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Journal Cover European Thyroid Journal
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   Full-text available via subscription Subscription journal
   ISSN (Print) 2235-0640 - ISSN (Online) 2235-0802
   Published by Karger Homepage  [121 journals]
  • Aspirin Increases the Risk of Nondiagnostic Yield of Fine-Needle
           Aspiration and Biopsy of Thyroid Nodules
    • Abstract: Background: The link between the diagnostic yield of thyroid fine-needle aspiration and biopsy (FNAB) in patients taking antithrombotic or anticoagulant medications (AT/AC) remains poorly characterized. Objectives: We studied the risk of obtaining a nondiagnostic sample with ultrasound-guided thyroid FNAB in patients taking AT/AC medications. Methods: This is a retrospective cohort study using medical rec­ords of 556 patients who underwent thyroid FNAB. All cytology samples were reported using the Bethesda classification. For patients with a nondiagnostic cytology, logistic regression was used to calculate OR for patients taking AT/AC medications. Multivariate regression was used to adjust for potential confounding variables including age, cystic ultrasound features, presence of eggshell calcifications, number of passes performed, cystic aspirate on FNAB, and position of the nodule. Results: Out of 556 patients, cytology results were available for 547 patients. Of these, 46 subjects were taking aspirin and 1 was on warfarin. Among the entire cohort, 17.5% of the subjects had a nondiagnostic cytology. Among the patients on AT/AC medications, 34% had a nondiagnostic result compared to 16% for those not taking them (OR = 2.70, p = 0.003). The subgroup of patients taking aspirin had similarly higher odds of a nondiagnostic cytology (OR = 2.78, p = 0.002). These differences remained statistically significant after multivariate adjustment. Conclusions: This is the first study to demonstrate a 3-fold independently greater risk of a nondiagnostic FNAB cytology in patients taking aspirin. Our results highlight the importance of evaluating the need for continuation of aspirin in patients undergoing thyroid FNAB as this may impact the diagnostic yield of the procedure.
      Eur Thyroid J
  • Thyroid Swelling: A Common Phenomenon in Art'
    • Abstract: Representations of thyroid swelling, intended as an enlarged anterior neck region, in the artworks of various periods are sporadically reported in the scientific literature, and different intents may be hypothesized. A comprehensive review of the international literature was performed on PubMed, Embase, and ResearchGate with the aim to analyze the modalities of representation of thyroid swelling through the ages by different artistic movements. Thyroid swelling is frequently represented in the artworks of many stylistic periods and seems to be a known condition even by the earliest cultures. Thyroid swelling may be considered a common finding among forms of art distant in time and style. It is not always possible to define whether thyroid swelling is a realistic representation or a detail added by the author. Although the function of the gland was discovered only at the end of the 19th century, thanks to the artworks of authors in many cultures, it is nowadays possible to formulate hypotheses about the distribution of thyroid diseases over the centuries.
      Eur Thyroid J
  • Bethesda Classification and Cytohistological Correlation of Thyroid
           Nodules in a Brazilian Thyroid Disease Center
    • Abstract: Background: The Bethesda System has been used to classify thyroid cytology in 6 categories besides presenting malignancy rates and respective approaches. Reference centers have validated its use by comparing its proposed malignancy rates with those in in their populations. However, to the best of our knowledge, there has been no corresponding study in Brazil. Objectives: To evaluate the performance of the Bethesda classification in a Brazilian thyroid reference center and correlate the results with cytohistological reports in patients referred to surgery. Methods: Data records from 980 fine-needle aspiration (FNA) results were retrospectively analyzed, and, in patients who underwent surgery, the results were correlated with the cytohistological findings. Results: 980 FNAs and 585 patients were evaluated. The incidence of each cytological category was: 11% nondiagnostic (ND), 59.6% benign, 7.1% (atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS), 8.5% follicular neoplasm or suspicious for follicular neoplasm (FN/SFN), 5.1% suspicious for malignancy (SM), and 8.3% malignant. The surgery rate was 41.8% (245/585). The malignancy rate in each category was: 6% benign, 12% AUS/FLUS, 20.8% FN/SFN, 72.5% SM, and 97.3% malignant. For ND nodules, the malignancy rate was 25.7% (66.6% multifocal and papillary microcarcinomas), a higher rate than in the literature. In this category, surgery was performed in multinodular goiters presenting with another nodule #x3e; 3.0 cm and/or with an FN/SFN, SM, or malignant cytological result. Conclusion: The Bethesda System can be applied to the Brazilian population, since the frequency and malignancy rates of each category were similar to those described by its classification. It is noteworthy that a higher risk of malignancy was observed in the ND cytological category.
