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Context: Thyrotoxicosis requires accurate and expeditious differentiation between Graves' disease (GD) and thyroiditis to ensure effective treatment decisions., Objective: This study aimed to develop a machine learning algorithm using ultrasonography and Doppler images to differentiate thyrotoxicosis subtypes, with a focus on GD., Methods: This study included patients who initially presented with thyrotoxicosis and underwent thyroid ultrasonography at a single tertiary hospital. A total of 7719 ultrasonography images from 351 patients with GD and 2980 images from 136 patients with thyroiditis were used. Data augmentation techniques were applied to enhance the algorithm's performance. Two deep learning models, Xception and EfficientNetB0_2, were employed. Performance metrics such as accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and F1 score were calculated for both models. Image preprocessing, neural network model generation, and neural network training results verification were performed using DEEP:PHI® platform., Results: The Xception model achieved 84.94% accuracy, 89.26% sensitivity, 73.17% specificity, 90.06% PPV, 71.43% NPV, and an F1 score of 89.66 for the diagnosis of GD. The EfficientNetB0_2 model exhibited 85.31% accuracy, 90.28% sensitivity, 71.78% specificity, 89.71% PPV, 73.05% NPV, and an F1 score of 89.99., Conclusion: Machine learning models based on ultrasound and Doppler images showed promising results with high accuracy and sensitivity in differentiating GD from thyroiditis., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Introduction: Technetium thyroid uptake (TcTU) measured by single-photon emission CT/CT (SPECT/CT) is an important diagnostic tool for the differential diagnosis of Graves' disease and destructive thyroiditis. Artificial intelligence (AI) may reduce CT-induced radiation exposure by substituting the role of CT in attenuation correction (AC) and thyroid segmentation, thus realising CT-free SPECT. This study aims to compare the diagnostic accuracy for the differential diagnosis of thyrotoxicosis between CT-free SPECT and SPECT/CT., Methods and Analysis: The AI-based CT-free SPECT is a single-blind, multicentre, prospective, non-inferiority, clinical trial with a paired design conducted in the Republic of Korea. Eligible participants are adult (≥19 years old) thyrotoxicosis patients without a previous history of hyperthyroidism or hypothyroidism. Approximately 160 subjects will be screened for quantitative thyroid SPECT/CT using Tc-99m pertechnetate. CT-free thyroid SPECT will be realised using only SPECT data by the trained convolutional neural networks. TcTU will be calculated by SPECT/CT and CT-free SPECT in each subject. The primary endpoint is the accuracy of diagnosing Graves' disease using TcTU. The trial will continue until 152 completed datasets have been enrolled to assess whether the 95% (two-sided) lower confidence limit of the accuracy difference (CT-free SPECT accuracy-SPECT/CT accuracy) for Graves' disease is greater than -0.1. The secondary endpoints include the accuracy of diagnosing destructive thyroiditis and predicting the need for antithyroid drug prescription within 1 month of the SPECT/CT., Ethics and Dissemination: The study protocol has been approved by the institutional review board of Seoul National University Bundang Hospital (IRB No. B-2304-824-301), Konkuk University Medical Center (IRB No. 2023-05-022-006) and Chonnam National University Hospital (IRB No. CNUH-2023-108). Findings will be disseminated as reports, presentations and peer-reviewed journal articles., Trial Registration Number: KCT0008387, Clinical Research Information Service of the Republic of Korea (CRIS)., Competing Interests: Competing interests: WWL and KK hold a patent for the CT-free thyroid SPECT technology. The title of the invention is ‘Artificial intelligence algorithm enabling CT-free quantitative thyroid single-photon emission computed tomography (SPECT)’ (PCT/KR2023/007541). Other than this, there are no conflicts of interest to declare., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Radioiodine (I-131) therapy for hyperthyroidism is a well-established and safe treatment option. This study aimed to investigate the relationship between the computed tomography (CT) value and the function and volume of the thyroid gland by identifying the factors that induce changes in the CT value of patients with hyperthyroidism., Methods: This retrospective study evaluated 38 patients with Graves' disease and 10 patients with Plummer disease. To obtain the mean CT value and volume of the thyroid gland, the entire thyroid gland was set as the region of interest. A test dose of 3.7 MBq I-131 was administered before initiating I-131 therapy, and the radioiodine uptake (RIU) rate was assessed after 3, 24, 96, and 168 h. An approximate curve was plotted based on the RIU values obtained, and the effective half-life (EHL) was calculated. The correlation between the mean CT value and the volume of the thyroid gland, 24-h RIU, EHL, and the free triiodothyronine (FT3), free thyroxine (FT4), thyroid-stimulating hormone (TSH), and TSH receptor antibody (TRAb) levels was evaluated., Results: The CT value exhibited a significant positive correlation with EHL in patients with Graves' disease (r = 0.62, p < 0.0001) as well as patients with Plummer disease (r = 0.74, p < 0.05). However, it did not display any correlation with the remaining parameters., Conclusion: The CT value is significantly correlated with EHL, suggesting that it reflects thyroid function and is mainly related to the factors associated with iodine discharge., (© 2024. The Author(s).)

Purpose: Multiple punctate echogenic foci (MPEF) on thyroid ultrasonography reflects psammoma bodies in papillary thyroid carcinomas. However, MPEF is also observed in benign thyroid lesions. The aim of this study was to determine the origin of MPEF in patients with benign thyroid lesions., Methods: We enrolled 26 patients with Graves' disease (GD) and 24 with follicular nodular disease (FND) who exhibited MPEF and underwent surgery. As controls, we enrolled 40 patients with GD and 32 with FND, but without MPEF, who underwent surgery., Results: MPEF was observed in both lobes in 80.8% of GDs with MPEF, but was limited to a single lobe in the remaining cases. MPEF was diffusely distributed in 72.3% of the cases and focally distributed in the remaining cases. On ultrasonography, most (92.3%) FNDs with MPEF were solid lesions, and seven nodules (26.9%) were interpreted as intermediate suspicion and their frequencies were higher than in those without MPEF (p < 0.01). Microscopically, calcium oxalate (CaOx) crystals were observed more frequently in GDs and FNDs with MPEF (100% and 88.5%, respectively) than in those without MPEF (p < 0.001). These differences were particularly significant for CaOx crystals > 100 μm. In GD cases, large CaOx crystals were observed more frequently in the lobes with MPEF than in those without (p < 0.05). No psammoma bodies were present in any of the cases., Conclusion: Appearance of MPEF in GDs and FNDs is not because of psammoma bodies; it is attributable to CaOx crystals larger than 100 μm. Therefore, MPEF is not an indicator of malignancy., (© 2024. The Author(s).)

To establish an easy way to perform volumetry of the thyroid gland using ultrasonography, we evaluated the accuracy of the products of the depth and width of the right thyroid lobe as indices of thyroid volume. The depth and width of both thyroid lobes were measured using ultrasonography before surgery in 193 patients with Graves' disease. The products were compared with the weight of the thyroid obtained from operative records. We also evaluated the depth and width of the right thyroid lobe in 312 subjects who presented without any thyroid disease. The products of depth and width of the right and left lobes of patients with Graves' disease correlated similarly well with the weight of the thyroid obtained from operative records (ρ = 0.896 for right, ρ = 0.886 for left, p < 0.0001). Because the right lobes were larger than the left lobes, the products of the depth and width of the right lobe were adopted as novel parameters for an easy volumetric approach. The relationship between the weight and the measurements of the right lobe was described using the following regression equation: weight (g) = [11.8 × depth (cm) × width (cm)] - 16.0. The products of the subjects without any thyroid diseases were distributed between 0.6 cm 2 and 4.4 cm 2 , with a median of 2.0 cm 2 . The upper limit of these values in these subjects was estimated to be 3.8 cm 2 . This easy ultrasonographic volumetric technique makes it possible to perform a semi-quantitative assessment of thyroid volume and to differentiate diffuse goiter from normal-sized thyroids.

