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Purpose: Worldwide, incidence of thyroid malignancy is increasing. The purpose of this study was to evaluate the pattern and magnitude of nodule types., Methods: A cross-sectional retrospective study was performed at Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia, among patients who underwent thyroidectomy from May 2018 to June 2022. Data were extracted using a structured format. Descriptive statistics were performed using SPSS version 26 software. Results were presented in terms of percentages and frequencies., Results: During a 4-year period, 1,476 patients had thyroidectomies and histopathologic information of 212 malignant cases was studied. Within multinodular goiter (MNG), thyroid cancer accounted for 69.8% (n = 148) of patients, whereas in solitary nodules, it accounted for 30.2%. From the total, 160 participants (75.5%) were female, and the female:male ratio was 3.1 (mean, 41.72; ± standard deviation [SD], 16.44) years, and age range of 12-88 years versus men, who have a mean of 44.71 (±SD, 14.91) years and an age range of 21-78 years. The mean age of male cases with solitary nodule and MNG was 40.6 and 46.5 years, respectively. The most frequent cancer in both types of nodules, accounting for 59% of patients, was papillary carcinoma, which was found in 64% of solitary nodules and 57.4% of multinodular nodules. Overall, 14.1% of tumors had multiple centers (17.4% in multinodular nodules and 6.9% in solitary nodules). In 7.1% of patients, microcarcinoma (<1 cm) was found, with papillary carcinoma accounting for 91.7% of the total., Conclusion: Compared with men, women with cancer typically manifested at a younger age. Males with malignancy in solitary nodules had a lower mean age than those with MNGs. The most frequent and significant cause of multicentric presentation is papillary carcinoma.

Background: Although hyperfunctioning thyroid disorders were thought to be protective against malignancy, some recent studies reported a high incidence of incidentally discovered cancer in patients with hyperfunctioning benign thyroid disorders. We performed this study to estimate the incidence and predictors of malignant thyroid disease in patients with toxic nodular goiter (TNG). Patients and Methods . The data of 98 patients diagnosed with TNG were reviewed (including toxic multinodular goiter SMNG and single toxic nodule STN). The collected data included patients age, gender, systemic comorbidities, family history of thyroid malignancy, previous neck radiation, type of disease (multinodular or single), size of the dominant nodule by the US, operative time, and detection of significant lymph nodes during operation. Based on the histopathological analysis, the cases were allocated into benign and malignant groups., Results: Malignancy was detected in 21 patients (21.43%). Although age distribution was comparable between the two groups, males showed a significant increase in association with malignancy. Medical comorbidities and family history of cancer did not differ between the two groups. However, TMNG showed a statistically higher prevalence in the malignant group. Operative data, including operative time and lymph node detection, were comparable between the two groups. On regression analysis, both male gender and TMNG were significant predictors of malignancy., Conclusion: The presence of thyroid hyperfunction is not a protective factor against malignancy, as malignancy was detected in about 1/5 of cases. Male gender and TMNG were significant risk factors of malignancy in such patients., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Tarek Zaghloul Mohamed et al.)

Background: Nowadays, the Republic of Belarus belongs to the countries with sufficient iodine supply, which made it possible to reduce the incidence of non-toxic goiter and congenital hypothyroidism. However, even a slight change in iodine consumption influences the pattern of thyroid diseases. In addition to iodine deficiency, other environmental conditions, as well as genetic factors, play a significant role in the etiology of thyroid diseases., Aim: To analyze the dynamics of the main epidemiological indicators of benign thyroid diseases from 2009 to 2019 in the adult population of the Republic of Belarus, using the data of official state statistics., Materials and Methods: The indicators of the incidence and prevalence of benign thyroid diseases were studied on the basis of state statistics for 2009-2019. To analyze the dynamics of the studied indicators, regression analysis was used with the construction of linear and polynomial models., Results: A decrease in the incidence and prevalence of diffuse euthyroid goiter and an increase in the incidence and prevalence of nodular euthyroid goiter, thyroiditis, acquired hypothyroidism, Graves' disease, as well as the incidence of nodular toxic goiter were revealed., Conclusion: Obtained data indicate, that there is an increase in the prevalence of most of the studied thyroid diseases, despite the adequate iodine supply. The above justifies the need for further study of the causes of the identified trends, as well as the necessity of developing new methods of diagnosis and treatment of thyroid diseases.

Background: This study aims to reveal the features of lymph node metastasis (LNM) and recurrence in papillary thyroid carcinoma (PTC) tumors located in the upper portion of the thyroid., Methods: A total of 1075 PTC patients were retrospectively reviewed, including 314 patients with a tumor in the upper portion of the thyroid. Another 103 PTC patients with upper portion diagonsis from three clinical centers were included for external validation., Results: The results showed no difference between the patients with a tumor in the upper portion of the thyroid and those with a tumor in the non-upper portion in terms of overall LNM rates. However, patients with a tumor in the upper portion were significantly more prone to LLNM and exhibited a significantly worse recurrence outcome than those with a tumor in other subregions. Multivariate analysis showed that four factors-age no more than 40, maximum tumor diameter no less than1.0 cm, the presence of thyroid capsular invasion, and tumor with ipsilateral nodular goiter-were independent risk factors for LLNM of the tumor in the upper thyroid. A predictive risk-scoring model was established based on these factors., Conclusions: Patients with PTC located in the upper portion may have an exclusive lymphatic drainage pathway to the lateral neck region and are more prone to suffer from LLNM and tumor recurrence than those with a tumor located in other subregions. A new postoperative strategy selection flow chart was established based on our newly created risk-scoring model that can effectively predict the individualized possibility of LLNM for PTC patients with a tumor in the upper portion., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Heng, Feng, Yang, Cai, Qiu and Tao.)

Background: The incidence rates of thyroid tumors and nodular goiter show an upward trend worldwide. There are limited reports on the risk of perchlorate and iodine on thyroid tumors, but evidence from population studies is scarce, and their impact on thyroid function is still uncertain. Therefore, the objective of this study was to investigate the association of perchlorate and iodine with the risk of nodular goiter (NG), papillary thyroid microcarcinoma (PTMC), and papillary thyroid carcinoma (PTC) and to assess the correlation between perchlorate and iodine with thyroid function indicators., Methods: A case-control population consisting of 184 pairs of thyroid tumors and nodular goiter matched by gender and age (±2 years) was recruited in this study. Serum and urine samples were collected from each participant. Thyroid function indicators in serum were tested by automatic chemical immunofluorescence, and perchlorate and iodine levels in urine were determined by ultra-high performance liquid chromatography tandem-mass spectrometry and inductively coupled plasma-mass spectrometry, respectively. Conditional logistic regressions and multiple linear regressions were used to analyze the associations., Results: Urinary perchlorate concentration was significantly higher in total cases, NG and PTC than in the corresponding controls (P < 0.05). Perchlorate was positively associated with PTC (OR = 1.058, 95% CI: 1.009, 1.110) in a non-linear dose-response relationship, but there was no association between perchlorate and NG or PTMC. Iodine was not associated with the risk of thyroid tumors and NG and did not correlate with the thyroid function indicators. Furthermore, perchlorate showed a positive correlation with thyroid stimulating hormone (TSH) at iodine adequate levels (P < 0.05), and a negative correlation with free triiodothyronine (FT3) and a positive correlation with thyroglobulin antibody (TgAb) at iodine more than adequate or excess levels (P < 0.05)., Conclusions: Perchlorate can increase the risk of PTC in a non-linear dose-response relationship and disturb the thyroid hormone homeostasis and thyroid autoantibody levels., (© 2021. The Author(s).)

