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Purpose: To estimate the prevalence and the clinical and economic consequences of management strategies for thyroid lesions detected incidentally on cross-sectional imaging of the head and neck., Methods: Two hundred consecutive CT scans and 200 consecutive MR images of the neck performed over a 1-year period in patients being examined for other purposes were reviewed retrospectively to determine the prevalence of unexpected thyroid lesions. After excluding patients with prior thyroidectomies, known thyroid disease, and inadequate examinations, 231 imaging studies were analyzed., Results: Incidental thyroid lesions were originally reported in 14 (6%) of the 231 patients, but an additional 22 (9.5%) were found on retrospective review for a total of nearly 16% (36 of 231). Six of the 36 patients received further workup, consisting of nuclear medicine scintigraphy (n = 3), sonography (n = 3), thyroid function tests (n = 5), fine-needle aspiration (n = 4), and thyroid lobectomy (n = 1). Final diagnoses, obtained in four of the six patients, included three multinodular goiters and one follicular adenoma. Two patients, one with nondiagnostic findings at fine-needle aspiration and a second with normal thyroid function test results, are being followed up. The mean cost of the workup and treatment per examined patient was $1158., Conclusion: Incidental thyroid lesions are frequently present and often overlooked on cross-sectional images of the neck in patients being examined for other reasons. The cost of pursuing a workup of these lesions and their high prevalence in the population raise questions regarding appropriate management strategies.

Hyperthyroidism is usually classified as follows: with diffuse or with toxic plurinodular goiter, respectively considered as autoimmune and non-autoimmune thyroid disorders. This classification seems partially inadequate as signs of thyroid immunity may be found in some plurinodular toxic goiter and alternatively may by lacking in some cases of Graves' disease. These observations led us to study the intensity of intrathyroidal autoimmune process (IAP) and the levels of TBIAb, TPO- and Thyroglobulin-antibodies in 105 cases with diffuse goiter, hyperthyroidism and elevated RAIU (92 women and 13 men, age 34 +/- 11, mean +/- SD). The intensity of intrathyroidal autoimmune process (IAP) was determined by one pathologist (HT) by semi quantitative method applicable to routine clinical use. Subtotal thyroidectomy was performed because of a large goiter (n = 29), a concomitant cold nodule (n = 20), a recurrent disease (n = 18), intolerance to antithyroid drugs (n = 5) or because patients chose surgical treatment (n = 33). All cases were rendered euthyroid at the time of surgery using antithyroid drugs or iodine. The results show a lack of IAP and undetectable levels of TBIAb, TPO- and Thyroglobulin-antibodies in 10%, 11%, 25% and 47% respectively. The intensity of IAP was not different in case of first episode or recurrence of hyperthyroidism and was not related to type or duration of medical treatment. Comparison of patients with or without IAP show higher levels of TPO- and thyroglobulin-antibodies but not of TBIAb in the former group (P < 0.005). TBIAb were higher when ophthalmopathy and/or dermopathy were present vs absent (p < 0.05) and were correlated with FT4 levels (p < 0.05). The negative predictive value of TBIAb, TPO- and thyroglobulin-antibodies to predict the lack of significant IAP was 42%, 65% and 64%. The total absence of clinical, biological and histological signs of thyroid autoimmunity was found in only one case (female aged 35 with first episode of hyperthyroidism and no family history of thyroid disease) (0.9%). These results suggest that routine available criteria of thyroid immunity (including IAP) have a low specificity. It follows that they are probably inadequate to screen cases of hereditary toxic familial hyperplasia, a rare entity of still unknown prevalence.

The main indication of thyroid hormone preparations is the treatment of hypothyroidism, ideally the goal of therapy is to restore the serum thyrotropin (TSH) concentration to a normal value. The optimal doses used to be stable, but several conditions may alter their requirements (reduced intestinal absorption, pregnancy,...). Levothyroxine therapy is also used in the benign nodular disease and after surgery in patients with thyroid cancer. The overtreatment with thyroxine and the problems related to bone mineral density seems of special importance.