Objective: To assess the bedside utility of Spectral Doppler Ultrasound (SDUS) in the initial evaluation of patients presenting with thyrotoxicosis., Methods: This is a retrospective cross-sectional study of patients diagnosed with thyrotoxicosis at an academic outpatient endocrinology clinic from August 2019 to November 2022. The thyroid arteries' peak systolic velocities (PSV) were measured bilaterally using SDUS. PSV ≥40 cm/s in at least a single thyroid artery was considered a reasonable cut-off for Graves' disease and PSV of perinodular artery ≥ 25 cm/s for toxic adenoma., Results: We identified 73 patients. Mean age ± standard deviation 45.2 ± 16.4 years, 54 (74.0%) were female, 49 (67.1%) were Caucasian, 23 (31.5%) were African American, and 1 (1.4%) was Asian. The confirmed diagnoses were 48 (65.8%) Graves' disease, 13 (17.8%) thyroiditis, four (5.5%) toxic adenoma, four (5.5%) amiodarone-induced thyroiditis type 2, 1 (1.4%) toxic multinodular goiter, 1 (1.4%) had an unremarkable repeat thyroid function testing, and two (2.7%) were unconfirmed. Diagnosis based on the SDUS initial assessment was accurate in 65 (89.0%) of the patients, and it was conclusive and confirmatory during the initial encounter in 55 (75.3%) of the patients before additional testing. A thyroid scan was obtained in nine (12.3%) patients. Incorrectly diagnosed patients were observed in two patients of each of the following categories: Graves' disease, thyroiditis, toxic adenoma, and unconfirmed diagnoses., Conclusions: SDUS can be a valuable, efficient, and cost-effective bedside tool in the initial assessment of patients presenting with thyrotoxicosis., Competing Interests: Disclosure The authors have no multiplicity of interest to disclose., (Copyright © 2024 AACE. Published by Elsevier Inc. All rights reserved.)

Ultrasound can identify important characteristics in primary hypothyroidism and diffuse hyperthyroidism (Graves' disease). Therefore, sonologists are actively investigating ultrasound criteria to differentiate between these two conditions. Nevertheless, practice shows the absence of such ultrasonic landmarks. For the first time in the literature, three cases of primary hypothyroidism have demonstrated an ultrasound pattern identical to that of Graves' disease. This pattern includes the presence of goiter, marked total hypoechogenicity of the parenchyma, significantly or moderately increased blood flow intensity ('thyroid inferno'), and elevated peak systolic velocity of the superior thyroid arteries. These signs are less common in hypothyroidism compared to hyperthyroidism. Diagnostic data suggest that the pathogeneses of primary hypothyroidism and Graves' disease share the same mechanisms, leading to similar thyroid ultrasound patterns. One of these shared mechanisms is presumably thyroid overstimulation by the autonomic nervous system, which is adequate to the body's hormonal requirements in hypothyroidism but excessive in hyperthyroidism., Competing Interests: The author declares no conflict of interest., (© 2024 by the authors.)

Background: The impact of near-infrared autofluorescence (NIRAF) imaging on postthyroidectomy hypocalcemia is controversial. As patients with Graves' disease are at increased risk, our aim was to compare postoperative parathyroid function in these patients undergoing total thyroidectomy (TT) with or without NIRAF imaging. Methods: This was a retrospective "before and after" study, comparing outcomes of patients who underwent TT without or with NIRAF imaging at a single center. Primary outcome was the incidence of temporary hypocalcemia and secondary outcomes, rates of incidental parathyroidectomy on final specimens and permanent hypocalcemia. Analyses were performed using Mann-Whitney U and chi-Square tests. Continuous data are expressed as median (interquartile range). Results: There were 85 patients in NIRAF and 100 patients in non-NIRAF group. Groups were comparable regarding age, gender, body-mass index, and thyroid weight. Number of parathyroid glands identified intraoperatively was 3 in both groups ( p  = 0.47). Intraoperative parathyroid implantation rate was 16.5% in NIRAF and 6% in non-NIRAF group ( p  = 0.02). Incidental parathyroidectomy rate on final pathology was 12.9% in NIRAF and 32% in non-NIRAF group ( p  = 0.002). The rates of temporary (11.7% vs. 16%) and permanent hypocalcemia (2.4% vs. 2%) were similar between the two groups, respectively ( p  = 0.66). Conclusion: To our knowledge, this is the first comparative study investigating the impact of NIRAF on postoperative parathyroid function after thyroidectomy for Graves' disease. The rate of incidental parathyroidectomy on final pathology was lower with use of NIRAF, without an impact on temporary or permanent hypocalcemia rates compared to conventional technique.

Introduction: Hyperthyroidismis a prevalent condition affecting global populations, with an overall prevalence of 1.2%. Our research aimed to establish a systematic diagnostic approach using multiparametric ultrasound (MPUS) to diagnose hyperthyroid diffuse thyroid disease (DTD)., Methods: We conducted a retrospective study from June 2021 to June 2023 at a specialized endocrinology center in Timisoara, Romania, enrolling subjects presenting with clinical hyperthyroidism. Using the Mach 30 Aixplorer ultrasound equipment, evaluations were performed initially in B-mode US, followed by Color Doppler and Spectral Doppler measurements, and finally, 2D Shear wave elastography (SWE)., Results: From the 218 patients analyzed, the diagnosis of DTD with hyperthyroidism was confirmed through biochemical assessment, subgrouping various pathologies such as subacute thyroiditis, Graves' disease, painless thyroiditis, Hashimoto's thyroiditis, iatrogenic, as well as healthy controls. In the first step, B-mode hypoechogenicity had an AUC of 0.951 for DTD detection. In the second step, the peak systolic velocity differentiated Graves' disease with a median of 42.4 cm/s and an AUC of 1. Lastly, the third step consisted of SWE evaluation, revealing a mean elasticity index in the SAT subgroup significantly higher from other subgroups (p<0.001) with an AUC of 1., Conclusion: Our study offers a step-by-step evaluation algorithm for DTD diagnosis, with a very good overall diagnostic performance (AUC of 0.946)., 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 © 2023 Stoian, Borlea, Moisa-Luca and Paul.)

Abstract: 99m Tc-DTPA dynamic renal scintigraphy for evaluating glomerular filtration rate was performed in a 29-year-old woman with hyperuricemia and Graves disease. Subsequently, 99m Tc-DTPA orbital scintigraphy was conducted to determine the activity of Graves ophthalmopathy. Thyroid accumulation of 99m Tc-DTPA was incidentally identified. This should be cautiously distinguished from 99m Tc-pertechnetate uptake, considering that the salivary glands, oral cavity, and stomach were not visualized. Our case demonstrates that augmentation of blood supply, enhancement of capillary permeability, and accumulation of inflammatory exudate may be involved in the pathological process of Graves disease., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Laboratory, imaging, and pathological features of Graves' disease (GD), although well characterized, have been barely correlated each other. Aim of the study was to link laboratory and ultrasound characteristics of GD with its pathological features., Methods: We correlated laboratory and ultrasound data at the time of diagnosis in 28 consecutive GD patients who underwent thyroidectomy with their pathological features, i.e., lymphocytic infiltration and follicular hyperplasia (both classified as mild or severe)., Results: Thyroid volume correlated positively with the levels of FT4 (P = 0.002, r 2  = 0.42), FT3 (P = 0.011, r 2  = 0.22), autoantibodies to thyroglobulin (TgAbs) (P = 0.016, r 2  = 0.32), autoantibodies to thyroid peroxidase (TPOAbs) (P = 0.011, r 2  = 0.34) and the extent of lymphocytic infiltration (P = 0.006 comparing mild to severe lymphocytic infiltration) but not with the levels of autoantibodies to the thyrotropin receptor (TRAbs) and to follicular hyperplasia. Compared to subjects with mild lymphocytic infiltration, those with severe lymphocytic infiltration showed higher levels of TgAbs (316 vs 0.0 IU/mL, P < 0.0001) and TPOAbs (295 IU/mL vs 14 IU/mL, P < 0.0001) and similar levels of TRAbs (7.5 vs 13 IU/mL, P = 0.68). Compared to patients with mild, those with severe follicular hyperplasia had similar levels of TgAbs (76 vs 30 IU/mL, P = 0.31) and TPOAbs (251 IU/mL vs 45 IU/mL, P = 0.26) but higher levels of TRAbs (39 vs 7.2 IU/mL, P < 0.001)., Conclusion: In GD, TgAbs and TPOAbs levels correlate with the extent of lymphocytic infiltration, TRAbs levels with the degree of follicular hyperplasia. Thyroid volume, the main factor influencing the severity of hyperthyroidism, is related to lymphocytic infiltration and not to follicular hyperplasia., (© 2023. The Author(s).)

