical complications occurred. No surgically treated patient had nodule recurrence or required re-treatment. Twenty-three patients were treated with radioactive iodine (median dose, 29.1 mCi; range, 19.7 to 100 mCi). Two of them were re-treated: one patient underwent thyroid lobectomy because of concern about the nodule, and one patient was re-treated with radioactive iodine because of persistent toxicity. Hypothyroidism was detected in eight of the 23 patients (35%) treated with radioactive iodine after treatment. Of the 16 patients treated with radioactive iodine with at least 1 year follow-up and no re-treatment, nine (56.3%) have had complete regression of the nodule. CONCLUSIONS: Surgical excision of solitary toxic thyroid nodules would appear to be the treatment of choice.
Adolescent↗
Thyrotoxic hypokalemic periodic paralysis in a white man.
Thyrotoxic periodic paralysis is an uncommon complication of hyperthyroidism. Hypokalemia, with associated flaccid paralysis, is the hallmark. Oriental men are most commonly affected. We have reported a case of TPP induced by Graves' disease in a white man with hypokalemia and hypophosphatemia. He was successfully treated with radioactive ablation and short-term administration of a beta blocker. The patient has remained asymptomatic for 12 months after treatment.
Adult↗
Parathyroid hormone-related protein and hypercalcemia secondary to massive mammary hyperplasia.
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Breast↗
Long-term course of patients with persistent hypercalcitoninemia after apparent curative primary surgery for medullary thyroid carcinoma.
Thirty-one patients with persistent hypercalcitoninemia after seemingly adequate primary operation for medullary thyroid carcinoma (MTC) were followed for a mean period of 11.9 years after operation. Ten patients had sporadic MTC and the remaining patients were members of families with multiple endocrine neoplasia (MEN)--either MEN 2A (15 patients) or MEN 2B (six patients). Overall 5- and 10-year survival rates were 90% and 86%, respectively. Only four patients died at the completion of the study: two of MTC and two of unrelated causes. Eleven patients (35.5%) underwent surgical re-exploration after demonstration of recurrent disease clinically or radiologically. In no patient did the calcitonin level return to normal after re-exploration. The presence of more than three metastatic nodes at the time of initial operation was a statistically significant (p = 0.003) predictor for disease recurrence. Factors approaching statistical significance were patients younger than age 35 (p = 0.06) and the percentage of cells in the S phase of cell division (0.07). This data supports a conservative surgical philosophy in the management of the patient with persistent hypercalcitoninemia after resection of MTC.
Adolescent↗
Thyrotoxic periodic paralysis. Report of 10 cases and review of electromyographic findings.
We reviewed the clinical characteristics of 10 patients with thyrotoxic periodic paralysis. In these patients, a relatively uniform group of young men, the periodic paralysis developed nearly concurrently with the onset of hyperthyroidism. The attacks were precipitated most frequently by rest and by exercise and, occasionally, by ingestion of a large carbohydrate load. In each patient, the paralysis resolved on return of euthyroidism. The approximate incidence rate for thyrotoxic periodic paralysis in our largely white North American patient population (all hyperthyroidism cases) ranged from 0.1% to 0.2%, which is one tenth the rate reported for Oriental populations. In 7 patients, electrodiagnostic testing revealed characteristic changes in compound muscle action potential amplitude in response to exercise of the muscle being tested.
Adult↗
Pseudohyperparathyroidism secondary to gigantic mammary hypertrophy.
Pseudohyperparathyroidism encompasses both ectopic hyperparathyroidism and the more commonly encountered nonparathyroid humoral hypercalcemia of malignancy--metastatic breast cancer being the classic example. Benign breast disease is a rare cause of hypercalcemia. We recently managed a patient with gigantic mammary hypertrophy that occurred during pregnancy who concomitantly manifested marked nonparathyroid hypercalcemia. This report strongly suggests that a casual relationship exists between benign breast disease and hypercalcemia.
Adult↗
Cushing's syndrome due to primary multinodular corticotrope hyperplasia.
In this report, a case of Cushing's syndrome due to primary multinodular corticotrope hyperplasia is described. The patient had typical features of Cushing's syndrome and dynamic pituitary-adrenal testing, which suggested an ectopic adrenocorticotropic hormone (ACTH) syndrome. Results of petrosal sinus catheterization indicated that the pituitary gland was the source of excess ACTH. Total hypophysectomy resulted in complete remission of Cushing's syndrome. Light microscopic and immunohistochemical studies revealed multinodular corticotrope hyperplasia. Plasma corticotropin releasing hormone (CRH) was undetectable, and computed tomography of the chest and abdomen disclosed no neoplastic source of CRH. We speculate that either an abnormality in hypothalamic CRH secretion or corticotrope hypersensitivity to CRH might have been responsible for Cushing's syndrome in this patient.
Adrenocorticotropic Hormone↗
Evaluation of nodular thyroid disease.
There is no doubt that FNA biopsy is the best initial diagnostic step for the evaluation of a nodular thyroid. The successful use of FNA biopsy depends greatly on the experience of the clinician performing the aspiration and the expertise of the cytopathologist. The procedure is safe, expedient, and cost-effective. Complications are extremely rare. The accuracy of the technique in experienced hands is better than 95 per cent.
