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Abstract Background I-131 treatment (RAI) decision relies heavily on serum thyroglobulin (Tg) levels, as higher Tg levels are assumed to be correlated with higher I-131 uptake. Tg elevation, negative iodine scintigraphy (TENIS) definition is becoming more clinically relevant as alternative treatment methods are available. This study examined the correlation between Tg levels with I-131 uptake in remnant thyroid gland to evaluate the reliability of serum Tg levels in predicting I-131 uptake. Methods From March 2012 to July 2019, 281 papillary thyroid cancer patients treated with 150 mCi RAI were retrospectively enrolled. Early (2nd day) and Delayed (7th day) post-RAI whole-body scan (WBS) neck counts were correlated with clinical and pathologic findings. Patients with normal neck ultrasound and undetectable level of serum Tg (

The study was to evaluate the effect of radioactive iodine (RAI) treatment application time and clinical, histopathological factors on ablation success in patients with operated papillary thyroid cancer (PTC) in low and intermediate-risk. One hundred sixty-one patients with PTC in the low and intermediate-risk were evaluated. Most patients (89.4%) were in the low-risk, and 10.6% were in the intermediate-risk. When the patients were divided into two groups according to the date of receiving RAI treatment after surgery, those who received early treatment (≤3 months) constituted the majority of the patients (72.7%). Seventeen patients received 1.85 Gigabecquerel (GBq), 119 3.7 GBq, 25 5.55 GBq RAI. Most patients (82%) achieved ablation success after the first RAI treatment. The time interval between surgery and RAI treatment did not affect ablation success. Stimulated Tg level measured on the RAI treatment day was an independent predictive factor for successful ablation (p<0.001). The cut-off value of Tg found to predict ablation failure was 5.86 ng/ml. It was concluded that 5.55 GBq RAI treatment could predict ablation success compared to 1.85 GBq dose (p=0.017). It was concluded that having a T1 tumor may predict treatment success compared to a T2 or T3 tumor (p=0.001, p<0.001, retrospectively). The time interval does not affect ablation success in low and intermediate-risk PTC. The ablation success rate may decrease in patients who receive low-dose RAI and have high Tg levels before treatment. The most crucial factor in achieving ablation success is giving enough doses of RAI to ablate the residual tissue. [ABSTRACT FROM AUTHOR]

Abstract This retrospective study was designed to compare the treatment response of patients with differentiated thyroid cancer (DTC) prepared for radioiodine ablation (RIA) with thyroid hormone withdrawal (THW) or recombinant human thyrotropin (rhTSH) stimulation. Patients with DTC were followed‐up retrospectively between 2013 and 2018 in Kaohsiung Chang Gung Memorial Hospital, Taiwan. We compared the excellent response ratios between THW (49.9%) and rhTSH (50.1%) stimulation. Patients were then divided into subgroups, on the basis of age, sex, extrathyroidal extension, lymph node metastasis, and tumor‐node‐metastasis stage, for analysis. In all, 647 patients were followed‐up after RIA. The ratios of THW or rhTSH use in the different subgroups were not statistically significant. In all the patients, the excellent response rate with THW and rhTSH was 80% and 76.5%, respectively, which was not statistically significant. The subgroup analysis, including age, sex, extrathyroidal extension, lymph node metastasis, and tumor‐node‐metastasis stage (low and high risk), showed similar results. Furthermore, the logistic regression analysis revealed no statistically significant differences among the subgroups. The multivariate analysis showed extrathyroidal extension, lymph node metastasis, and high I131 dose were the prognostic factors affecting the excellent response rate. In conclusion, the THW and rhTSH preparations for RIA were similar in terms of the excellent response rates and subgroup clinical outcomes.

Thyroid cancer is one of the most common endocrine cancers. The most common histological subtypes are papillary and follicular variants; these are "differentiated thyroid cancers" and are associated with an excellent prognosis. The exact mechanism of thyroid cancer is not known. Several genetic alterations and environmental factors are found to be associated with this cancer. Patients with differentiated thyroid cancer are treated with postoperative radioactive iodine (RAI) therapy to ablate residual thyroid tissue and metastatic micro-foci. It is thought that after RAI, there is an increased risk of secondary malignancies such as lung, renal, and stomach cancer and lymphomas. However, the risk of secondary malignancy is not clear. They may be associated with genetic syndromes, environmental factors, and radiation exposure. The secondary malignancy may be detected incidentally during follow-up or present with signs and symptoms of that malignancy. There is no direct association between second malignancy and radiation exposure in I-131 therapies. We present a case series of five patients treated with high doses of I-131 for the remnant. The patients developed metachronous malignancies later in life. [ABSTRACT FROM AUTHOR]

Simple Summary: The aim of the present study was to retrospectively evaluate the efficacy of low (1.1 GBq) versus moderate (2.2 GBq) 131I activities in a large series (n = 299) of low-risk differentiated thyroid carcinoma (DTC) patients requiring postoperative 131I ablation. At the follow-up, according to the ATA criteria, an excellent response was observed in 96.9% of patients treated with moderate 131I activities versus 85.6% of patients treated with low 131I activities (p = 0.029). Conversely, a biochemically indeterminate or incomplete response was observed in 22.2% of patients treated with low 131I activities versus 1.8% of patients treated with moderate 131I activities (p = 0.001), and an incomplete structural response was observed in three patients treated with low 131I activities versus two patients treated with moderate 131I activities (p = 0.654). In conclusion, we encourage the use of moderate instead of low activities when 131I ablation is indicated in order to reach an excellent response in a significantly larger proportion of patients, including patients with the unexpected persistence of the disease. Objectives: To compare the efficacy of low and moderate 131I activities in low-risk differentiated thyroid carcinoma (DTC) patients requiring postoperative thyroid remnant ablation in a real-world clinical setting. Methods: We retrospectively reviewed the records of 299 low-risk DTC patients (pT1-T2, Nx(0) Mx) who had undergone (near)-total thyroidectomy followed by 131I therapy, using either low (1.1 GBq) or moderate (2.2 GBq) radioiodine activities. The response to initial treatments was evaluated after 8–12 months, and patient responses were classified according to the 2015 American Thyroid Association guidelines. Results: An excellent response was observed in 274/299 (91.6%) patients, specifically, in 119/139 (85.6%) and 155/160 (96.9%) patients treated with low and moderate 131I activities, respectively (p = 0.029). A biochemically indeterminate or incomplete response was observed in seventeen (22.2%) patients treated with low 131I activities and three (1.8%) patients treated with moderate 131I activities (p = 0.001). Finally, five patients showed an incomplete structural response, among which three and two received low and moderate 131I activities, respectively (p = 0.654). Conclusions: When 131I ablation is indicated, we encourage the use of moderate instead of low activities, in order to reach an excellent response in a significantly larger proportion of patients, including patients with the unexpected persistence of the disease. [ABSTRACT FROM AUTHOR]