Objective: Hashimoto's thyroiditis and Graves' disease are autoimmune diseases of the thyroid gland, and both diseases are diagnosed with ultrasound findings and autoantibody height. However, ultrasound (US) findings may be normal in both diseases rarely. In some pediatric studies, it was reported that shear wave velocity values in autoimmune thyroiditis were significantly higher than normal thyroid parenchyma and it was recommended to be used as a diagnostic method. Our study will address the evaluation of patients with Hashimoto's thyroiditis and Graves' disease by thyroid elastography and the role of this method in diagnosis., Materials and Methods: 28 patients with Hashimoto's thyroiditis, 20 patients with Graves' disease and 40 healthy controls were enrolled in our study prospectively. Thyroid Elastography and US were applied to all patients., Results: In US, Hashimoto's thyroiditis had a hypoechoic echo pattern compared to graves' disease (p < 0.05). When shear wave velocity (SWV) value of children with Hashimoto's thyroiditis and Graves' disease were compared with the control group, thyroid tissue showed more stiffness in both disease groups (p = 0.001). When SWV values were compared between Hashimoto's thyroiditis and Graves' disease, there was no statistically significant difference (p = 0.73)., Conclucion: SWV values were found to be higher in children with Hashimoto's thyroiditis and Graves' disease compared to the control group and contributes to the diagnosis of these diseases. However, the elastography technique alone is not sufficient to differentiate. Hashimoto's thyroiditis and Graves' disease., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Moyamoya syndrome is commonly associated with sickle cell anemia, neurofibromatosis type 1, cranial therapeutic irradiation, and Down syndrome. However, it is rare for Moyamoya syndrome associated with Graves' disease., Case Report: Here we report a case of Moyamoya syndrome associated with Graves' disease in a 19-year-old girl with sudden weakness of the right arm, progressive caries, and alopecia for 4 years. Brain magnetic resonance imaging revealed acute intraventricular hemorrhage and cerebral infarction of left middle cerebral artery territory and narrowing of the proximal portion of bilateral anterior and middle cerebral arteries., Conclusion: Acute cerebral infarction and intraventricular hemorrhage can occur simultaneously in Moyamoya syndrome associated with Graves' disease. Hydrocortisone, combined with prothiouracil medication, can correct thyroid dysfunction and improve neurological function. Caries may be the first symptom of Graves' disease., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: There is no standardized approach to iodine-131 (I-131) therapy of hyperthyroidism in pediatric Graves disease. This prevents systematic study of outcomes., Objective: To characterize current radioiodine dosing and define therapeutic outcomes at multiple institutions that use ultrasound to measure thyroid size to guide I-131 ablation of Graves disease., Materials and Methods: This was a retrospective cohort study conducted at three institutions. The three sites collected demographic data, thyroid volume measured by ultrasound (mL), pre-ablation radioiodine uptake, I-131 activity administered, and outcomes at 6 and 12 months for children younger than 18 years of age treated with I-131 between November 2004 and October 2019. Comparisons of continuous variables were performed using the Mann-Whitney U test., Results: Sixty-nine patients (mean age: 14.5±2.5 years) were included, 59 (85.5%) of whom were female. The mean administered I-131 radioiodine activity was 12.5 mCi (463 MBq) (range: 3.8-29.9 mCi [141-1,106 MBq]). At 6 months post-ablation, 54 (80.5% of 67) patients were hypothyroid, 8 (11.9% of 67) were euthyroid and 5 were hyperthyroid. Two of the five hyperthyroid patients had become euthyroid at 12 months. At 12 months, 1 previously euthyroid patient was hyperthyroid. Administered activity per mL of thyroid tissue adjusted for 24-h uptake was lower (0.18 mCi [6.7 MBq] x %/mL vs. 0.31 mCi [11.5 MBq] x %/mL, P=0.0054) for patients who remained hyperthyroid at 6 months., Conclusion: There is substantial variability in administered activity for radioiodine ablation of Graves disease in children. Efforts to standardize practice should start by standardizing administered activity guided by measurement of thyroid size by ultrasound. Our results and those of previous studies suggest the need for administered activities ≥0.25 mCi [9.3 MBq] x %/mL of thyroid tissue., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

In Europe thyroid ultrasound has been used at outpatient endocrine clinics since many years, and in southern Sweden only during the last years. Ultrasound has a role in the investigation of Graves' disease, subacute thyroiditis, gestational thyrotoxicosis, postpartum thyroiditis, amiodarone thyrotoxicosis and goiter with or without adenoma, but adenomas are usually investigated by endocrine surgeons in Sweden. If widely used the risk for detection of incidentaloma increases. Indications have to be strictly used to avoid further investigations. If an adenoma is localized, the risk for malignancy and requirement of aspiration is estimated by use of the EU-TIRADS classification based on morphology and size. The aspirate is judged by the Bethesda classification, which determines if further investigation is needed. The use of ultrasound at the outpatient clinic has improved the diagnostic quality and follow-up of thyroid patients.

Autoimmune thyroid diseases (AITD) are a heterogeneous group of disorders. They include, in particular, Graves' disease and Hashimoto's thyroiditis with a wide range of different functional status ranging from subclinical biochemical abnormalities to severe hyperthyroidism or severe hypothyroidism respectively. Furthermore, other conditions more frequently infectious or drug related can cause an immune reaction in the thyroid tissue. In AITDs, positron emission tomography/computed tomography (PET/CT) does not play a primary role for disease diagnosis or management, but accidental findings can occur in both symptomatic and asymptomatic patients, and they should be recognized and well interpreted. A comprehensive literature search of the PubMed databases was conducted to identify papers (systematic review, prospective and retrospective study, case report) evaluating the role of PET/CT in thyroid autoimmune diseases. Thyroid diffuse uptake of 18F-fluoro-2-deoxy-2-d-glucose ([18F]FDG) has been shown to be frequently associated with AITDs, but also with immune-induced thyroid disorders related to SARS-CoV-2 or immunotherapy, while malignant lesions more often have a focal aspect. Other radiopharmaceuticals as [68Ga]-DOTA-peptides, [68Ga]-fibroblast activation protein inhibitors (FAPIs) and [68Ga]-prostate specific membrane antigen ([68Ga]-PSMA) showed similar findings. In conclusion, PET/CT scan in AITDs does not play a primary role in the diagnosis, but the occasional finding of a thyroid uptake must always be described in the report and possibly investigated for a better patient's management.