      Eur Thyroid J
  • Variables Contributing to Thyroid (Dys)Function in Pregnant Women: More
           than Thyroid Antibodies'
    • Abstract: Variability in thyroid function in pregnant women is the result of 2 main determinants, each accounting for approximately half of it. The first is the genetically determined part of which the knowledge increases fast, but most remains to be discovered. The second determinant is caused by an ensemble of variables of which thyroid autoimmunity is the best known, but also by others such as parity, smoking, age, and BMI. More recently, new candidate variables have been proposed, such as iron, endocrine disruptors, and the ethnicity of the pregnant women. In the future, the diagnosis and treatment of thyroid (dys)function may be optimized by the use of each individual’s pituitary-thyroid set point, corrected with a factor taking into account the impact of nongenetically determined variables.
      Eur Thyroid J
  • Sorafenib-Induced Acute Pancreatitis in a Patient with Differentiated
           Thyroid Cancer
    • Abstract: Background: Sorafenib is a tyrosine kinase inhibitor approved for the treatment of metastatic renal cell carcinoma, hepatocellular carcinoma, and recently for radioactive iodine (RAI)-refractory metastatic differentiated thyroid carcinoma (DTC). Several side effects have been described including alterations in amylase and lipase levels. Nonetheless, only a few cases of pancreatitis during renal carcinoma and hepatocellular carcinoma treatment have been described. Objective: To describe the first case report of sorafenib-induced acute pancreatitis during the treatment of thyroid carcinoma. Methods and Results: In a 60-year-old Latin woman with RAI-refractory papillary thyroid carcinoma, T4bN1bM1, sorafenib was indicated due to locally recurrent, metastatic, and progressive lung involvement without iodine uptake. Therapy was initiated (200 mg) every 8 h. Three days after starting the medication, abdominal pain, nausea, and emesis appeared. A blood test revealed elevated amylase (343 U/L RV: 28–100) and lipase (1,969 U/L RV: 23–300) levels, but no other findings, confirming acute mild pancreatitis. Hypertriglyceridemia, hypercalcemia, and alcohol and biliary etiologies were ruled out and sorafenib-acute pancreatitis was concluded. Two weeks later, sorafenib was resumed without recurrence. To date, this is the tenth sorafenib-related pancreatitis report and the first in a patient with RAI-refractory metastatic DTC. Conclusions: Sorafenib-acute pancreatitis may develop in patients with RAI-refractory thyroid cancer. This adverse event seems to be inde­pendent of the treatment duration and administered dose. Resuming the medication with an adjusted dose after pancreatitis resolution may be safe.