Abstract Background Currently, surgery alone is the gold standard treatment for minimally invasive follicular thyroid cancer (mi-FTC). Case presentation A case of a mi-FTC diagnosed in 1994 was treated with total thyroidectomy and radioiodine (RAI) ablation, according to the therapeutic algorithm used at that time. Nevertheless, he had a recurrence with distant metastasis after 24 years from the initial treatment. Conclusion Total thyroidectomy and RAI ablation might have delayed the development of distant metastasis but they were not sufficient to avoid disease recurrence. Certainly, remnant ablation simplified the follow-up and the monitoring of serum thyroglobulin allowed the early detection of the biochemical recurrence, but didn’t change the outcome of the disease. Moreover, because of this early detection the patient was exposed to useless biochemical and imaging examinations. The aim of this report is to discuss the pros and cons of an aggressive treatment of a patient with mi-FTC.

This retrospective study was designed to compare the treatment response of patients with differentiated thyroid cancer (DTC) prepared for radioiodine ablation (RIA) with thyroid hormone withdrawal (THW) or recombinant human thyrotropin (rhTSH) stimulation. Patients with DTC were followed‐up retrospectively between 2013 and 2018 in Kaohsiung Chang Gung Memorial Hospital, Taiwan. We compared the excellent response ratios between THW (49.9%) and rhTSH (50.1%) stimulation. Patients were then divided into subgroups, on the basis of age, sex, extrathyroidal extension, lymph node metastasis, and tumor‐node‐metastasis stage, for analysis. In all, 647 patients were followed‐up after RIA. The ratios of THW or rhTSH use in the different subgroups were not statistically significant. In all the patients, the excellent response rate with THW and rhTSH was 80% and 76.5%, respectively, which was not statistically significant. The subgroup analysis, including age, sex, extrathyroidal extension, lymph node metastasis, and tumor‐node‐metastasis stage (low and high risk), showed similar results. Furthermore, the logistic regression analysis revealed no statistically significant differences among the subgroups. The multivariate analysis showed extrathyroidal extension, lymph node metastasis, and high I131 dose were the prognostic factors affecting the excellent response rate. In conclusion, the THW and rhTSH preparations for RIA were similar in terms of the excellent response rates and subgroup clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Currently, surgery alone is the gold standard treatment for minimally invasive follicular thyroid cancer (mi-FTC). Case presentation: A case of a mi-FTC diagnosed in 1994 was treated with total thyroidectomy and radioiodine (RAI) ablation, according to the therapeutic algorithm used at that time. Nevertheless, he had a recurrence with distant metastasis after 24 years from the initial treatment. Conclusion: Total thyroidectomy and RAI ablation might have delayed the development of distant metastasis but they were not sufficient to avoid disease recurrence. Certainly, remnant ablation simplified the follow-up and the monitoring of serum thyroglobulin allowed the early detection of the biochemical recurrence, but didn't change the outcome of the disease. Moreover, because of this early detection the patient was exposed to useless biochemical and imaging examinations. The aim of this report is to discuss the pros and cons of an aggressive treatment of a patient with mi-FTC. [ABSTRACT FROM AUTHOR]

Background: Thyroid cancer and radioactive iodine (RAI) ablation for postsurgical management may lead to uncontrolled inflammation. Objective: This study was intended to assess the prophylactic and therapeutic immunomodulatory effects of omega-3 fatty acids in patients with differentiated thyroid cancer (DTC). Methods: A total of 85 patients with DTC were allocated into two groups based on RAI dosage after thyroidectomy. Patients in each group were randomly distributed into three subgroups: G1 with RAI ablation only, G2 treated with omega-3 for 30 days before RAI ablation, and G3 treated with omega-3 for 30 days after RAI ablation. Fifteen healthy individuals were included as controls. Serum cytokine levels including IL-2, IL-4, IL-5, IL-6, IL-9, IL-10, IL-13, IL-17A, IL-17F, IL-21, IL-22, TNF-α and IFN-γ were determined by cytometric bead assay. Results: IL-4, IL-6, IL-21 and IL-22 levels in patients with DTC were higher than in the healthy controls. Regardless of RAI dosage, IL-6 showed an increasing trend after RAI ablation. IL-4, IL-22, and IL-17A remained at considerably higher levels than in the healthy controls after RAI ablation. Within-group comparisons showed a significant reduction in Th1+Th17/Th2+Th22 ratio in G2 patients 1 week after RAI ablation. Between-group comparisons showed increased IL-10 levels in G3 compared with G1 patients one week after high-dose RAI ablation. In G3, Th1+Th17/Th2+Th22 and Th1+Th17/Th2+Th9+Th22 ratios were remarkably lesser than in G2 patients 1 month after intermediate-dose RAI ablation. Conclusion: Our results showed better anti-inflammatory effects of omega-3 when it was used therapeutically after RAI ablation in patients with DTC than when it was used prophylactically before RAI.

Background The detrimental effects of excessive thyroid hormone on glucose metabolism have been widely investigated. However, the risk of diabetes in patients with long-standing hyperthyroidism, especially according to treatment modality, remains uncertain, with few longitudinal studies. Methods The risk of diabetes in patients with Graves’ disease treated with antithyroid drugs (ATDs) for longer than the conventional duration (≥2 years) was compared with that in age-and sex-matched controls. The risk was further compared according to subsequent treatment modalities after a 24-month course of ATD: continuation of ATD (ATD group) vs. radioactive iodine ablation (RIA) group. Results A total of 4,593 patients were included. Diabetes was diagnosed in 751 (16.3%) patients over a follow-up of 7.3 years. The hazard ratio (HR) for diabetes, after adjusting for various known risk factors, was 1.18 (95% confidence interval [CI], 1.10 to 1.28) in patients with hyperthyroidism. Among the treatment modality groups, the RIA group (n=102) had a higher risk of diabetes than the ATD group (n=4,491) with HR of 1.56 (95% CI, 1.01 to 2.42). Further, the risk of diabetes increased with an increase in the ATD treatment duration (P for trend=0.019). Conclusion The risk of diabetes was significantly higher in patients with long-standing Graves’ disease than in the general population, especially in patients who underwent RIA and prolonged ATD treatment. Special attention to hyperglycemia during follow-up along with effective control of hyperthyroidism may be necessary to reduce the risk of diabetes in these patients.