Background: Rates of thyroid cancer in patients with multinodular goitre (MNG) vary widely, from 3 per cent in older studies to 35 per cent in more recent studies. The purpose of the present study was to evaluate the prevalence of thyroid cancer in patients operated on for MNG, and to determine risk factors for incidental thyroid malignancy., Methods: A prospectively developed database of all patients who underwent thyroidectomy for a benign MNG at the high-volume endocrine surgery unit of a tertiary referral university hospital was interrogated., Results: A total of 3233 patients were analysed, separated into three groups according to their functional thyroid status (hypothyroid, hyperthyroid or euthyroid). There were 2788 women (86.2 per cent); the mean patient age was 56.4 years and mean preoperative disease duration was 106.2 months. Incidental thyroid cancer was identified in 1026 patients (31.7 per cent), of which 917 (89.4 per cent) were papillary cancers. Multivariable regression analysis identified functional thyroid status, younger age, male sex, smaller adenoma size, smaller thyroid glands, Hashimoto's thyroiditis and chronic non-specific thyroiditis as independent risk factors for thyroid cancer., Conclusion: MNG was associated with a considerable rate of incidental thyroid cancer, which has been underestimated. A variety of factors should be taken into account when considering the malignant potential of a presumed benign MNG., (© The Author(s) 2020. Published by Oxford University Press on behalf of BJS Society Ltd.)

Importance: Genetic disorders are historically defined through phenotype-first approaches. However, risk estimates derived from phenotype-linked ascertainment may overestimate severity and penetrance. Pathogenic variants in DICER1 are associated with increased risks of rare and common neoplasms and thyroid disease in adults and children. This study explored how effectively a genome-first approach could characterize the clinical traits associated with germline DICER1 putative loss-of-function (pLOF) variants in an unselected clinical cohort., Objective: To examine the prevalence, penetrance, and phenotypic characteristics of carriers of germline DICER1 pLOF variants via genome-first ascertainment., Design, Setting, and Participants: This cohort study classifies DICER1 variants in germline exome sequence data from 92 296 participants of the Geisinger MyCode Community Health Initiative. Data for each MyCode participant were used from the start of the Geisinger electronic health record to February 1, 2018., Main Outcomes and Measures: Prevalence of germline DICER1 variation; penetrance of malignant tumors and thyroid disease in carriers of germline DICER1 variation; structured, manual review of electronic health records; and DICER1 sequencing of available tumors from an associated cancer registry., Results: A total of 92 296 adults (mean [SD] age, 59 [18] years; 98% white; 60% female) participated in the study. Germline DICER1 pLOF variants were observed in 1 in 3700 to 1 in 4600 participants, more than double the expected prevalence. Malignant tumors (primarily thyroid carcinoma) were observed in 4 of 25 participants (16%) with DICER1 pLOF variants, which is comparable (by 50 years of age) to the frequency of neoplasms in the largest registry- and clinic-based (phenotype-first) DICER1 studies published to date. DICER1 pLOF variants were significantly associated with risks of thyroidectomy (odds ratio [OR], 6.0; 95% CI, 2.2-16.3; P = .007) and thyroid cancer (OR, 9.2; 95% CI, 2.1-34.7; P = .02) compared with controls, but there was not a significant increase in the risk of goiter (OR, 1.8; 95% CI, 0.7-4.9). A female patient in her 80s who was a carrier of a germline DICER1 hotspot variant was apparently healthy on electronic health record review. The term DICER1 did not appear in any of the medical records of the 25 participants with a pLOF DICER1 variant, even in those affected with a known DICER1-associated tumor or thyroid phenotype., Conclusions and Relevance: This cohort study was able to ascertain individuals with germline DICER1 variants based on a genome-first approach rather than through a previously established DICER1-related phenotype. Use of the genome-first approach may complement more traditional approaches to syndrome delineation and may be an efficient approach for risk estimation.

Objective: To compare the haemogram parameters of patients with thyroid papillary cancer and nodular goiter., Methods: The retrospective comparative study was conducted at Van Training and Research Regional Hospital, Van, Turkey, and comprised data of patients who underwent thyroidectomy from 2011 to 2015. The data was compared between patients with papillary thyroid cancer (group 1) and those with nodular hyperplasia (group 2) in terms of age, gender and thyroid stimulating hormone level as well as haemogram parameters, neutrophil-lymphocyte ratio and platelet-lymphocyte ratio. SPSS 20 was used for statistical analysis., Results: Of the 90 patients, 53(59%) were in group 1 with papillary thyroid cancer and 37(%) in group 2 with nodular hyperplasia. Platelet-lymphocyte ratio was significantly higher in group 1 (p=0.015). Mean platelet volume was significantly higher in group 1 patients with a diameter of 1cm or more (p<0.05). Within group 1, lymphocyte count was significantly high in patients with invasion (p<0.05). In correlation analysis, group 1 patients with a tumour diameter of 1cm or more showed a significant correlation in mean platelet volume, tumour multicentricity, lymphocyte count, vascular invasion, thyroglobulin, platelet distribution width, platelet number and tumour multicentricity (p<0.05)., Conclusion: Only platelet-lymphocyte ratio could assist in distinguishing benign goiter from thyroid cancer. Also, mean platelet volume, lymphocyte count, and platelet distribution width appeared to be effective prognostic markers for papillary thyroid cancer.

Background: The suppressive effect of the increase in thyroid hormone in patients with toxic nodular goiter is thought to protect the extranodular thyroid tissue from thyroid malignancy. In this study, we aimed to evaluate the prevalence and features of thyroid cancer in patients with toxic nodular goiter who underwent thyroidectomy., Methods: Medical data of patients who had solitary toxic or nontoxic nodules and underwent total thyroidectomy were reviewed retrospectively. We reviewed the clinical, laboratory, and histopathologic features of patients with toxic nodular goiter and nontoxic solitary nodules., Results: There were 73 patients with toxic nodular goiter and 366 patients with nontoxic solitary nodules. Median age was greater in the toxic nodular goiter compared with nontoxic solitary nodules patients (50 years; range: 18-73 vs 42 years; range: 18-83, P < .001). Median nodule diameters were 40.9 mm (range: 11.0-98.0) and 23.3 mm (range: 4.9-99.0) in patients with toxic nodular goiter and nontoxic solitary nodules, respectively (P < .001). Histopathologic examination revealed thyroid cancer in 14 patients (19%) with toxic nodular goiter and 132 (36.1%) patients with nontoxic solitary nodules (P = .008). Median tumor diameters were 6 mm (range: 1-50) in toxic nodular goiter and 14 mm (range: 1-80) in nontoxic solitary nodules (P = .150). The malignant nodule was the hyperfunctioning nodule in 7 patients with toxic nodular goiter; 4 were follicular and 3 were papillary thyroid cancer. The other 7 malignant foci were located in the suppressed contralateral lobe, and all were papillary microcarcinomas. The incidence of thyroid cancer outside the main nodule was similar in 2 groups (P = .934)., Conclusion: Thyroid cancer in patients operated for toxic nodular goiter was 19%, which is not as rare as previously thought. A careful histopathologic examination of both the hyperfunctioning nodule and the extranodular thyroid tissue might help to disclose an unexpected tumor foci when thyroidectomy is performed in patients with toxic nodular goiter., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Studies have showed that lead was associated with human health. However, the effects of lead on thyroid functions are inconsistent, and studies based on Chinese population are fragmentary. To evaluate the correlation between lead and thyroid functions of Chinese with different thyroid diseases, we conducted a hospital-based study. Ninety-six papillary thyroid carcinoma (PTC), 10 nodular goiter (NG), and 7 thyroid adenoma (TA) patients were recruited from the First Affiliated Hospital of Wenzhou Medical University, China. Serum triiodothyronine (T3), free triiodothyronine (FT3), free thyroxin (FT4), and thyroid stimulating hormone (TSH) were evaluated with chemiluminescent microparticle immunoassay. Serum lead was assessed with ICP-MASS. Partial correlation was used to explore the correlations of serum lead and thyroid diseases. Compared to PTC, the level of lead was significantly higher in TA, and lower in NG (p < 0.05). This difference remained significant in females when stratified by sex. Serum lead was negatively correlated with TSH (r s  =  - 0.27, p < 0.05) in PTC group. T3 was positively related to lead at quartile4 (r s  = 0.61, p < 0.05) in PTC group. No significant correlations were observed between lead and FT3 or FT4 in any group. The results suggested that lead might have different etiological roles in these three thyroid diseases.

