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 103,950 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

This article discusses several aspects of the evaluation and management of differentiated thyroid carcinoma that are changing or may change in the near future. Although conventional treatment of this disease is highly effective, some modification may improve the welfare of patients and the overall results. Because the symptoms of hypothyroidism are vexing, there has been great interest in using recombinant human thyroid-stimulating hormone (rhTSH) to prepare patients for iodine 131 imaging. rhTSH has been about as effective as thyroid hormone withdrawal for diagnostic imaging so that approval for this use is expected. Another topic of interest is the administration of 131I therapy to patients whose serum thyroglobulin levels are abnormal but whose diagnostic 131I scans are negative. Because the 131I scans after therapy are often abnormal in these patients and a reduction of serum thyroglobulin can occur, this approach seems effective. The long-term impact of this therapy on recurrence and survival, however, is unknown. A third issue that is currently under review is the amount of 131I that should be used for diagnostic scanning. Although past opinion favored larger doses, "stunning" of thyroid remnant and tumor can occur with diagnostic 131I imaging. Substituting iodine 123 is an alternative for postthyroidectomy scanning, but when administered as 300 uCi it is less accurate than 131I for recurrent disease or distant metastases. Related to these issues, two other topics are reviewed: the use of other radiopharmaceuticals for imaging patients with thyroid cancer, and 131I dosimetry.
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PMID:The changing role of radioiodine in the management of differentiated thyroid cancer. 914 57

It is very important to diagnose correctly the etiology of thyrotoxicosis, because the course and treatment of thyrotoxicosis with low radioactive iodine uptake differ significantly from that of hyperthyroidism due to Graves' disease or toxic nodular goiter. Many causes of subacute thyroiditis have been identified producing a characteristic course of transient hyperthyroidism, followed by hypothyroidism, and usually recovery. Ectopic hyperthyroidism includes factitious thyroid hormone ingestion, struma ovarii, and, rarely, large deposits of functioning thyroid cancer metastases. Iodine-induced hyperthyroidism may be associated with low radioiodine uptakes. Amiodarone-associated hyperthyroidism may be the result of subacute thyroiditis or iodine-induced hyperthyroidism; assessment and treatment can be quite challenging.
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PMID:Syndromes of thyrotoxicosis with low radioactive iodine uptake. 953 35

A consensus meeting held by the Chilean Endocrinological Society reached to 22 consensus proposals on the use of iodine-131 in hyperthyroidism and thyroid cancer, that are reported in this paper. Some of these propositions are: 1) Hyperthyroidism: A previous 131I uptake test must be performed. A calculated or an ablative dose should be administered. Hypothyroidism must be considered an objective rather than a complication. In patients with cardiovascular risk, normal thyroid function must be attained with prophythioturacil. In cases of treatment failure, the dose should not be repeated before six months. It must be used with used with caution in children and teenagers. 2) Thyroid cancer: A iodine free diet is recommended prior to the therapeutic dose. A 100 mCi complementary ablative dose should be given after surgery, with a posterior exploration. This examination must not be done routinely, and if required, a 5 mCi dose should be used. For the treatment of metastases, a dose of 150 to 200 mCi is recommended. There is no radiation risk in hyperthyroidism or thyroid cancer. The only absolute contraindication is pregnancy. Recommendations for radiological protection are formulated. Hospitalization is suggested to protect other people from radiation exposure.
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PMID:[Consensus proposal on the use of 131I in the treatment of thyrotoxicosis and thyroid cancer]. 983 Jul 80

Many malignancies may present with metastases to the pituitary gland. The association of thyroid carcinoma with pituitary metastases is, however, very rare. This report describes two patients in whom metastases from a papillary thyroid carcinoma to the pituitary gland resulted in panhypopituitarism with blunted endogenous thyrotropin (TSH) production following withdrawal of levothyroxine. Both required the use of recombinant human TSH prior to radioiodine therapy. Symptoms of hypopituitarism may be difficult to distinguish clinically from those of hypothyroidism in the setting of levothyroxine withdrawal. Clinicians should be aware of the clinical and biochemical manifestations of this rare association.
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PMID:Papillary thyroid carcinoma metastatic to the pituitary gland. 1056 Sep 58