Background: Thyroid withdrawal in preparation for radioiodine ablation (RIA) may have a profound impact on health-related quality of life (HRQL). Cost implications and scheduling limit the use of recombinant TSH and triiodothyronine (T3) with its shorter half-life is a conceptually attractive alternative. Methods: Prospective cohort study design with patients having withdrawal of thyroxine (n = 37) or T3 supplementation (n = 33). HRQL was assessed using EORTC QLQ-C30, QLQ-H&N35 and modified Billewicz questionnaires. Time interval to achieve optimal TSH levels (at least 30 mIU/ml) prior to RIA was determined. Results: With the exception of emotional domain (QLQ-C30 p = 0.045), LT3 supplementation did not confer significant benefit when compared to LT4 withdrawal. Target serum TSH levels was achieved in 95% of patients by week 4 post thyroidectomy. Conclusions: LT3 supplementation delivered equivocal benefit and therefore the alternate strategies to minimize the impact on HRQL of reduction in the duration of hypothyroidism in T4 withdrawal are suggested. [ABSTRACT FROM AUTHOR]

Objective: Two large randomized trials of patients with differentiated thyroid cancer (DTC) reported recently (HiLo and ESTIMABL1) found that the recurrence rate among patients who underwent 1.1 GBq radioactive iodine (RAI) ablation was not higher than that of patients who underwent 3.7 GBq radioactive iodine (RAI) ablation. However, no similar studies have been conducted in China. We aimed to report clinical outcomes in Chinese patients with low/intermediate risk of recurrence DTC after long‐term follow‐up, and evaluate the risk factors that influence the presence or absence of incomplete response at the final follow‐up. Design: A long‐term follow‐up of a Chinese randomized clinical trial (October 2014 and February 2021) was conducted. Patients: A total of 506 DTC patients at low/intermediate risk of recurrence who were randomized into two groups to receive 1.1 (n = 251) or 3.7 GBq (n = 255) RAI ablation following thyroid hormone withdrawal were followed on levothyroxine treatment for a median of 4.5 years (range: 1.6−6.3). Measurements: Suppressed serum thyroglobulin (Tg) and anti‐thyroglobulin antibody (TgAb) levels were determined, and neck ultrasonography was performed. Results: At the final follow‐up, 499 (98.6%) patients showed an excellent response. The other seven patients (two patients underwent 1.1 GBq and five patients underwent 3.7 GBq RAI ablation, respectively) showed either structural incomplete response (lymph node metastasis, n = 1), biochemical incomplete response (increased serum Tg ≥ 1 ng/ml, or increased positive TgAb levels, n = 5), or indeterminate response (stable positive TgAb levels, n = 1). The risk of incomplete response at the final follow‐up was significantly increased in patients with stimulated serum Tg ≥ 10 ng/ml at ablation (p =.003) and in patients with unsuccessful ablation (p =.008). Conclusion: Our findings indicated that there was no difference in the long‐term outcomes with RAI ablation using either 1.1 or 3.7 GBq in patients with low/intermediate risk of recurrence DTC, and 1.1 GBq RAI might be suitable for patients who are recommended for ablation. [ABSTRACT FROM AUTHOR]

Hurthle cell carcinoma is a rare subtype of follicular thyroid carcinoma. Its aggressive nature and poor prognosis require prompt diagnosis and treatment, which is often challenging. We herein report a case of a woman who complained of lumps on her left and right neck which move with swallowing motion for 15 years, and have gotten bigger in the previous 6 months. Follicular thyroid carcinoma was first suspected based on previous fine needle aspiration biopsy. Total thyroidectomy and selective neck dissection procedure were performed and histopathology examination post-surgery showed Hurthle cell carcinoma. The patient also received thyroid replacement hormone therapy. This case discusses the diagnosis and management of Hurthle cell carcinoma leading to better patient outcome.

Background: Optimal treatment for persistent Graves' disease following 12–18 months of treatment with anti-thyroid drugs (ATDs) is unclear. Given the increased risk of cardiovascular morbidity and mortality with hyperthyroidism, assessing the risk of cardiovascular events associated with different treatment modalities after the conventional ATD course would be valuable in determining the appropriate next-line therapy. Methods: This retrospective cohort study included data from the Korean National Health Insurance database of 16,882 patients with newly diagnosed hyperthyroidism who received primary ATD treatment for 24 months. Patients were categorized based on the treatment they received after receiving ATD for 24 months: continued ATD for at least 12 more months (ATD group), radioiodine ablation (RIA) with remission (RIA group 1), and RIA without remission (RIA group 2). The incidence and risk of heart failure (HF), the leading cause of cardiovascular mortality in hyperthyroidism, were compared between patients and age-and sex-matched controls. Results: There were 16,516 (97.8%) patients in the ATD group, 230 (1.4%) in RIA group 1, and 136 (0.8%) in RIA group 2. Compared to that of controls, a significant difference in the cumulative incidence of HF was observed according to second-line treatment modality after adjusting for covariates; the risk was highest in patients in RIA group 2, with a hazard ratio (HR) of 2.54 (95% confidence interval (CI) 1.60–4.03), followed by those in the ATD group, with an HR of 1.23 (95% CI 1.20–1.36). Patients in RIA group 1 were not at an increased risk of HF compared to their matched controls (HR 0.77; 95% CI 0.38–1.54). When patients in the ATD group were further classified by the duration of ATD treatment at one-year intervals, the risk of HF was higher in patients with longer ATD use (p for linear trend < 0.001). Conclusions: In patients with long-standing hyperthyroidism treated with conventional duration of ATD therapy, the risk of HF was attenuated by RIA with remission of hyperthyroidism and increased as ATD was required for longer duration. To reduce the risk of HF, resolution of hyperthyroidism with RIA should be considered in patients with long-standing Graves' disease. [ABSTRACT FROM AUTHOR]

