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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  [101 journals]
  • Nonrecurrent Laryngeal Nerve and Associated Anatomical Variations: The Art
           of Prediction
    • Abstract: Introduction: A nonrecurrent laryngeal nerve (NRLN) is a rare anatomical variation in which the nerve enters the larynx directly off the cervical vagus nerve. Case Report: We present 2 patients who underwent thyroid surgery for benign disease. Intraoperatively, type 2a and 1 NRLN were identified. Due to the frequent association with a vascular abnormality, an ultrasound and a computed tomography were performed which showed a right aberrant subclavian artery with a retroesophageal course and a common trunk of the common carotids in both patients. Discussion and Conclusion: The presence of an NRLN is a major risk during surgical procedures and the surgeon should be aware of the possibility of its existence. NRLN may be associated with rare vascular anomalies, such as arteria lusoria and a bicarotid trunk. This paper reveals this association in 2 patients for the first time.
      Eur Thyroid J
  • The 2015 European Thyroid Association Guidelines on Diagnosis and
           Treatment of Endogenous Subclinical Hyperthyroidism
    • Abstract: Endogenous subclinical hyperthyroidism (SHyper) is caused by Graves' disease, autonomously functioning thyroid nodules and multinodular goitre. Its diagnosis is based on a persistently subnormal serum thyroid-stimulating hormone (TSH) level with free thyroid hormone levels within their respective reference intervals. In 2014 the European Thyroid Association Executive Committee, given the controversies regarding the treatment of Endo SHyper, formed a task force to develop clinical practice guidelines based on the principles of evidence-based medicine. The task force recognized that recent meta-analyses, including those based on large prospective cohort studies, indicate that SHyper is associated with increased risk of coronary heart disease mortality, incident atrial fibrillation, heart failure, fractures and excess mortality in patients with serum TSH levels
  • Unusual Manifestation of Graves' Disease: Ventricular Fibrillation
    • Abstract: Background: It is well known that thyrotoxicosis causes rhythm disorders including sinus tachycardia, atrial fibrillation, and atrial flutter. Atrial fibrillation is the most common arrhythmia in thyrotoxicosis, occurring in 5-15% of patients over 60 years of age, whereas ventricular arrhythmia is an unusual manifestation. Case Report: An 18-year-old Japanese woman was admitted to our emergency department because of loss of consciousness caused by ventricular fibrillation. She had been diagnosed with Graves' disease only 5 days earlier and had no other past medical history. Blood examination showed no obvious abnormality except thyrotoxicosis, and coronary angiography revealed patent coronary arteries. She was diagnosed with thyroid storm due to Graves' disease and is currently healthy during outpatient follow-up. Conclusion: This case highlights that thyrotoxicosis can, albeit extremely rarely, cause ventricular fibrillation even in the absence of hypokalemia or underlying cardiovascular disease.
      Eur Thyroid J
  • Thyroid Growth and Cancer
    • Abstract: It is proposed that most papillary thyroid cancers originate in infancy and childhood, based on the early rise in sporadic thyroid carcinoma incidence, the pattern of radiation-induced risk (highest in those exposed as infants), and the high prevalence of sporadic papillary thyroid cancers in children and adolescents (ultrasound screening after the Fukushima accident). The early origin can be linked to the growth pattern of follicular cells, with a high mitotic rate in infancy falling to very low replacement levels in adult life. The cell of origin of thyroid cancers, the differentiated follicular cell, has a limited growth potential. Unlike cancers originating in stem cells, loss of the usually tight link between differentiation and replicative senescence is required for immortalisation. It is suggested that this loss distinguishes larger clinically significant papillary thyroid cancers from micro-papillary thyroid cancers of little clinical significance. Papillary carcinogenesis can then be divided into 3 stages: (1) initiation, the first mutation in the carcinogenic cascade, for radiation-induced papillary thyroid cancers usually a RET rearrangement, (2) progression, acquisition of the additional mutations needed for low-grade malignancy, and (3) escape, further mutations giving immortality and a higher net growth rate. Most papillary thyroid cancers will not have achieved full immortality by adulthood, and remain as so-called micro-carcinomas with a very low growth rate. The use of the term ‘cancer' to describe micro-papillary thyroid cancers in older patients encourages overtreatment and alarms patients. Invasive papillary thyroid tumours show a spectrum of malignancy, which at its lowest poses no threat to life. The treatment protocols and nomenclature for small papillary carcinomas need to be reconsidered in the light of the new evidence available, the continuing discovery of smaller lesions, and the model of thyroid carcinogenesis proposed.