Recombinant human TSH has been developed to facilitate monitoring for thyroid carcinoma recurrence or persistence without the attendant morbidity of hypothyroidism seen after thyroid hormone withdrawal. The objectives of this study were to compare the effect of administered recombinant human TSH with thyroid hormone withdrawal on the results of radioiodine whole body scanning (WBS) and serum thyroglobulin (Tg) levels. Two hundred and twenty-nine adult patients with differentiated thyroid cancer requiring radioiodine WBS were studied. Radioiodine WBS and serum Tg measurements were performed after administration of recombinant human TSH and again after thyroid hormone withdrawal in each patient. Radioiodine whole body scans were concordant between the recombinant TSH-stimulated and thyroid hormone withdrawal phases in 195 of 220 (89%) patients. Of the discordant scans, 8 (4%) had superior scans after recombinant human TSH administration, and 17 (8%) had superior scans after thyroid hormone withdrawal (P = 0.108). Based on a serum Tg level of 2 ng/mL or more, thyroid tissue or cancer was detected during thyroid hormone therapy in 22%, after recombinant human TSH stimulation in 52%, and after thyroid hormone withdrawal in 56% of patients with disease or tissue limited to the thyroid bed and in 80%, 100%, and 100% of patients, respectively, with metastatic disease. A combination of radioiodine WBS and serum Tg after recombinant human TSH stimulation detected thyroid tissue or cancer in 93% of patients with disease or tissue limited to the thyroid bed and 100% of patients with metastatic disease. In conclusion, recombinant human TSH administration is a safe and effective means of stimulating radioiodine uptake and serum Tg levels in patients undergoing evaluation for thyroid cancer persistence and recurrence.
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PMID:A comparison of recombinant human thyrotropin and thyroid hormone withdrawal for the detection of thyroid remnant or cancer. 1056 23

In this study in-vitro (31)P high-resolution NMR spectroscopy of human blood plasma was optimized to obtain absolute concentrations of the major plasmaphospholipids: phosphatidylethanolamine plus sphingomyelin (PE + SM), 1- and 2-acyl-lysophosphatidylcholine (LPC1 and LPC2), phosphatidylinositol (PI) and phosphatidylcholine (PC). Plasma spectra of 33 patients with thyroid carcinoma were acquired at 121.49 MHz using a 300 MHz spectrometer. The patients were rendered hypothyroid (TSH >30 mU/l) in preparation for a whole-body scintigraphy. The whole-body scintigraphy showed tumour tissue or metastases in 16 patients (group C). Owing to an inconclusive whole-body scintigraphy, 17 patients were classified as being in remission (group B). After levothyroxine substitution 14 patients of group B were measured in euthyroidism too (group D). Besides these sub-groups, there was a control group made up of 23 healthy volunteers (group A). Group B showed significantly higher PE + SM and PC concentrations than group C (0.59 +/- 0.02 mmol/l PE + SM in B vs 0.48 +/- 0.02 mmol/l in C; 2.1 +/- 0.1 mmol/l PC in B vs 1.6 +/- 0.1 mmol/l in C). In comparison with group D higher concentrations of the phospholipids PE + SM and PC as well as PI were found in group B (0.59 +/- 0.02 mmol/l PE + SM in B vs 0.48 +/- 0.03 mmol/l in D; 0.074 +/- 0.005 mmol/l PI in B vs 0.046 +/- 0.004 mmol/l in D; 2.1 +/- 0.1 mmol/l PC in B vs 1.6 +/- 0.1 mmol/l in D). The data indicate that under the condition of hypothyroidism only patients in remission (group B) show significantly increased phospholipid concentrations, whereas the values in patients with remaining tumour tissue (group C) do not differ from those of the reference groups A and D. This finding is interpreted as an interference between the hormonal status and the systemic effects of cancer.
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PMID:Systemic alterations in phospholipid concentrations of blood plasma in patients with thyroid carcinoma: an in-vitro (31)P high-resolution NMR study. 1066 49

Hypothyroidism is a well-documented complication after treatment of head and neck cancer and is particularly significant among patients undergoing laryngectomy. The objective of this study was the identification of factors associated with the development of hypothyroidism in this population. Records of 136 patients treated with laryngectomy were retrospectively reviewed in an attempt to define a risk factor profile for patients in whom hypothyroidism is most likely to develop after laryngectomy. The Cox proportional hazards model was used to identify factors significantly related to an increased risk for development of hypothyroidism. The actuarial method was used to estimate the period of greatest risk for the development of hypothyroidism. Increased risks were found for patients who were female (P = 0.0049), received preoperative radiation therapy (P = 0.0022), had invasion of the thyroid gland by tumor (P = 0.0003), had presence of cervical metastases (P = 0.0022), and had postoperative fistula (P = 0.0095). From the actuarial method, we estimated that the period of time when patients were at greatest risk for development of hypothyroidism was between 0 and 14 months after surgical intervention. Wound complications were twice as frequent in hypothyroid patients. Perioperative awareness of risk factors associated with the development of hypothyroidism in patients undergoing laryngectomy allows for early recognition and management of hypothyroidism and may reduce the number of complications related to wound healing and fistula.
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PMID:Risk factors associated with hypothyroidism after laryngectomy. 1096 93