      Eur Thyroid J
  • Noninflammatory Diffuse Follicular Hypertrophy/Hyperplasia of Graves
           Disease: Morphometric Evaluation in an Experimental Mouse Model
    • Abstract: Objectives: Experimental models of Graves hyperthyroid disease accompanied by Graves orbitopathy (GO) can be efficiently induced in susceptible inbred strains of mice by immunization by electroporation of heterologous human TSH receptor (TSHR) A-subunit plasmid. The interrelated pathological findings in the thyroid glands of Graves disease (GD) that explain the core changes classically include diffuse follicular hyperplasia and multifocal mild lymphocytic infiltrate. However, the relative contributions of different thyroid tissue components (colloid, follicular cells, and stroma) have not been previously evaluated. In this study, we characterize the thyroid gland of an experimental mouse model of autoimmune GD. Our objective was to define the relative contribution of the different thyroid tissue components to the pathology of glands in the experimental model. Methods: Mice were immunized with human TSHR A-subunit plasmid. Antibodies induced to human TSHR were pathogenic in vivo due to their cross-reactivity to mouse TSHR. Results: Autoimmune thyroid disease in the model was characterized by histopathology of hyperplastic glands with large follicular cells. Further examination of thyroid glands of immunized animals revealed a significantly increased follicular area and follicle/stroma ratio, morphometrically correlated with a noninflammatory follicular hyperplasia/hypertrophy. The increased follicle/stroma ratio was the most relevant morphometrically variable summarizing the pathological changes for screening purposes. Conclusion: GD thyroid glands are enlarged and characterized by a noninflammatory diffuse follicular cell hyperplasia/hypertrophy and a significant increase in the follicles with an increased follicle/stroma ratio. Overall, this mouse model is a faithful model of an early hyperthyroid status of GD (diffuse glandular involvement and follicular expansion).
      Eur Thyroid J
  • Lenvatinib for Anaplastic Thyroid Cancer and Lenvatinib-Induced Thyroid
    • Abstract: Background: Lenvatinib is an oral multitargeted tyrosine kinase inhibitor that has an anticancer action in patients with differentiated thyroid cancer that is refractory to radioiodine. Knowledge of the efficacy and safety of lenvatinib in patients with anaplastic thyroid cancer (ATC) is limited. Tyrosine kinase inhibitors frequently cause hypothyroidism, but the incidence of hypothyroidism with lenvatinib is unclear. Objectives: We conducted a retrospective study to investigate the efficacy and safety of lenvatinib in ATC. Methods: Five patients with unresectable ATC were enrolled. Lenvatinib 24 mg once daily was administered until disease progression, unmanageable toxicity, withdrawal, or death occurred. We retrospectively analyzed the objective response rate (ORR), time to progression (TTP), overall survival, and safety. Results: Three of the 5 patients (60%) had a partial response, and 5 (40%) had stable disease. The ORR was 60%. Median TTP was 88 days, and overall survival was 165 days. Hypothyroidism was a common treatment-related adverse effect; 4 patients (80%) had hypothyroidism of any grade. These 4 patients had not undergone total thyroidectomy prior to lenvatinib administration, and the other patient had undergone total thyroidectomy. Treatment-related adverse effects of any grade were hypertension in 80% of patients, diarrhea in 40%, fatigue in 80%, and decreased appetite in 80%. Conclusions: Lenvatinib is an effective treatment and may improve the prognosis of unresectable ATC. Four of the 5 patients had hypothyroidism, which may have been associated with treatment-induced injury of the thyroid gland. There were many treatment-related adverse effects, most of which were manageable by dose modification and medical therapy.
      Eur Thyroid J
  • Successful Treatment of Differentiated Thyroid Carcinoma with
           Transaxillary Robotic Surgery and Radioiodine: The First European
    • Abstract: Objectives: Transaxillary robotic thyroidectomy surgery (TARS) has been reported to be a safe approach in patients with differentiated thyroid carcinoma, and oncological responses are promising. Study Design: This study aimed to evaluate the oncological outcomes of TARS followed by radioiodine (RAI) therapy in patients with differentiated thyroid carcinoma. Between 2011 and 2016, patients treated for differentiated thyroid carcinoma by TARS in a single institution, followed by RAI, were retrospectively included. The oncological response was performed according to the 2015 American Thyroid Association (ATA) guidelines 6–12 months later and at the last available visit. Results: A total of 42 patients (30 females) were included, with a median tumor size of 20 mm (12 cases of N1a and 5 cases of N1b on initial pathology report). According to ATA classification of recurrence risk after surgery, 17 and 25 patients were classified as low and intermediate risk, respectively. After RAI, all patients had a normal posttherapeutic whole body scan (except 1 patient, who had pathological lymph node uptake), but no unusual uptake was seen. At the 6- to 12-month evaluation (n = 37), 24 patients had excellent response, 8 had indeterminate response, and 5 had incomplete response (2 biological and 3 structural); no distant metastasis was found. At the last evaluation (median follow-up 15.9 months), 35 patients had no evidence of disease and 1 patient had a structural incomplete response. In total, a second open surgery was necessary for 3 patients to treat persistent lymph nodes (all intermediate risk). Conclusion: In this study, TARS followed by RAI therapy seems to be curative, even for patients with lymph node metastases, after good preoperative staging. More studies are required to confirm the findings.
