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The essentially desirable standardisation of various European and American guidelines for the evaluation of thyroid nodules has led to the recommendation to perform fine-needle biopsy (FNB) in all nodules >1 cm in order to detect clinically occult thyroid carcinoma early. However, in iodine-deficient areas such as Germany (where thyroid nodules are found in approximately 25% of the adult population) this recommendation would substantially increase both the number of FNB and thyroid operations without significantly increasing the cancer detection rate. The recommendation for FNB in Germany, therefore, should be restricted to hypofunctioning ("cold") nodules >1 cm.

In the framework of the Thyroid initiative Papillon 2001 - 2002 thyroid nodules and sonographically detectable focal lesions with a diameter more than 5 mm were verified in 23.1% of 64.123 persons without a history of thyroid disease. The frequency of such findings was with 33.0% in 46-65 years old persons three times higher then in persons aged 18-30 years (9.6%). In the diagnostic workup thyroid cancer was detected in 15 patients operated on up to now (6 women and 9 men; papillary cancers in 12 cases, follicular cancers in 3 cases) The smallest tumor had a diameter of 1.3 cm, the mean diameter was 2.3 +/- 91 cm. In 3 patients the tumor had invaded the tissue beyond the thyroid capsule, in 4 cases multicentric growth was detected. Lymph node metastases were found in 7/15 cases and distant metastases in 2/15 cases. These result reveal, that thyroid cancer detected by chance may be relatively aggressive. In daily routine, sonographically detectable lesions with poor echogenicity, irregular margins or internal calcifications with a diameter of more than 1 cm should be clarified by fine needle aspiration biopsy.

In the first quarter of 2003 a National Health Survey for Children and Adolescents will be started and carried out over a period of three years. In 11,300 children and adolescents between 6 and 18 years a comprehensive iodine monitoring will be realised. The volume of the thyroid gland will be determined sonographically, thyroid hormones and the urinary iodine excretion will be measured. Apart from the nutritional intake of iodine and the use of supplements, socio-demographic and other variables relevant to health will be recorded in a self-administered questionnaire. In the pilot study of the Health Survey for Children and Adolescents from March 2001 to March 2002 the method was tested on 426 children and adolescents and has proved feasible. The sample for the pretest was not representative for the population of children and adolescents in Germany but may already be an indication for the iodine supply. A low goitre prevalence of 4.2% was found. The total thyroid volume correlated significantly with height and weight. There was no significant difference between boys and girls or between a rural and an urban sample point.

Background and Objective: Administration of levothyroxine and/or iodide can effectively reduce the volume of endemic goitre. However, TSH suppression during levothyroxine treatment may increase the number of recurrences through the persistence of intrathyroidal iodine deficiency. With special attention paid to the level of levothyroxine, a comparison was made of two dosages of combined levothyroxine and iodide., Patients and Methods: 44 patients with diffuse euthyroid goitre were randomized to two treatment groups. Group A received 100 micrograms levothyroxine + 100 micrograms iodide, group B 75 micrograms levothyroxine + 150 micrograms iodide, all of them for three months. This was followed by three months without the medication. Intrathyroidal iodine concentration was measured at the onset of the study, then three months and six months later. At these same times thyroid volume was measured by ultrasound, as well as urinary iodine and various parameters of thyroid function., Results: Thyroid gland volume was reduced in both groups (group A: -17.3%; group B: -14.8%; p < 0.001). There was no significant difference of intrathyroidal iodine concentration and thyroid volume between both groups. After the treatment period, TSH suppression was more marked in group A, while TSH rise was greater in group B., Conclusions: Both drug combinations resulted in comparable reduction of thyroid volume, while the intrathyroid concentration of iodine remained unchanged. The smaller rise of TSH after the treatment suggests that the dosage of 75 micrograms levothyroxine + 150 micrograms iodine is to be preferred.

