Peter B. Andersen

Recombinant Human Thyrotropin-Stimulated Radioiodine Therapy of Large Nodular Goiters Facilitates Tracheal Decompression and Improves Inspiration

INTRODUCTION The impact on tracheal anatomy and respiratory function of recombinant human (rh)TSH-stimulated (131)I therapy in patients with goiter is not clarified. METHODS In a double-blinded design, patients (age 37-87 yr) with a large multinodular goiter (range, 99-440 ml) were randomized to placebo (n = 15) or 0.3 mg rhTSH (n = 14) 24 h before (131)I therapy. The smallest cross-sectional area of the trachea (SCAT; assessed by magnetic resonance imaging) and the pulmonary function were determined before, 1 wk, and 12 months after therapy. RESULTS Data on goiter reduction have been reported previously. In the placebo group, no significant changes in the lung function or SCAT were found throughout the study. In the rhTSH group, a slight decrease was observed in the forced vital capacity 1 wk after therapy, whereas the mean individual change in SCAT was significantly increased by 10.5% (95% confidence interval = 0.9-20.0%). A further increase in SCAT to 117 +/- 36 mm(2) (P = 0.005 compared with 92 +/- 38 mm(2) at baseline) was seen at 12 months, corresponding to a mean of 31.4% (95% confidence interval = 16.0-46.8%). The expiratory parameters did not change significantly, whereas forced inspiratory flow at 50% of the vital capacity (FIF50%) increased from initially 3.34 +/- 1.33 liters/sec to ultimately 4.23 +/- 1.88 liters/sec (P = 0.015) in the rhTSH group, corresponding to a median increase of 24.6%. By 12 months, the relative improvements in FIF50% and in SCAT were inversely correlated to the respective baseline values (FIF50%: r = -0.47, P = 0.012; SCAT: r = -0.57, P = 0.001). CONCLUSION On average, neither compression of the trachea nor deterioration of the pulmonary function was observed in the acute phase after rhTSH-augmented (131)I therapy. In the long term, tracheal compression is diminished, and the inspiratory capacity improved, compared with (131)I therapy alone.

Prestimulation with Recombinant Human Thyrotropin (rhTSH) Improves the Long-Term Outcome of Radioiodine Therapy for Multinodular Nontoxic Goiter

OBJECTIVE The objective of the study was to evaluate the long-term outcome of recombinant human TSH (rhTSH)-augmented radioiodine ((131)I) therapy for benign multinodular nontoxic goiter. PATIENTS AND METHODS Between 2002 and 2005, 86 patients with a multinodular nontoxic goiter were treated with (131)I in two randomized, double-blind, placebo-controlled trials. (131)I-therapy was preceded by 0.3 mg rhTSH (n = 42) or placebo (n = 44). In 2009, 80 patients completed a follow-up (FU) visit, including determination of thyroid volume, thyroid function, and patient satisfaction by a visual analog scale. RESULTS In both groups, thyroid volume was further reduced from 1 yr to final FU (71 months). The mean goiter volume reductions obtained at 1 yr and final FU [59.2 ± 2.4% (sem) and 69.7 ± 3.1%, respectively] in the rhTSH group were significantly greater than those obtained in the (131)I-alone group (43.2 ± 3.7 and 56.2 ± 3.6%, respectively, P = 0.001 and P = 0.006), corresponding to a gain of 24% at final FU. At last FU the mean reduction in compression visual analog scale score was significantly greater in patients receiving rhTSH (P = 0.049). Additional therapy (thyroid surgery or (131)I) was required more often in the placebo group (nine of 44) compared with the rhTSH group (two of 42) (P = 0.05). The prevalence of hypothyroidism at 1 yr [9 and 43% in the placebo and rhTSH groups, respectively (P < 0.0001)] increased to 16 and 52%, respectively, at final FU (P = 0.001). CONCLUSION Enhanced goiter volume reduction with rhTSH-augmented (131)I therapy improves the long-term reduction in goiter-related symptoms and reduces the need for additional therapy compared with plain (131)I therapy. Overall patient satisfaction is benefited, despite a higher rate of permanent hypothyroidism.

Does radioiodine therapy have an equal effect on substernal and cervical goiter volumes? Evaluation by magnetic resonance imaging.

Most often thyroidectomy is recommended in patients with large goiters. However, high-dose (131)I therapy may be used in case of contraindications to surgery. Large goiters are often partially located in the mediastinum. The aim of this study was to evaluate the impact of (131)I therapy on the cervical and the substernal goiter volume, separately. Fourteen patients (median age, 69 years; range, 52-86 years) with a large multinodular goiter (three hyperthyroid) and with a substernal extension greater than 15 mL were included. T1-weighted magnetic resonance (MR) estimates of the thyroid volume in the cervical and substernal compartments were obtained before and 1 year after high-dose (131)I therapy. The total goiter volumes ranged from 182 to 685 mL. The median substernal volume was 66 mL (fraction of total volume, 17.6%; range, 8.0%-78.9%). One year after treatment, the median substernal goiter volume was reduced by 29.2% (range, -6.1%-59.4%, mean: 26.1% +/- 6.0%), and the cervical goiter volume by 30.3% (range, 6.0%-75.4%, mean, 35.6 +/- 5.6%) compared to baseline values; p = 0.25 for difference in a regional effect. The volume reduction was unrelated to initial substernal goiter size. Likewise, deterioration of the inspiratory capacity did not correlate with the magnitude of the substernal goiter extension. In conclusion, high-dose (131)I therapy seems as effective in reducing the substernal as the cervical goiter volume. However, because the overall effect is modest, this therapy should primarily be considered for the patient with a high surgical risk.