Nodular goiters are encountered commonly in clinical practice by primary care physicians, endocrinologists, surgeons, and otolaryngologists. Epidemiologic data suggest that in the United States, the incidence of such goiters is approximately 0.1% to 1.5% per year, translating into 250,000 new nodules annually. Nodular goiters are more common in women than in men, with advancing age, and after exposure to external irradiation. These goiters may be asymptomatic, with normal TSH levels (nontoxic), or may be associated with systemic thyrotoxic symptoms (toxic MNG or Plummer's disease). Diagnostic evaluation of patients with nodular goiters consists of clinical evaluation, biochemical testing, FNA, and imaging studies. The serum TSH level is a sensitive and reliable index of thyroid function. FNA results are pivotal to assess cancer risk in patient management for prominent palpable and suspicious nodules. Chest radiography, high-resolution ultrasonography, and computed tomography help to delineate the size and extent of a goiter in evaluating compression symptoms. Indications for treatment in patients with MNG include hyperthyroidism, local compression symptoms attributed to the goiter, cosmesis, and concern about malignancy based on FNA results. The use of levothyroxine suppression therapy to effectively decrease and control MNG size is controversial. Thyroid hormone should not be used, however, in patients with suppressed serum TSH levels, to avoid the development of toxic symptoms. Management of toxic MNG by surgery is well established. Radioiodine is also effective therapy for many of these patients. When treatment is necessary for nontoxic MNG, surgical excision is preferred. Our recommendations are as follows. For patients who have small, nontoxic multinodular goiters that are clinically asymptomatic, who are biochemically euthyroid according to serum TSH levels, and who have prominent palpable or suspicious nodules benign by FNA, yearly evaluation with serum TSH determinations and thyroid palpation is sufficient. Patients with modest but stable MNG size and normal serum TSH levels may also be managed by yearly clinical observation. In this second group, levothyroxine suppression therapy is often unsuccessful and has the potential for untoward effects from exogenous hyperthyroidism. For large nontoxic multinodular goiters with local compression symptoms, the preferred treatment is surgery. In patients with toxic MNG, treatment with either surgery or radioiodine is recommended, although patients with large goiters and large, autonomously functioning nodules become euthyroid more quickly following surgery.

Thyroid nodules are among the most common clinical problems in endocrinology. Among several factors responsible for the development of goiter, circulating TSH plays a major role because of its direct growth-promoting effects on the thyroid cells; moreover TSH may enhance the effects of other local growth factors which act in a paracrine mode in the thyroid gland. In addition, autoimmune thyroiditis can clinically appear as thyroid nodules frequently with the functional aspect of a subclinical hypothyroidism. For these reasons a therapeutical approach based on the thyroxine suppression of TSH secretion has become largely used by 1970s and is correctly employed in 75% of the patients with thyroid nodules whose biopsies result benign.

Post-operative therapy with L-Tiroxine can have a suppressive or substitutional aim. After a total thyroidectomy the patients need a substitutional therapy, while after subtotal thyroidectomy the aim of the therapy is to suppress the TSH secretion. In the second case we want either to avoid the recurrence, either to give the hormones that residual gland cannot produce. The drug of choice is L-Tiroxine for both suppressive o substitutional therapy: There is a difference in dosage, that must be greater in first case. While there are some doubts in the literature on the success of the suppressive therapy, we believe that there is enough evidence of his utility.

The authors treated nine women with autonomous adenomas of the thyroid gland by repeated ethanol injections under ultrasonographic control. In all patients clinical and laboratory characteristics of hyperthyroidism were present. After treatment is seven patients euthyroidism was induced, in two patients subclinical hypothyroidism which persisted also during the 6-month follow-up period. In all patients ultrasonographic changes in the nodes were recorded: a reduced echogenity the development of "halo"--hypoechogenic outlines--a change of the shape and on average a 37% reduction of the volume. Treatment was feasible also under out-patient conditions: it was well tolerated by the patients, undesirable effects were not serious and only transient and receded spontaneously.