BackgroundOptimal treatment for persistent Graves’ disease following 12–18 months of treatment with anti-thyroid drugs (ATDs) is unclear. Given the increased risk of cardiovascular morbidity and mortality with hyperthyroidism, assessing the risk of cardiovascular events associated with different treatment modalities after the conventional ATD course would be valuable in determining the appropriate next-line therapy.MethodsThis retrospective cohort study included data from the Korean National Health Insurance database of 16,882 patients with newly diagnosed hyperthyroidism who received primary ATD treatment for 24 months. Patients were categorized based on the treatment they received after receiving ATD for 24 months: continued ATD for at least 12 more months (ATD group), radioiodine ablation (RIA) with remission (RIA group 1), and RIA without remission (RIA group 2). The incidence and risk of heart failure (HF), the leading cause of cardiovascular mortality in hyperthyroidism, were compared between patients and age-and sex-matched controls.ResultsThere were 16,516 (97.8%) patients in the ATD group, 230 (1.4%) in RIA group 1, and 136 (0.8%) in RIA group 2. Compared to that of controls, a significant difference in the cumulative incidence of HF was observed according to second-line treatment modality after adjusting for covariates; the risk was highest in patients in RIA group 2, with a hazard ratio (HR) of 2.54 (95% confidence interval (CI) 1.60–4.03), followed by those in the ATD group, with an HR of 1.23 (95% CI 1.20–1.36). Patients in RIA group 1 were not at an increased risk of HF compared to their matched controls (HR 0.77; 95% CI 0.38–1.54). When patients in the ATD group were further classified by the duration of ATD treatment at one-year intervals, the risk of HF was higher in patients with longer ATD use (p for linear trend < 0.001).ConclusionsIn patients with long-standing hyperthyroidism treated with conventional duration of ATD therapy, the risk of HF was attenuated by RIA with remission of hyperthyroidism and increased as ATD was required for longer duration. To reduce the risk of HF, resolution of hyperthyroidism with RIA should be considered in patients with long-standing Graves’ disease.

Well-differentiated thyroid carcinoma is predominantly a slow-growing malignancy, amendable to treatment, and has an excellent prognosis following thyroidectomy and radioiodine (RAI) therapy. However, patients who fail the initial RAI treatment attempt may require repeated RAI or other treatments and with this, comes an associated impact on patient quality of life. Therefore, the anticipation of patients in whom there is a higher risk of RAI failure may help in patient risk stratification and subsequent management. We conducted a retrospective review to determine the factors associated with initial RAI therapy failure in well-differentiated thyroid cancer patients. Using scikit-learn from Python, we implemented a machine-learning algorithm to determine the clinical patient factors associated with a higher likelihood of treatment resistance. We found that clinical factors such as tumor focality (P = 0.026) and lymph node invasion at surgical resection (P = 0.0135) were significantly associated with initial treatment failure following RAI. Elevated serum thyroglobulin (Tg) and Tg antibody levels following surgery but before RAI were also associated with treatment resistance (P < 0.0001 and P = 0.011 respectively). Less expected factors such as decreased time from surgery to RAI were also associated with treatment failure, however not to a statistically significant degree (P > 0.064). Clinical outcomes following RAI can be stratified by identifying factors that are associated with initial treatment failure. These findings can help restratify patients for RAI treatment and change patient management in certain cases. Such stratification will ultimately help to optimize successful treatment outcomes and improve patient quality of life. [ABSTRACT FROM AUTHOR]

Background. Traditional endogenous stimulation of thyroid-stimulating hormone (TSH) by means of long-term withdrawal of thyroid hormones for radioiodine diagnostics and radioiodine therapy causes severe hypothyroidism, which worsens patients general well-being and may lead to side effects and cause tumor growth and dissemination. Exogenous stimulation with recombinant human TSH (rh-TSH, thyrotropin-alfa) causes short-term increases in TSH levels and does not have the above-mentioned side effects. Purpose. To estimate the efficacy and safety of rh-TSH in preparation of patients with well-differentiated thyroid cancer for radioiodine diagnostics and radioiodine therapy. Methods. We conducted an interventional single-center prospective unblinded uncontrolled study of the efficacy and safety of thyrotropin-alfa to prepare patients with well-differentiated thyroid cancer to radioiodine diagnostics and post-surgery radioiodine ablation. The study included 88 patients with well-differentiated thyroid cancer: 54 patients were prepared for post-surgery radioiodine ablation; 34 patients for radioiodine diagnostics to evaluate combined treatment efficacy and exclusion of tumor recurrence. The level of TSH, thyroglobulin, antibodies to thyroglobulin, whole body scintigraphy, and side effects were measured during exogenous stimulation with thyrotropin-alfa. Results. The level of TSH reached or exceed the target level (30 mIU/ml) 24 hours after the first injection of recombinant thyrotropin-alfa in 86% of patients; after 48 hours in 100%, the level exceeding 100 IU/ml was observed in 66 (75.1%) patients. The maximum levels of thyroglobulin and antibodies to thyroglobulin were reached 72 and 48 hours after the first injection, respectively. The injections of thyrotropin-alfa were well-tolerated by the patients. In the group for radioiodine diagnostics 2 (5.8%) patients complained of fatigue, 1 (2.9%) patient had signs of dyspeptic disorder, while in the group for radioiodine ablation 4 (7.4%) patients complained of fatigue, 1 (1.8%) patient had marked memory problems that disappeared later (they must have been caused by the patients advanced age (82 years)). Conclusions. Exogenous recombinant human thyroid-stimulating hormone (thyrotropin-alpha) is highly effective in preparation of patients with well-differentiated thyroid cancer for radioiodine diagnostics and radioiodine ablation. It does not have side effects, which are typical of withdrawal of thyroid hormones. The levels of thyroglobulin and antibodies to thyroglobulin measured 72 hours after the first injection of thyrotropin-alfa have the biggest diagnostic informative value.