Background: Microvascular ultrasonography (MVUS) is a third-generation Doppler technique that was developed to increase sensitivity compared to conventional Doppler. The purpose of this study was to compare MVUS with conventional color Doppler (CD) and power Doppler (PD) imaging to distinguish Graves' disease (GD) from destructive thyroiditis (DT)., Methods: This prospective study included 101 subjects (46 GDs, 47 DTs, and eight normal controls) from October 2020 to November 2021. All ultrasonography examinations were performed using microvascular flow technology (MV-Flow). The CD, PD, and MVUS images were semi-quantitatively graded according to blood flow patterns. On the MVUS images, vascularity indices (VIs), which were the ratio (%) of color pixels in the total grayscale pixels in a defined region of interest, were obtained automatically. Receiver operating characteristic curve analysis was performed to verify the diagnostic performance of MVUS. The interclass correlation coefficient and Cohen's kappa analysis were used to analyze the reliability of MVUS (ClinicalTrials.gov:NCT04879173)., Results: The area under the curve (AUC) for CD, PD, MVUS, and MVUS-VI was 0.822, 0.844, 0.808, and 0.852 respectively. The optimal cutoff value of the MVUS-VI was 24.95% for distinguishing GD and DT with 87% sensitivity and 80.9% specificity. We found a significant positive correlation of MVUS-VI with thyrotropin receptor antibody (r=0.554) and with thyroid stimulating immunoglobulin bioassay (r=0.841). MVUS showed high intra- and inter-observer reliability from various statistical method., Conclusion: In a real time and quantitative manner, MVUS-VI could be helpful to differentiate GD from thyroiditis in thyrotoxic patients, with less inter-observer variability.

Diagnosis: The diagnosis of Graves' disease is mainly based on ultrasonography and laboratory diagnostics. This includes the determination of the TSH value and the peripheral thyroid hormones. TSH receptor antibody (TRAb) measurement is highly sensitive and specific for the detection of Graves' disease (GD) and helps to distinguish from autoimmune thyroiditis (AIT). However, as recent studies show, some may AIT patients may also reveal TRAb., Therapy: Current guidelines recommend primarily the use of thiamazol/carbimazole in GD. Due to the comparatively higher hepatotoxicity, propylthiouracil is not recommended as first line therapy. In case of relapse during 12 up to 18 months of antithyroid drug therapy or after a frustrating attempt at cessation, definitive therapy should be considered. Alternatively, in accordance with the current recommendations of the European Thyroid Association, drug therapy may be continued for up to 12 months after initial diagnosis., Pregnancy: The treatment of active GD during pregnancy is problematic due to diaplacental crossing of peripheral thyroid hormones, TSH receptor stimulating antibodies and antithyroid drugs. According to current guidelines, PTU is recommended during the first 16 weeks of pregnancy, whereas for the 2nd and 3 rd trimester no special recommendations are given. After that, you can choose which antithyroid drug might be used. The aim of antithyroid drug therapy during pregnancy is to achieve a suppressed TSH value together with normal or slightly increased fT4 while using lowest effective dose of antithyroid drug., Immune Checkpoint Inhibitors (ici): The most common endocrine side effect with this therapy is thyroid dysfunction. Hyperthyroidism; occur most frequently in combination therapy (CTLA-4 / anti-PD-1 therapy) ICI mainly causes destructive thyroiditis with lymphocytic infiltration; GD is absolutely rare in this context and only few cases are described., Competing Interests: Mitglied der Sektion Schilddrüse., (Thieme. All rights reserved.)

Previous studies have reported reduced bone mineral density (BMD) in patients with hyperthyroidism. We assessed the association of BMD in children and adolescents with Graves' disease (GD) after correcting for potential confounders affecting BMD such as age, sex, and pubertal status. Forty-four children and adolescents with GD and 172 age- and sex-matched healthy controls were enrolled in this study. We analyzed auxological features, BMD, and levels of thyroid hormone, thyroid-stimulating hormone, and thyroid autoantibodies. We measured BMD by dual-energy X-ray absorptiometry at the time of diagnosis in all patients. The mean age of all patients with GD (9 boys and 32 girls) was 12.1 ± 2.2 years (range, 7.0-16.0). Their initial mean free T4 and thyroid-stimulating hormone levels were 3.51 ± 1.56 ng/dL and 0.04 ± 0.03 IU/L, respectively. The mean BMD Z-scores of the lumbar spine (LS), femoral neck, and total body less head of patients with GD were significantly lower than those of control subjects. Eleven patients (26.8%) had low bone density (LS BMD Z-scores < -2.0). To identify correlations of patient characteristics with BMD Z-scores at each site, alkaline phosphatase had a significant negative correlation with BMD Z-scores at LS and femoral neck, but not total body less head (r = -0.441; p = 0.004 and r = -0.351; p = 0.025, respectively). Children and adolescents with newly diagnosed GD had lower bone mass than their healthy peers. These results suggest that BMD measurement at initial evaluation may be necessary in this population., (Copyright © 2020 The International Society for Clinical Densitometry. Published by Elsevier Inc. All rights reserved.)

Objectives: The first aim was to evaluate the stiffness of thyroid parenchyma with shear wave elastography (SWE) in patients with Graves disease (GD) and compare the elastographic values with those of asymptomatic volunteers. The second aim was to evaluate whether there was a correlation between SWE values and grayscale ultrasound (US) and laboratory parameters., Methods: In this prospective study, the thyroid gland parenchyma of 50 patients whose clinical and laboratory findings were indicative for GD and 54 asymptomatic participants with normal laboratory values was examined by SWE. Grayscale US images of the thyroid and submandibular gland were recorded. The volume of the thyroid gland was measured. Elastographic measurements were performed with a free region of interest. The quantitative SWE values (meters per second and kilopascals) of the patient and control groups were compared. A correlation analysis between the SWE values and grayscale US and laboratory parameters was performed., Results: The median (range) SWE values of the thyroid gland in patients with GD were significantly higher than those of the control group [17.34 (12.58-56.15) versus 12.05 (7.72-23.67) kPa and 2.28 (1.83-4.12) versus 1.92 (1.55-2.61) m/s; P < .001 for both comparisons]. When 14.5 kPa or 2.115 m/s was designated as the cutoff value, GD could be diagnosed with a high sensitivity and specificity. We showed a negative weak correlation between the SWE values and parenchymal echogenicity in the GD group., Conclusions: Shear wave elastography can be used as an effective imaging method with high sensitivity and specificity rates in the diagnosis of GD., (© 2020 American Institute of Ultrasound in Medicine.)