Context: The risk of thyroid cancer and multinodular goiter (MNG) in DICER1 syndrome, a rare tumor-predisposition disorder, is unknown., Objective: To quantify the risk of thyroid cancer and MNG in individuals with DICER1 syndrome., Design: Family-based cohort study., Setting: National Institutes of Health (NIH) Clinical Center (CC)., Participants: The National Cancer Institute DICER1 syndrome cohort included 145 individuals with a DICER1 germline mutation and 135 family controls from 48 families., Interventions: Each individual completed a detailed medical history questionnaire. A subset underwent a 3-day evaluation at the NIH CC., Main Outcome Measures: The cumulative incidence of MNG (or thyroidectomy) was quantified using the complement of the Kaplan-Meier product limit estimator. We compared the observed number of thyroid cancers in the NCI DICER1 cohort with matched data from the Surveillance, Epidemiology, and End Results (SEER) Program. We performed germline and somatic (thyroid cancer, MNG) DICER1 sequencing., Results: By the age of 40 years, the cumulative incidence of MNG or thyroidectomy was 75% in women and 17% in men with DICER1 syndrome compared with 8% of control women (P < 0.001) and 0% of control men (P = 0.0096). During 3937 person-years of observation, individuals with DICER1 syndrome had a 16-fold increased risk of thyroid cancer (95% confidence interval, 4.3 to 41; P < 0.05) compared with the SEER rates. Of 19 MNG nodules and 3 thyroid cancers, 16 (84%) and 3 (100%), respectively, harbored germline and somatic pathogenic DICER1 mutations., Conclusions: We propose a model of thyroid carcinogenesis in DICER1 syndrome. Early-onset, familial, or male MNG should prompt consideration of the presence of DICER1 syndrome., (Copyright © 2017 by the Endocrine Society)

Introduction: Acromegaly results from oversecretion of growth hormone and subsequently insulin growth factor-1. According to some authors, the disease can cause increased prevalence of nodular goitre and thyroid cancer (TC). However, the number of studies comparing acromegalic patients with control groups is low. We aimed to assess the prevalence of thyroid lesions in patients with acromegaly in comparison to an age- and sex-matched control group and to update the meta-analysis previously performed in our department by the same authors., Material and Methods: We searched medical documentation of patients with acromegaly treated in our department between 2003 and 2013. The prevalence of thyroid abnormalities was compared with the group of patients with hormonally inactive adrenal incidentalomas. To perform the meta-analytic part of the paper we also searched ten databases to find relevant papers., Results: Two hundred and five patients with acromegaly and 184 patients with incidentalomas were included. Any thyroid lesions were present in 77.6% of patients with acromegaly vs. 63.0% with incidentalomas (p = 0.002), multinodular goitre - 66.8% vs. 47.8% (p = 0.0002), and TC- 5.4% vs. 2.7% (p = 0.21) respectively. For thyroid lesions the pooled odds ratio (OR) was 3.1 (95% confidence interval [CI] 1.8-5.5), and for TCs the OR was 4.5 (95% CI 1.9-10.3)., Conclusions: According to our results thyroid lesions were significantly more common in patients with acromegaly; in case of TC the difference was not significant. The updated meta-analysis showed significantly increased prevalence of both disorders. In conclusion, systematic thyroid examination should be an important part of follow-up in case of acromegalic patients. (Endokrynol Pol 2017; 68 (1): 2-6).

Background and Objective: Thyroid cancer may be clinically evident as a tumor mass in the neck or as a histopathological incidental finding after thyroid surgery for an apparent benign condition. Our objective was to assess the differences in clinical signs, surgical management, and course between incidental and clinically diagnosed thyroid tumors., Methods: A retrospective study was conducted on patients operated on for benign or malignant thyroid disease from January 2000 to March 2014. Among the 1415 patients who underwent any thyroid surgery, 264 neoplasms were found, of which 170 were incidental. A comparison was made of incidental versus non-incidental carcinomas. Among incidental carcinomas, cases whose indication for surgery was Graves' disease were compared to those with multinodular goiter., Results: Incidental carcinomas were in earlier stages and required less aggressive surgery. There were no differences in surgical complications between incidental and clinical tumors, but mortality and relapses were markedly higher in non-incidental cancers (4.4% vs 0% and 13.2% vs 4.8% respectively). Carcinomas developing on Graves' disease showed no differences from all other incidental tumors in terms of complications, mortality, or relapse after surgery., Conclusions: Early stage thyroid cancer has better survival and prognosis after surgical treatment., (Copyright © 2016 SEEN. Publicado por Elsevier España, S.L.U. All rights reserved.)

We present a retrospective case series of patients with hyperthyroidism and thyroid cancer. Our goal was to look at their clinical characteristics and outcomes to determine which patients would require further investigation. We reviewed the case notes of all patients with a histopathologic diagnosis of thyroid cancer and biochemical evidence of hyperthyroidism who had been treated at a thyroid cancer center from January 2006 through October 2013. During that time, 66 patients had been diagnosed with thyroid cancer. Of these, 8 patients (12%)-all women, aged 29 to 87 years (mean: 55.6; median: 50.5)-had biochemical evidence of hyperthyroidism. Among these 8 patients, 4 had an autonomously functioning toxic nodule (AFTN), 3 were diagnosed with Graves disease, and 1 had a toxic multinodular goiter. Five patients had suspicious features on preoperative ultrasonography. All 8 patients were diagnosed with the papillary type of thyroid carcinoma. The mean size of the tumor in the 4 patients with AFTN was significantly larger than it was in those with Graves disease (42.3 ± 23.8 mm vs. 3.8 ± 1.6; p = 0.04). The 3 patients with Graves disease all had incidentally found papillary microcarcinoma. Between these two groups, the patients with AFTN had a poorer prognosis; 2 of them had extracapsular invasion and lymph node metastasis, and another died of her disease. We found that the incidence of hyperthyroidism in thyroid cancer patients was relatively high (12%). In contrast to what has previously been reported in the literature, patients with AFTN seem to have more aggressive disease and poorer outcomes than do patients with Graves disease. Any suspicious nodule associated with hyperthyroidism should be evaluated carefully.

Objectives: The incidence of papillary thyroid carcinoma increased in several countries. The purpose of this study was to quantify the changes in thyroid carcinomas in our University Hospital., Study Design: Retrospective study., Methods: All 1.927 thyroidectomy cases studied in the Pathology Department of Hotel-Dieu de France Hospital (Beirut, Lebanon), between 2003 and 2013, were included., Results: The Female/Male Sex Ratio of the studied population was 3.7/1. The mean age of female patients was significantly lower than that of male patients. The most frequent diagnoses were multinodular goiter (78%) and papillary-carcinoma (26%). 337 cases had a single lesion on gross examination. 21 of them were diagnosed with follicular carcinoma and 59 with follicular adenoma. A statistically significant correlation was found between the unicity of the lesion on gross examination and the final diagnosis of a follicular neoplasm. Thyroid carcinoma was multifocal in 33% of the cases and bilateral in 24%. A statistically significant increase in thyroid carcinoma proportion (from 15% in 2003 to 44% in 2013) was found. Among all thyroid carcinomas, the proportion of papillary type increased from 65% in 2003 to 94% in 2013 ; this increase remained statistically significant after the exclusion of papillary micro-carcinomas, whose proportion was stable throughout the 11 years., Conclusions: In this study, we noted a statistically significant increase in the frequency of thyroid carcinoma, especially of the papillary type. The unicity of the lesion on gross examination is significantly associated with a follicular neoplasm., (© Acta Chirurgica Belgica.)

Introduction: Thyroid nodules constitute frequent medical condition. Ultrasonographic (US) examination remains the basis in the diagnostics of nodular goiter and selection of the suspected ones requiring fine-needle aspiration biopsy (FNAB). The aim of this study was to evaluate if the features so far considered to be US malignancy markers are dependent or independent variables and to check if these data are clinically relevant., Materials and Methods: Patients with diagnosed thyroid nodular goiter admitted for thyroidectomy, irrespectively of the indications for surgery, were involved. The following parameters were assessed: echogenicity, the presence of calcifications, presence of halo, shape, margins, structure (solid, partially or pure cystic), and elasticity of the nodules (assessed quantitatively)., Results: 122 consecutive patients with 393 thyroid nodules were included. There were significant associations between halo absence and irregular borders, micro- and macrocalcifications, taller-than-wide feature and macrocalcifications, irregular margins and macrocalcifications, and also decreased elasticity of nodules and several attributes (partially cystic character, micro- and macrocalcifications)., Conclusions: Not only diagnostic value of particular sonographic features but also data about cooccurrence and associations between them are clinically relevant. Although most of these features turned out to be independent, omitting significant association can lead to incorrect assessment of the risk of malignancy.