A rare case of orbital involvement in Riedel’s thyroiditis

We report a case of Riedel’s thyroiditis in a 59-yr-old Caucasian female. She presented hypothyroidism and a stony hard, painful goiter. Due to fever, a high sedimentation rate and a high C-reactive protein (CRP), as well as high levels of anti-thyroid peroxidase antibodies (anti-TPOab), differential diagnostic considerations included acute and subacute thyroiditis as well as Hashimoto’s thyroiditis and thyroid malignancy. At the same time the patient had clinical and radiological features of bilateral orbital pseudotumor with lacrimal gland involvement. During L-thyroxine therapy orbital symptoms and signs improved and thyroid size decreased. This case report serves as a reminder of differential diagnostic considerations in the etiology of goiter as well as ophthalmopathy. Although extremely rare, orbital sclerosing fibrosis can be seen in conjunction with Riedel’s thyroiditis as part of multifocal fibrosclerosis.

Serum thyroxine and age — rather than thyroid volume and serum TSH — are determinants of the thyroid radioiodine uptake in patients with nodular goiter

Background: Radioiodine (131|) therapy is widely used for treatment of non-toxic goiters. A limitation for this treatment is a low thyroid radioiodine uptake (RAIU), often encountered in these patients. Aim: To estimate the impact of various factors on the thyroid RAIU. Methods: We examined prospectively 170 patients (146 females; age range: 22–87 yrs) with nodular goiter (median 64 ml, range: 20–464 ml) selected for 131| therapy. Serum TSH was sub-normal in 42.4%. None were treated with anti-thyroid drugs. The thyroid RAIU was determined at 24h and 96h. The goiter volume was measured by ultrasound (no.=127), or by magnetic resonance imaging (no.=43). Results: The 24h and the 96h RAIU were 34.2±9.8(SD)% (range: 11.4–66.0%) and 34.0±10.0% (range: 10.5–60.9%), respectively. Sixty-one patients had a 24h RAIU <30% and these individuals were older than patients with a 24h RAIU ≥30% (median 58 vs 51 yrs, p=0.02). These two subgroups did not differ significantly in other variables. Overall, the 24h RAIU was positively correlated to the serum (s) free T4-index (r=0.20, p=0.01), and negatively to age (r=−0.18, p=0.02), but not significantly related to serum TSH or thyroid volume. Age correlated positively with thyroid volume (r=0.31, p<0.001). In a regression analysis, s-free T4-index and age remained as the only determinants of the 24h and the 96h RAIU. Conclusions: In patients with a symptomatic nodular goiter, serum T4 and age are the major determinants of the thyroid RAIU. A sub-normal serum TSH is not a marker of a compromised thyroid RAIU but reflects that the iodine is confined to a few ‘hot spots’.

Vertebral osteonecrosis associated with pancreatitis in a woman with pancreas divisum. A case report.

Intraosseous fat necrosis is a well-known complication of pancreatitis1-11. Vertebral osteonecrosis associated with pancreatitis has been described only once, to our knowledge, and on that occasion it was associated with trauma-induced pancreatitis in a child12. There have been no reports of symptomatic vertebral osteonecrosis associated with pancreatitis in an adult, to our knowledge, although such lesions were described in an autopsy report11. We present a case of fatal pancreatitis in a woman who had pancreas divisum, adenocarcinoma of the dorsal aspect of the pancreas, and associated osteonecrosis of the thoracolumbar spine. Afifty-year-old woman was admitted to the hospital with epigastric and left upper-quadrant pain, loss of appetite, nausea and vomiting, and vague low-back pain that radiated to the left thigh. The back pain became worse the following day. Seven weeks earlier, the patient had been admitted for pancreatitis and had been diagnosed with a pancreas divisum, which occurs when the embryologic ventral and dorsal pancreatic anlagen fail to fuse. The patient had no history of alcohol abuse, back pain, or rheumatologic disease, and she had not taken any medication. Palpation of the spine at the thoracolumbar junction resulted in intense pain. Deep tendon reflexes and sensation were normal. The serum amylase level was marginally elevated. The patients condition improved after marsupialization of a pancreatic pseudocyst was performed, although the lumbar pain persisted. A radiograph of the spine revealed mild spondylosis. When the patient was discharged a few weeks later, she still had low-back pain of varied intensity. She was admitted again one week later with abdominal pain, low-back pain that radiated to the left thigh, and dysesthesia in the proximal-lateral portion of the left thigh. Clinical examination revealed a positive Lasegue sign at 50° on the left side. Flexion of the left …