Mortality rates from thyroid cancer have fallen significantly in recent decades, almost certainly as the result of earlier diagnosis and improved treatment of differentiated (papillary and follicular) thyroid cancer. Enhanced survival is likely a result of early diagnosis and therapy applied at a disease stage when treatment is most effective. In the United States and Europe, most patients at high risk for relapse and death from thyroid cancer are treated with total or near-total thyroidectomy and receive radioiodine ablation of residual normal or malignant thyroid tissue, followed by treatment with thyroid hormone, a strategy that cures more than 80% of patients. Still, some die of the disease and nearly 15% have local recurrences, while another 5% to 10% develop distant metastases. Over 50% of recurrences appear in the first five years, but distant metastases may surface years, and sometimes decades, after initial therapy. Much has been learned about risk stratification to predict recurrence and death from thyroid cancer but individual patients continue to have adverse outcomes not always foreseen by a low tumor stage. Follow-up must accordingly be meticulous and prolonged. The National Cancer Center Network (NCCN) has recently established consensus practice guidelines that give explicit advice about the diagnosis and management of benign and malignant thyroid tumors, including paradigms for long-term follow-up and the treatment of recurrent disease. The guidelines confirm that diagnostic scanning with 131I and measurement of serum thyroglobulin (Tg) levels are the mainstay of follow-up, offering the opportunity to detect recurrent or persistent cancer at very early stages. These guidelines advocate TSH-stimulated serum Tg measurements, done either during thyroid hormone withdrawal or stimulation with recombinant human TSH (rhTSH, Thyrogen), that often identify the presence of cancer well before diagnostic whole-body scanning or other imaging studies can spot the tumor, which offers the opportunity to treat recurrent disease at an early stage. The use of rhTSH adds a new dimension to long-term follow-up that avoids putting patients through the symptoms of hypothyroidism, and offers the opportunity to follow some patients with rhTSH-stimulated serum Tg levels without performing 131I whole-body scans. A multicenter international study has shown that serum Tg measurements alone are not as sensitive in the identification of patients with persistent or recurrent tumor as are rhTSH-stimulated serum Tg determinations. Although not yet approved for preparation of patients for 131I therapy, rhTSH has been used successfully in a compassionate use program for this purpose in a relatively large number of patients. Formal clinical investigations now planned to provide guidelines for the use of rhTSH for therapeutic 131I portend a new set of effective therapeutic paradigms for the management of differentiated thyroid cancer.
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PMID:Using recombinant human TSH in the management of well-differentiated thyroid cancer: current strategies and future directions. 1104 54

Therapeutic use of radionuclides includes 131I for thyroid cancer and hyperthyroid Graves' disease, 89SrCl3 for metastatic bone tumors, 131I-MIBG for malignant pheochromocytoma and neuroblastoma, and radioimmunotherapies. 131I is concentrated in 60-70% of metastases from differentiated thyroid cancer following total thyroidectomy. Radioiodine uptake in metastatic lesions is greater in younger patients than in older ones. Hypothyroidism is often mild or even absent in patients with a large amount of tumor tissue, indicating that thyroid hormones produced by highly differentiated tumors compensate partially or even completely for hypothyroidism following total thyroidectomy. Adequate uptake of 131I has been reported to be associated with significant reduction in the size and number of metastases, and with lower recurrence and higher survival rates. Other favorable factors for longer survival are younger age, well-differentiated histological type, small disease extent, and early discovery of metastases. Older patients with extensive metastases and/or bulky tumor masses in the bone have a poor prognosis. Therefore, it is important to discover metastases as early as possible, when patients are still young. Long-term follow-up with periodic thyroglobulin measurements and imaging studies is strongly recommended. In Japan, 131I treatment for Graves' disease is performed only in selected patients in whom antithyroid drugs cannot be used because of side effects or not effective, considering the high prevalence of permanent hypothyroidism. 89SrCl3 is useful for reducing pain due to bone metastases of malignant tumors. 131I-MIBG therapy is effective for improvement of QOL in some patients with metastatic malignant pheochromocytoma. Radioimmuno-therapy using anti-CD20 has been used successfully in clinical application in patients with malignant B cell lymphoma.
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PMID:[Recent progress in radionuclide therapy]. 1114 Mar 21

Among patients with advanced melanoma, the development of autoimmune phenomena or of hypothyroidism during therapy has been associated with a favourable outcome. The objective of this study was to determine the prevalence of autoimmunity and of hypothyroidism in the melanoma population as a whole and to determine if these disease states confer a survival advantage for patients with metastatic disease. We report our findings in the uveal melanoma population. The study population (n = 91) consisted of all patients registered at this institution with the diagnosis of uveal melanoma during a 2 year study period. Eight (8.8%) had a systemic autoimmune disease; 12 (13.2%) were hypothyroid, including 9/46 (19.6%) females. Survival of the stage 4 patients was determined from diagnosis of the primary tumour (SvDx) and from diagnosis of metastatic disease (SvMt), and was compared to that of age/sex matched stage 4 controls. For autoimmune patients versus controls, the median SvDx was 111 months vs 37 months (P = 0.2734) and the median SvMt was 17 months vs 4 months (P = 0.0887). For the hypothyroid patients versus controls, the median SvDx was 58 months vs 49 months (P = 0.5348) and the median SvMt was 4 months vs 8 months (P = 0.2437). We conclude that there is a trend toward longer survival from the date of metastasis in uveal melanoma patients with a systemic autoimmune disorder, suggesting that systemic autoimmunity may play a role in modifying the activity of established metastases. This trend is not seen among the uveal melanoma patients with hypothyroidism. The high prevalence of hypothyroidism suggests a possible molecular interaction between the two disease processes.
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PMID:Autoimmunity and hypothyroidism in patients with uveal melanoma. 1172 10


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