Objective: The prevalence and clinical significance of incidental differentiated thyroid cancer (DTC) in patients with Graves' disease (GD) remain uncertain. Thyroid stimulating antibody (TSI Ab)-titers were thought to be responsible for the potentially increased incidence or aggressiveness of PTC in that setting. The aim of this study was to compare the prevalence of incidental DTC among patients with GD and euthyroid goiter (EG), to assess the ability of TSI to predict DTC in GD and to investigate the clinical features that may predict incidental DTC in GD and EG., Methods: Two hundred and forty eight patients with EG and 245 patients with GD patients who had undergone total thyroidectomy at our institution between 2005 and 2013 were retrospectively selected from our data base. An analysis of incidentally discovered DTC was conducted comparing GD group with EG group., Results: Incidental micro-papillary thyroid cancer (MPTC) was found in 28% in EG group, as compared to 26% in GD group. PTC Patients with GD were significantly younger (44 vs 59) and less likely to have compressive symptoms than with EG before surgery (p<0.001). In GD group, patients with MPTC were also significantly older (p=0.009) than those without, were more likely to have symptomatic goiter (p<0.001), and to have a nodular disease (p<0.001). TSI ab titer did not predict MPTC in GD group (The AUC curve was 0.55 (95% CI: 0.46, 0.64). Among patients with GD and incidental MPTC, 58% of patients had at least one nodule., Conclusion: The prevalence of incidental DTC in GD is comparable to EG. Each is increased compared to general population. Age of presentation of PTC was significantly lower in GD suggesting an increased risk for MPTC in GD. Nodule size greater than 1cm predicted incidental DTC whereas TSI ab titers and disease duration did not., (Published by Elsevier Inc.)

Objective: To study the changes in the constituent ratio of patients received surgical therapy for their thyroid diseases in Peking Union Medical College Hospital from 1986 to 2012., Methods: The clinical data of patients received surgical therapy with pathologically confirmed findings from 1986 to 2012 were collected, and a corresponding database was established. The constituent ratios of thyroid diseases and thyroid malignant tumor among different population groups in different years were analyzed., Results: The number of patients with thyroid diseases admitted to our hospital had significantly increased in the past 27 years, particularly those with nodular goiter or thyroid cancer. The composition ratios of thyroid cancer and nodular goiter increased significantly, and among malignancies the papillary thyroid carcinoma increased obviously. The detection rate of papillary thyroid micro-carcinoma had continuously increased since 2008., Conclusion: Thyroid diseases and malignant tumor pathological types had dramatically changed in hospitalized patients in our hospital in the past 27 years.

Background: Diseases of the thyroid are not uncommon, particularly in the highlands of Ethiopia. The aim of the present study was to describe the experience of thyroid surgery in a rural hospital in Southern Ethiopia., Methods: The present study was based on review of surgical cases of thyroid diseases operated in a rural hospital in Southern Ethiopia during the period 2009-2010., Results: During the study period, 211 patients underwent surgery for goiter. The mean age was 31.9 years (range: 14-80 years). The sex ratio, M:F, was 1:9. A total of 103 patients had unilateral nodules, and in 108 patients the nodules were located bilaterally. The mean duration of symptoms was 5.7 years (range: 0.7-25 years). In total, 161 (76.7 %) subtotal thyroidectomy operations, and 50 (23.3 %) hemi-thyroidectomy operations were performed. Histological examination revealed multinodular goiters in 203 (96.2 %) cases. Papillary and follicular cancers were found in 7 (3.3 %) and 1 (0.5 %) cases, respectively., Conclusions: Thyroid surgery is feasible in a small rural Ethiopian District Hospital. The provision of surgical services in rural areas of low income and middle income countries is extremely important and delivers more health opportunities to the local people.

Background: Whether the prevalence of thyroid cancer is different in thyroid glands with a single nodule (SN) versus multinodular goiter (MNG) remains uncertain. Therefore, a meta-analysis was performed to evaluate the extant literature on the comparative prevalence of thyroid cancer in SN compared with MNG., Methods: We searched MEDLINE, EMBASE, Scopus, Cochrane Central, and reference list for selected observational, cross-sectional, and longitudinal studies evaluating thyroid cancer in SN and MNG. Toxic nodules were not included in the analysis. Two reviewers working independently extracted descriptive, methodological and outcome data from each study with consensus resolution of discrepancies. Meta-analytic estimates of treatment effects were generated using a random-effect model., Results: Fourteen studies encompassing 23565 patients with MNG and 20723 patients with SN were eligible for inclusion. Most eligible studies were at a moderate risk of bias. MNGs were associated with a lower risk of thyroid cancer than SN (pooled odds ratio 0.8 [95% confidence interval 0.67-0.96]; I(2)=35%). Subgroup analysis suggested that this difference depends on the inclusion of studies conducted outside the United States (odds ratio 0.71 [95% confidence interval 0.60-0.83]; I(2)=11%)., Conclusions: Thyroid cancer may be less frequent in MNG compared to SN, particularly outside the United States and perhaps in iodine-deficient areas.

Purpose of Review: To highlight recent advances in our understanding of the incidence of multinodular goitre (MNG) risk of malignancy, evaluation of patients with MNG, rates and factors predictive of malignancy in MNG, and the choice of surgical procedure for patients with neoplastic MNG., Recent Findings: The incidence of MNG when screened by ultrasound scanning (USS) is between 10 and 20% and when using high resolution USS can be up to 70%. The incidence of occult malignancy within MNG lies between 10 and 35% in surgical series. Younger patients and men have higher rates of malignancy, as do patients with a family history, prior irradiation and those with signs of compressive or invasive disease. Subtotal thyroidectomy has been rejected in favour of either total lobectomy or total thyroidectomy for most patients with MNG., Summary: An increasing number of patients with MNG will be encountered in surgical practice. Most patients can be cured with total lobectomy or total thyroidectomy, which minimizes recurrence rates and ensures an oncological approach to patients with incidentally discovered malignancy within MNG.

Objective: Thyroid disease is very common, particularly nodular goiter. Total thyroidectomy is a therapeutic option for both malignant and benign disease. The aim of the study was to evaluate the number of total thyroidectomy surgeries and the rate of benign and malignant histologic exams over the last decade., Methods: Hospital discharge records in the Emilia Romagna region (Italy) that reported total thyroidectomy as the principal surgical procedure and included the relative histologic diagnosis were reviewed for the period 2000 to 2010. Mean increment and geometric mean of increments per year were calculated to evaluate differences over the years., Results: More than 25,000 patients underwent total thyroidectomy between 2000 and 2010. The total number of thyroidectomies increased over this period, with a mean increment of 7.16% per year. The percentage of malignancies among the total number of thyroidectomies increased from 26.1% (2000) to 39.9% (2010) (mean increment, 1.38% per year). Nontoxic multinodular goiter was the most frequent diagnosis, accounting for 36% of all thyroidectomies., Conclusions: Between 2000 and 2010, the proportion of patients thyroidectomized for benign disease progressively decreased, as documented by a lower thyroidectomy/malignancy ratio. Currently, about 60% of thyroid interventions are performed for benign pathology. Improved preoperative diagnostic accuracy and the availability of nonsurgical procedures will presumably further reduce the number of thyroidectomies with benign histologic diagnoses.

Surgical therapy for thyroid neoplasms is based on tumor histology and comprises stage-adapted procedures with a high degree of inter-individual variability. This can range from waiting and monitoring, to extensive multivisceral surgery. Grouping together histologically different types of malignancies leads to false assumptions when gauging the radicality of surgery necessary in each particular case. Surgical therapy requires not only an understanding of the biological behavior of the tumor and the risk that it or the therapy poses to the patient, but also knowledge of a wide surgical spectrum of limited and complex resection procedures in the neck and thorax region. The following recommendations are based primarily on the guidelines of the Surgical Working Group for Endocrinology of the German Society for General and Visceral Surgery as well as on the authors' own experience and, where indicated, the guidelines of other working groups.