Radioiodine ablation following surgery is the accepted treatment for patients with differentiated thyroid cancer (DTC). Since that surgical volume and radioiodine dose can have impact on treatment outcome, we aimed to evaluate them on the treatment outcome of low-risk DTC patients. Low-risk DTC patients were classified into four groups, including (1) thyroidectomy was performed by thyroid surgeon and low-dose (1850 MBq [30 mCi]) radioiodine was administered (n = 17), (2) thyroidectomy was performed by thyroid surgeon and high-dose (3700 MBq [100 mCi]) radioiodine was administered (n = 10), (3) thyroidectomy was performed by general surgeon and low-dose radioiodine was administered (n = 22), and (4) thyroidectomy was performed by general surgeon and high-dose radioiodine was administered (n = 29). All patients were followed at least for 6 months and also for evaluation of treatment success, neck sonography, thyroid-stimulating hormone-off, thyroglobulin (Tg)-off, and anti-Tg-off tests were performed. Furthermore, two common radioiodine treatment-associated side effects, including dry mouth, and nausea/vomiting were assessed for all patients. Seventy-eight low-risk DTC patients (female: 70 [89.7%]; male: 8 [10.3%]) aged from 18 to 78 years old with mean of 41.96 ± 13.42 years were enrolled in this study. In total, the treatment was successful in 96.2% of patients. There was no significant difference in treatment success among groups (P > 0.05), while there was a significant association among administered activity and side effects. In low dose patients, only one patient complained from dry mouth; however, 11/39 patients who received high dose of iodine complained from dry mouth (P = 0.002). In addition, 9/39 high dose patients suffered from vomiting/nausea, while none of low-dose patients suffered from vomiting/nausea (P = 0.001). In low-risk DTC patients, surgical volume and amounts of radioiodine had no significant impact on treatment results; therefore, low dose radioiodine following thyroidectomy may be preferable to low-risk DTC patients to avoid side effects. [ABSTRACT FROM AUTHOR]

Hurthle cell carcinoma is a rare subtype of follicular thyroid carcinoma. Its aggressive nature and poor prognosis require prompt diagnosis and treatment, which is often challenging. We herein report a case of a woman who complained of lumps on her left and right neck which move with swallowing motion for 15 years, and have gotten bigger in the previous 6 months. Follicular thyroid carcinoma was first suspected based on previous fine needle aspiration biopsy. Total thyroidectomy and selective neck dissection procedure were performed and histopathology examination post-surgery showed Hurthle cell carcinoma. The patient also received thyroid replacement hormone therapy. This case discusses the diagnosis and management of Hurthle cell carcinoma leading to better patient outcome. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to investigate inflammation indices based on preablation hematological parameter of the lymphocyte-to-monocyte ratio (LMR) to predict the clinical outcome in papillary thyroid cancer (PTC) patients with low- and intermediate-risk stratification. Methods: This retrospective study analyzed 772 patients with low- and intermediate-risk PTC who underwent total thyroidectomy followed by radioiodine therapy between July 2005 and July 2009 with a median of 10 years. Kaplan–Meier statistics were used to test differences in recurrence-free survival (RFS) between groups based on the optimal cutoff point of biomarkers identified using receiver operating characteristic curves. Results: With an optimal cutoff point of 7.05, 215 patients (29.8%) were classified as having low LMR and 557 patients (71.2%) were classified as having high LMR. High LMR was significantly associated with a prolonged RFS (hazard ratio [HR]: 2.048, 95% confidence interval [CI]: 1.062–4.359, p = 0.001). Multivariate analysis showed that low LMR (HR = 2.035, 95% CI: 1.011–4.095, p = 0.012), tumor size over 2 cm (HR = 2.762, 95% CI: 1.303–5.852, p = 0.008), and high preablative simulated thyroglobulin level over 10 ng/ml (HR = 7.826, 95% CI: 2.353–26.033, p < 0.001) were independent prognostic markers for worse RFS in the enrolled PTC patients. Conclusions: LMR at the time of radioiodine therapy has comparable predictor for the clinical outcome with both tumor size and preablative simulated thyroglobulin level in low- to intermediate-risk PTC patients. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to evaluate the success rate in preparation of patients with thyroid cancer for I-131 total body scan by 3-week discontinuation of LT4 including clinical characteristics affecting the success. Methods: Ninety-six patients with well-differentiated thyroid cancer on LT4 suppressive treatment were indicated for I-131 total body scan. After 3-weeks of LT4 withdrawal, T4 and TSH were measured whether TSH was ≥ 30 mIU/L. Then I-131 total body scan, Tg and TgAb measurements were performed upon achievement of TSH ≥ 30 mIU/L. If TSH was below 30 mIU/L, LT4 was still withheld and T4 together with TSH were evaluated weekly until TSH was ≥ 30 mIU/L. The percentage of success rate after 3-week withdrawal of LT4 was studied. Clinical characteristics between the success and failure rates after LT4 withdrawal for 3 weeks were compared. Results: Success rate in preparation for I-131 total body scan was 54.2%, 81.3% and 93.8% by discontinuation of LT4 for 3, 4 and 5 weeks, respectively. Bivariate analysis indicated that factors which significantly affected the success were age (pvalue = 0.0002), baseline TSH (p-value = 0.041) and cancer staging (p-value = 0.019). When multivariate analysis was used, only age and staging affected the success, independently. Patients who were older than 45 years old and stage I together with patients who were older than 45 years old and above stage I had more tendency to not achieve the target TSH after 3-week LT4 withdrawal as compared to the patients who were younger than 45 years old and stage I (Odd ratio, 9.281; 95% C.I., 2.269-37.957 and Odd ratio, 8.25; 95% C.I., 2.793- 24.366, respectively). Conclusion: The success rate of 3-week discontinuation of LT4 was 54.2%. This method should be considered in patients under the age of 45 years old or being classified as stage I.

ABSTRACT Objective To retrospectively evaluate the outcomes of patients with low and intermediate risk thyroid carcinoma treated with total thyroidectomy (TT) and who did not undergo radioiodine remnant ablation (RRA) and to compare them to patients receiving low dose of iodine (30 mCi). Subjects and methods A total of 189 differentiated thyroid cancer (DTC) patients treated with TT followed by 30mCi for RRA or not, followed in two referral centers in Brazil were analyzed. Results From the 189 patients, 68.8% was ATA low-risk, 30.6% intermediate and 0.6% high risk. Eighty-seven patients underwent RRA and 102 did not. The RRA groups tended to be younger and had a higher frequency of extra-thyroidal extension (ETE). RRA did not have and impact on response to initial therapy neither in low (p = 0.24) nor in intermediate risk patients (p = 0.66). It also had no impact on final outcome and most patients had no evidence of disease (NED) at final follow-up. Recurrence/persistence of disease was found in 1.2% of RRA group and 2% in patients treated only with TT (p = 0.59). Conclusions Our study shows that in low and intermediate-risk patients, RRA with 30 mCi seems to have no major advantage over patients who did not undergo RRA regarding response to initial therapy in each risk group and also in long term outcomes.