Basic Problem and Objective: Intrathyroid deficiency and the influence of thyroid stimulating hormone (TSH) are the main pathogenetic factors in the development of endemic euthyroid goitre. Goitre reduction is achieved with either administration of levothyroxine, which diminishes hypophyseal TSG production, or of iodide. Aim of this study was to compare the efficacy of treatment with a dose-fixed combination of levothyroxine plus iodide with that of an individualized dosage of levothyroxine plus iodide., Patients and Methods: After randomization 49 patients with euthyroid goitre (24 women, 25 men, aged 20-43 years) were treated for 12 weeks in a double-blind trial. Patients in group A received levothyroxine in a weight-adapted dosage (75,100 or 150 micrograms) plus 150 micrograms iodide, while those in group B were given a fixed dosage of 100 micrograms levothyroxine plus 100 micrograms iodide. Basal TSH, thyroid hormones, iodide excretion, hyperthyroid score and sonographic volume of the thyroid were determined before treatment and after 12 weeks., Results: Basal TSH levels were reduced in both groups (P < 0.0001), without significant difference between the two groups (median relative change: group A 78.1%, group B 52.8%). Thyroid volume was decreased independently of the form of treatment (P < 0.0001) (median relative reduction: group A 37.6%, group B 30.9%; difference not significant). Iodide excretion rose in both groups, without significant difference (group A 107%, group B 49%). There was hardly any change of the hyperthyroid score in both groups. There were no side effects., Conclusion: Both forms of medication were equally efficacious and well tolerated in the treatment of euthyroid goitre.

Aim: In patients with euthyroid goitre, the efficacy of treatment with 400 micrograms iodine and 100 micrograms levothyroxine combined with 100 micrograms iodine was compared to that of the previous standard of therapy, individually dosed levothyroxine., Patients and Methods: A total of 78 patients presenting with euthyroid diffuse goitre (> or = 25 ml) were prospectively enrolled, randomised and treated for 6 months. The course of thyroid volume was followed using thyroid volumetry., Results: Data of 69 patients were included in the final evaluation (57 women, 12 men, age 31 +/- 1 years, thyroid volume 31.5 +/- 1.4 ml, 23 per treatment group). In the patients treated with individually dosed levothyroxine, the thyroid volume decreased by about 39% (95%-confidence limit [CL]-31% to -41%). However, the volume reductions achieved in the patients treated with 400 micrograms iodine or 100 micrograms levothyroxine/100 micrograms iodine were not significantly different (p = 0.35, variance analysis, mono-iodine -34%, 95%-CL -29% to -43%, 100 micrograms levothyroxine/100 micrograms iodine -39%, 95%-CL -32% to -45%)., Conclusions: In patients with euthyroid diffuse goitre, treatment with mono-iodine or combination of levothyroxine with iodine should have principally the same status as the previous standard of therapy, individually dosed levothyroxine. In the view of the authors, its preferential treatment with mono-iodine appears most reasonable.

Background: Date, studies on thyroid volume and urinary iodide excretion in patients with diabetes mellitus are not available. Sonographically determined parameters of the thyroid size are correlated to other anthropometrous data and the urinary iodide excretion is correlated to glucosuria, the HbA1c value and the diabetes duration., Method: In this prospective study we evaluated sonographically the thyroid volume in 107 patients with type I diabetes mellitus and 112 healthy children. The urinary iodide excretion was measured photometrically by using a modified ceric ion arsenious acid method for spontaneous urinary specimen and if available for the 24 h collected urin., Results: The thyroid volume depended on site and age. A positive correlation of the thyroid volume and age, body weight and height, could be demonstrated. Referring to reference data a goitre prevalence of 30% in juvenile patients with diabetes mellitus type I was detected. Interestingly, juvenile type I diabetics presented with an average urinary iodide excretion of 183.0 micrograms iodide/g creatinine. Even the urinary iodide excretion of 162.5 micrograms iodide confirmed this increased level. The urinary iodide excretion in 24 hours correlated with glucosuria and the HbA1c level. The healthy children presented with an average urinary iodide excretion of 42.6 micrograms iodide/g creatinine. The mean value was clearly below the WHO recommendation of 150-300 micrograms iodide/g creatinine. Only 2.8% of the healthy children examined exceeded the lower limit of this range., Conclusion: In addition to the existing distinct under supply of iodide we assume an increased urinary iodide excretion in context with the osmotic diuresis in juvenile diabetics. Contrary to current opinion, that these data are correlated to the daily intake of iodide, which was calculated from urinary excretion rate, this thesis could not be affirmed for juvenile diabetics. Therefore it seems reasonable to frequently control thyroid volume and thyroid function in children and adolescents with diabetes mellitus.

