The Association of Thyroid Nodule with Non-Iodized Salt among Chinese Children

Objective

The controversy that iodized salt may increase the risk of thyroid disorders has been aroused in China during the past decade. Most of studies focused on adult rather than children. We aimed to explore whether iodized salt was associated with an increased risk of thyroid nodule in Chinese children.

Methods

The cross-sectional study was conducted in Hangzhou, China, in 2010. Iodized salt intake, urine iodine concentration (UIC) and thyroid nodule (by ultrasonography) were measured in 3026 children. The associations of iodized salt with thyroid nodule were evaluated using multiple logistic regression models.

Results

The prevalence of thyroid nodule was 10.59% among Chinese children. Girls (11.89%) had higher prevalence of thyroid nodule than boys (9.26%). No significant association was observed between type of salt and thyroid nodule in pooled samples, boys and girls, respectively. Similar associations were observed between UIC and thyroid nodule. There was no significant association between milk consumption and thyroid nodule as well.

Conclusion

The present study indicated that non-iodized salt may not increase the risk of thyroid nodules among Chinese children. Similar associations were observed between milk consumption, UIC and thyroid nodules.     

Fine-Needle Aspiration Biopsy as a Preoperative Procedure in Patients with Malignancy in Solitary and Multiple Thyroid Nodules

Background

Fine-needle aspiration biopsy (FNAB) is a recognized technique for the basic, preoperative cytological diagnosis of thyroid nodules.

Aim of the Study

To analyze the accuracy of FNAB in the diagnosis of thyroid cancer in patients with solitary and multiple thyroid nodules and to compare the demographic, clinical and pathological characteristics of patients with thyroid carcinoma in solitary and multiple tumors.

Materials and Methods

The case records of 2,403 patients with solitary and multiple thyroid tumors treated consecutively between 2008 and 2013 were analyzed retrospectively. We selected 1,645 for further analysis. A solitary thyroid nodule was observed in 493 patients, and multiple nodules were detected in 1,152 patients. Further classification of the patients in these two groups was performed on the basis of the FNAB results, type of surgery performed and histopathology. TC was histopathologically confirmed in 166 patients, and benign disease was found in 1,479. The TC patients were assigned to the study group, and those with benign thyroid disease were placed into the control group. The study group was divided into two subgroups according to the presence of cancer in a single thyroid nodule or in multiple nodules. Malignancy in a solitary thyroid nodule was diagnosed in 98 (59.0%) patients, and cancer in multiple nodules was diagnosed in 68 (41.0%). Comparative analyses of the demographic, clinical and histopathological characteristics were performed for both subgroups. The following statistical analyses were performed: comparative characteristic of subgroups, ROC analysis for study group and subgroup of patients, and multivariable logistic regression analysis for study group.

Results

The rate of prediction of TC by FNAB was three times higher in the patients with a solitary thyroid nodule compared with those with multiple thyroid nodules and it was statistically significant (p<0.001). The rate of total thyroid resection and lack of necessity for reoperation were also significantly higher in the TC patients with a solitary nodule. The histopathological results showed that significantly more patients with a solitary nodule had advanced-stage TC (stage III or IV) and tumor progression (pT3 or pT4) (p = 0.002 for both). ROC analysis demonstrated that the overall accuracy of FNAB as a predictor of thyroid cancer presence was high, especially for the subgroup of patients with a solitary thyroid nodule (AUC = 0.958, p<0.0001). Multivariable logistic regression analysis confirmed that a positive FNAB result was the sole predictor of the performance of total resection in the TC study group (p<0.0001), while a negative FNAB result and the presence of a papillary cancer type were independent predictors of the risk of reoperation (p<0.0001 and p = 0.002, respectively).

Conclusions

FNAB often produces false-negative results in patients with multiple malignant thyroid tumors, which results in reoperation in many cases. False-negative FNAB results are rare in patients with a solitary tumor. Because of the low predictive capacity of FNAB for thyroid cancer in patients with multiple thyroid tumors, total thyroid excision should be considered in most cases despite a "negative" (no malignant) FNAB result.     