Background: The COVID-19 pandemic in Bangladesh is part of the worldwide pandemic of coronavirus disease 2019 which has crowded out services for both covid and non-covid patients, in a country where the health care system was already under huge stress even before the pandemic. Objectives: To postpone non-urgent surgeries along with active surveillance of thyroid cancer patients to make sure the hospitals are not unnecessarily occupied. Methods: Document based categorization of thyroid cancer patients, like-low risk, high risk and clinically extremely vulnerable groups who are at greatest risk of severe illness from coronavirus are to be done accordingly. Individuals with thyroid cancer are mostly not susceptible to COVID-19. However, patients with thyroid cancer (papillary or medullary) having lung metastases or undergoing certain types of cancer treatment might be at increased risk of viral infection or complications. Risk benefit ratio is checked and explained to the patient and their attendants. Recommendations: As COVID-19 is spreading across the Bangladesh, hospitals are being forced to reallocate resources to the care of critically ill. So it is crucial to adhere to the advice from experts to reduce the risk of infection. All non-essential surgeries and hospital admissions can be postponed to make sure that hospitals are not unnecessarily occupied. Conclusion: In the face of the COVID-19 pandemic, cancer care has had to adapt rapidly given recommendations to postpone nonurgent surgeries with active surveillance of thyroid cancer patients except thyroid tumors requiring acute airway management. [ABSTRACT FROM AUTHOR]

The aim of the study was to evaluate the clinical impact of pre-ablation rhTSH-stimulated fluorine-18 fluorodeoxyglucose (F-18 FDG) PET/CT in addition to post-therapeutic whole body radioiodine scanning in patients with intermediate to high risk differentiated thyroid carcinoma (DTC). This was a retrospective single center study including 73 patients with thyroid cancer (44 females, mean age 43.2±16.2 years, 62% papillary, 31% follicular, 7% poorly differentiated). All patients underwent ablative radioiodine treatment (mean activity: 3661±673 MBq I-131) using rhTSH after thyroidectomy and lymph node (LN) dissection (01/2013–10/2016) and TSH-stimulated F-18 FDG PET/CT (4 MBq/kg body weight, low dose CT). Post-treatment I-131 whole body scan (I-131 WBS) was obtained 9 days afterwards in planar technique and in case of equivocal or abnormal findings using SPECT/CT. Thirty-one patients (42%) showed F-18 FDG avid lesions, 14 patients showed more FDG than iodine positive lesions and 5 patients more iodine positive lesions in I-131 WBS, respectively. Fifty-three patients showed identical F-18 FDG PET/CT and I-131 WBS. The initial treatment plan was changed from follow-up to therapy (surgery, systemic therapy using tyrosine-kinase inhibition) in 11 patients (15%) on the basis of F-18 FDG PET/CT imaging. Six of these 11 patients had papillary thyroid cancer. Three patients with histologically proven LN metastases had stimulated thyroglobulin-levels<2.0 ng/ml. Our study demonstrated a clinical benefit of pre-ablation rhTSH-stimulated F-18 FDG PET/CT imaging in about 20% of patients with intermediate to high risk DTC, leading to change in patient management in 15%. [ABSTRACT FROM AUTHOR]

Introduction: Only about 30% of pediatric patients with Graves' hyperthyroidism achieve remission with medical therapy, and therefore radioactive iodine (RAI) therapy is often used as a definitive treatment. Although the goal of RAI is permanent hypothyroidism, this is not consistently achieved. We conducted a chart review to determine the factors associated with the success of RAI. We also tried to determine optimal follow-up post RAI and if there was an optimal L-thyroxine dose that would normalize the hypothyroid state quickly. Methods: This is a retrospective chart review of Graves' patients who underwent RAI between 2008 and 2017. We included age, sex, time from diagnosis, thyroid gland size, total dose of I-131 and dose in μCi/g of thyroid tissue. Patients were grouped based on outcome and analyzed using univariate and multivariate logistic regression. Follow-up thyroid levels post RAI and after starting l-thyroxine were analyzed. Results: There were 78 ablations including six repeat ablations. Seventy-three percent became hypothyroid, 23% remained overtly or subclinically hyperthyroid, and 4% were euthyroid. Smaller thyroid size (36.5 vs. 47.4 g; p = 0.037) and higher dose of I-131 (242 vs. 212 μCi/g thyroid tissue; p = 0.013) were associated with a higher likelihood of hypothyroidism. Most patients remained hyperthyroid at 1 month post RAI, but by 3 months the majority became hypothyroid. There was no clear L-thyroxine dose that normalized hypothyroidism quickly. Conclusions: An I-131 dose close to 250 μCi/g of thyroid tissue has a higher likelihood of achieving hypothyroidism. Testing at 2–3 months after RAI is most helpful to confirm response to RAI. [ABSTRACT FROM AUTHOR]

Abstract Background Recurrent papillary thyroid carcinoma (PTC) beyond the first two decades of definitive treatment (i.e. total thyroidectomy and radioactive iodine ablation) is a rare occurrence. Case presentation We present a case of a 71-year old Caucasian female with a distant history of PTC treated with total thyroidectomy and radioactive iodine ablation who experienced recurrence of her disease 43 years following initial diagnosis and definitive treatment. She presented with palpable left-sided neck mass and subsequently underwent a level II, III, neck dissection and adjuvant iodine ablation. This case presents the latest recurrence in papillary thyroid cancer documented to date in the literature. Conclusion This case exemplifies the need for the head and neck surgeon, radiation oncologist, general practitioner and radiologist to consider new lateral neck mass as late-presenting recurrence of PTC until proven otherwise regardless of low recurrence rates beyond two decades from treatment and low prognostic risk scores.