This manuscript describes the case of a young woman, with no prior psychiatric history, who developed hypomania and paranoia as the principal presenting features of Graves' disease. After starting treatment with carbimazole and propranolol, symptoms resolved without the use of antipsychotic drugs. Close liaison between psychiatry and endocrinology services was essential. This demonstrates that treating underlying thyrotoxicosis in patients presenting with psychiatric symptoms may lead to recovery without the use of antipsychotic medication. While agitation, irritability and mood lability are well-recognised thyrotoxic symptoms, psychosis is a rare presenting feature of Graves' disease. All patients with agitation, delirium or psychiatric symptoms should have thyroid function checked as part of initial tests screening for organic disease. In new or relapsing psychiatric conditions, it is important to ask patients, their carers or relatives about symptoms of hypothyroidism or thyrotoxicosis., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The existence of a link between Graves' Disease (GD) and Thyroid Cancer (TC) has long been investigated, however a clear pathogenic correlation is yet to be found., Objective: We verified the presence of TC in patients submitted to surgery for GD, both with and without thyroid nodules (TN)., Methods: In this study we analyzed retrospectively a cohort of 151 patients treated at our clinic with total thyroidectomy between 2013 and 2018. All the patients were symptomatic at the time of surgery, preoperatively ultrasonographic (US) study was performed to evaluate the presence of nodules and their distribution. All patients reached euthyroid state before surgery., Results: Nodules were detected in 53% of cases, above 60 years of age, at least one nodule was found; however, younger patients were mostly nodules free. Bilateral diffusion of nodules appeared with increasing age. Cancer was found in 19 of 151 subjects (12.5%), all were papillary carcinomas, and among them 93% were microcarcinomas. Among cancer-proven patients, 14 had thyroid nodules while 5 were nodule-free. During the follow up period, no cancer recurrence was recorded. The most common complication after surgery was transient hypocalcemia (36%)., Conclusions: Graves' patients are burdened by major incidence of TC in the context of their TN. Pre-operative assessment in GD patients should consider the risk of cancer, US scan can help in rapid evaluation of nodules and new rising frontiers in molecular biomarkers analysis may help defining pathogenic basis of Graves' neoplastic development., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Purpose:  The objective of this study was to prove the efficacy of Doppler ultrasonography (US-Doppler) in the follow-up of patients with GD treated with radioactive iodine., Methods:  97 patients (77 female and 20 male) with a mean age of 42 years (SD ± 15) and with prior diagnosis of GD were treated with radioiodine. In total, 88.5 % achieved euthyroidism or hypothyroidism after treatment. The study was documented before treatment and one, three, and six months after treatment with radioactive iodine (131I) by a single investigator. The volume, echogenicity, echotexture and vascularization of the glands as well as the peak systolic velocity (PSV) of the inferior thyroid arteries were evaluated and compared with the laboratory data., Results:  Thyroid volume and PSV had a statistically significant correlation with hormone levels (p < 0.05). The mean pre-dose therapeutic thyroid volume was 43.01 ± 3.88 cm 3 and was 11.58 ± 11.26 cm 3 6 months after treatment. The mean PSV before 131I was 90.06 ± 44.13 cm/s and decreased significantly over time (p < 0.001). Six months after the therapeutic dose, the mean PSV was 32.95 ± 16.36 cm/s. However, the subjective parameters did not have a significant correlation with the normalization of the thyroid hormones., Conclusion:  Doppler US was useful for monitoring the therapeutic response of GD patients after treatment with radioiodine by evaluating the thyroid volume and peak systolic velocity., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: Compared with conventional thyroidectomy, hypocalcemia rate was reported to be lower after total thyroidectomy (TT) utilizing near infrared fluorescence imaging (NIFI). The aim of this study is to evaluate the impact of NIFI on postoperative parathyroid function after TT., Methods: This was a retrospective institutional review board-approved study comparing 100 patients who underwent TT with NIFI guidance and 200 patients without, by the same surgeon. Clinical parameters were compared using χ 2 and t test., Results: Average number of parathyroid glands identified intraoperatively was similar between two groups. However, rate of incidental parathyroidectomy was higher in conventional (14%) versus NIFI group (6%) (P = .039), despite similar (4% vs 6%, respectively) autotransplantation rates (P = .562). Incidences of transient (6.5% vs 5.0%) and permanent (0.5% vs 0%) hypocalcemia were not statistically different between conventional and NIFI groups (P = NS)., Conclusion: The use of NIFI during thyroidectomy may decrease the rate of incidental parathyroidectomy by increasing the ability of the surgeon to recognize parathyroid glands with fluorescent contrast distinction. Nevertheless, in contrary to recent reports in literature, postoperative hypocalcemia rate was not altered compared with conventional technique, suggesting that preservation of parathyroid vasculature, rather than an augmented ability to detect the glands, may dominantly affect postoperative function., (© 2020 Wiley Periodicals LLC.)

Polarization-sensitive second harmonic generation (SHG) microscopy is an established imaging technique able to provide information related to specific molecular structures including collagen. In this investigation, polarization-sensitive SHG microscopy was used to investigate changes in the collagen ultrastructure between histopathology slides of normal and diseased human thyroid tissues including follicular nodular disease, Grave's disease, follicular variant of papillary thyroid carcinoma, classical papillary thyroid carcinoma, insular or poorly differentiated carcinoma, and anaplastic or undifferentiated carcinoma ex vivo. The second-order nonlinear optical susceptibility tensor component ratios, χ (2) zzz '/χ (2) zxx ' and χ (2) xyz '/χ (2) zxx ', were obtained, where χ (2) zzz '/χ (2) zxx ' is a structural parameter and χ (2) xyz '/χ (2) zxx ' is a measure of the chirality of the collagen fibers. Furthermore, the degree of linear polarization (DOLP) of the SHG signal was measured. A statistically significant increase in χ (2) zzz '/χ (2) zxx ' values for all the diseased tissues except insular carcinoma and a statistically significant decrease in DOLP for all the diseased tissues were observed compared to normal thyroid. This finding indicates a higher ultrastructural disorder in diseased collagen and provides an innovative approach to discriminate between normal and diseased thyroid tissues that is complementary to standard histopathology.

Objectives: We aimed to investigate the differences between spectral Doppler and Superb Microvascular Imaging (SMI; Canon Medical Systems, Tokyo, Japan) findings in children with Hashimoto thyroiditis (HT) and Graves disease (GD) compared to healthy control participants., Methods: The study included 34 patients with GD, 37 patients with HT, and 22 healthy volunteers. All patients with HT and 11 patients with GD were euthyroid; 23 patients with GD had symptoms of hyperthyroidism and had thyrotropin values of less than 0.5 mIU/L. Thyroid volumes, mean resistive indices, and peak systolic velocities along with vascularity indices (VIs) on Superb Microvascular Imaging were measured., Results: Patients with GD had a significantly higher mean thyroid volume (P < .001; right lobe, 11.80 mL; left lobe, 9.10 mL) and peak systolic velocity (right, 32.5 cm/s; left, 30 cm/s) with a lower resistive index (right, 0.48%; left, 0.48%) compared to patients with HT (right, 8.78 mL, 20 cm/s, 0.55%; left, 7.41 mL, 20 cm/s, 0.55%, respectively) and also control participants (right, 4.59 mL, 15 cm/s, 0.56%; left, 3.52 mL, 15 cm/s, 0.54%). Patients with GD had a significantly higher median VI (right, 25%; left, 26%) compared to patients with HT (right, 11%; left, 13%) and control participants (right, 8%; left, 8%). When patients with GD were categorized as euthyroid and hyperthyroid based on thyrotropin levels and clinical symptoms, both euthyroid and hyperthyroid patients with GD had significantly higher thyroid volumes compared to patients with HT (P < .001). Hyperthyroid patients with GD had higher thyroid volumes compared to euthyroid patients with GD; however, the difference failed to reach statistical significance. A significant strong positive correlation with the VI and thyrotropin receptor autoantibody levels (r = 0.696) was found. The highest area under the curve was obtained for the right lobe VI (0.885), followed by the left lobe VI (0.872), right lobe volume (0.828), and peak systolic velocity (0.810). The optimal cutoff VI value for distinguishing between HT and GD was 17.35% with sensitivity, specificity, and diagnostic accuracy of 85.3%, 78.4%, and 81.7%, respectively., Conclusions: Superb Microvascular Imaging is a new method that can detect subtle vascularity changes with higher accuracy compared to spectral Doppler parameters in distinguishing between HT and GD., (© 2019 by the American Institute of Ultrasound in Medicine.)