Diagnosis of cervical thymoma by fine needle aspiration biopsy with flow cytometry. A case report

BACKGROUND: Cervical thymoma is a rare entity. To our knowledge, this is the 20th reported case of cervical thymoma and the fourth case of fine needle aspiration biopsy (FNAB) of this entity. To our knowledge, this is the only case in which cervical thymoma was a diagnostic consideration at the time of the FNAB diagnosis. The diagnosis was rendered because, unlike in previous cases, flow cytometric immunophenotyping was performed. CASE: A 46-year-old, white female presented with what was clinically thought to be a left thyroid nodule. The patient underwent FNAB at an outside institution, and the diagnosis of "possible mixed lymphoma" was made by morphology alone. The patient was referred to our institution for repeat FNAB. Based upon the cytologic findings (cells with lymphoid morphology), flow cytometry was performed, and a diagnosis of cervical thymoma (versus ectopic thymic tissue) was based upon flow cytometry findings combined with morphology. CONCLUSION: When FNAB of a cervical mass, particularly one clinically thought to be a thyroid nodule, shows lymphoid cells without thyroid follicular cells, immunophenotyping may be extremely helpful in arriving at the correct diagnosis.     

Prognosis of Thyroid Nodules in Individuals Living in the Zhitomir Region of Ukraine

Objective

After the accident at the Chernobyl Nuclear Power Plant (CNPP), the incidence of thyroid cancer increased among children. Recently, a strong relationship between solid thyroid nodules and the incidence of thyroid cancer was shown in atomic bomb survivors. To assess the prognosis of benign thyroid nodules in individuals living in the Zhitomir region of Ukraine, around the CNPP, we conducted a follow-up investigation of screening data from 1991 to 2000 in the Ukraine.

Patients and Methods

Participants of this study were 160 inhabitants with thyroid nodules (nodule group) and 160 inhabitants without thyroid nodules (normal control group) intially identified by ultrasonography from 1991 to 2000. All participants were aged 0 to 10 years old and lived in the same area at the time of the accident. We performed follow-up screening of participants and assessed thyroid nodules by fine needle aspiration biopsy.

Results

Among the nodule group participants, the number and size of nodules were significantly increased at the follow-up screening compared with the initial screening. No thyroid nodules were observed among the normal control group participants. The prevalence of thyroid abnormality, especially nodules that could be cancerous (malignant or suspicious by fine needle aspiration biopsy), was 7.5% in the nodule group and 0% in the normal control group (P<0.001).

Conclusions

Our study indicated that a thyroid nodule in childhood is a prognostic factor associated with an increase in the number and size of nodules in individuals living in the Zhitomir region of Ukraine.     

Use of immunohistochemistry in fine needle aspiration of thyroid nodules in patients with a history of malignancy. A report of two cases

BACKGROUND: A history of a nonthyroid malignancy may present a diagnostic dilemma in the assessment of fine needle aspiration (FNA) of thyroid nodules. One reported series, on patients with prior malignancies and a thyroid nodule, indicated that in 17% of patients, the thyroid nodule represented metastatic malignancy, 6% were classified as primary thyroid cancers, and the remainder were benign or inconclusive lesions. The resolution of this problem is essential to patient management. CASES: We report two cases in which patients with a history of renal cell carcinoma presented with a thyroid nodule. The first patient was an 80-year-old female whose Papanicolaou-stained FNA demonstrated clusters of round to polygonal cells with round to ovoid, hyperchromatic nuclei and abundant, wispy cytoplasm. The second patient was a 55-year-old female with clusters and single cells with round to oval, eccentric nuclei and copious, granular, gray cytoplasm noted on Papanicolaou-stained material. In each case, the diagnosis was inconclusive on initial review of Papanicolaou-stained slides, and immunohistochemical staining was ordered to better characterize the lesions. Tumor cells from case 1 were positive for cytokeratin cocktail and vimentin and negative for thyroglobulin, epithelial membrane antigen and calcitonin, suggestive of metastatic renal cell carcinoma. In contrast, the tumor cells from case 2 expressed cytokeratin, thyroglobulin and vimentin, consistent with a primary thyroid neoplasm. In each case, the cytologic diagnoses were confirmed in the resected specimens. CONCLUSION: Immunohistochemistry is a helpful adjunct in the evaluation of thyroid nodules in patients with a past history of malignancy.     