      Eur Thyroid J
  • Guidance in Subclinical Hyperthyroidism and Subclinical Hypothyroidism:
           Are We Making Progress'
    • Abstract:
      Eur Thyroid J
  • Metformin Is Associated with a Favorable Outcome in Diabetic Patients with
           Cervical Lymph Node Metastasis of Differentiated Thyroid Cancer
    • Abstract: Background and Objective: Type 2 diabetes is known to increase the risk and progression of certain types of cancer. Metformin treatment of diabetic patients is reported to have beneficial effects on some cancers. We evaluated the clinical outcome of diabetic patients with differentiated thyroid cancer (DTC) according to metformin treatment. Methods: We reviewed 943 patients diagnosed with DTC after total thyroidectomy between 1995 and 2005 in a tertiary hospital. The study involved 60 diabetic patients and 210 control patients matched for age, sex, body mass index (BMI), and tumor size. Results: There were no differences in the clinicopathological features and disease-free survival (DFS) between diabetic patients and the control group over 8.9 years of follow-up. Of the diabetic patients with DTC, 35 patients (58%) were treated with metformin. There were no differences in age, sex, BMI, tumor size, antidiabetic medication, glycated hemoglobin, or C-peptide levels in metformin and nonmetformin groups. However, cervical lymph node (LN) metastasis was more prevalent in the metformin group than in the nonmetformin group (OR 3.52, p = 0.035). Among diabetic patients with cervical LN metastasis of DTC, the metformin subgroup (17.1 years) was associated with longer DFS than the nonmetformin subgroup (8.6 years) (HR 0.16, p = 0.021); metformin treatment was also associated with longer DFS in this subgroup in multivariate analysis after adjusting age, BMI, duration of diabetes, presence of tumor at resection margin, and serum thyroglobulin level at ablation (HR 0.03, p = 0.035). Conclusions: Metformin treatment is associated with low recurrence in diabetic patients with cervical LN metastasis of DTC.
      Eur Thyroid J
  • Hypertrophic Osteoarthropathy and Follicular Thyroid Cancer: A Rare
           Paraneoplastic Syndrome
    • Abstract: Background: Hypertrophic osteoarthropathy (HOA) is a rare condition characterized by bone and joint pain and digital clubbing usually associated with bronchopulmonary diseases. Primary HOA is rare and the pathogenesis remains unclear. Objectives: Cases of HOA as a paraneoplastic syndrome associated with thyroid carcinoma are very rare - only 2 cases have been described in the literature. Results: We present the first case of a 40-year-old patient affected by HOA associated with invasive differentiated follicular thyroid carcinoma operated in 2 stages. Both operations were followed by radioiodine ablation, and then a rapid unresectable local recurrence developed requiring cervical radiotherapy (70 Gy). A second treatment with 100 mCi of 131I confirmed it was a refractory thyroid cancer. Further surgery confirmed a poorly differentiated follicular cancer and 12 cycles of chemotherapy by gemcitabine and oxaliplatin followed. During the 8 years of follow-up, cervical recurrence was stable, but severe episodes of hemoptysis occurred requiring iterative embolization of the bronchial and tracheal arteries. Other lung diseases were excluded. Digital clubbing appeared, which was associated with arthritis, bone pain and inflammatory syndrome. X-rays and magnetic resonance imaging found periosteal apposition in the long bones; bone scintigraphy confirmed the HOA diagnosis. Other causes of arthritis were eliminated. She was treated with colchicine, corticosteroids and nonsteroidal anti-inflammatory drugs, but only the combination of methotrexate and hydroxychloroquine reduced the morphine requirements. Conclusion: HOA is exceptionally associated with thyroid cancer and we raised the hypothesis of the secretion of a circulating factor in a patient with invasive and recurrent follicular thyroid cancer, refractory to radioiodine.