Microvascular ultrasonographic imaging is the most recent and unique Doppler ultrasound technique. It uses an advanced clutter filter that can remove clutter artifacts and preserve the low-velocity microvascular flow signal. The potential advantages of microvascular ultrasonography are its superiority in detection and visualization of the small blood vessels in tissues, providing radiologists with more information on the vascular structures. Therefore, it has shown particular value in the clinical fields. The aim of this study was to provide microvascular ultrasonographic images for the tissue microvasculature, including the brain, thyroid gland, kidney, urinary bladder, small bowel, ovary, testis, lymph node, and hemangiomas in children, focusing on the comparison with conventional color Doppler ultrasonographic images., Competing Interests: The authors have no potential conflicts of interest to disclose., (Copyright © 2020 The Korean Society of Radiology.)

Background: Graves' Disease is an autoimmune disorder characterized by increased levels of thyroid hormones correlated with increased thyroid blood flow. Thyroid scintigraphy is an important and conventional method. However, it has limited accessibility, has ionizing radiation, and is expensive., Objectives: To investigate the thyroid blood flow in patients with Graves' Disease by color Doppler Ultrasonography and a newly developed software Color Quantification., Methods: Forty-one consecutive subjects with GD and 41 healthy controls were enrolled. Color Doppler ultrasonography parameters of the thyroid arteries and Color Quantification values of the gland were measured by a radiologist. The correlations between thyroid blood flow parameters, levels of 99mTechnetium pertechnetate uptake, thyrotropin, and free thyroxine were evaluated. The diagnostic performances of these parameters were investigated., Results: The peak systolic-end diastolic velocities of thyroid arteries and Color Quantification values were increased in the study group (p < 0.05 for all). We observed negative correlations between thyrotropin levels and peak-systolic and end-diastolic velocities of superior thyroid arteries and Color Quantification values. There were positive correlations between 99mTechnetium uptake levels and thyroid blood flow parameters (p < 0.05 for all). In the diagnostic performance of thyroid blood flow parameters, we observed utilities significantly in peak-systolic and end-diastolic velocities of thyroid arteries and Color Quantification values (p < 0.05 for all)., Conclusion: The increased peak-systolic and end-diastolic velocities of thyroid arteries, and increased Color Quantification values might be helpful in the diagnosis of Graves' Disease., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Fine-needle aspiration (FNA) is among the first diagnostic tools used in the evaluation of thyroid nodules. It has the ability to triage patients with benign and malignant lesions, thus defining the optimum clinical and/or surgical management. The Bethesda System for Reporting Thyroid Cytopathology has found worldwide acceptance. Thyroid FNA offers high positive predictive value (97%-99%), with sensitivities and specificities of 65% to 99% and 72% to 100%, respectively. Nonetheless, many potential diagnostic pitfalls exist that can lead to false-positive and/or false-negative results. This article discusses several of the potential pitfalls in the cytologic evaluation of thyroid lesions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Cognitive impairment and reduced well-being are common manifestations of Graves' disease (GD). These symptoms are not only prevalent during the active phase of the disease but also often prevail for a long time after hyperthyroidism is considered cured. The pathogenic mechanisms involved in these brain-derived symptoms are currently unknown. The overall aim of the CogThy study is to identify the mechanism behind cognitive impairment to be able to recognise GD patients at risk., Methods and Analysis: The study is a longitudinal, single-centre, case-controlled study conducted in Göteborg, Sweden on premenopausal women with newly diagnosed GD. The subjects are examined: at referral, at inclusion and then every 3.25 months until 15 months. Examinations include: laboratory measurements; eye evaluation; neuropsychiatric and neuropsychological testing; structural MRI of the whole brain, orbits and medial temporal lobe structures; functional near-infrared spectroscopy of the cerebral prefrontal cortex and self-assessed quality of life questionnaires. The primary outcome measure is the change in medial temporal lobe structure volume. Secondary outcome measures include neuropsychological, neuropsychiatric, hormonal and autoantibody variables. The study opened for inclusion in September 2012 and close for inclusion in October 2019. It will provide novel information on the effect of GD on medial temporal lobe structures and cerebral cortex functionality as well as whether these changes are associated with cognitive and affective impairment, hormonal levels and/or autoantibody levels. It should lead to a broader understanding of the underlying pathogenesis and future treatment perspectives., Ethics and Dissemination: The study has been reviewed and approved by the Regional Ethical Review Board in Göteborg, Sweden. The results will be actively disseminated through peer-reviewed journals, national and international conference presentations and among patient organisations after an appropriate embargo time., Trial Registration Number: 44321 at the public project database for research and development in Västra Götaland County, Sweden (https://www.researchweb.org/is/vgr/project/44321)., Competing Interests: Competing interests: HNF has received lecture fees from Siemens Inc., AstraZeneca and Bristol-Myers Squibb., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

This study aimed at evaluating hybrid multispectral optoacoustic tomography/ultrasound for imaging of thyroid disorders, including Graves' disease and thyroid nodules. Methods: The functional biomarkers and tissue parameters deoxygenated hemoglobin, oxygenated hemoglobin, total hemoglobin, saturation of hemoglobin, fat content, and water content were analyzed in thyroid lobes affected by Graves' disease ( n = 6), thyroid lobes with healthy tissue ( n = 8), benign thyroid nodules ( n = 13), and malignant thyroid nodules ( n = 3). Results: In Graves' disease, significantly higher deoxygenated hemoglobin (3.18 ± 0.52 vs. 2.13 ± 0.62; P = 0.0055) and total hemoglobin (8.34 ± 0.88 vs. 6.59 ± 1.16; P = 0.0084) and significantly lower fat content (0.64 ± 0.37 vs. 1.69 ± 1.25; P = 0.0293) were found than in healthy controls. Malignant thyroid nodules showed significantly lower saturation of hemoglobin (55.4% ± 2.6% vs. 60.8% ± 7.2%; P = 0.0393) and lower fat content (0.62 ± 0.19 vs. 1.46 ± 0.87; P = 0.1295) than benign nodules. Conclusion: This pilot study showed the applicability and the potential of hybrid multispectral optoacoustic tomography/ultrasound to semiquantitatively provide tissue characterization and functional parameters in thyroid disorders for improved noninvasive diagnostics of thyroid diseases., (© 2019 by the Society of Nuclear Medicine and Molecular Imaging.)

Objectives: The differentiation between the various etiologies of thyrotoxicosis, including those with hyperthyroidism (especially Graves' disease [GD], the most common cause of hyperthyroidism) and without hyperthyroidism (like thyroiditis), is an important step in planning specific therapy. Technetium-99m (99mTc) pertechnetate thyroid scanning is the gold standard in differentiating GD from thyroiditis. However, this technique has limited availability, is contraindicated in pregnancy and lactation, and is not helpful in cases with history of recent exposure to excess iodine. The aim of this study was to identify the diagnostic value of the peak systolic velocity of the inferior thyroid artery (PSV-ITA) assessed by color-flow Doppler ultrasound (CFDU) and compare the sensitivity and specificity of this method versus 99mTc pertechnetate thyroid uptake., Subjects and Methods: We prospectively analyzed 65 patients (46 with GD and 19 with thyroiditis). All patients were evaluated with clinical history and physical examination and underwent 99mTc pertechnetate scanning and measurement of TRAb levels and PSV-ITA values by CFDU. The diagnosis was based on findings from signs and symptoms, physical examination, and 99mTc pertechnetate uptake., Results: Patients with GD had significantly higher mean PSV-ITA values than those with thyroiditis. At a mean PSV-ITA cutoff value of 30 cm/sec, PSV-ITA discriminated GD from thyroiditis with a sensitivity of 91% and specificity of 89%., Conclusion: Measurement of PSV-ITA by CFDU is a good diagnostic approach to discriminate between GD and thyroiditis, with sensitivity and specificity values comparable to those of 99mTc pertechnetate thyroid uptake.