Thyroid Nodules and Thyroid Cancer

A review of clinical and laboratory features of thyroid cancer, designed to help in a more precise selection of patients for operation, showed that factors contributing to a high index of suspicion of cancer include previous exposure to low doses of radiation, the presence of a firm, solitary thyroid nodule clearly different from the rest of the gland, a young patient, nodules that are “cold” on scan with radioiodine, and nodules that fail to regress after an adequate trial of thyroxine therapy. Factors contributing to a low index of suspicion of thyroid cancer include soft or cystic lesions, multinodular goiters, nodules that are “hot” on ¹³¹ I scan, and those that regress during thyroxine treatment.When these factors are used to select patients for surgical operation, about 30 percent are found to have thyroid cancer.Until more precise methods for preoperative diagnosis are established, it is suggested that this type of clinical selection may be very helpful in the management of patients with thyroid nodules or nontoxic goiter.     

The role of surgery in the management of thyroid cancer.

This is a review of one surgeon''s personal experience with 85 patients with thyroid cancer treated over a 20-year period. The data confirm that for papillary thyroid tumours, with rare exceptions, the prognosis is excellent. Anaplastic lesions, however, are consistently lethal. Follicular carcinoma and medullary carcinoma fall between these extremes. A simple clinical classification is offered as a guide to operative management and a reliable index of prognosis. Patients with clinically apparent, "manifest cancer" have serious, life-threatening disease; many such patients die of their disease. Patients with "neck lumps not yet diagnosed" usually have papillary carcinoma; their prognosis is excellent. Patients whose thyroid tumours fall into the category of "malignant nodule" or "pathologist''s cancer" are particularly fortunate: in this series no such patient has died. The importance of age in relation to thyroid cancer is also confirmed: non of the patients first treated before the age of 40 years has died of cancer. For young patients with favourable disease the author recommends conservative surgical treatment, which avoids cosmetic deformity or functional disability, to be followed by administration of levothyroxine to suppress production of thyroid=stimulating hormone. For patients with "unfavourable" thyroid cancer valuable palliation can often be achieved by a combination of surgery and irradiation. Survival rates for the total series are 76% at 5 years and 60% at 10 years.     

Anaplastic thyroid carcinoma developed after treatment of "hot" thyroid nodule with radioiodine]

A case of 55 years old woman with "hot" right lobe toxic thyroid nodule, presenting with paroxysmal atrial fibrillation, and therefore treated with 131I 666MBq (18 mCi) is described. After six years she became pyrexic and suffered of severe cough proxyisms. The fine needle biopsy of the above nodule showed the presence of anaplastic thyroid carcinoma. Strumectomy followed by local radiotherapy resulted in complete disappearence of all symptoms. The microscopic of the removed thyroid tissue confirmed the above diagnosis. After 22 months' observation the patient remained in good general condition. The possible reasons for the development of the thyroid carcinoma in this case are discussed.     

The Ultrasonic Evaluation of Nonfunctioning Thyroid Nodules

Thyroid echography was carried out on 100 patients with thyroid abnormalities to evaluate the diagnostic accuracy of ultrasound in differentiating simple thyroid cysts from solid thyroid nodules.In all 46 proven cases, the ultrasonic diagnosis of the solid or cystic nature of thyroid nodules was correct.A proposed diagnostic workup of a hypofunctioning (cold) thyroid nodule is suggested with primary needle aspiration and cytologic examination of the cyst fluid being recommended if the nodule is shown to be entirely cystic by ultrasound.     