Establishment of new centers for nuclear medicine in our country made diagnostic and treatment procedures more accessible for patients with differentiated thyroid cancer (DTC). It includes radioiodine therapy, considered as a non-alternative method of treatment, and positron emission tomography combined with computed tomography (PET/CT), which is essential in some clinical cases. For many years suspected tumor relapse with increased level of thyroglobulin and negative radioiodine scan was the only indication for PET/CT use among patients with DTC. But over the last decade the indications for PET/CT use in DTC cases expanded significantly. This review is aimed to analyze currently available data on PET/CT in DTC patients, its indications for use, advantages and limitations, new trends and recommendations.

A 55-year-old female presented with a 10 years history of swelling in the front part of her neck, and a persistent headache for the past 4 months. During the course of her hospital stay, she developed right upper limb monoplegia. An examination showed that she had papillary carcinoma thyroid in an euthyroid state. Further work-up revealed a solitary pulmonary nodule on the left lower lobe, right ventricular tumor thrombus in the heart, and hemorrhagic metastases involving the left cerebral and cerebellar hemispheres. Total thyroidectomy with bilateral functional and central neck dissection was performed. Postoperatively, the patient received radioiodine ablation with I131 for lung and brain metastases, and remnant ablation for primary treatment. She has received regular follow-up care for the past 3 months. [Arch Clin Exp Surg 2016; 5(4.000): 238-241]

ABSTRACT Objective Our objective was to evaluate the trend of antithyroglobulin antibodies (TgAb) during follow-up of patients with differentiated thyroid cancer (DTC) treated without RAI, as well as their role in the risk of recurrence. Subjects and methods This was a prospective, descriptive study. A total of 152 consecutive patients with DTC treated in a single institution undergoing total thyroidectomy without RAI and followed for a median of 2.3 years (0.5-10.3) were divided in two groups: TgAb(-) (n = 111) and TgAb(+) (n = 41). Patients were classified according to AJCC 7th and 8th editions, as well as to their risk of recurrence and response to treatment categories. Results Both groups, TgAb(-) and TgAb(+), were similar regarding patient and tumor characteristics. At the end of follow-up, 90 (59.2%), 57 (37.5%), 3 (2%) and 2 (1.3%) patients achieved excellent, indeterminate, biochemically incomplete and structurally incomplete response, respectively. The risk of structural recurrence was similar in both groups (TgAb[-] 0.9% vs. TgAb[+] 2.4%, p = 0.46). In the TgAb(+) group, TgAb became negative in 10 (24.4%), decreased ≥ 50% without negativization in 25 (60.9%), decreased < 50% in 4 (9.8%) and remained stable or increased in 2 (4.9%) cases. The only incomplete structural response had increasing TgAb during follow-up. Conclusions In properly selected patients with DTC, TgAb concentration immediately after total thyroidectomy should not mandate RAI ablation, and their trend during follow-up may impact the risk of recurrence.

Changing insights regarding radioiodine (I-131) administration in differentiated thyroid carcinoma (DTC) stir up discussions on the utility of pre-ablation diagnostic scintigraphy (DxWBS). Our retrospective study qualitatively and semi-quantitatively assessed posttherapy I-131 whole-body scintigraphy (TxWBS) data for thyroid remnant size and metastasis. Findings were associated with initial treatment success after nine months, as well as clinical, histopathological, and surgical parameters. Possible management changes were addressed. A thyroid remnant was reported in 89 of 97 (92%) patients, suspicion of lymph node metastasis in 26 (27%) and distant metastasis in 6 (6%). Surgery with oncological intent and surgery by two dedicated thyroid surgeons were independently associated with a smaller remnant. Surgery at a community hospital, aggressive tumor histopathology, histopathological lymph node metastasis (pN1) and suspicion of new lymph node metastasis on TxWBS were independently associated with an unsuccessful treatment. Thyroid remnant size was unrelated to treatment success. All 13 pN1 patients with suspected in situ lymph node metastases on TxWBS had an unsuccessful treatment, opposite 19/31 (61%) pN1 patients without (p = 0.009). Pre-ablative knowledge of these TxWBS findings had likely influenced management in 48 (50%) patients. Additional pre-ablative diagnostics could optimize patient-tailored I-131 administration. DxWBS should be considered, especially in patients with pN1 stage or suspected in situ lymph node metastasis. Dependent on local surgical expertise, DxWBS is not recommended to evaluate thyroid remnant size.

Objective: This study aimed to compare the clinical outcomes of patients who received radioactive iodine (RAI) ablation after undergoing thyroidectomy for intermediate-to-high-risk differentiated thyroid carcinoma (DTC) according to the American Thyroid Association (ATA) criteria.Methods: We retrospectively examined patients who underwent RAI ablation for DTC after surgical resection without macroscopic residual lesions or metastatic lesions between December 2011 and August 2016. Among 147 patients who underwent RAI ablation, those whose initial pathological stages or RAI ablation results were unknown and whose distant metastases were confirmed during RAI ablation were excluded. Low-dose therapy was defined as administration of 1110 MBq of 131iodine (131I), while high-dose therapy referred to administration of 2960-3700 MBq of 131I. We defined initial success of RAI ablation as a serum thyroglobulin concentration of < 2.0 ng/mL without thyroid-stimulating hormone stimulation and disappearance of 131I uptake in the thyroid bed on 131I scintigraphy 6-12 months after RAI ablation. RAI ablation success rates were compared between the low-dose and high-dose groups using Fisher's exact test, and inverse probability of treatment weighting (IPTW) analysis was performed for adjusting potential biases.Results: Among the 119 patients examined in this study (39 men and 80 women), 79 were classified as having intermediate risk, while 40 were classified as having high risk based on the ATA guideline. Initial RAI ablation success was achieved in 50/68 (73.5%) patients from the low-dose group and in 36/51 patients (70.6%) from the high-dose group (p = 0.84). Moreover, IPTW analysis showed no significant difference between the low-dose and high-dose groups. However, the success rate tended to be superior in high-risk patients who received high-dose therapy (86.2%) than in those who received low-dose therapy (72.7%) (p = 0.37).Conclusion: There was no significant difference in the RAI ablation success rate between the low-dose and high-dose groups involving patients with intermediate-to-high-risk DTC. However, high-dose RAI ablation may be recommended in high-risk patients. [ABSTRACT FROM AUTHOR]