Background: Thyrotoxicosis is often caused by destructive thyroiditis (DT) or Graves' disease (GD), and a prompt and accurate differential diagnosis for thyrotoxicosis is needed as management strategy differs. A meta-analysis of published literature was performed to evaluate the diagnostic accuracy for differentiating GD from DT patients by the measurement of mean peak systolic velocity of superior thyroid artery (STA-PSV) using ultrasonography., Methods: The databases of Embase, Pubmed, Cochrane, Web of Science, Wanfang, and CNKI were retrieved without time limit to identify eligible studies. The statistical information and scientific quality were assessed and classified. The data were analyzed using Stata12.0 software., Results: A total of 11 studies with 1052 cases only from Asia were included. Meta-analysis results showed the pooled sensitivity and pooled specificity of STA-PSV by ultrasonography were 0.86 (95% CI, 0.80-0.90) and 0.93 (95% CI, 0.86-0.97) in distinguishing GD from DT, respectively, with the AUC of 0.94 (95% CI, 0.92-0.96) ., Conclusion: STA-PSV by ultrasonography is a useful diagnostic method in differentiating GD from DT. More studies from other countries are needed to further evaluate the accuracy of STA-PSV for the differential diagnosis of thyrotoxicosis.

The clinical applications of the quantitative single photon emission computed tomography (SPECT)/computed tomography (CT) are being expanded to a variety of fields of nuclear medicine. However, clinical application of quantitative SPECT/CT for the evaluation of Graves' disease (GD) still needs further investigation. Our aim was to investigate the feasibility of standard uptake value (SUV) of the thyroid for the clinical diagnosis and evaluation of GD. In this prospective multicenter study, 116 patients diagnosed with GD (Graves group) and 74 healthy volunteers (control group) were enrolled from 8 different hospitals. All patients underwent technetium pertechnetate ( 99m TcO 4 - ) SPECT/CT imaging with Q.Metrix quantitative software and 24-hour thyroid radioactive iodine uptake (24h-RAIU) test. The SUVmax and SUVmean in Graves group were significantly higher than those of control group ( P <0.01). Cut-off values of SUVmax and SUVmean to predict GD were 231.425 and 116.66 by ROC curves, respectively. The SUVmax and SUVmean in Graves patients were significantly related to serum thyroxine level with correlation coefficient of 0.493 and 0.512 for FT 3 and 0.449 and 0.464 for FT 4 , respectively (all P <0.01). Additionally, the SUVmax and SUVmean in GD positively correlated with 24h-RAIU with a coefficient of 0.832 and 0.830, respectively ( P <0.01). The volumes determined by Q.Metrix (35.65 ± 20.56ml) of 72 subjects also positively correlated with that from ultrasound (36.67 ± 21.00ml) with a coefficient of 0.927 ( P <0.01). SUV measurements derived from thyroid SPECT/CT may be useful for the clinical diagnosis and evaluation of GD.

A 74-year-old woman with a left neck mass and thyrotoxicosis was referred to our hospital, and was later diagnosed with Marine-Lenhart syndrome based on positivity for thyroid autoantibodies, ultrasonographically evident left lobe thyroid nodule with increased blood flow, and scintigraphically identified not only increased tumor-like accumulation but also diffused uptake. Disease control was difficult despite administration of antithyroid drugs, so subtotal thyroidectomy was performed. No hyperplastic changes or histopathological findings characteristic of Graves disease were evident on histopathology, so Plummer disease was considered to be dominant. In case of hot in low type which showed higher uptake in the nodule and lower uptake in the extranodular part on scintigraphy, there is a possibility of relapse in drug treatment.

Purpose: Graves' orbitopathy (GO) is a complication of Graves' disease (GD), the development of which cannot be predicted at the time of diagnosis of GD. Our aims were (i) to test if orbital 99m Tc-labelled diethylenetriamine pentaacetic acid single-photon emission computer tomography (DTPA SPECT) can predict development of GO later during the course of the disease and (ii) to study whether orbital immune activity can be detected in GD patients who do not develop GO during follow-up., Methods: Fifty-four orbits of 27 patients with newly diagnosed GD were entered into the case-control study. Individuals showing signs of GO at enrolment were excluded. During the two-year follow-up, eye signs were recorded every 3 months. Orbital DTPA uptakes on SPECT images were measured when entering the study and at the end of the follow-up period, or when clinical signs of GO developed, whichever occurred first., Results: During the follow-up, 6 patients (22%) were diagnosed with GO. There was no significant difference between the initial DTPA uptakes of the patients with or without later developing GO (10.45±1.72 MBq/cm 3 vs. 9.18±1.18 MBq/cm 3 respectively). However, the DTPA uptakes of both GD groups (ie. with and without GO) were higher than that of the control group (7.45±1.36 MBq/cm 3 , p<0.05)., Conclusions: We have shown that GD is accompanied by moderate orbital immune activity in GD patients without GO, irrespective of later development of GO. Why this orbital autoimmunity remains subclinical in the majority of the cases, and progresses into clinically detectable GO in others, remains unclear., Competing Interests: No conflict of interest has been declared by the authors., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: The aim of this study was, first, to ascertain the efficacy of radioiodine therapy (RIT) for Graves' disease (GD) based on a calculated-dose regime and, second, to determine the value of 99m Tc-pertechnetate thyroid scintigraphy in predicting the clinical outcomes of RIT., Methods: One hundred and thirty 9consecutive GD patients who underwent RIT using a calculated-dose method in our hospital from January 2015 to September 2015 were retrospectively evaluated. Radioiodine dose was calculated based on the Marinelli's formula. 99m Tc-pertechnetate uptake, age, gender, thyroid mass, duration of the disease, previous antithyroid drugs treatment, serum levels of TSH, FT3 and FT4, a positive rate of TPOAb and Anti-TRAb, radioiodine dose and follow-up were evaluated as potential interference factors for RIT success., Results: One hundred and 8(77.7%) GD patients including 71 (51.1%) euthyroid and 37 (26.6%) hypothyroid were successful, but 31 (22.3%) remained hyperthyroid (treatment failure). Significant differences were found between the treatment success group and the failure group in 99m Tc-pertechnetate uptake (p<0.0001), the duration of disease (P=.0140) and positive rate of Anti-TRAb (P=.0103). 99m Tc-pertechnetate uptake is an independent risk factor for predicting treatment failure (P=.0394). Using a cut-off value of 18.4%, 99m Tc-pertechnetate uptake could predict treatment failure with a sensitivity of 84.3%, and a specificity of 80.6%., Conclusion: Our study has shown that a calculated radioiodine dose is effective in treating GD patients with a consequent low rate of hypothyroid. A 99m Tc-pertechnetate uptake above 18.4% is a significant predictor of treatment failure and these patients should receive a higher radioiodine dose in this scenario., (Copyright © 2018. Publicado por Elsevier España, S.L.U.)