Drivers of the Decision to Biopsy and Follow-Up of Small Suspicious Thyroid Nodules

Objective: In 2015, the updated American Thyroid Association (ATA) guidelines recommended observation for suspicious subcentimeter thyroid nodules, based on their indolent course. We aimed to evaluate the frequency of biopsy in suspicious thyroid nodules since the introduction of these guidelines, including factors contributing to clinical decision-making in a tertiary care center.Methods: We conducted a retrospective study of patients in the Mayo Clinic, Rochester, Minnesota, with new, subcentimeter suspicious thyroid nodules (by report or by sonographic features) between March, 2015, and November, 2017, not previously biopsied.Results: We identified 141 nodules in 129 patients: mean age 58.1 ± 14.1 years, 74% female, 87% Caucasian. The frequency of biopsy in suspicious thyroid nodules was 39%. Ultrasound features that were the strongest predictors for biopsy on multivariate analysis included: nodule volume (odds ratio [OR] 37.3 [7.5–188.7]), radiology recommendation for biopsy (OR 2.6 [1.8–3.9]) and radiology report of the nodule as “suspicious” (OR 2.1 [1.4–3.2]). Patient’s age and degree of comorbidities did not change the likelihood for biopsy, nor did it vary by clinician type or how the nodule was initially found (incidentally or not incidentally). Among 86 nodules that were not biopsied, 41% had no specific follow-up recommendations.Conclusion: One third of suspicious thyroid nodules underwent biopsy since the release of updated ATA guidelines. Factors driving thyroid biopsy seem to be associated with nodule characteristics but not with patient factors including age and comorbidities. Further studies and development of decision aides may be helpful in providing individualized approaches for suspicious thyroid nodules.Abbreviations: ATA = American Thyroid Association; OR = odds ratio     

甲状腺结节的现代诊疗进展

绝大多数甲状腺结节都是经影像学检查无意间发现的,即使是良性甲状腺结节,也有必要进行治疗。临床医生需要综合患者的病史、体格检查及实验室、影像学或细胞学穿刺活检等检查结果尽可能明确诊断结节的良恶性。非手术微创治疗方法对于多数的良性结节行药物或放射性碘治疗如无水酒精注射(PEI)、激光光凝(ILP)、放射性碘消融(RFI)和微波消融(MWA)效果较好;而恶性或高度怀疑恶性及部分较大良性结节需行外科手术切除,根据结节的具体类型并结合各高危因素选择适当的切除范围,某些恶性结节术后还需进一步辅助碘131放射治疗并跟踪随访。本文综述了有关甲状腺结节的最新诊断和治疗进展,重点阐述了美国甲状腺协会关于甲状腺结节和分化型甲状腺癌的诊治指南的相关主张。     

Diagnostic Use of Ultrasonography in Patients with Nodular Thyroid Disease

ObjectiveTo review the published reports pertaining to the diagnostic utility of ultrasonography for evaluation of thyroid nodules.MethodsVarious roles for diagnostic thyroid ultrasonography and screening ultrasound studies of the thyroid are discussed, and ultrasound characteristics of thyroid nodules and their association with malignant potential are described.ResultsIn two studies that correlated ultrasound findings with physical examination findings in patients with a solitary thyroid nodule detected by palpation, 16% of such patients had no corresponding nodule evident on ultrasonography, and 45% of such patients had an additional nodule detected by ultrasonography. Similarly, approximately 18% of patients with a palpable multinodular thyroid had no nodules larger than 1 cm in diameter on ultrasound studies. Thyroid nodules larger than 1 cm have been found by ultrasonography to be present in from 2 to almost 5% of the population with normal findings on examination of the thyroid. Use of screening ultrasound study of the thyroid has been suggested for patients with a history of childhood irradiation to the head and neck or a family history of thyroid cancer. Numerous investigations that have evaluated ultrasound features of thyroid nodules have suggested five characteristics as suggestive of malignant potential—hypoechogenicity, microcalcifications. irregular or microlobulated border, absent or irregular thick halo, and increased intranodular vascularity.ConclusionCorrelation of ultrasound and palpation findings will provide a comprehensive evaluation of nodular thyroid disease. Moreover, real-time ultrasonography facilitates characterization of features associated with an increased risk of a malignant lesion. High-resolution thyroid ultrasonography is a dynamic tool for endocrinologists. (Endocr Pract. 2004;10:246-252)     

