Angela Fumarola

Iodine deficiency in pregnant women residing in an area with adequate iodine intake

OBJECTIVE To prevent iodine deficiency disorders, the World Health Organization, United Nations Childrens Fund, and International Council for the Control of Iodine Deficiency Disorders established that for a given population median urinary iodine concentrations (UIC) must be 100-199 microg/L in clinically healthy subjects and 150-249 microg/L in clinically healthy pregnant women. We evaluated whether in the urban area of Rome, Italy, where a salt iodination program (30 mg/kg) was introduced since 2005, an increased demand of iodine during pregnancy is guaranteed. METHODS During 2006, 51 pregnant women at first trimester of a physiologic gestation were consecutively enrolled on presentation to evaluate UIC in morning spot urine samples. As controls, 100 age-matched clinically healthy non-pregnant women were evaluated. RESULTS The median UICs were 182 microg/L (range 85-340 microg/L) and 74 microg/L (range 17-243 microg/L), respectively, in the control and pregnant groups. This difference was highly significant (P < 0.001). In particular, the UIC was found to be lower than adequate in 4% of control women compared with 92% of pregnant women. This difference of occurrences was highly significant (P < 0.001). CONCLUSION This observational study demonstrated that, despite the adequate supplementation of iodine intake, most pregnant women appear not to be protected against iodine deficiency. If confirmed in larger case studies, this finding claims the attention of relevant professionals to monitor iodine nutrition during gestation, assuming that ordinary supplementation of iodine intake seems to be sufficient only in non-gestational conditions.

Thyroglobulin in Lymph Node Fine-Needle Aspiration Washout: A Systematic Review and Meta-analysis of Diagnostic Accuracy

CONTEXT The thyroglobulin measurement in the needle washout after fine-needle aspiration (FNA) has been reported to increase the sensitivity of FNA in identifying lymph node (LN) metastases from differentiated thyroid cancer (DTC). OBJECTIVE The aim of the study was to estimate the diagnostic accuracy of this technique. DATA SOURCES To identify eligible studies, we searched electronic databases for original articles in English from 1975 through 2013. STUDY SELECTION Studies that enrolled participants with suspicious neck LNs during thyroid nodule workup or thyroid cancer follow-up were included. DATA EXTRACTION Working independently, authors used a standard form to extract data. For quality assessment, QUADAS2 guidelines were applied. DATA SYNTHESIS Including all the selected studies (24 studies, 2865 LNs) in the pooled analysis, overall sensitivity was 95.0% (95% confidence interval [CI], 93.7-96.0%), specificity was 94.5% (95% CI, 93.2-95.7%), and diagnostic odds ratio (DOR) was 338.91 (95% CI, 164.82-696.88) with significant heterogeneity (inconsistency [I(2)] = 65.7%; heterogeneity, P < .001). Stratifying different populations and including only patients with thyroid gland (410 LNs), pooled sensitivity was 86.2% (95% CI, 80.9-90.5%), specificity was 90.2% (85.1-94.0%), and DOR was 56.621 (22.535-142.26; I(2) = 37.3%; heterogeneity, P = .121). Including only patients after thyroidectomy (1007 LNs), pooled sensitivity was 96.9% (95% CI, 94.9-98.2%), specificity was 94.1% (91.7-96.0%), and DOR was 407.65 (198.67-836.46; I(2) = 0.0%; heterogeneity, P = .673). CONCLUSIONS Thyroglobulin measurement in washout from LN FNA has high accuracy in early detection of nodal metastases from DTC. The technique is simple, but a better standardization of criteria for patient selection, analytical methods, and cutoff levels is required.