Knowledge of the variations of the pyramidal lobe of the thyroid is important for surgeons to perform complete resection of the functional thyroid tissue. Complete excision of the thyroid tissue surgery reduces the chances of recurrence in both the benign and the malignant diseases. It is important to remove all functioning thyroid tissue especially in the differentiated thyroid cancer so the postoperative radioiodine ablation is more effective and serum thyroglobulin acts as an efficient marker. We report a case of the double pyramidal lobe of thyroid gland in a woman of age 63 years with follicular thyroid cancer. Our literature search revealed only three documented cases of the double pyramidal lobe. Knowledge and recognition of such a rare variation is essential to perform safe and effective thyroid surgery. [ABSTRACT FROM AUTHOR]

Background: Thyroglobulin (Tg) antibodies (TgAb) can interfere with Tg measurement and can be used as “Tg surrogate” in patients with differentiated thyroid cancer (DTC) treated with total thyroidectomy (TTx) and radioiodine remnant ablation (RRA). In contrast, few data, and in patients usually followed for a short-term follow-up, have been reported about the changes of TgAb levels in patients treated with TTx but without RRA. The aims of this study were to evaluate the changes of TgAb levels in DTC patients treated with TTx but not RRA and to identify the factors that influence these changes. Methods: The change in TgAb levels in 107 DTC (<1 cm) patients submitted to TTx but not RRA was evaluated. Patients were followed for a median of 6.3 years, and all had at least three determinations of TgAb and neck ultrasound (nUS). Results: TgAb levels showed a progressive decrease during follow-up. Initial TgAb levels and degree of lymphocytic infiltration influenced the time but not the rate of TgAb disappearance. No influence on time and rate of the decrease in TgAb was observed when the association with thyroperoxidase antibodies (TPOAb) levels were considered. A TgAb cutoff value of 61.9 IU/mL at first postoperative evaluation was a good indicator for disappearance of the TgAb within six years. No tumor recurrence was observed in the series. In one case, the progressive increase in TgAb anticipated the reappearance of benign thyroid tissue with lymphocytic infiltration. Conclusions: TgAb levels decline in the majority of DTC patients treated with TTx but not ablated with radioiodine. The levels decrease rapidly after the surgical treatment and continue to decrease over time. The time of disappearance is influenced by the initial TgAb levels and the degree of lymphocytic infiltration. No influence of the actual TPOAb levels has been observed. An increase in TgAb levels should not be overlooked, since it can indicate the presence or reappearance of either normal thyroid tissue or tumor recurrence. [ABSTRACT FROM AUTHOR]

Introduction: Postoperative radioiodine (RJ) ablation (TERJ) with a preferred use of low dose can be indicated also at low-risk patients with a differentiated thyroid carcinoma (DTC) according to current guidelines. Aim: Assessment of TERJ effectivity used in low-risk patients with DTC after applying of 1.1 GBq of 131I. Material: 61 pts (53 females) with a DTC after declared total thyroidectomy due to a papillary or papillary-follicular cancer (60 pts) and follicular cancer (1 pt). Classification according to the tumor volume was as follows: T1a 45 pts, T1b 10 pts, and T2 6 pts. Methods: Pts were admitted to our department at hypothyroidism; neck scintigraphy with the detection of residual thyroid tissue after surgery was assessed. Initial level of thyroglobulin (Tg) ranges from < 0.1 to 9.0 μg/l. Blood content of antibody against Tg (anti-Tg) was increased in 18 cases (0.9-333 U/ml). Radioiodine ablation dose of 1.1 GBq was applied in all pts. Rehospitalization again at hypothyroidism was performed 6 months later; whole-body scan was done after a diagnostic dose of 110 MBq 131I. Negative scintigraphy at the region of the neck together with a low level of Tg below 2 μg/l or decline of anti-Tg in pts with a low Tg <0.1 μg/l was considered as an effective TERJ. Results: Negative follow-up scintigraphy with no detectable thyroid tissue was present in 52/61 pts. The second criterion, i.e. level of Tg below 2 μg/l or decline of anti-Tg was present in all these pts; the therapeutic effectivity of TERJ was thus 85.2 %. TERJ was not effective in 9/61 pts (14.8 %). Conclusion: According to our experience, the efficacy of TERJ after applying of 1.1 GBq of 131I (85.2 %) is comparable to the literature and also to our previous results with a group of 131 pts after applying of 3.7 GBq of 131I form the years 2007 to 2012, when the therapeutic effectivity was 80 %. [ABSTRACT FROM AUTHOR]

Differentiated Thyroid Carcinoma (DTC) constitute up to 90 per cent of all thyroid malignancy. The overall prognosis of patients with DTC is good, but when bone metastases are present, the overall survival at 10 years ranges from 13 to 21%. Treatment of metastatic thyroid cancer that are non iodine avid offers a surgical challenge. This paper reviews a series of three cases of DTCs with bone metastasis treated by surgery.

The use of radioiodine as the first line of treatment in Graves′ disease is restricted in India because of its limited availability and an unrealistic risk perception associated with it. Additionally, the effectiveness of radioiodine ablation in Graves′ disease is influenced by many factors. Prior medical antithyroid therapy is one such important factor. Aims: To analyze the efficacy of low dose radioiodine therapy (5 mCi) in treatment of naive patients of Graves′ disease in comparison to that in which it was already primed with an antithyroid drug, carbimazole. Settings and Design: A non-randomized, interventional study conducted in the Department of Medicine and Endocrinology of a tertiary care institute in South India. Materials and Methods: The study had two groups; Group A (36 treatment naive, uncomplicated Graves′ disease patients) and B (34 Graves′ disease patients on carbimazole prior to radioiodine therapy). Both groups had baseline clinical, biochemical evaluation and were reassessed at 3 and 6 months for evaluating the clinical status for possible documentation of cure. Results: The cure rate was 61.1% in drug naive group and 58.8% in pretreated group at 6 months following radioiodine (P = 0.845). Higher baseline 999m technicium (99m Tc) uptake, male gender, BMI and higher baseline free thyroxine (fT4) level predicted treatment failure following radioiodine therapy. Conclusions: Administration of carbimazole prior to low dose radioiodine therapy does not alter the efficacy of radioiodine. Low fixed dose (5 mCi) of radioactive iodine may be a safe and effective primary therapeutic option in Graves′ disease patients pretreated with antithyroid drugs.