甲状腺结节数对钙化甲状腺病变良恶性的鉴别价值

目的:通过甲状腺病变术前超声声像图与术后病理间的对照,分析结节单发或多发在鉴别伴钙化甲状腺病变良恶性中的意义。方法:回顾性分析我院2010年1月至2013年12月收治的218例甲状腺病变患者的临床资料,将患者术前超声声像图与术后病理结果进行对比。结果:术前超声探及甲状腺单发结节伴钙化其术后病理恶性比例显著高于多发结节伴钙化,差异具有统计学意义(P0.05);多发结节伴钙化其术后病理恶性比例显著高于多发结节不伴钙化,差异具有统计学意义(P0.05)。结论:术前超声探及甲状腺单发结节伴钙化其术后病理恶性比例较高,应积极手术治疗,多发结节伴钙化因其术后病理恶性病理较低,不宜作为手术治疗甲状腺病变的绝对指征。     

Physical and radiological findings specific for medullary carcinoma of the thyroid gland.

Preoperative physical and radiological findings, if specific to a certain extent, are important for detecting patients with sporadic form of medullary thyroid carcinoma and especially for the first patient in the family having a hereditary form of medullary thyroid carcinoma and pheochromocytoma syndrome. To delineate clinical features of medullary thyroid carcinoma, a total of 9 patients with this tumor were reviewed retrospectively. In most patients, the thyroid lesions were located in the upper two thirds of the lobe, which was determined by careful palpation or 131I scintiscanning of the thyroid. The primary lesion in the thyroid could be felt more or less as a round, sharply demarcated nodule with fairly good mobility. These findings suggested rather a benign thyroid nodule when there was no lymph node involvement. However, it could be considered a sign suggesting medullary thyroid carcinoma when accompanied by marked lymph node metastasis. In our recent 2 cases, the diagnosis of medullary thyroid carcinoma was strongly suspected on these clinical bases, one of the cases being presented in detail. In 4 patients, lymph node metastasis in the central neck extended to either submandibular or upper mediastinal regions or both. In about one third of the patients, calcified deposits were shown in the cervical roentgenograms. With the use of soft tissue roentgenography, grossly punctate calcific deposits associated with psammoma-like shadows were recognized and the pattern was a criterion for definitive diagnosis of medullary thyroid carcinoma.     

健康体检人群甲状腺结节多普勒超声检查结果及影响因素分析

目的:研究健康体检人群甲状腺结节多普勒超声检查结果及影响因素。方法:将从2018年1月~2019年12月,于医院接受体检的健康体检人员5270例纳入研究,对所有受试者均进行多普勒超声检查,分析超声检查结果和体检人群基线资料的关系,分析甲状腺结节多普勒超声特征。采用单因素以及多因素Logistic回归分析健康体检人群甲状腺结节的影响因素。结果:在5270例健康体检人群中,甲状腺结节检出率为51.86%(2733/5270),女性甲状腺结节检出率为52.83%(2355/4458),高于男性的46.55%(378/812),且随着年龄的不断增长,健康体检人群甲状腺结节检出率呈逐渐升高趋势(均P<0.05)。甲状腺结节患者的多普勒超声检查特征以低回声以及结节直径<2 cm为主(均P<0.05),但是结节数目以及病变部位比较无明显差异(均P>0.05)。经单因素分析发现:吸烟、甲状腺疾病家族史、高血压及糖尿病的健康体检人员甲状腺结节检出率高于不吸烟、无甲状腺疾病家族史、无高血压及无糖尿病的健康体检人员(均P<0.05),而不同民族、受教育年限、体质量指数(BMI)、是否饮酒的健康体检人员甲状腺结节检出率比较无统计学差异(均P>0.05)。经多因素Logistic回归分析发现:女性、年龄、吸烟、甲状腺疾病家族史、高血压及糖尿病均是健康体检人群甲状腺结节发生的独立危险因素(均OR>1,P<0.05)。结论:甲状腺结节多普勒超声检查特征以低回声以及结节直径≤2 cm为主,其影响因素包括年龄、性别、吸烟、甲状腺疾病家族史、高血压及糖尿病,值得临床重点关注。     