Objective: Stiffness has been associated to malignancy in prostate and breast, as well as thyroid. Ultrasound elastography objectively measures tissue elasticity, and previous studies have described it as a high sensitivity and specificity technique for the detection of malignant thyroid nodules in high-risk populations. The aim was to assess the accuracy of elastography in a population with low risk of malignancy., Design and Patients: 128 consecutive patients with nodular goiter were recruited. Elastography and ultrasound-guided fine-needle aspiration were performed. When malignancy was suspected by citology, surgery was recommended. Thyroid nodules were classified by elastography according the criteria described by Ueno, and an alternative classification. Sensitivity, specificity, predictive values, and odds ratio were calculated., Results: Most patients were female, aged 56.1 year, with single nodule (52.0%) or multinodular goiter (45.6%), and a few thyroiditis (2.4%). The majority of nodules were mostly elastic. Fine-needle aspiration found 86% of benign nodules, 9.3% of indeterminate, and 4.7% possibly malignant. After surgery, 3 malignant nodules were confirmed, all of them being papillary carcinomas. All the malignant nodules were mostly elastic, as well as 75% of indeterminate nodules. Low values of sensitivity and specificity were found for elastic nodules being benign and hard nodules malignant., Conclusion: In a low-risk population for thyroid cancer, elastography lacks accuracy for the diagnosis of malignant nodules., (© J. A. Barth Verlag in Georg Thieme Verlag KG Stuttgart · New York.)

Incidence of unexpected diagnosis of thyroid carcinoma among operations on benign thyroid surgical diseases (nodular goiter and Graves' disease) was studied in 608 patients within 2008-2009 years in specialized clinic of endocrine surgery. In 56 (9.2%) patients the "incidental" thyroid carcinoma including 43 (77%) - papillary microcarcinoma were diagnosed in histological investigations. In 10 (18%) patients which were performed within the first postoperative week. Repeated surgery demonstrates increased risk of complication (damage of parathyroid glands, recurrent laryngeal nerves and other anatomic structures of neck) considering less favoring conditions for secondary operations, it is worth to implement wider indications to frozen section, radical primary operation (total thyroidectomy at multi-nodular bilateral goiter and Graves' disease), and also maximal complete examination prior to surgery.

Background: Multinodular goiters (MNG) have recently been shown to have an incidence of cancer that approaches that of solitary thyroid nodule. However, fine needle aspiration (FNA) of a MNG is limited due to the presence of multiple nodules. Therefore we sought to identify risk factors for malignancy in patients with MNG., Methods: A total of 1791 consecutive patients underwent thyroidectomy at a single academic institution between May 1994 and December 2009. Of these, 838 patients had a MNG, which we defined as ≥ 2 nodules on preoperative ultrasound. The medical records of these patients were reviewed and analyzed., Results: A final pathologic diagnosis of malignancy was found in 260 of 838 (31%) of MNG patients. Of the 260 patients with malignancy, 113 (44%) had a focus of cancer <1 cm. Of the patients with malignancy on final pathology, preoperative FNA detected only 46% (n = 120). Of the 140 cancers not recognized preoperatively, 61 (44%) were >1 cm in size. On univariate analysis risk factors for malignancy were younger age and male gender. Patients with malignant nodules also had smaller nodules, smaller thyroids, and fewer nodules than those patients with benign findings on pathology. On multivariate analysis all predictors remained independently associated with malignancy with the exception of thyroid weight., Conclusion: Risk factors for malignancy in a MNG included male gender, younger age, fewer nodules, and smaller nodule size. The low predictive value of FNA in our population suggests there needs to be better ways to predict malignancy in patients with MNG. Therefore, these clinical risk factors should be considered when consulting patients with MNG in regards to their risk of malignancy., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: Risk factors for differentiated thyroid carcinoma (DTC) are poorly understood, but serum TSH levels, thyroid nodularity, and presence of autoimmunity are well-recognized factors that modulate DTC prevalence. TSH stimulates proliferation of both normal and neoplastic follicular cells. Consequently, thyroid-stimulating immunoglobulins (TSI), because of its TSH-like action, should induce DTC progression in patients with Graves' disease (GD). The study objective was to compare the prevalence of incidental DTC in patients undergoing thyroidectomy for benign thyroid disease., Methods: The pathology reports of 372 patients with preoperative diagnosis of euthyroid multinodular goiter (EMG) or hyperthyroidism were reviewed. Scintigraphy results and serum TSI levels were used to diagnosed either GD or hyperactive MG (HMG) to hyperthyroid subjects. Prevalence of DTC in each category was calculated using a Chi-square test., Results: EMG, GD, and HMG were diagnosed in 221, 125, and 26 patients. There were 58 DTCs, distributed as follows [n (%)]: EMG, 49 (22.2%); GD, 8 (6.4%), and HMG, 1 (3.8%). Difference in prevalence of incidental DTC between the groups was statistically significant (p<0.001). After adjustment for age, patients with EMG had a greater DTC prevalence than GD patients, with an OR of 4.17 (p<0.001). Tumor size (mm, mean ± SD) was 6.92 ± 11.26, 1.97 ± 1.85, and 9.0 for EMG, GD and HMG respectively (p=0.017)., Conclusions: Incidental DTC was less prevalent in GD as compared to EMG irrespective of age. This finding may suggest a predisposition to develop DTC in patients with thyroid nodular disease and/or a potential effect of autoimmunity to protect against development of neoplastic disease., (Copyright © 2011 SEEN. Published by Elsevier Espana. All rights reserved.)

The aim of the study was to analyze the frequency of incidental thyroid carcinoma (unknown tumor smaller than or equal to 10 mm) in a consecutive series of 462 total thyroidectomies for multinodular goiter and to investigate the clinical risk factors for this type of malignancy. A retrospective, single-center study of outcome data collected from patients with preoperative diagnosis of multinodular goiter who underwent total thyroidectomy at the General Surgery Unit of Pavia (Italy) between January 2000 and December 2008 was performed. Possible risk factors for malignancy were: gender, age, time of evolution of goiter, presence of a dominant nodule in multinodular goiter, hyperthyroidism, history of radiation to the neck, residence in an area of endemic goiter, prior thyroid surgery, calcifications in the goiter detected by neck ultrasound or chest X-rays, and a family history of thyroid diseases. In a 9-year period, 462 patients underwent total thyroidectomy. We found 41 cases of incidental thyroid carcinoma; the most common histopathological type was papillary. The multivariable analysis demonstrated that the clinical variables associated with occult carcinoma were a personal history of radiation therapy to the neck, the presence of calcifications detected by ultrasound or neck X-rays, and a family history of thyroid diseases; residence in an area of endemic goiter was a protective factor. A personal history of radiation to the neck, detection of calcifications by ultrasound or by neck X-rays, and a family history of thyroid diseases should be considered clinical risk factors for malignancy in multinodular goiter.

In this retrospective study, we sought to investigate the prevalence and the clinical significance of thyroid uptake discovered by FDG PET/CT within the thyroid gland during imaging investigation of non-thyroid disorders. This study included 5,877 subjects with no previous history of thyroid malignancy referred to our PET/CT center (1,596 for cancer screening and 4,281 for primary staging or restaging purposes) from June 2006 to April 2009. All of the patients had at least 12 months of follow-up or were censored on the date of the last follow-up. The disease status was analyzed for correlation with the maximum standardized uptake value (SUVmax). Receiver operating characteristics (ROC) curves were constructed to determine the optimal cutoff values for SUVmax. In the screening group (n=1,596), 55 patients (4%) had thyroid FDG uptake. Twenty-two subjects were referred for cytological or histological assessment and 4 (18%) were diagnosed with thyroid carcinoma. In the primary staging/restaging group (n=4,281), 165 patients (4%) had thyroid FDG-avid sites. Thirty-three patients were referred for cytological or histological assessment and 4 (12%) were found to have thyroid carcinoma. Of the 8 malignant lesions, 7 were papillary thyroid carcinoma, and 1 medullary thyroid carcinoma. Surgical resection was performed in seven out of eight patients. Three patients had lymph node metastasis (one case detected by preoperative PET/CT) and three bilateral malignant diseases (all false negative in PET/CT scans). Of the 47 benign lesions, 35 were nodular goiter or nodular hyperplasia, 6 multinodular goiter, and 6 autoimmune thyroid disease. The average value of SUVmax of malignant thyroid lesions was significantly higher than that of benign thyroid lesions (8.2±4.5 vs. 5.6±3.2, P=0.048). However, we were unable to identify an optimal SUVmax cutoff because the total area under the curve was small. The prevalence of thyroid uptake on FDG PET/CT in this study is 3.7%, which is consistent with previous observations. Of patients who received verification by cytology or histology, 14% (8/55) were found to have thyroid malignancies. However, we were unable to establish an optimal SUVmax cutoff value to differentiate benign from malignant lesions. FDG PET/CT scans were false negative in a significant proportion of patients with thyroid carcinoma and regional lymph node metastases or separate tumor nodule(s) in a contralateral lobe. Further diagnostic tests (thyroid ultrasound/fine needle aspiration) are recommended in presence of focal thyroid uptake detected by FDG PET/CT scans.