Objective: To investigate the efficacy of 1.53 mg iodide administered once weekly in the prophylaxis of goitre recurrence in patients with endemic euthyroid goitre after initial treatment to reduce the goitre size., Patients and Methods: 46 consecutive patients who had undergone initial L-thyroxine, iodide or combined treatment were included in the prospective study. Thyroid volume was measured sonographically at the beginning as well as 6 and 18 months later. An increase in thyroid volume of more than 15% was taken as recurrence., Results: The study was concluded in 41 patients. During the prophylaxis mean thyroid volume increased from initially 21.7 +/- 9.9 ml to 22 +/- 10.9 ml after 6 months and to 24.5 +/- 12.1 ml after 18 months (P < 0.01). While thyroid volume remained unchanged in at least two thirds of patients, a recurrence occurred in 32% (n = 13; from initially 22.7 +/- 9.7 ml, to 26.3 +/- 11.3 ml at 6 months and to 29.7 +/- 12.3 ml at 18 months). In all patients with a recurrence a doubling of the iodide dosage to twice weekly 1.53 mg for 6 months reduced thyroid volume again (mean of 25.7 +/- 10.0 ml; P < 0.01)., Conclusions: In at least two third of patients a once-weekly dose of 1.53 mg iodide is a reliable means of preventing a recurrence of endemic euthyroid goitre, but in the remainder the same dose must be increased to twice weekly.

Aim: The aim of the study was to assess the prevalence of thyroid enlargement by ultrasonic volume measurements., Results: 1336 adults living in the iodine-deficient area of Aachen, West Germany (760 females, 576 males, mean age: 54.05 +/- 16.09 years) were included in the investigation. The ultrasonic examination was carried out in patients who did not suffer from thyroid disease at the time of study., Results: The thyroid volume was age-dependent and varied from 13.3 +/- 10.4 ml in patients < 21 years to 29.9 +/- 24.3 ml in patients > 70 years. The prevalence of thyroid enlargement ranged from 14.3% in young people to 51.3% in the elderly. There was no difference in the volumes of the left and right thyroid lobe. The prevalence of thyroid enlargement was higher in females compared to males (p < 0.05). Retrosternal thyroid mass was detected in 25% of all patients > 70 years., Conclusion: There is evidence of a high prevalence of thyroid enlargement in iodine-deficient areas.

Recently 99mTc-Sestamibi (MIBI) has been introduced into parathyroid imaging. The purpose of this study was to evaluate the MIBI scan in an endemic goiter area. 25 patients with primary and 9 with secondary hyperparathyroidism (HPT) underwent a MIBI scan one day prior to surgical exploration of the neck. Cervicothoracic planar scintigraphy was performed 5, 15 and 120 min after i.v. injection of 444 MBq of 99mTc-Sestamibi. The MIBI scan correctly detected 20 of 25 adenomas in 25 patients with pHPT. In only 6 of 9 patients with parathyroid hyperplasia a focal uptake was found. The cause of one false-positive result in the control group was an increased MIBI uptake by a follicular adenoma of the thyroid. Parathyroid scintigraphy using 99mTc-Sestamibi as a single radiopharmaceutical is as sensitive in detecting and localizing parathyroid adenomas as the Tl/Tc-scintigraphy. Due to a high prevalence of thyroid adenomas in an endemic goiter area a higher rate of falsely positive results may be expected.