Nodular thyroid disease can be defined as the presence of one or more nodules in a thyroid gland of normal or increased size. To diagnose and treat patients with nodular goiters cost-effectively is often challenging because many thyroid illnesses present with a nodule; often the patient is unaware of its presence. Although most thyroid nodules are benign, it is occasionally difficult to exclude malignant neoplasm in an enlarged gland. It is essential for the primary care physician to be comfortable with examining and treating patients with thyroid nodules. A rational, stepwise approach to the evaluation of nodular thyroid disease was developed.

This is a retrospective study of 361 thyroid specimens during a 6 1/2-year period with the objective of investigating the prevalence and pattern of thyroid malignancy associated with multinodular goitre (MNG) and solitary nodule (SN). Fourteen of 172 MNG (8%) and 16 of 105 SN (15.2%) were associated with malignancy, a statistically insignificant difference (P = 0.06). Unlike in males, malignancy was significantly commoner in females with SN than those with MNG (P = 0.03) and generally occurred at a significantly older age (P < 0.05). On analysing thyroid carcinoma and lymphoma separately, patients with SN had a higher incidence of carcinoma compared with those with MNG (P = 0.01). It is concluded that surgical intervention may be the appropriate method of treating male patients presenting with MNG. However, in females, conservative management of MNG should be adopted unless surgery is indicated depending on clinical judgement and, if feasible, the result of fine needle aspiration biopsy.

Graves' disease and toxic uni- or multinodular goiter are the most frequent causes of hyperthyroidism. Graves' disease is caused by thyroid stimulating immunoglobulins which are directed against the TSH receptor of thyroid follicular cells. Graves' disease affects more females than males and is associated with diffuse goiter and a rapid appearance of symptoms and signs of hyperthyroidism. Patients with Graves' disease are on average younger than patients with toxic nodular goiter. The diagnosis of Graves' disease is usually easy, particularly if signs of endocrine opthalmopathy are present. Toxic nodular goiter is seen more often in older patients with pre-existing goiters. Symptoms and signs of hyperthyroidism often appear only slowly. Hyperthyroidism in these older patients can be oligosymptomatic. Older patients should therefore be investigated for the presence of hyperthyroidism, even if they present only a few symptoms or signs which could suggest this diagnosis. The development of ultrasensitive TSH assays has simplified the diagnosis of hyperthyroidism and made the TRH-test, often used in the past, almost superfluous. At the present time, it is practically always possible to differentiate between Graves' disease and toxic nodular goiter as the cause of hyperthyroidism on the basis of clinical and laboratory findings alone, and in many cases thyroid scintiscans are therefore no longer necessary. A patient with newly diagnosed Graves' disease is treated with antithyroid drugs (carbimazole or PTU) for one year. If hyperthyroidism persists after this one year of antithyroid drug treatment, or if it recurs, another year of therapy with carbimazole or PTU is indicated.(ABSTRACT TRUNCATED AT 250 WORDS)

The thyroid gland is known to become more nodular with age. The clinical questions in a given patient are whether the nodule(s) is benign or malignant and euthyroid or toxic. Toxic multinodular goiter (MNG) is more common in the elderly than Graves' disease but is not associated with the classic eye or skin findings. Drug therapy is usually effective, but total thyroidectomy may be preferred. Nontoxic MNG is common among older women. Treatment remains controversial because of potential side effects of suppressive therapy. Although thyroid carcinoma is rare, most of the more aggressive tumors are seen after age 50. Fine-needle aspiration and cytologic examination are useful in separating benign from malignant tumors.

Depression is commonly encountered in medical settings and often may be a symptom of an underlying medical illness. This case report illustrates the disabling symptoms of anxiety and depression that can accompany a toxic nodular goiter, and underscores the importance of both accurate psychiatric diagnosis and appropriate medical evaluation in the assessment of psychiatric disorders in the elderly.

The association of diffuse hyperthyroid goiter and thyroid cancer is rare and interesting, considering that both diseases affect the same organ but have different pathogenesis and prognosis. We report two patients that consulted for diffuse hyperthyroid goiter and were subjected to a subtotal bilateral thyroidectomy due to antithyroid drug failure. Pathological study revealed the coexistence of diffuse gland hyperplasia and a papillary thyroid carcinoma of less than 7 mm phi. In both cases, the thyroid remanent was ablated with radioactive iodine during the postoperative period and thyroid substitution was started.