Analysis of clinical, ultrasound and colour flow‐Doppler characteristics in predicting malignancy in follicular thyroid neoplasms

Fine-needle aspiration cytology (FNAC) represents the main diagnostic tool in the evaluation of thyroid nodules because of its high sensitivity, specificity and accuracy. However, while FNAC is very reliable in detecting papillary thyroid carcinomas (PTC) and anaplastic thyroid carcinomas, follicular neoplasms (FN) represent the grey zone in which cytology cannot discriminate malignant from benign tumours. 1 Consequently, in presence of nodules cytologically classified as FN, thyroidectomy is usually required and the histological evaluation reveals that about 80% are benign lesions. Thus, identification of parameters associated with malignancy is needed. In this context, several studies have focused on clinical, ultrasonographic and cytological aspects, with controversial results. 2,3

Strain US elastography for the characterization of thyroid nodules: Advantages and limitation

Thyroid nodules, with their high prevalence in the general population, represent a diagnostic challenge for clinicians. Ultrasound (US), although absolutely reliable in detecting thyroid nodules, is still not accurate enough to differentiate them into benign and malignant. A promising novel modality, US elastography, has been introduced in order to further increase US accuracy. The purpose of this review article is to assess the thyroid application of US strain elastography, also known as real-time elastography or quasistatic elastography. We provide a presentation of the technique, and of up-to-date literature, analyzing the most prominent results reported for thyroid nodules differentiation. The practical advantages and limitations of strain elastography are extensively discussed herein.

Thyroid function in infertile patients undergoing assisted reproduction.

Thyroid disease is one of the most common endocrine conditions affecting women during reproductive age. A link between thyroid and assisted reproduction outcome is debated.

Intrinsic factors affecting adequacy of thyroid nodule fine-needle aspiration cytology.

To evaluate intrinsic nodule features predictive of an inadequate report in fine‐needle aspiration cytology (FNAC).

Iodine supplementation restores fertility of sheep exposed to iodine deficiency

The aims of the study were to monitor sheep iodine intake in different sheep breeding farms in Abruzzo and to evaluate the effects of iodine supplementation on ovine fertility. The urinary iodine concentrations (UIC) in animals of 8 out of the 11 breeding farms analyzed were borderline (UIC 100–150 μg/l) or very low (UICФ50 μg/l). Only animals bred in 3 farms showed an adequate iodine intake with a mean UICГ300 μg/l. Animals with very low iodine intake had lower T4 and T3 (plt;0.01) serum levels, compared to those with adequate iodine intake. To investigate the effects of iodine supplementation on ovine fertility, 32 ewes and 20 rams, characterized by low UIC, were randomly divided into 2 groups. One group (16 ewes and 10 rams) received a sc injection of 1 ml of Lipiodol, containing 480 mg of iodine, while the remaining animals were employed as control. This treatment was able to maintain UIC above 300 μg/l for 3 months and to increase T4 and T3 serum levels (plt;0.01). After 9 months, the fertility of control and treated animals was assessed by monitoring the rate of successful matings by ultrasonography. The results showed that 100% of treated ewes mated with treated rams were pregnant vs 37% of the control ewes mated with control rams (p=0.007). The iodine content was 4-fold higher in milk from treated ewes (2393±453 μg/l), compared to controls (675±154 μg/l).The results demonstrated that iodine supplementation restores fertility of sheep living in iodine deficient areas and may represent a means to achieve a silent iodine prophylaxis of local populations.

Therapy of hyperthyroidism in pregnancy and breastfeeding.

Uncontrolled hyperthyroidism in pregnancy is associated with an increased risk of perinatal complications. The state of the art discussed here has been derived through a wide MEDLINE search throughout English-language literature by using a combination of words such as hyperthyroidism, propylthiouracil (PTU), methimazole, rituximab, and pregnancy to identify original related works and review articles. Thioamides are the main first-line therapeutic options, whereas beta-blockers and iodine are second-choice drugs; surgery is resorted to only in exceptional cases. Methimazole and PTU reduce the production of thyroid hormones by selectively inhibiting thyroid peroxidase. PTU was once considered to be the first-choice drug in the treatment of gestational hyperthyroidism; however, the United States Food and Drug Administration now recommends it as a second-line thioamide, which should be used solely by women in their first trimester of pregnancy. Thyroidectomy is to be carried out only in pregnant women affected by life-threatening, uncontrollable hyperthyroidism, or in cases with thioamide intolerance. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the physician should be better able to choose appropriate therapies for hyperthyroidism in pregnant women, assess the risk of possible complications due to maternal hyperthyroidism, and evaluate strategies for patient follow-up.