Fine needle aspiration cytologic findings in the black thyroid syndrome

The cytologic presentation of a case of minocycline-associated black thyroid adenoma in a 30-year-old woman is described. A nodule was discovered in the left lobe of the patient's thyroid gland, and fine needle aspiration (FNA) was performed; the nodule and adjacent thyroid were subsequently surgically removed. The cytologic findings included sparse groups of epithelial cells with prominent intracytoplasmic pigment granules. The surgical specimen was interpreted as black thyroid adenoma. This case is unusual in that the pigment had accumulated preferentially in the adenoma. In retrospect, the finding of distinctive pigment in the aspirate of the nodule suggests that the black thyroid syndrome should be considered whenever dark-brown pigment is encountered in FNA cytologic specimens from the thyroid gland.     

Ultrasonographic and scintigraphic studies of "hot" autonomic thyroid nodules

Scintigraphic and gammagraphic (gamma-camera) techniques have been applied in diagnosing "hot" non-TSH dependent thyroid nodules. On the basis of frequent uneven accumulation of isotopic tracer observed in scintigraphic studies it was concluded that the structure of these nodules is heterogeneous. In some cases paradoxical patterns have been obtained following the dynamic tests of suppression and stimulation of the thyroid: after the administration of thyroid preparations paranodular thyroid tissue appears, while TSH administration causes an increase in the iodine uptake by the nodule. Ultrasonographic and gamma-camera studies have been carried out in 50 cases of "hot" autonomic thyroid nodules previously diagnosed by scintigraphy. Ultrasonographic studies revealed a weaker echogenicity in some cases and an intensified echo in the other. Sometimes by using this technique it was possible to demonstrate the occurrence of heterogeneous structures suggesting a cystic degeneration of the nodule. Paranodular thyroid tissue, invisible in scintigraphic scanning, could usually be observed by applying gamma-camera. It was concluded that both gamma camera and ultrasonographic studies confirm heterogeneous structure of intranodular tissue producing paradoxical patterns in scintigraphic scanning, with the latter technique usually aiding the detection of paranodular thyroid tissue without the necessity of application of the TSH test.     

Anti-inflammatory effect of rosiglitazone is not reflected in expression of NFκB-related genes in peripheral blood mononuclear cells of patients with type 2 diabetes mellitus

Background

The aim of this study is to perform a cost-effectiveness comparison between palpation-guided thyroid fine-needle aspiration biopsies (P-FNA) and ultrasound-guided thyroid FNA biopsies (USG-FNA).

Methods

Each nodule was considered as a case. Diagnostic steps were history and physical examination, TSH measurement, Tc^99m thyroid scintigraphy for nodules with a low TSH level, initial P-FNA versus initial USG-FNA, repeat USG-FNA for nodules with initial inadequate P-FNA or USG-FNA, hemithyroidectomy for inadequate repeat USG-FNA. American Thyroid Association thyroid nodule management guidelines were simulated in estimating the cost of P-FNA strategy. American Association of Clinical Endocrinologists guidelines were simulated for USG-FNA strategy. Total costs were estimated by adding the cost of each diagnostic step to reach a diagnosis for 100 nodules. Strategy cost was found by dividing the total cost to 100. Incremental cost-effectiveness ratio (ICER) was calculated by dividing the difference between strategy cost of USG-FNA and P-FNA to the difference between accuracy of USG-FNA and P-FNA. A positive ICER indicates more and a negative ICER indicates less expense to achieve one more additional accurate diagnosis of thyroid cancer for USG-FNA.