The evaluation and management especially of cold thyroid nodules remains an area of controversy. The past decade has witnessed two important advances. The increased availability of fine-needle aspiration of thyroid nodules has altered the clinician's approach to this disease, and provides for the single most precise method for selecting appropriate patients for surgery. The introduction of high-resolution thyroid ultrasonography provides for anatomic definition that is clearly superior to thyroid scintigraphy. However, radionuclide imaging remains critical for determining the functional status of abnormal thyroid tissue. This review attempts to provide a practical approach to the evaluation and management of the thyroid nodule. Only rare data exists concerning the therapeutic approach of cold thyroid nodules and non-toxic nodular goitre. There seems to be a size-reducing effect by thyroxin-treatment, but no data are reported from iodine deficient areas. Concerning the treatment of differentiated thyroid carcinoma total thyroidectomy combined with eradication of remaining thyroid tissue with iodine 131 is usually preferred. In case of smaller or occult carcinoma various modes of uni- or bilateral subtotal resection are used. Chemotherapy is of little use in treating differentiated thyroid carcinoma and remains as a last possibility if usual approaches are no longer effective. To control local-invasive growth of anaplastic thyroid carcinoma combined treatment with mitoxantrone and hyperfractionated irradiation seems to be a successful approach.

Although surgical treatment of nontoxic multinodular goiter remains the most effective therapy, I-131 is a reasonable alternative in cases where thyroidectomy is not appropriate. Selection of I-131 activity in the management of nontoxic multinodular goiter has largely been empirical. The use of dosimetric measurements in guiding I-131 therapy in the treatment of a patient with a recurrent, nontoxic, multinodular goiter is described.

Thyroid adenoma is commonly associated with surgery and radiometabolic treatment; recently, according to previous successful reports, percutaneous ethanol injection therapy under sonographic guidance, has been introduced as an alternative. This technique has already been favourably used in the treatment of focal lesions, such as liver cancer and hyperparathyroidism. In our experience, we have treated with such therapy 69 patients affected by thyroid adenoma (55 females, 14 males; 28 pretoxic, 41 toxic). Ethanol (0.5-2.8 mL/mL nodular tissue) was injected, under sonographic guidance, in 4-9 sessions (1 weekly). Thyroid hormone profile was assessed during treatment and at 3 and 6 months follow-up. Apart from local transient pain in 21% sessions, two cases of pyrexia (38.5 degrees-1 day) and 3 cases of transient dysphonia, no relevant adverse effects were observed. A slight thyroid hormone increase was seen in both groups immediately following treatment. Six months after therapy a biochemical and clinical remission of hyperthyroidism was observed in 33 out of 41 toxic patients (80%); a significant increase of TSH levels was seen in both groups (p < 0.001). With follow-up, significant volume shrinkage (70-80% volume reduction--p < 0.0001) as well as structural alterations of the nodule, were consistently recorded at sonography, in both groups; a linear relationship (p < 0.0001) between pretreatment volume and volume reduction was found. At scintiscan functional activity of extranodular parenchyma was found in 75% of patients affected by pretoxic adenoma and in 63.1% of patients with toxic adenoma. These data confirm that percutaneous ethanol injection therapy is effective in obtaining functional ablation and in inducing remission of hyperthyroidism, when present; so it represents a valid and safe alternative to standard therapeutic tools of thyroid adenoma.

Surgery, the treatment of choice for hyperthyroidism due to nodular goiter, requires an euthyroid state, which is generally achieved with thionamides. Leukopenia is the most serious toxic effect of thionamides, and it causes controindication. We report a 50-year old woman with severe hyperthyroidism and leukopenia, in whom an euthyroid state before thyroidectomy was obtained with the use of therapeutic plasmapheresis. This procedure was carried out immediately before surgery using an intermittent flow separator; three sessions removed a total of 6,300 cc of plasma. Plasmapheresis caused a rapid reduction of both total and free thyroid hormone levels. Thyroidectomy was performed without any complications. Plasmapheresis can be considered a valid and safe method to prepare hyperthyroid patients for thyroidectomy when other therapies are ineffective or counterindicated.