Is Minimally Invasive Surgery Appropriate for Small Differentiated Thyroid Carcinomas

PurposeTo retrospectively evaluate the surgical completeness of minimally invasive total thyroidectomy for small (<20 mm) differentiated thyroid carcinoma (DTC).MethodsThe subjects of this study were 30 patients who underwent minimally invasive total thyroidectomy as a single procedure. We registered the following postoperative measurements in the LT4 withdrawal period: serum thyroglobulin level, 6-h radioiodine uptake diagnostic test results, and neck ultrasound (US) findings.ResultsThe mean serum thyroglobulin level was 4.99 ± 4.67 ng/ml, the mean radioiodine uptake diagnostic test after 6 h was 3.11% ± 2.90%, and US showed no thyroid remnant.ConclusionsThe short-term outcome measures showed adequate resection of thyroid tissue, comparable with that reported after conventional surgery. Our findings suggest that small nodules with suspicious or malignant cytology are one of the best indications for minimally invasive surgery.

Grey-Scale Analysis Improves the Ultrasonographic Evaluation of Thyroid Nodules.

AbstractUltrasonography is the main imaging method for the workup of thyroid nodules. However, interobserver agreement reported for echogenicity and echotexture is quite low. The aim of this study was to perform quantitative measurements of the degree of echogenicity and heterogeneity of thyroid nodules, to develop an objective and reproducible method to stratify these features to predict malignancy.A retrospective study of patients undergoing ultrasonography-guided fine-needle aspiration was performed in an University hospital thyroid center. From January 2010 to October 2012, 839 consecutive patients (908 nodules) underwent US-guided fine-needle aspiration. In a single ultrasound image, 3 regions of interest (ROIs) were drawn: the first including the nodule; the second including a portion of the adjacent thyroid parenchyma; the third, the strap muscle. Histogram analysis was performed, expressing the median, mean, and SD of the gray levels of the pixels comprising each region. Echogenicity was expressed as a ratio: the nodule/parenchyma, the nodule/muscle, and parenchyma/muscle median gray ratios were calculated. The heterogeneity index (HI) was calculated as the coefficient of variation of gray histogram for each of the 3 ROIs. Cytology and histology reports were recorded.Nodule/parenchyma median gray ratio was significantly lower (more hypoechoic) in nodules found to be malignant (0.45 vs 0.61; P = 0.002) and can be used as a continuous measure of hypoechogenicity (odds ratio [OR] 0.12; 95% confidence interval [CI] 0.03–0.49). Using a cutoff derived from ROC curve analysis (<0.46), it showed a substantial inter-rater agreement (k = 0.74), sensitivity of 56.7% (95% CI 37.4–74.5%), specificity of 72.0% (67.8–75.9%), positive likelihood ratio (LR) of 2.023 (1.434–2.852), and negative LR of 0.602 (0.398–0.910) in predicting malignancy (diagnostic odds ratio 3.36; 1.59–7.10). Parenchymal HI was associated with anti-thyroperoxidase positivity (OR 19.69; 3.69–105.23). The nodule HI was significantly higher in malignant nodules (0.73 vs 0.63; P = 0.03) and, if above the 0.60 cutoff, showed sensitivity of 76.7% (57.7–90.1%), specificity of 46.8% (42.3–51.4%), positive LR of 1.442 (1.164–1.786), and negative LR of 0.498 (0.259–0.960).Evaluation of nodule echogenicity and echotexture according to a numerical estimate (nodule/parenchyma median gray ratio and nodule HI) allows for an objective stratification of nodule echogenicity and internal structure.