Introduction: Suspicion of a neoplasm is one of the contraindications to radioiodine therapy in benign thyroid disease. The aim of this study was to present an optimal qualification scheme for fine-needle aspiration biopsy (FNAB) to rule out neoplastic lesions prior to radioiodine therapy., Material and Methods: 4207 patients with hyperthyroidism were referred for 131I therapy in 2000-2006. Prior to 131I therapy, all patients underwent thyroid function assessment, radioiodine uptake, scintigraphy, and ultrasound. Fine-needle aspiration biopsy with cytology was done in 578 (13.7%) patients. Therapeutic radioiodine was administered to 3564 (84.7%) patients., Results: Malignancy was confirmed or suspected in 12 female patients (0.28% of all patients and 2.07% of patients who underwent FNAB). Prior to the study, cytology was done in only one patient. The diameter of the lesions was 6-28 mm. Cytology confirmed papillary carcinoma in 4 patients, follicular tumour in 6, and Hürthle's cell tumour in 1. There were indications for histopathology in one patient due to the presence of atypical cells. The primary diagnosis was toxic nodular goitre in 8 patients and Graves' disease in 4 patients. One of the patients with follicular tumour was referred for radioiodine therapy due to intolerance to thyrostatic drugs, elderly age, and comorbidities., Conclusions: 1. Thyroid scintigraphy prior to therapy is important for the choice of the site of FNAB. 2. Thyroid lesions in patients with nodular Graves' disease must be carefully investigated to exclude malignancy. 3. Preselection of patients for treatment of benign thyroid disease should be followed by cytology of the lesions at the Department of Nuclear Medicine.

Objective: Although the majority of biopsies is adequate for a cytological diagnosis, 5-20 % will be insufficient or nondiagnostic. Patients with nondiagnostic FNABs (ND-FNAB) may be further managed by continued observation, repeated FNAB, or thyroidectomy. The aim of this study was to determine the risk of malignancy in ND-FNAB, and to determine if there are any clinical factors that can be used to distinguish malignant versus benign disease in multinodular goitre patients with ND-FNAB., Methods: A total of 411 multinodular goiter patients who underwent both a FNAB and thyroidectomy was the subject of study. Seventy nine of these patients with ND-FNAB were further reviewed retrospectively, and demographical and clinical factors were investigated to determine if there is any predictor of malignancy in this group of patients. Among these patients, FNAB has been repeated one more time in 5 (6.3 %) patients, and two more times in 9 (11.3 %) patients., Results: Among 79 patients with ND-FNAB, 10 patients (12.6 %) had malignancy as found postoperatively. There were no differences in age, sex, functional status of the thyroid gland, and nodule size between patients with benign versus malignant disease., Conclusion: Nondiagnostic FNAB remains a significant problem in the evaluation of thyroid nodules. Despite ultrasound guidance, clinicians should inform patients that there is a 5-15 % malignancy risk of initial nondiagnostic specimens.

Background: Cancer is an occasional incidental finding in nodular goiter, but there has been no formal study on this disease in our locality., Aims and Objectives: To determine the occurrence of histologically diagnosed malignancy in patients who present with nodular goiters., Methodology: This is a 7-year (2000-2006) retrospective study of all histologically diagnosed malignancies within nodular goiters at Aminu Kano Teaching Hospital, Kano., Results: There were 160 multinodular goiters during the study period, out of which 24 (15.0%) had histologically diagnosed cancer, and 1 out of the thirteen patients with solitary thyroid nodule (7.6%) had carcinoma. The ages of the patients with carcinoma ranged from 16 to 65 years, with a mean age of 38.8 years. Eighteen (72%) were females, and 7 (28%) were males. Six out of the 25 cases of carcinoma were detected preoperatively by fine needle aspiration cytology. Well differentiated follicular carcinoma was the predominant histological type in 13 (52%) cases, followed by papillary in 10 (40%), medullary carcinoma in 1 (4%) and anaplastic carcinoma in 1 (4%) patient., Conclusion: One-seventh of nodular goiters in our center harboured malignancy, and follicular carcinoma was the prevalent histological type. This is consistent with the findings elsewhere in endemic goitrous regions. Ultrasound guided fine needle aspiration would improve preoperative diagnosis and guide appropriate surgical management.

In many parts of the world, especially those of current or former iodine deficiency, multinodular goiter is still an endemic disease. In this brief review several clinically relevant issues in the complex association between nodular goiter and differentiated thyroid cancer will be highlighted. There are some intriguing links between the etiologies of multinodular goiter and that of thyroid cancer. This could also influence the incidence of thyroid cancer in multinodular goiter. However, multinodular goiter causes extra difficulties in the diagnosis of differentiated thyroid cancer; these same difficulties also cause additional issues in thyroid cancer treatment in multinodular goiter patients. Last but not least it will be discussed whether there is a possibility to impede the development of thyroid cancer in multinodular goiter.

Background: Routine measurement of serum calcitonin to detect medullary thyroid carcinoma (MTC) continues to be fiercely debated, although less attention has been paid to the positive predictive value (PPV) of this method., Methods: We collected data from 959 patients with nontoxic nodular goiter; thyroidectomy was performed in 307 of these patients., Results: Thirty-nine patients had elevated serum calcitonin; 6 of these patients had MTC detected by the initial diagnostic setup. No additional patient in the cohort was registered in the Danish Thyroid Cancer Database, reflecting that all patients with MTC were classified correctly initially. The sensitivity of serum calcitonin for detection of MTC was 100%, the specificity was 95.3%, the positive predictive value was 15.4%, and the negative predictive value was 100%., Conclusion: Serum calcitonin has high sensitivity and specificity for detection of MTC. The low PPV might lead to unnecessary thyroid surgery. Thus, the result of serum calcitonin measurement should always be interpreted in the context of other clinical variables.

Background: It has recently been suggested that the use of fine-needle aspiration (FNA) biopsy of thyroid nodules in male patients is associated with an unacceptably high false-negative rate in the detection of thyroid malignancy. We hypothesize that FNA biopsy is an accurate preoperative tool for detecting thyroid cancer in men, and that false negative rates are significantly lower than recently reported., Materials and Methods: A retrospective database analysis was performed on all male patients who underwent thyroid surgery from May 1994 through January 2007 at a single institution. The results of preoperative FNA biopsies were compared with final surgical pathologic results. FNA biopsy results were reported as benign, malignant, inconclusive (i.e., follicular neoplasm), or nondiagnostic; final surgical pathology was reported as benign or malignant., Results: Of 1205 patients who underwent thyroidectomy, 273 (23%) were male. Preoperative FNA biopsy results were obtained in 60% of these male patients and were read as benign in 45/165 (27%) patients, malignant in 47/165 (28%) patients, inconclusive in 66/165 (40%) patients, and nondiagnostic in 7/165 (4%) patients. In male patients with cytology reported as benign, 3/45 (6.7%) FNAs were determined to be malignant on final pathology., Conclusions: Our study determined that FNA biopsy of thyroid nodules in male patients has an acceptably low false-negative rate of 6.7% and is, therefore, an accurate and useful diagnostic tool. We recommend preoperative FNA biopsy for all male patients presenting with thyroid nodules as a standard of practice.