Ultrasonic dissection of goitre allows a controlled resection. This method saves time and diminuishes risk of operation. Not suturing the remnants of thyroid gland, optimal blood supply is obtained and hazard for the recurrent laryngeal nerve is decreased. Loss of blood is insignificant. To increase acceptance of this method, handling of apparatus has to be improved.

Nodular goiter is a worldwide problem involving millions of persons. Endemic goiter, and associated cretinism, is totally preventable by ensuring an adequate dietary iodine intake and eliminating malnutrition and dietary goitrogens. Therapy, on the other hand, is difficult in that the goiters often do not regress and the cretinoid changes are irreversible. Nonendemic goiter due to autoimmune thyroid disease, genetic defects in thyroid hormone biosynthesis, and environmental goitrogens or neoplasia is not usually preventable. The usual therapy, involving TSH suppression by administration of L-thyroxine orally, will frequently bring about regression of early, diffuse goiters but is often ineffective in bringing about regression of large, multinodular goiters. In these patients, surgical removal of the goiter may be necessary for alleviation of obstructive symptoms. Further research is needed to elucidate the factors involved in the development of these multinodular goiters and to control the autocrine and paracrine factors involved in nodule growth.

Eight patients with autonomous thyroid nodules 2.4-4.3 cm in diameter received percutaneous ethanol injections (PEIs) under guidance by means of ultrasound (US). Sterile ethanol at 95% was injected with a 22-gauge needle and a 7.5-MHz probe with a guide device. Each patient received one or two treatments, with 1-3 mL of alcohol (depending on the nodule size) per treatment, each week for a total of three to six injections per lesion. After a total of 36 injections in all eight patients, there were no complications. Follow-up ranged from 2 to 10 months. After therapy, symptoms subsided and hormonal levels became normal or reached the range of subclinical hypothyroidism. Scintigrams showed that the previously suppressed thyroid tissue had resumed functioning. At US, all nodules had shrunk. PEI was risk free and easy to perform. If these preliminary results are confirmed in a larger study with longer follow-up, the new treatment may become an alternative to surgical or radioiodine ablation of autonomous thyroid nodules.

Suppression daily doses of thyroxine (T4) were determined and the daily amounts of T4 required to replace T4 were established in 217 hypothyroid patients. Patients with Hashimoto's thyroiditis treated daily with 2-3 micrograms/kg lean body mass or 1-2 micrograms/kg body weight T4 had normal serum thyrotrophin (TSH) concentrations, normal response to TSH-releasing hormone (TRH) and normal systolic time intervals but doses higher than 3 micrograms/kg lean body mass or 2 micrograms/kg body weight decreased serum TSH concentrations, with no response to TRH and systolic time intervals typical of hyperthyroidism. In 13/32 (41%) hypothyroid patients with Graves' disease following 131I and/or surgery, the daily T4 replacement dose was similar to that in Hashimoto's thyroiditis patients but in 12 (38%) patients daily doses of 2-3 micrograms/kg lean body mass or 1-2 micrograms/kg body weight T4 increased serum T4 and suppressed TSH levels, and in six (9%) lower doses were required to control hypothyroidism. The T4 suppression dose for patients with thyroid cancer was more than 3 micrograms/kg lean body mass or 2 micrograms/kg body weight, whereas approximately 30% of non-toxic nodular goitre patients required less than 3 micrograms/kg lean body mass. It is concluded that replacement or suppression doses of T4 should be individually determined and that different criteria should be applied for their calculation depending on the thyroid abnormality.

The results of 131I treatment in combination with pre- and post-treatment with carbimazole (n = 122) were compared to the results of 131I used as the only antithyroid treatment (n = 203). The two groups of patients were fully comparable in regard to age, size of goitre and time of observation, and the same diagnostic criteria and dosage regimen of 131I were used. The incidence of early myxoedema in patients with diffuse goitre was significantly reduced after combination therapy, 5 per cent, compared to 16 per cent after 131I as the only antithyroid therapy (P less than 0.05). The incidence of late myxoedema was 6 per cent in both groups 3 years after the last treatment, and fully compensated myxoedema was found in 13 and 22 per cent (n.s.). No severe acute side effects were observed after 131I therapy in any of the two groups. It is concluded that--in diffuse toxic goitre--a lower early incidence of myxoedema was obtained on the combined regimen because of either a possibly lower absorbed radiation dose or a more fractionate therapy. A major advantage of the combination therapy is also, that the patients are rendered euthyroid shortly after the diagnosis and remain so during the prolonged period of treatment. 131I treatment in combination with carbimazole is advocated in all patients with diffuse and nodular toxic goitre if the patient is above fertile age and thyroidectomy is not indicated.