Goiter, Nodular↗
Hyperthyroidism following hypothyroidism. Data on six cases.
Hypothyroidism complicated by spontaneous hyperthyroidism is an interesting but rare occurrence in the spectrum of autoimmune thyroid disorders. We report data on six patients who had hyperthyroidism two to 20 years (mean, eight years) after the diagnosis of hypothyroidism. In three patients, triiodothyronine toxicosis accounted for the hyperthyroid symptoms. The presence of thyroid antibodies and lymphocytic infiltration in the thyroid gland points to an autoimmune mechanism. It is believed that this phenomenon occurs more often than is recognized.
Adult↗
Suppressive therapy with levothyroxine for solitary thyroid nodules. A double-blind controlled clinical study.
Thyroid nodules are present in up to 50 percent of adults in the fifth decade of life. Patients are often treated with thyroxine in order to reduce the size of the nodule, but the efficacy of thyrotropin-suppressive therapy with thyroxine remains uncertain. In this study, 53 patients with a colloid solitary thyroid nodule confirmed by biopsy were randomly assigned in a double-blind manner to receive placebo (n = 25) or levothyroxine (n = 28) for six months. Before treatment, pertechnetate-99m thyroid scanning showed that 22 percent of the nodules were functional, 25 percent hypofunctional, and 53 percent nonfunctional. High-resolution (10-MHz) sonography was used to measure the size of the nodules before and after treatment. Suppression of thyrotropin release was confirmed in the levothyroxine-treated group by the administration of thyrotropin-releasing hormone; thyrotropin release was normal in the placebo group. Six months of therapy did not significantly decrease the diameter or volume of the nodules in the levothyroxine group as compared with the placebo group. We conclude that the efficacy of levothyroxine therapy in reducing the size of colloid thyroid nodules is not apparent within six months, despite effective suppression of thyrotropin.
Adult↗
Fine-needle aspiration. Usefulness for diagnosis and management of metastatic carcinoma to the thyroid.
The usefulness of fine-needle aspiration (FNA) for the diagnosis and management of metastatic carcinoma to the thyroid was determined by reviewing the records of 19 patients identified during a six-year period. Fine-needle aspiration was able to document metastatic cancer to the thyroid in 14 patients with, and five patients without a history of prior nonthyroidal cancer. Breast, kidney, and lung were the most frequent carcinomas metastatic to the thyroid. Age range and time from diagnosis of the primary carcinoma to documentation of metastasis were similar to those in prior surgical series from this institution. The finding of metastatic disease on FNA was totally unexpected in four patients. The possibility of metastasis was not mentioned before FNA in six patients with a known history of nonthyroidal cancer. Only six patients underwent a thyroid operation after FNA. Fine-needle aspiration was able to direct appropriate surgical or conservative management without adversely affecting survival among patients.
Biopsy, Needle↗
Primary idiopathic hypothalamic hypothyroidism. Report of four cases.
One man and three women with hypothalamic hypothyroidism are described; they had isolated thyrotropin-releasing hormone deficiency, otherwise normal pituitary function, and no identifiable central nervous system anatomic abnormality. Serum thyrotropin levels were low and thyrotropic response to thyrotropin-releasing hormone was uniformly present, consistent with a hypothalamic cause of hypothyroidism. In two patients, hypothyroidism was transient and spontaneously resolved; in one of them, it was recurrent. Because hypothalamic hypothyroidism is mild and potentially reversible, it is suggested that such patients have follow-up evaluation before therapy is initiated in order to avoid unnecessary treatment.
Adult↗
Determination of silica-purified plasma calcitonin for the detection and management of medullary thyroid carcinoma: comparison of two provocative tests.
Radioimmunoassays for human calcitonin in whole plasma are limited in sensitivity and specificity; basal values of calcitonin are often undetectable in normal plasma, and nonspecific increases are occasionally found in seemingly healthy persons. We avoided these problems by applying a silica-cartridge extraction-concentration technique for calcitonin assay, and the effectiveness of two calcitonin stimulation tests in healthy volunteers and patients with medullary thyroid carcinoma was compared. The radioimmunoassay was improved by using a new antiserum and a sequential incubation procedure that reduced the previously used sample-volume requirement and incubation period substantially. This method was used to measure mean basal plasma levels of calcitonin (+/-SD) in 45 normal men (8.2 +/- 5 pg/ml) and 47 normal women (4.8 +/- 4 pg/ml) (P less than 0.001). Calcium infusions (2 mg/kg over 5 minutes) in 18 normal men and 37 normal women yielded a significantly greater secretory response than did pentagastrin (0.5 micrograms/kg as a bolus). Among 12 patients with medullary thyroid carcinoma, pentagastrin seemed to be a better secretagogue than calcium (P less than 0.001). We recommend routine measurement of plasma silica-extractable calcitonin and pentagastrin injection as the provocative test of choice for the detection and management of medullary thyroid carcinoma. The short calcium-infusion test is a good alternative.
Adult↗