Thyroid nodule management: clinical, ultrasound and cytopathological parameters for predicting malignancy

Although fine-needle aspiration cytology is considered to be the reference method for evaluating thyroid nodules, the results are inaccurate in approximately 10-30% of cases. Several studies have attempted to predict the risk of malignancy in thyroid nodules based on age, nodularity, thyrotropin values, thyroid autoimmune disease, hot/cold nodule status, and ultrasound parameters. However, no consensus has been found, and none of these parameters has significantly affected patient management. The management of indeterminate thyroid nodules and re-biopsies of nodules with initially benign cytological results remain important and controversial topics of discussion. The Bethesda cytological system and several studies on the use of molecular markers to predict malignancy from cytological samples of thyroid nodules need further clarification. More in-depth discussions among and continuous education of the specialists involved in treating thyroid disease are necessary to improve the management of these patients. This review aims to examine the clinical, laboratory, ultrasound, and scintigraphic parameters that can be used for thyroid nodule management

Usefulness of pre-thyroidectomy neutrophil–lymphocyte, platelet–lymphocyte, and monocyte–lymphocyte ratios for discriminating lymph node and distant metastases in differentiated thyroid cancer

OBJECTIVE: This study aimed to analyze the relationship of neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and monocyte-lymphocyte ratio (MLR) with clinicopathological characteristics of patients with differentiated thyroid cancer (DTC). METHODS: This retrospective study included 390 patients with DTC who had complete blood cell counts available at the time of surgery. NLR, PLR, and MLR were calculated, and the risk of cancer-related death, structural recurrence, and response to therapy were assessed using the eighth edition of the tumor-node-metastasis classification, American Thyroid Association (ATA) Risk Stratification System, and ATA Response to Therapy Reclassification, respectively. RESULTS: PLR was higher in patients with distant metastasis than in those without (133.15±43.95 versus 119.24±45.69, p=0.0345) and lower in patients with disease-free status (117.72±44.70 versus 131.07±47.85, p=0.0089) than in those who experienced persistent disease or death. Patients aged ≥55 years had a higher MLR than those aged <55 years (0.26±0.10 versus 0.24±0.12, p=0.0379). Higher MLR (odds ratio [OR]: 8.775, 95% confidence interval [CI]: 1.532-50.273, p=0.0147), intermediate ATA risk (OR: 4.892, 95% CI: 2.492-9.605, p≤0.0001), and high ATA risk (OR: 5.998, 95% CI: 3.126-11.505, p≤0.0001) were risk factors associated with active disease. NLR was not significantly different among the studied variables. Receiver operating characteristic curve cut-off values for NLR, PLR, and MLR were able to differentiate distant metastasis from lymph node metastasis (NLR>1.93: 73.3% sensitivity and 58.7% specificity, PLR>124.34: 86.7% sensitivity and 69.2% specificity, MLR>0.21: 80% sensitivity and 45.2% specificity). CONCLUSION: Cut-off values of NLR, PLR, and MLR differentiated distant metastasis from lymph node metastasis with good sensitivity and accuracy. PLR was associated with disease-free status and it was higher in DTC patients with distant metastasis, persistent disease, and disease-related death. MLR was a risk factor for active disease

Insulin sensitivity is not decreased in adult patients with hypopituitarism without growth hormone replacement

Decreased insulin sensitivity in patients with hypopituitarism without GH replacement (pHP-WGHR) remains conflicting in literature. It is known that these patients present a decrease in free fat mass and an increase in fat mass. Typically, these kinds of alterations in body composition are associated with a decrease in insulin sensitivity; however, there is no consensus if this association is found in pHP-WGHR. Thus, we investigated pHP-WGHR regarding insulin sensitivity by euglycemic hyperinsulinemic clamp, the gold standard method, and body composition. In a cross-sectional study, we evaluated 15 pHP-WGHR followed up in a Service of Neuroendocrinology and 15 individuals with normal pituitary function as a control group with similar age, gender and body mass index. Insulin sensitivity was evaluated by euglycemic hyperinsulinemic clamp and homeostatic model assessment insulin resistance (HOMA-IR). Kappa coefficient evaluated the agreement between these two methods. Percentage of fat mass, percentage of free fat mass, fat mass weight and free fat mass weight were assessed by electrical bioimpedance. The pHP-WGHR presented similar insulin sensitivity to control group by euglycemic hyperinsulinemic clamp, both by the M-value, (p = 0.0913) and by the area under the glucose infusion rate curve, (p = 0.0628). These patients showed lower levels of fasting glycemia (p = 0.0128), insulin (p = 0.0007), HOMA-IR (p = 0.009). HOMA-IR shows poor concordance with euglycemic hyperinsulinemic clamp (Kappa = 0.16) in pHP-WGHR, while in the control group the agreement was good (Kappa = 0.53). The pHP-WGHR presented higher values of percentage of fat mass (p = 0.0381) and lower values of percentage of free fat mass (p = 0.0464) and free fat mass weight (0.0421) than the control group. This study demonstrated that the insulin sensitivity evaluated by euglycemic hyperinsulinemic clamp in pHP-WGHR was similar to individuals with normal pituitary function, despite the pHP-WGHR presenting higher fatmass percentage. HOMA-IR was not a good method for assessing insulin sensitivity in pHP-WGHR10CONSELHO NACIONAL DE DESENVOLVIMENTO CIENTÍFICO E TECNOLÓGICO - CNPQSem informaçã