      Eur Thyroid J
  • Treating Hypothyroidism with Thyroxine/Triiodothyronine Combination
           Therapy in Denmark: Following Guidelines or Following Trends
    • Abstract: Background: Five to ten percent of patients with hypothyroidism describe persistent symptoms despite being biochemically well regulated on levothyroxine (L-T4). Thyroxine (T4)/triiodothyronine (T3) combination therapy [L-T4/liothyronine (L-T3) or desiccated thyroid] are still regarded as experimental with no evidence of superior effect on persistent symptoms according to meta-analyses. However, some randomized controlled trials have demonstrated patients' preference for T4/T3 combination therapy as compared to L-T4 monotherapy. In 2013, attention to combination therapy increased in Denmark after a patient published a book describing her experiences with hypothyroidism and treatment. Objective: To investigate current Danish trends in the use of T4/T3 combination therapy. Methods: We used an Internet-based questionnaire, distributed as a link via two Danish patient fora. Further, information was obtained from the Division of Pharmacies and Reimbursement at the Danish Health and Medicines Authority and from the only pharmacy in Denmark producing desiccated thyroid and L-T3 tablets. Results: A total of 384 patients answered the questionnaire, and 293 responders were included. Sixty-nine percent of the responders had six or more symptoms, and 84% reported a treatment effect. Forty-four percent of the responders received their prescriptions from general practitioners; 50% received desiccated thyroid and 28% reported that they adjust their dose themselves. Responders followed by general practitioners more frequently received desiccated thyroid and adjusted their dose themselves. Conclusions: Increased media focus has changed the prescription pattern of thyroid hormones; European guidelines on T4/T3 combination therapy are not always followed in Denmark and many patients adjust their medication themselves and may therefore be at risk of overtreatment.
      Eur Thyroid J
  • Clinical Utility of SPECT/CT Imaging Post-Radioiodine Therapy: Does It
           Enhance Patient Management in Thyroid Cancer
    • Abstract: Background: The aim of this study was to evaluate post-therapy iodine-131 single-photon emission computed tomography/computed tomography (131I-SPECT/CT) imaging in comparison to conventional planar 131I whole-body imaging, and to assess its clinical impact on the management of patients. Methods: We retrospectively reviewed planar 131I whole-body and 131I-SPECT/CT imaging findings in 67 patients who underwent 131I therapy for thyroid cancer. Two nuclear medicine physicians reviewed the scans independently. The foci of increased tracer uptake were identified in the neck, thorax and elsewhere. Within the neck, the foci of 131I-increased uptake were graded qualitatively as probable or definite uptake in thyroid remnants and probable or definite uptake in the lymph nodes. Serum thyroglobulin level, histopathology and other imaging findings served as the reference standard. Results: Of the 67 patients, 57 (85%) had radioiodine avid disease and 10 (15%) demonstrated non-radioiodine avid disease. Overall, post-therapy 131I-SPECT/CT downstaged lymph node staging in 10 patients and upstaged it in 4 patients. This translated into a change of management for 9/57 (16%) patients with radioiodine avid disease. A change of management was observed in 5/10 patients with non-radioiodine avid disease confirmed in the post-131I-SPECT/CT study. Additionally, clinically significant findings such as incidental lung cancer, symptomatic pleural effusion and consolidation were also diagnosed in both groups of patients. Conclusion: In patients with thyroid cancer, 131I-SPECT/CT is a valuable addition to standard post-therapy planar imaging. SPECT/CT also improved diagnostic confidence and provided crucial clinical information leading to change of management for a significant number of these patients.
      Eur Thyroid J
  • Presence of Thyroid-Stimulating Hormone Receptor Antibodies in a Patient
           with Subacute Thyroiditis followed by Hypothyroidism and Later Graves'
           Disease with Ophthalmopathy: A Case Report
    • Abstract: Background: The development of Graves' disease (GD) after subacute thyroiditis (SAT) is very rare and only a limited number of cases have been reported. Objectives: Here, we report a patient with SAT followed by hypothyroidism and later GD, with ophthalmopathy, occurring 11 years after SAT. Conclusion: This case illustrates the appearance of thyroid-stimulating hormone (TSH) receptor antibodies in a female 1 year after SAT, the development of hypothyroidism requiring thyroxine, and later the occurrence of GD with severe ophthalmopathy, 11 years after SAT. The occurrence of SAT and GD may be coincidental but SAT may have induced the appearance of TSH-receptor antibodies, with the bioactivity changing from blocking, leading to hypothyroidism, and later to a stimulating activity that led to GD in a genetically susceptible patient.
      Eur Thyroid J
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