The risk of papillary thyroid cancer (PTC) is related to serum TSH, and the development of thyroid autonomy by reducing TSH levels decreases the frequency of PTC in patients with nodular goiter. Our aim was to investigate the effect of L-thyroxine (LT(4)) on the frequency of PTC diagnosed by cytology in a large series of patients with nodular goiter untreated (n=20 055) or treated with L-T(4) (n=7859). L-T(4)-treated patients with respect to untreated patients presented significantly lower serum TSH (median, interquartile range: 0.30 muU/ml, 0.08-0.62 microU/ml versus 0.70 muU/ml, 0.38-1.14 muU/ml; P<0.0001) and prevalence of PTC (3.2 vs 5.1%; P<0.0001). The frequency of PTC was closely related to serum TSH, with it being lowest in patients with TSH below the normal range (<0.4 muU/ml; 189/10 059, 1.9%) and highest in patients with TSH above the normal range (>3.4 muU/ml; 21/127, 16.5%), also showing a progressive increase from the lower to the upper quartile of normal range. A significantly higher proportion of L-T(4)-treated patients (6650/7859, 84.6%) had serum TSH below the median (0.90 muU/ml) with respect to untreated patients (12,599/20,055, 62.8%; chi(2) P value <0.0001), with it being included in the range of TSH associated with a lower frequency of PTC. The relationship between serum TSH and frequency of PTC was unrelated to the type of nodularity (solitary versus multinodular) and was not age dependent. In conclusion, patients with nodular goiter, treatment with L-T(4) is responsible for the reduction of serum TSH and is associated with a decreased frequency of PTC.

Background: Clinically relevant thyroid carcinomas can be found in 5-6% of nodular goiters which undergo surgery. Moreover, multinodular goiters fre- quently contain hot areas. Therefore, efficient and rational methods for the differential diagnosis and decision are required to identify those nodules with an increased cancer risk or those which are hot among the many thyroid nodules., Methods: Description of a newly revised and further guidelines and consensus statements as well as selected literature search., Results: Already history, ultrasound and TSH (thyroid-stimulating hormone) determination do allow a first risk assessment for the further diagnostic work-up. Fine-needle biopsy (FNB) offers the best sensitivity and specificity for the distinction between benign and malignant thyroid nodules. The combination of several clinical and ultrasound criteria and laboratory determinations (calcitonin) can help with the selection of thyroid nodules with scintigraphically normal or decreased uptake > 1 cm for FNB. However, the efficiency of FNB requires sufficient training and experience of both the cytopathologist and the person performing FNB., Conclusion: Whereas solitary thyroid nodules with a suspicion for malignancy should be referred to the surgeon, euthyroid thyroid nodules without clinical ultrasound or cytological indicators of malignancy may be followed up - possibly under medication -, if surgery is not indicated by local complaints, tracheal or mediastinal involvement.

Rio Grande do Norte (RN) shows the highest relative incidence of papillary carcinomas in Brazil. To analyze histological features that might be associated with this incidence, the authors compared thyroid glands from 463 autopsies performed in RN with 427 surgical and autopsy glands previously studied in Sao Paulo (SP). The authors found 41 papillary thyroid microcarcinomas (PTMs) in 35 glands (8.1%), an incidence similar to the one reported in SP (7.8%). However, PTMs were predominantly nonencapsulated nonsclerosing at microscopy (44.0%), in contrast with SP where these types of lesion represented only 4 out of 32 PTMs (12.5%; P = .0046). The authors suggest that these nonencapsulated lesions with no sign of inflammation may represent an early stage that may evolve to clinical cancers, contributing to the high incidence of clinically differentiated thyroid carcinomas observed in RN.

Purpose: To prospectively evaluate the efficacy of routine ultrasound-guided fine-needle aspiration cytology (FNAC) of thyroid nodules in an endemic area and to analyze the factors influencing it., Methods: Patients with thyroid nodules were randomly subjected to either conventional palpation-guided fine-needle aspiration cytology (PFNAC) or ultrasound-guided fine-needle aspiration cytology (USFNAC). The results of cytology were compared with the final histopathologic diagnosis in 112 patients who had undergone surgery. The performance of both methods was individually analyzed in solid nodules, cystic nodules, and solitary and multinodular goitres., Results: Overall, USFNAC showed a significantly higher sensitivity (83.3% vs 54.6%, p < .001), positive predictive value (100% vs 85.7%, p < .001), and greater diagnostic accuracy (96.5% vs 89.1%, p = .052) compared with PFNAC. The sensitivity of USFNAC was significantly higher compared with that of PFNAC in cystic and complex nodules (75% vs 50%, p < .001) but not in solid nodules (77.8% vs 75%, p > .05). USFNAC was more sensitive and more accurate than PFNAC for detection of malignancy in multinodular goitres (66.7% vs 50%, p < .05; 95.6% vs 86.2%, p < .05, respectively)., Conclusion: The superiority of "routine" USFNAC over PFNAC is mainly due to its better performance in cystic nodules and multinodular goitres. Hence, routine USFNAC can be recommended in areas where such lesions constitute the majority of thyroid nodules.

Objective: Environmental and genetic factors influence thyrotoxicosis, but how population migration affects the disease panorama is not known. In an urban area in southern Sweden, during the years 1990 until 2003, the population increased from 232 000 to 267 000. In parallel, the proportion of inhabitants born outside Sweden increased. The aim was to investigate whether the incidence of Graves' thyrotoxicosis (GD), toxic multinodular goiter (TMNG), and solitary toxic adenoma (STA) has changed in Malmö since 1990 and to study the influence of geographic origin., Design and Method: An open label prospective registration of thyrotoxicosis, gender, age, smoking habits, and ethnic background during 2003-2005 in an urban area in southern Sweden (Malmö) was undertaken., Results: The total incidence of thyrotoxicosis has changed from 43 to 41.6 cases/100,000/year from the years 1988-1990 to 2003-2005 (p-value 0.72). GD increased from 22 to 29.6 (p-value 0.0051), TMNG decreased from 16 to 9.9 (p-value 0.0011) and STA from 4.8 to 2.1 (p-value 0.0054)/100,000/year. The total incidence of GD was higher in inhabitants born outside Sweden up to the age of 69 years and age-specific incidence showed a peak in women aged 50-59 years old in both groups. The greatest difference between immigrants and Swedes up to the age of 69 years was observed in women aged 20-29 years old., Conclusion: The incidence of GD has increased and of TMNG has decreased in Malmö since 1990. Geographic origin seems to affect the incidence of GD. Whether the observed peak in age-related incidence in women 50-59 years is explained by menopausal changes has to be further investigated.

Objective: The high prevalence of goiter in acromegalic patients is well known. Several studies revealed increased frequency of thyroid carcinoma in these patients. The aim of the study was to evaluate the incidence of thyroid lesions, including thyroid cancer in acromegalic patients and to estimate possible factors influencing their occurrence, especially high IGF-1 level., Materials and Methods: 86 consecutive patients with acromegaly were retrospectively analyzed. 45 patients had been previously treated for acromegaly and 41 were newly diagnosed. In all subjects hGH, IGF-1, TSH, FT4 levels were determined. Thyroid gland was evaluated in ultrasound examination. Fine needle aspiration biopsy (FNAB) was performed in every solid or mixed thyroid nodule., Results: Thyroid morphology abnormalities were found in 75 patients (87.2%). 10 patients (11.6%) had diffuse goiter and 65 patients (75.6%) had nodular goiter. There were 5 cases of thyroid carcinoma (5.8%): 3 papillary carcinomas and two follicular variants of papillary cancer. Out of five cancers three were multifocal, one infiltrated thyroid capsule and one was diagnosed at the stage of metastases to four lymph nodes., Conclusions: Our study confirmed common co-existence of acromegaly and thyroid lesions. Furthermore, it revealed considerably high occurrence of thyroid carcinoma in these patients. In view of this correlation, the potential role of IGF-1 in pathogenesis of benign and malignant thyroid neoplasms should be considered. Due to high frequency of thyroid cancer in acromegalic patients, we suggest to perform fine needle aspiration biopsy in each case of thyroid nodule.