Doença tiroideana auto-imune : expressão de colageno IV e laminina e relação com anti-corpos circulantes antimembrana basal

Orientadores: Ricardo de Lima Zollner, Jose VassalloTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: O trabalho teve o intuito de estudar aspectos séricos e morfológicos na relação entre a membrana basal do folículo tiroideano e doença tiroideana auto-imune, procurando elementos que possam acrescentar subsidios para o entendimento de sua fisiopatologia. O estudo sorológico de pacientes com diversas alterações tiroideanas foi realizado através de eletroforese de transferência seguida de "immunoblot", com a finalidade de detectar anticorpos anticolágeno IV e antil~rninina, dois dos elementos principais da membrana basal. Tal procedimento possibilitou a detecção de anticorpos reativos a várias frações do colágeno IV encontrados apenas na doença de Basedow-Graves. Da mesma forma, esta especificidade pôde ser verificada para os anticorpos antilarninina existentes nos soros destes pacientes, através do reconhecimento da fração reativa de 57 kDa da estrutura da larninina. . Estes anticorpos estariam envolvidos na fisiopatologia dos mecanismos auto-imunes da doença tiroideana e não somente com o estado hipermetabólico devido à tirotoxicose, pois não ocorreram em hipertiroidismo de origem tumoral benigna. Assim, o estudo morfológico através de imuno-histoquimica, especificamente do colágeno IV e laminina J poderia elucidar alguns aspectos sobre a existência de anormalidades da membrana basal folicular na doença tiroideana auto-imune. Entretanto, não houve a demonstração de alterações importantes da membrana tanto na doença de Basedow-Graves quanto na tiroidite de Hashimoto, especialmente interrupção, inclusive em áreas de intenso infiltrado linfoplasmocitário. Foram vis11:1117.ados locais de adelgaçamento da membrana, sobretudo na doença de Graves, talvez flutos do hipermetabolismo, que liberaria colágeno IV e Jarn1n1na para a circulação, e conseqüentemente, induziria a produção de seus respectivos anticorpos.Desta forma, o anticorpo anticolágeno N poderia tratar¬se não apenas de reflexo do estado hipermetabólico, mas integrante do processo fisiopatológico da doença de Graves. De modo semelhante, nossos resultados sugerem que a tração de 57 kDa da laminina seja um provável marcador sorológico para a Doença de Basedow-Graves, contudo existe a necessidade da ampliação do estudo para que possamos relacioná-los ao estágio da doençaAbstract: The purpose of the present study is to evaluate serological and morphologic aspects concerning the basement membrane (BM) of the thyroid follicle in autoimmune thyroid disease (ATD). In this way, new elements for ~ better understanding of its pathophisiology could be suggested. In order to detect antibodies to collagen IV and laminin, two major components of the BM, serological tests of patients with the diagnosis of different thyroid diseases were performed by the transfer eletrophoresis method followed by immunoblot. Only in the Basedow-Graves' disease antibodies,' to various collagen IV fractions were detected. Also, antibodies to laminin were found in these patients' sera, detected by recognition of the 57 kDa fraction of laminin. These antibodies are probably involved in the pathogenesis of ATD and are not just consequence of hypermetabolic states due to hyperthyroidism, since no antibodies could be detected in thyroid hyperfunction caused by benign thyroid neoplasia. Production of such antibodies could be atributed to or cause BM alterations as a consequence of disturbed immunological tolerance to their components, which are otherwise recognized as self, and induction of immunologic response. If this is true, immunohistochemical staining of collagen IV an Iaminin could be useful in detecting follicIe BM disruption in A TD. Our results do not corroborate this hypothesis, since we were not able to find BM alterations in thyroid diseases, even in areas of heavy lymphoplasmatic inflamation. Finding of focal BM thinning, mainly in Graves' disease, could be preliminarly explained by hypermetabolism, delivery of collagen IV and laminin to the circulation and induction of antibody production against them. This hypothesis, however, is not corroborated by the findings in toxicadenoma, another cause of hyperthyroidism, in wich BM thinning is not present. In Hashimoto thyroiditis, in disagreement with previously reported data, no disruption, nor significant BM thinnin g were seen. The pathogenetic role of these antibodies is not yet clear, but it does not seem that they cause follicular BM damage. Further investigations are needed to characterize biologically such antibodies and to understand their relationship to follicular BM in A TDDoutoradoMedicina InternaDoutor em Ciências Médica

