Thyroid Nodules Burman, Kenneth D; Wartofsky, Leonard
The New England journal of medicine,
12/2015, Letnik:
373, Številka:
24
Journal Article
Recenzirano
Ultrasonography of the thyroid and ultrasonographically guided fine-needle aspiration can help determine whether a nodule is probably benign or malignant. In the absence of growth or suspicious ...clinical or radiologic findings, nodules with a benign finding on FNA can be monitored.
Foreword
This
Journal
feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors’ clinical recommendations.
Stage
A 40-year-old woman presents with a thyroid nodule, 2.0 cm by 2.0 cm on palpation. The nodule, located on the right side of the gland, was found on routine physical examination. She has no history of childhood radiation exposure or family history of thyroid abnormalities. She reports no symptoms of nervousness, weight loss, palpitation, fatigue, or neck discomfort. Ultrasonography confirms a thyroid nodule, 2.0 cm by 2.0 cm by 2.5 cm (volume, 5.23 cm
3
), on the right side of the gland that does not have ultrasonographic characteristics associated with an increased risk of cancer; there is no cervical . . .
Primary Thyroid Lymphoma: A Clinical Review Stein, Stephanie Aleskow; Wartofsky, Leonard
The journal of clinical endocrinology and metabolism,
2013-August, Letnik:
98, Številka:
8
Journal Article
Recenzirano
Odprti dostop
Context:
Although primary thyroid lymphoma is a rare cause of both thyroid malignancy and extranodal lymphoma, awareness of this disease is important in order to achieve an early diagnosis and ...implement treatment. We review the epidemiology, clinical presentation, diagnosis, and treatment of this rare disorder.
Evidence Acquisition:
This review is based on a search of PubMed and MDConsult for English language articles containing the term “primary thyroid lymphoma.” The authors reviewed original and review articles and case series from all years of publication but focused on those published within the last 5 years.
Evidence Synthesis:
Primary thyroid lymphoma should be suspected in patients with a rapidly enlarging neck mass, especially in women with Hashimoto's thyroiditis. Certain ultrasound features such as enhanced posterior echoes can suggest the diagnosis, but biopsy for confirmation is ultimately needed. With advances in immunophenotypic analysis, fine-needle aspiration can be used for diagnosis in the hands of experienced physicians. The most common type of primary thyroid lymphoma is diffuse large B-cell lymphoma, which behaves in a more aggressive manner than mucosa-associated lymphoid tissue lymphoma. Radiation therapy can be employed for treatment of localized mucosa-associated lymphoid tissue lymphoma, but a combination of chemotherapy and radiation is needed for disseminated disease or aggressive histological subtypes.
Conclusions:
It is important to consider the diagnosis of primary thyroid lymphoma in patients presenting with an enlarging neck mass and a history of Hashimoto's thyroiditis. Advances in both diagnosis and treatment in recent years have altered our approach to the management of this disease.
Because of the longstanding controversy regarding whether hypothyroid patients can be optimally replaced by treatment with levothyroxine (L-T4) alone, numerous studies have addressed potential ...benefits of combined therapy of triiodothyronine (T3) with L-T4. Results of these studies have failed to support a potential benefit of combined therapy. A strong argument for the addition of L-T3 to L-T4 monotherapy has been lacking until recent genetic studies indicated a rationale for such therapy among a small fraction of the hypothyroid patient population.
Interest in this issue has focused on the importance of the deiodinases in maintaining the euthyroid state and the role of genetic polymorphisms in the deiodinase genes that would affect thyroid hormone concentrations in both blood and tissues. One such polymorphism in the D2 gene, Thr92Ala, is associated with reduced T4 to T3 activation in skeletal muscle and thyroid, linked to obesity and alterations in thyroid-pituitary feedback, and in responses to thyroid hormone treatment.
Although our professional organizations continue to recommend L-T4 alone for the treatment of hypothyroidism, the possibility of a D2 gene polymorphism should be considered in patients on L-T4 monotherapy who continue to complain of fatigue in spite of dosage achieving low normal serum thyroid stimulating hormone levels. A suggestive clue to the presence of this polymorphism could be a higher than normal free T4/free T3 ratio. Clinicians could consider adding T3 as a therapeutic trial in selected patients. Future well controlled clinical trials will be required to more fully resolve the controversy.