Among the 984 patients suffering from thyroid pathology observed in our Department between 1956 and 1964, we took into consideration the 184 patients who having been diagnosed as having a normally functioning goitre, were not given any treatment. We chose 88 patients living in our region, under 60 years old: 55 of these were included in our study. The long period involved--30 years--allowed us to check the natural course of this pathology, which was shown to be totally benign as well as frequent, and unconnected with other pathologies. Only in one case, at a distance of 20 years, did a neoplasia arise. The evaluation of the results justifies a decision of non-intervention, while recognising the paramount importance of a correct diagnosis, already possible with the diagnostic instruments then available.

On radioisotope scanning, thyroid nodules present one of five characteristic patterns. A "cold" nodule is most likely to be malignant and often necessitates surgery and functional ablation. However, any nodule that is growing and insuppressible probably should be removed.

Eleven malignant thyroid tumors were found in 100 consecutive patients more than sixty years old having thyroid operations. Based on preoperative findings, these 100 patients could be separated into two groups according to high and low risk for malignancy. Clinical manifestations in the high risk group were presence of a discrete cold thyroid nodule, hoarseness, dysphagia, an enlarging mass, or palpable ipsilateral cervical adenopathy; and in the low risk group, asymptomatic multinodular goiter, diffusely enlarged glands with elevated antithyroid antibody titers, and a family history of goiter. All eleven patients with malignant thyroid tumors were found in the sixty-six patients considered at high risk, whereas no malignant lesions were found in the low risk patients. Six of the malignant thyroid tumors were undifferentiated and in three of these a thyroid nodule had been present for more than fifteen years. There were no operative deaths and only one significant complication, a recurrent laryngeal nerve injury. Thyroidectomy is indicated for elderly patients with thyroid nudules who have features of the high risk group, whereas patients in the low risk group can be safely followed.

Results of therapy with thyroid hormones (LT4 and/or LT3) were evaluated in 104 patients (95 females and 9 males) with simple diffuse or nodular goiter. The mean interval of observation was 7.2 years. The reported results were analysed in relation to patient's age at the onset of the pathology, time elapsed since its appearance, place of origin and sex of the patient, results of laboratory studies, and clinical signs.

In order to evaluate the efficacy of, and the risk associated with, the definite treatment of euthyroid goiter with autonomy, the data of 88 patients treated between 1982 and 1986 (50 by subtotal thyroidectomy; 38 by 131I-treatment, mean radiation dose 200 Gy without protection by thyroxine) were analyzed in a retrospective study. The following criteria were used before and after treatment: the results of scintigraphy under suppression qualitatively (in focal autonomy) and quantitatively (global thyroid uptake) (TcUs), the means of FT4I, FT3I and delta TSH after TRH, the improvement of mechanical signs and symptoms and the decrease of thyroid volume. Measured by TcUs and delta TSH, autonomy could be removed completely in 85-90% of all patients. Surgery was slightly more successful (100%) compared to treatment by 131I (75-80%). This was also true for removal of mechanical symptoms and reduction of the goiter. The incidence of manifest hypothyroidism was greater after surgery (16%) than after 131I treatment (3%). At a higher grade of autonomy (TcUs greater than 3.2%) surgery was more effective (95-100%) than treatment with 131I (60-70%) but at a higher risk of hypothyroidism (24 vs 0%). It is imperative to improve the methods of estimating the amount of 131I to be administered in euthyroid goiter with autonomy. Selection of patients with autonomy in euthyroid goiter for definite treatment is difficult, since until now their risk to become hyperthyroid cannot be predicted properly.