Abnormalities of Thyroid Hormone Metabolism during Systemic Illness: The Low T3 Syndrome in Different Clinical Settings

Thyroid hormone abnormalities are common in critically ill patients. For over three decades, a mild form of these abnormalities has been described in patients with several diseases under outpatient care. These alterations in thyroid hormone economy are a part of the nonthyroidal illness and keep an important relationship with prognosis in most cases. The main feature of this syndrome is a fall in free triiodothyronine (T3) levels with normal thyrotropin (TSH). Free thyroxin (T4) and reverse T3 levels vary according to the underlying disease. The importance of recognizing this condition in such patients is evident to physicians practicing in a variety of specialties, especially general medicine, to avoid misdiagnosing the much more common primary thyroid dysfunctions and indicating treatments that are often not beneficial. This review focuses on the most common chronic diseases already known to present with alterations in serum thyroid hormone levels. A short review of the common pathophysiology of the nonthyroidal illness is followed by the clinical and laboratorial presentation in each condition. Finally, a clinical case vignette and a brief summary on the evidence about treatment of the nonthyroidal illness and on the future research topics to be addressed are presented

Thyroid nodule management: clinical, ultrasound and cytopathological parameters for predicting malignancy

Although fine-needle aspiration cytology is considered to be the reference method for evaluating thyroid nodules, the results are inaccurate in approximately 10-30% of cases. Several studies have attempted to predict the risk of malignancy in thyroid nodules based on age, nodularity, thyrotropin values, thyroid autoimmune disease, hot/cold nodule status, and ultrasound parameters. However, no consensus has been found, and none of these parameters has significantly affected patient management. The management of indeterminate thyroid nodules and re-biopsies of nodules with initially benign cytological results remain important and controversial topics of discussion. The Bethesda cytological system and several studies on the use of molecular markers to predict malignancy from cytological samples of thyroid nodules need further clarification. More in-depth discussions among and continuous education of the specialists involved in treating thyroid disease are necessary to improve the management of these patients. This review aims to examine the clinical, laboratory, ultrasound, and scintigraphic parameters that can be used for thyroid nodule management

Primary thyroid tuberculosis: a rare etiology of hypothyroidism and anterior cervical mass mimicking carcinoma Tuberculose tireoidiana primária: rara etiologia de hipotireoidismo e massa cervical anterior mimetizando carcinoma

AbstrAct Objective: The involvement of the thyroid by tuberculosis (TB) is rare. Hypothyroidism caused by tissue destruction is an extremely rare report. Our aim was to report a patient with primary thyroid TB emphasizing the importance of diagnosis, despite the rarity of the occurrence. Case report: Women, 62 years old, showing extensive cervical mass since four months, referring lack of appetite, weight loss, dysphagia and dysphonia. Laboratorial investigation revealed primary hypothyroidism. Cervical ultrasound: expansive lesion in left thyroid lobe, involving adjacent muscle. Computed tomography scan: 13 cm diameter cervical mass with central necrosis. Fine needle biopsy: hemorrhagic material. Surgery: total thyroidectomy, left radical neck dissection and protective tracheotomy. The pathological examination showed chronic granulomatous inflammatory process with areas of caseous necrosis and lymph node involvement. The thyroid baciloscopy was positive. Pulmonary disease was absent. The patient was treated with antituberculosis drugs. Conclusions: Thyroid TB is not frequent, and should be considered as differential diagnosis of hypothyroidism and anterior cervical mass. Arq Bras Endocrinol Metab. 2009;53(4):475-8. Keywords Thyroid tuberculosis; hypothyroidism; anterior neck mass; thyroidectomy rEsUMO Objetivo: A tuberculose tiroidiana ocorre raramente. O hipotireoidismo decorrente da destruição tiroidiana é um relato raríssimo. Nosso objetivo foi descrever o caso de paciente com tuberculose tiroidiana primária e ressaltar a raridade e a importância da doença. Relato do caso: Mulher, 62 anos, apresentando massa cervical extensa há quatro meses, associada à inapetência, à perda de peso, à disfonia e à disfagia. A investigação laboratorial mostrou hipotireoidismo primário. Ultrassonografia: lesão expansiva em lobo esquerdo, envolvendo musculatura subjacente. Tomografia computadorizada: massa heterogênea com centro necrótico, 13 cm de diâmetro. Biópsia por agulha fina: material serossanguinolento. Cirurgia: tireoidectomia, dissecção radical à esquerda e traqueostomia protetora. Exame anatomopatológico: processo inflamatório crônico granulomatoso com áreas de necrose caseosa e comprometimento linfonodal. Baciloscopia tiroidiana positiva. Ausência de comprometimento pulmonar. A paciente foi tratada com drogas antituberculosas. Conclusões: Tuberculose tireoidiana não é frequente, mas deve ser considerada como diagnósti-co diferencial de hipotireoidismo e massa cervical anterior. Arq Bras Endocrinol Metab. 2009;53(4):475-8