Abstract
Amiodarone is a class III antiarrhythmic drug containing 37% iodine by weight, with a structure similar to that of thyroid hormones. Deiodination of amiodarone releases large amounts of ...iodine that can impair thyroid function, causing either hypothyroidism or thyrotoxicosis in susceptible individuals reflecting ~20% of patients administered the drug. Not only the excess iodine, but also the amiodarone (or its metabolite, desethylamiodarone) itself may cause thyroid dysfunction by direct cytotoxicity on thyroid cells. We present an overview of the epidemiology and pathophysiology of amiodarone-induced thyroid disorders, with a focus on the various forms of clinical presentation and recommendations for personalized management of each form.
Debate and controversy currently surround the recommendations of a recent consensus conference that considered issues related to the management of early, mild, or so-called subclinical hypothyroidism ...and hyperthyroidism. Intimately related to the controversy is the definition of the normal reference range for TSH. It has become clear that previously accepted reference ranges are no longer valid as a result of both the development of more highly sensitive TSH assays and the appreciation that reference populations previously considered normal were contaminated with individuals with various degrees of thyroid dysfunction that served to increase mean TSH levels for the group. Recent laboratory guidelines from the National Academy of Clinical Biochemistry indicate that more than 95% of normal individuals have TSH levels below 2.5 mU/liter. The remainder with higher values are outliers, most of whom are likely to have underlying Hashimoto thyroiditis or other causes of elevated TSH. Importantly, data indicating that African-Americans with very low incidence of Hashimoto thyroiditis have a mean TSH level of 1.18 mU/liter strongly suggest that this value is the true normal mean for a normal population. Recognition and establishment of a more precise and true normal range for TSH have important implications for both screening and treatment of thyroid disease in general and subclinical thyroid disease in particular.
Thyroid emergencies Klubo-Gwiezdzinska, Joanna; Wartofsky, Leonard
The Medical clinics of North America,
03/2012, Letnik:
96, Številka:
2
Journal Article
Recenzirano
This review presents current knowledge about the thyroid emergencies known as myxedema coma and thyrotoxic storm. Understanding the pathogenesis of these conditions, appropriate recognition of the ...clinical signs and symptoms, and their prompt and accurate diagnosis and treatment are crucial in optimizing survival.
Treatment With Thyroid Hormone Biondi, Bernadette; Wartofsky, Leonard
Endocrine reviews,
2014-June, Letnik:
35, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Thyroid hormone deficiency can have important repercussions. Treatment with thyroid hormone in replacement doses is essential in patients with hypothyroidism. In this review, we critically discuss ...the thyroid hormone formulations that are available and approaches to correct replacement therapy with thyroid hormone in primary and central hypothyroidism in different periods of life such as pregnancy, birth, infancy, childhood, and adolescence as well as in adult patients, the elderly, and in patients with comorbidities. Despite the frequent and long term use of l-T4, several studies have documented frequent under- and overtreatment during replacement therapy in hypothyroid patients. We assess the factors determining l-T4 requirements (sex, age, gender, menstrual status, body weight, and lean body mass), the major causes of failure to achieve optimal serum TSH levels in undertreated patients (poor patient compliance, timing of l-T4 administration, interferences with absorption, gastrointestinal diseases, and drugs), and the adverse consequences of unintentional TSH suppression in overtreated patients. Opinions differ regarding the treatment of mild thyroid hormone deficiency, and we examine the recent evidence favoring treatment of this condition. New data suggesting that combined therapy with T3 and T4 could be indicated in some patients with hypothyroidism are assessed, and the indications for TSH suppression with l-T4 in patients with euthyroid multinodular goiter and in those with differentiated thyroid cancer are reviewed. Lastly, we address the potential use of thyroid hormones or their analogs in obese patients and in severe cardiac diseases, dyslipidemia, and nonthyroidal illnesses.
PDF