Background/aim: This study was performed to assess the diagnostic accuracy of shear wave elastography by virtual touch tissue imaging quantification in patients with diffuse thyroid gland pathology and to differentiate Graves' disease from Hashimoto's thyroiditis. Materials and methods: Thirty patients with Hashimoto's thyroiditis and 22 patients with Graves' disease were evaluated with conventional ultrasonography and shear wave elastography by virtual touch tissue imaging quantification. Thirty healthy participants formed the control group. Ten elastographic measurements of each thyroid lobe were performed in all three study groups. The mean shear wave velocity was calculated and compared between the patients and controls. Results: The mean shear wave velocity of the controls (1.92 ± 0.14 m/s) was significantly lower than that of the patients with Graves' disease (2.71 ± 0.22 m/s) and Hashimoto's thyroiditis (2.50 ± 0.20 m/s). Patients with Graves' disease had significantly higher shear wave velocities than those with Hashimoto's thyroiditis (P < 0.001). Conclusion: Shear wave elastography by virtual touch tissue imaging quantification can be used to discriminate a normal thyroid gland from diffuse thyroid gland pathology after conventional sonography and may assist in the diagnosis of Graves' disease and Hashimoto's thyroiditis., (CC-BY 4.0)

Purpose: The aim of this study is to discuss the value of ultrasound-based shear wave™ elastography (SWE) in diffuse thyroid disease (DTD)., Method: Thyroid stiffness in 154 patients with DTD and 30 normal subjects was measured by SWE. The serum indicators of all subjects were detected., Results: The area under the receiver operating characteristic (AUROC) curve for DTD by SWE was 0.852. The AUROCs of SWE for differentiating chronic autoimmune thyroiditis (CAT) from Graves' disease (GD) and subacute thyroiditis (SAT) were 0.549 and 0.989, respectively. The AUROCs for distinguishing GD from SAT by SWE and the fT3/fT4 ratio were 0.975 and 0.713, respectively., Conclusion: SWE aids in the diagnosis of DTD, and SWE is superior to the fT3/fT4 ratio for distinguishing GD from SAT. However, SWE was unsuitable for differentiating CAT from GD., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose To evaluate the safety and efficacy of ultrasonography (US)-guided high-intensity focused ultrasound (HIFU) ablation as a treatment for medically refractory Graves disease (GD). Materials and Methods After ethics approval, a prospective trial (NCT02685514) was performed from November 2015 to February 2016. Thirty patients underwent ablation of the entire right and left thyroid lobes, with areas near the tracheal-esophageal groove and common carotid artery left unablated. Serum thyroid-stimulating hormone (TSH), free T4 (FT4), antithyroid autoantibodies, and TSH receptor (TSHR) antibody levels were evaluated afterward, and US color Doppler, US volumetry, and eye assessment were performed. The primary outcome was the 12-month relapse rate. Relapse referred to hyperthyroidism (FT4 > 23 pmol/L) afterward. Variables associated with relapse were analyzed by using binary logistic regression. Results The technical success rate was 96.7%. The cohort comprised entirely women, with a median age of 38.2 years (interquartile range, 29.5-49.0 years). After 12 months, eight patients (26.7%; 95% confidence interval [CI]: 14.19%, 44.95%) experienced relapse. One patient (3.3%; 95% CI: 0.59%, 16.67%) experienced vocal cord palsy, while two patients (6.7%; 95% CI: 1.85%, 21.33%) experienced Horner syndrome, but none of these conditions were permanent. No changes in gland volume, antithyroid autoantibody levels, and ophthalmic parameters were found at 12-month follow-up. Baseline TSHR was found to have decreased significantly at 6- and 12-month follow-up (P < .001 for both). TSHR antibody (odds ratio [OR] = 1.414; 95% CI: 1.018, 1.965; P = .039) and gland volume (OR = 0.557; 95% CI: 0.353, 0.880; P = .012) were associated with 12-month relapse, with higher antibody levels conferring a higher likelihood and smaller gland volumes conferring a lower likelihood. Conclusion US-guided HIFU of the thyroid may be a safe and efficacious treatment in patients with persistent or relapsed GD. However, further study is warranted before it can become mainstream for this indication. © RSNA, 2017 Online supplemental material is available for this article.

Objective: Prediction and early diagnosis of orbitopathy is needed in patients with Graves' disease, especially when radioiodine therapy is planned. Positron emission tomography/computerized tomography (PET/CT) using flourine-18-fluorodeoxyglucose (FDG) is an effective imaging modality in detection of inflammation, however, its ability to detect orbital inflammation has not been well studied. The aim of our study is to determine the ability of FDG PET/CT to detect orbital inflammation related with Graves' disease, identify active orbitopathy, predict the radioiodine-triggered orbitopathy, and find out the effects of radioiodine on orbital inflammation., Materials and Methods: Total 31 Graves' disease patients and 17 controls were included. All Graves' disease patients underwent cranial FDG PET/CT imaging prior therapy. Radioiodine therapy and post-treatment PET/CT study was applied to 21 patients. PET/CT images of all examinees were evaluated, measuring extraocular muscle maximum standard uptake value (SUVmax) and muscle thickness., Results: FDG uptake was increased in the majority of extraocular muscles in Graves' disease patients in comparison to controls and this increase was found to be irrelevant from muscle thickness. Extraocular muscle SUVmax values did not increase in Graves' orbitopathy patients who received radioiodine under corticosteroid prophylaxis. SUVmax level of all orbital rectus muscles were increased after radioiodine therapy in nonsmokers, whereas no increase was detected in smokers., Conclusion: FDG PET/CT may be helpful in detection of extraocular muscle inflammation and it may show ongoing orbitopathy in early stages of inflammation before anatomical changes occur.

We present two patients with Graves' disease and concurrent myasthenia gravis. The impact of the dual diagnosis on the clinical course and the potential for a delayed diagnosis of myasthenia gravis is discussed. Patient 1, a 28-year-old man was diagnosed with Graves' disease following his second respiratory arrest. His history was strongly suggestive of a second pathology. Patient 2, a 66-year-old Cantonese woman with established Graves' disease presented with thionamide-related neutropaenia. Examination revealed bilateral ptosis and right lateral rectus palsy. Both patients had thyrotoxicosis secondary to Graves' disease with concurrent myasthenia gravis. Although neuromuscular weakness is common in Graves' disease, coexisting myasthenia gravis (MG) is rare and can cause profound morbidity. Ocular signs in both diseases may cause diagnostic confusion although ptosis suggests coexisting MG. In both cases, the thyrotoxicosis delayed the diagnosis of MG., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Radioactive iodine in the treatment of Graves' disease has been associated with the development of de novo Graves' ophthalmopathy (GO). In this report, we describe five individuals who required extensive ophthalmic treatment for post-RAI de novo GO.

Graves disease is the most common cause of thyrotoxicosis. Although medical intervention with antithyroid drugs (ATDs) is commonly the first choice of treatment in Korea, the remission rate associated with this approach is not satisfactory. During ATD therapy, low or undetectable serum levels of thyroid-stimulating hormone (TSH) receptor antibodies (TRAbs) have been reported to affect the incidence of Graves disease remission. This study evaluated the correlation between serum 25-hydroxyvitamin D levels and TRAb levels, as well as the effect of 25-hydroxyvitamin D on the recurrence of Graves disease.A total of 143 patients, who were diagnosed with Graves disease and treated with ATDs, were retrospectively included in our observational study. These patients were followed for more than 1 year after ATD discontinuation. The levels of serum 25-hydroxyvitamin D and TRAb (ie, thyroid-stimulating antibody [TSAb], as detected by bioassay, and TSH-binding inhibitory immunoglobulins [TBIIs]) were measured, and a thyroid function test was performed upon ATD discontinuation. Recurrence was evaluated every 3 months, and was defined as an occurrence of overt thyrotoxicosis during the follow-up period.A total of 95 patients (66.4%) experienced recurrence with a median latency period of 182 days (ranging 28-1219 days). The serum 25-hydroxyvitamin D levels at the time of ATD discontinuation were not correlated with either TBII or TSAb. In the Cox proportional hazard regression analysis, higher free T4 levels (>1.4 ng/dL; hazard ratio [HR], 3.252; 95% confidence interval [CI], 1.022-10.347) and low levels of 25-hydroxyvitamin D (≤14.23 ng/mL) were associated with a higher probability of Graves disease recurrence (HR, 3.016; 95% CI, 1.163-7.819).Lower serum 25-hydroxyvitamin D levels were associated with a higher incidence of Graves disease recurrence. Therefore, serum 25-hydroxyvitamin D might be an independent risk factor for predicting Graves disease recurrence after ATD discontinuation.