      Eur Thyroid J
  • Prevalence of Radiological Signs of Dysthyroid Optic Neuropathy in
           Magnetic Resonance Imaging in Patients with Active, Moderate-to-Severe,
           and Very Severe Graves Orbitopathy
    • Abstract: Background: Differentiating between dysthyroid optic neuropathy (DON), which requires urgent therapy to prevent blindness, and moderate-to-severe Graves orbitopathy (GO) remains challenging. There is no pathognomonic feature of DON in either ophthalmological or radiological examinations. Objectives: Our aim was to investigate the prevalence of radiological signs of DON in magnetic resonance imaging (MRI) in patients with moderate-to-severe and very severe GO. Methods: Two researchers reassessed MRI scans of 23 consecutive patients (46 eyes) with active, moderate-to-severe GO and 14 patients (23 eyes) with very severe GO. Typical signs of DON in MRI include apical crowding and optic nerve stretching. These were evaluated in the eyes of both groups of patients. Lack of cerebrospinal fluid in the optic nerve sheath as well as muscle index values were also studied. These clinical evaluations and laboratory results were then compared between groups. Results: At least one of the typical radiological features of DON was found in 22 (96%) and 16 (35%) eyes with very severe and moderate-to-severe GO, respectively. Each occurred statistically more often in patients with very severe GO. There were no ophthalmological signs of very severe GO observed in the group of patients with moderate-to-severe GO during the study or its subsequent follow-up (234 weeks). Conclusions: MRI is a useful tool in evaluating very severe GO. However, features typical for DON are also found in up to 35% of eyes in patients with active, moderate-to-severe GO. Therefore, ophthalmological evaluation seems to be most important in the recognition of very severe GO.
      Eur Thyroid J 2018;7:88–94
  • 2018 European Thyroid Association (ETA) Guidelines for the Management of
           Amiodarone-Associated Thyroid Dysfunction
    • Abstract: Treatment with amiodarone is associated with changes in thyroid function tests, but also with thyroid dysfunction (amiodarone-induced hypothyroidism, AIH, and amiodarone-induced thyrotoxicosis, AIT). Both AIH and AIT may develop in apparently normal thyroid glands or in the presence of underlying thyroid abnormalities. AIH does not require amiodarone withdrawal, and is treated with levothyroxine replacement if overt, whereas subclinical forms may be followed without treatment. Two main types of AIT are recognized: type 1 AIT (AIT 1), a form of iodine-induced hyperthyroidism occurring in nodular goitres or latent Graves disease, and type 2 AIT (AIT 2), resulting from destructive thyroiditis in a normal thyroid gland. Mixed/indefinite forms exist due to both pathogenic mechanisms. AIT 1 is best treated with thionamides that may be combined for a few weeks with sodium perchlorate to make the thyroid gland more sensitive to thionamides. AIT 2 is treated with oral glucocorticoids. Once euthyroidism has been restored, AIT 2 patients are followed up without treatment, whereas AIT 1 patients should be treated with thyroidectomy or radioiodine. Mixed/indefinite forms of AIT are treated with thionamides. Oral glucocorticoids can be added from the beginning if a precise diagnosis is uncertain, or after a few weeks if response to thionamides alone is poor. The decision to continue or to stop amiodarone in AIT should be individualized in relation to cardiovascular risk stratification and taken jointly by specialist cardiologists and endocrinologists. In the presence of rapidly deteriorating cardiac conditions, emergency thyroidectomy may be required for all forms of AIT.
      Eur Thyroid J 2018;7:55–66
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