Results

Seventy-eight P-FNAs and 190 USG-FNAs were performed between April 2003 and May 2008. There were no differences in age, gender, thyroid function, frequency of multinodular goiter, nodule location and diameter (median nodule diameter: 18.4 mm in P-FNA and 17.0 mm in USG-FNA) between groups. Cytology results in P-FNA versus USG-FNA groups were as follows: benign 49% versus 62% (p = 0.04), inadequate 42% versus 29% (p = 0.03), malignant 3% (p = 1.00) and indeterminate 6% (p = 0.78) for both. Eleven nodules from P-FNA and 18 from USG-FNA group underwent surgery. The accuracy of P-FNA was 0.64 and USG-FNA 0.72. Unit cost of P-FNA was 148 Euros and USG-FNA 226 Euros. The cost of P-FNA strategy was 534 Euros and USG-FNA strategy 523 Euros. Strategy cost includes the expense of repeat USG-FNA for initial inadequate FNAs and surgery for repeat inadequate USG-FNAs. ICER was -138 Euros.

Conclusion

Universal application of USG-FNA for all thyroid nodules is cost-effective and saves 138 Euros per additional accurate diagnosis of benign versus malignant thyroid nodular disease.

Trial registration

ClinicalTrials.gov, NCT00571090     

Overview of Molecular Biomarkers for Enhancing the Management of Cytologically Indeterminate Thyroid Nodules and Thyroid Cancer

ObjectiveTo provide information on molecular bio markers that can help assess cytologically indeterminate thyroid nodules.MethodsPublished studies on immunohistologic, somatic mutation, gene expression classifier, microRNA, and thyrotropin receptor messenger RNA biomarkers are reviewed, and commercially available molecular test pan els are described.ResultsThyroid nodules are common, and clinical guidelines delineate an algorithmic approach including serum thyroid-stimulating hormone measurement, diagnostic ultrasound examination, and, when appropriate, fine-needle aspiration (FNA) biopsy for determination of a benign versus malignant status. In clinical practice, approximately 20% of FNA-derived cytology reports are classified as “indeterminate” or follicular nodules that do not fulfill either benign or malignant criteria. In this set ting, the actual risk for malignancy of a cytologically indeterminate nodule ranges from approximately 15% to 34%. Research describing molecular biomarkers from thyroid cancer tissue has been applied to FNA-derived thyroid nodule material. There is also a serum molecular marker that has been reported with goals similar to those for the FNA-derived molecular markers: to enhance the preoperative diagnosis of thyroid cancer and reduce the large number of patients who have a diagnostic surgical procedure for benign thyroid nodules.ConclusionProgress toward the foregoing goals has been made and continues to evolve with the recent appearance of molecular biomarker tests that can be selectively applied for further assessment of cytologically indeterminate thyroid nodules. (Endocr Pract. 2012;18:611-615)     

Wasting syndrome with deep bradycardia as presenting manifestation of long-standing severe male hypogonadotropic hypogonadism: a case series

Background

Non-thyroidal illness (NTI) refers to changes in thyroid hormone levels in critically ill patients in the absence of primary hypothalamic-pituitary-thyroid dysfunction, and these abnormalities usually resolve after clinical recovery. However, NTI can be accompanied by primary thyroid dysfunction. We report herein a case of a woman with NTI accompanied by primary hyperthyroidism.

Case presentation

A 52-year-old female was admitted to the intensive care unit with heart failure and atrial fibrillation. She had a longstanding thyroid nodule, and a thyroid function test revealed low levels of triiodothyronine and free thyroxine as well as undetectable thyroid stimulating hormone (TSH). She was diagnosed with NTI, and her TSH level began to recover but not completely at discharge. The thyroid function test was repeated after 42 months to reveal primary hyperthyroidism, and a thyroid scan confirmed a toxic nodule.

Conclusion

This case suggests that although NTI was diagnosed, primary hyperthyroidism should be considered as another possible diagnosis if TSH is undetectable. Thyroid function tests should be repeated after clinical recovery from acute illness.