Background: Diabetic neuropathy is reported to be an independent risk factor for the development of a vocal fold palsy (VFP), and nerves in diabetic patients are suspected to have an increased vulnerability to mechanical trauma. This retrospective study was performed to find out whether diabetic patients were at a greater risk to acquire VFP than were nondiabetic patients in a large cohort who underwent thyroid surgery., Methods: Records of patients who underwent initial thyroid surgery at our institution between 1995 and 1999 were reevaluated. Results of preoperative and postoperative laryngoscopy, repeated laryngoscopy 6 months after operation, and concomitance of diabetes were registered., Results: Six hundred thirty patients were retrospectively analyzed. Preoperative laryngoscopy revealed a unilateral VFP in 3 of 44 diabetic patients (6.8%) and in 4 of 586 (0.7%) nondiabetic patients. Five of 44 diabetic patients (11.4%) and 49 of 586 nondiabetic patients (8.4%) acquired VFP perioperatively, which was permanent in 2 diabetic patients (4.5%) and 8 nondiabetic patients (1.4%). The incidence of preoperative VFP in the diabetic patients was significantly greater than in nondiabetic patients (P = .0091). The incidence of postoperative and permanent VFP did not differ significantly., Conclusion: Thyroid surgery can be performed safely in diabetic patients, as they are not at a greater risk to acquire VFP than nondiabetic patients.

Systematic examination of the thyroid gland allows discovering diffuse or multinodular goitres as well as solitary nodules. Goitre may be the only clinical manifestation of an underlying thyroid disease. Its evaluation should consider the familial history as well as nutritional and environmental factors. Thyroid ultrasonography is of critical importance to assess the diagnosis. Hashimoto's thyroiditis, colloid and endemic goitre are the most frequent causes of the diffuse form, particularly during puberty. Multinodular goitre and solitary thyroid nodule are rare in the paediatric age group: both conditions can reveal a malignant lesion. In this case, a total thyroidectomy should be performed. Long term outcome is excellent with an exception for medullary carcinoma which can be part of a multiple endocrine neoplasia (MEN type 2 A).

In parathyroidectomy, it has been recognized that a shift to a minimally invasive procedure may be accompanied by a possibility of missing thyroid pathology. However, only a few findings concerning preoperative thyroid evaluation have been reported. We investigated the prevalence of concomitant thyroid pathology by preoperative neck ultrasonography (US) in patients with primary hyperparathyroidism. There were 85 patients (66 women, 19 men; mean age 57 years) in the study group. The mean preoperative calcium level was 11.2mg/dL, and the mean intact parathyroid hormone level was 206 pg/mL. All patients underwent neck US following fine-needle aspiration biopsy (FNAB). Of the 85 patients, 21 (24.7%) had thyroid nodules. Among 21 patients with thyroid nodules, 9 (10.6%) had malignant thyroid tumors, while 12 (14.1%) patients had benign thyroid nodules including multinodular goiter. Of the 9 patients with malignant thyroid nodules, 4 had papillary carcinomas with lymph node metastases. The prevalence of thyroid disease associated with hyperparathyroidism is high, and evaluation of the thyroid pathology by US enables the shift from bilateral neck exploration to the minimally invasive parathyroid surgery.

We evaluated the usefulness of ultrasound-guided fine-needle-aspiration biopsy (US-FNAB) for infracentimetric nodules. In addition, we used sonography to assess the risk of malignancy of thyroid nodules, and we evaluated the extent of disease in infracentimetric cancers. The cytopathological results of 472 US-FNABs from 207 nodular goiter patients (170 women, 37 men; mean age, 51.5 +/- 13.1 yr) seen between 1999 and 2004 were categorized into five groups: inadequate, benign, suspicious, follicular neoplasm, and malignant. There were 145 infracentimetric nodules and 327 supracentimetric nodules. All patients underwent surgery. Final histopathological results correlated with cytologic results. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of US-FNAB for infracentrimetric nodules were 96.3%, 71.2%, 44.8%, 98.8%, and 76.1%; and for supracentimetric nodules, these values were 98.1%, 63.1%, 35.6%, 99.4, and 69.1%, respectively. There were no significant differences between infracentimetric and supracentimetric nodules. More thyroid cancer could be detected in infracentimetric nodules that were hypoechoic or had fine calcification on ultrasonography (which may be helpful in discriminating which nodules are appropriate for FNAB) than in supracentimetric nodules. However, logistic regression analyses showed that no single variable was predictive of malignancy in infracentimetric nodules. The malignancy rate in infracentimetric nodules was 21.4%. In this subgroup, 4 of 31 patients (12.9%) had multifocal tumors at surgery, 3 of 31 had extrathyroidal invasion, and 1 had a metastasis to the lung. In addition, at surgery, 11 of 55 tumors (20%) larger than 1 cm were multifocal. In conclusion, small tumor size does not guarantee a low risk of thyroid cancer, and US-FNAB may be useful tool for diagnosing malignant infracentimetric nodules.

The association of a toxic multinodular goitre with papillary thyroid carcinoma and primary hyperparathyroidism is very rare. Only one case is reported in the literature, we present the second one. It is a 51 year old woman, who initially presented with a toxic nodular goitre. The diagnosis of primary hyperparathyroidism was made following renal complications and the discovery of papillary thyroid carcinoma was incidental during the surgical treatment of parathyroid adenoma. Whilst the association of those three diseases is exceptional, the coexistence of any two of them is relatively frequent without any known common etiopathogenetis. It is recognised that hyperparathyroidism can be found in hyperthyroid patients, but the diagnosis of hyperparathyroidism in these cases is very difficult. The fortuitous discovery of papillary thyroid carcinoma during parathyroid surgery has already been reported but in most cases it is a microcarcinoma. In patients presenting with hyperthyroidism the risk of an associated carcinoma is generally felt to be negligeable. However, this associations is not rare. The association of primary hyperparathyroidism, hyperthyroidism and papillary carcinoma of the thyroid is rare. However, the authors suggest that the presence of any of the pathologies should trigger a search for the other two.

Background: The catchment area of the patients under study was the sub-Himalayan plains, which are recognized as iodine-deficient areas., Methods: A retrospective analysis of 1576 surgically treated patients with thyroid disorders is presented. The indications for surgery were hyperthyroidism or cytologically diagnosed malignancy and large size, pressure symptoms, cosmesis, suspicious cytologic findings for malignancy, and clinical suspicion of malignancy in clinically benign euthyroid goiters., Results: Histologically, 83 of 703 solitary thyroid nodules, 36 of 329 clinically benign euthyroid multinodular goiters, and four of 181 Graves' disease were cancers. Of all follicular cell cancers in this study, 132 were papillary, 83 were follicular, and 38 were anaplastic and squamous cell cancers. The different histologic types exhibited an aggressive clinical behavior, with advanced lesions with cervical lymph node involvement and distant metastases frequently seen at presentation. Locoregional recurrence occurred frequently even after radical surgical ablation, and overall mortality caused by the disease was high., Conclusions: Even well-differentiated cancers pursued a virulent clinical course with high mortality, despite routine radical surgical and radionuclide ablation., (2005 Wiley Periodicals, Inc.)

Thyroid carcinoma (TC) is a relatively rare tumour, but it represents the most frequent form of cancer of the endocrine glands. Epidemiologically ascertained risk factors are ionising radiation, the presence of thyroid adenoma and multinodular goiter (MNG). Multinodularity of goiter should no longer be considered an indicator of probable benign disease. A retrospective analysis was performed on patients operated of MNG at the Unit of Otolaryngology, Sanremo Hospital (Italy) from January 1st 1995 to December 31st 2002, in order to establish the incidence of carcinoma. The results of this retrospective study, demonstrate that in 13.7% of the patients operated for goiter, the presence of a carcinoma was noticed in the definitive histopathologic examination. Such incidence percentage of MNG is in accordance with the data reported in published reports. Thus, the authors conclude that the risk of malignancy in MNG has not to be underestimated, and that a dominant nodule in MNG should be valued as if it were a solitary nodule in an otherwise normal gland.