The thyroid gland of 536 patients of a medical hospital in an iodine deficient area was investigated by ultrasound. According to the sonographic pattern and to the scintigraphic imaging the focal lesions were analysed as micro- or macrofollicular adenomas, autonomous adenomas, cysts and chalk. The prevalence of goitres was 37.7%. The prevalence of goitres was higher in women (45%) than in men (30%). Focal lesions could be observed in 27.6%, equally more often in women (36%) than in men (18.9%). The frequency of focal lesions increased with the age of the patients and with the volume of the thyroid gland. Autonomous adenomas were found three times more often in women than in men. Hyperthyroidism was only observed in patients with nodules larger than 4 cm in diameter. Sonographic screening examinations of the thyroid gland seem to be useful in all patients of a clinic of medicine because of the risk (25%) of iodine contamination by diagnostic measures.

Global TcTU was determined in 568 patients without any specific thyroid drug intake--54 with normal thyroid, 274 with goitre and euthyroidism and 240 with thyroid autonomy. 57 patients with autonomy and overt hyperthyroidism were the only group with TcTU values significantly higher than normals. Common to all groups was a large scatter of the TcTU values. In 332, the effects of individual iodine supply were studied by measuring the iodine concentration in spot urine samples. There was a significant inverse correlation between the TcTU values and the urinary iodine excretion in the groups of normal thyroids and of goitres with euthyroidism. In the group with autonomy an effect of iodine supply could only be seen in cases of greatly increased urinary iodine excretion, resulting in very low TcTU values. Out of 20 patients with autonomy and iodine contamination, only 4 showed overt hyperthyroidism. The large scatter of TcTU values in all groups may be explained by the persistent iodine deficiency as well as by the frequent exposure to unknown amounts of iodine in patients with thyroid disease. Therefore, the spontaneous TcTU alone cannot identify a small group of patients with autonomy and high risk of iodine-induced hyperthyroidism, from a very large group of patients with goitre.

Following the application of 10 000 to 15 000 rd, to 471 patients with benign goitres, mechanical symptoms were relieved in 72 to 82% during a course of six follow-up examinations; the circumference of the neck was reduced by 1.2 to 1.6 cm., the scintigraphic area by 9 to 31% and maximal 131I uptake was reduced by 18 to 31%. Follow-up examinations at 6.4 and 5.5 years in 155 patients showed the best regression of neck circumference (2.2 to 2.6 cm.) and of the area of the scintigram (28 to 31%). 50% of the patients had had recurrences from previous goitre removals and 1 to 3% developed post-therapeutic hypothyroidism. There was no significant change in the level of the peripheral thyroid hormones following treatment, but 10 to 20% were within the hypothyroid range for the area of iodine deficiency.

We determined the CT density of the thyroid gland in 60 patients with normal thyroids and 176 patients with various thyroid disorders. The density was 75 +/- 6.2 H.U. in normal thyroids, which was markedly higher than in goiters (66 +/- 6.0 H.U.), while there was a considerable further decrease in patients with immunogenic hyperthyroidism, the density being 48.5 +/- 7.9 H.U. The thyroids of patients with nonimmunogenic hyperthyroidism differed from these by virtue of a significantly greater density, 79.8 +/- 12.5 H.U. The clinical importance of CT investigation of the thyroid is its ability to distinguish rapidly between immunogenic hyperthyroidism without ocular symptoms and the (mostly iodine induced) non-immunogenic form. There is a linear correlation between CT density and iodine concentration in the thyroid tissue; this was determined in surgical specimens from 17 patients. Iodine concentration in the thyroid, as well as the iodine content of the whole gland, can thus be calculated from the measured CT density at any time by estimating the volume of the gland with ultrasound and combining this value with the measured iodine concentration. The results correlate well with those found using the x-ray fluorescence method.