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Ethanol percutaneous treatment of autonomous and cystic nodules
was reported by Rodrigues and co-worker (Lodz, Poland). Percutaneous
ethanol injection (PEI) has been successfully used as an alternative to
surgery for managing of cystic and autonomous nodules. In the present study
thirty nine females with non functional solid nodules and twenty two with
autonomous hyperfunctional solid nodules were treated with ethanol injection.
In all patients the cytological studies were suggestive of benign disorders.
The thyroid lab tests were within the normal range. The patients were followed
up to 24 months and the size of the nodules had a mean reduction of 82%.
The procedure had no significant side effects or morbidity, was easy to
perform and was acceptable to patients.
The clinical outcome of nodular goiter with a benign cytologic diagnosis was evaluated by Sieiro-Netto and co-works (Rio de Janeiro, Brazil). Retrospectively 92 patients were evaluated: 25 were treated with LT4 (125-250 µg/day), during 8-24 months, with serum TSH maintained between below 0.3µU/mL. Of the remaining 67 individuals, thirty-five were operated (lobectomy), twenty-six remained on observation and six were lost for follow-up. Only 24% of the LT4 patients had a significant reduction of the nodular volume. In the non treated group 7.6% had a reduction in the nodule size. Surprisingly 11.4% (4 patients) of the 35 subjects submitted to surgery had a final diagnosis of thyroid cancer (one medullar, three papillary). They concluded that the FNAB had a concordency with the pathology in 88% of the cases but occasionally a false negative diagnosis is present. The ablative therapy with radioiodine of solitary autonomous toxic nodules was reported by Kiy and co-workers (Botucatu, Sào Paulo, Brazil). Thirty-one patients (29F and 2M) were retrospectively analyzed (ages: 28-78y, median: 68y). Only three patients received two radioiodine (RAI) doses. The mean doses of RAI was 29.5 mCi. Follow up between 4-228 months (mean: 46 months) indicated permanent hypothyroidism only in 3 patients (9.7%). A thyroid scan with technetium 99m indicated that the nodule was not trapping the tracer (cold nodule) in 14 subjects (45.2%) and suggestive of still a "hot" nodule in 54.8%. They concluded that radioiodine treatment of toxic adenomas is a safe and effective procedure as an alternative to surgery or ethanol transcutaneous injection. A new classification of thyroid nodules based on cytologic and ultrasonographic studies was proposed by Camargo and collaborators (Sào Paulo, Brazil). According to the ultrasonographic studies the authors classified the solitary solid nodules in five categories (I to V) each one with an individual score (1-5 points). Similarly the cytologist classified the fine needle aspiration biopsy result in four categories (I to IV) with scores of, respectively, 1 to 4. The combination of the sum of the scores progressively indicates the highest possibility of thyroid cancer. Based on these criteria a score of 2-3 points was considered as benign, a score of 4-5 was denominated doubtful, a score of 6-7 suspicious of malignancy and a score of 8-9, probably malignancy. Thirty-eight patients were submitted to surgery and the results are shown in table 2. They concluded that scores equal or higher than 6 were present in 71% (n=27) of final diagnosis of neoplastic disease (of whom 23 were malignant). It was proposed that this new classification will be helpful for the clinician to make the decision to send patients for surgery. Table 2
The controversial use of LT4 suppressive therapy for treatment of thyroid solid nodules and multinodular goiters was discussed by Lima and co-workers(Sào Paulo, Brazil). The authors prospectively evaluated the effect of TSH-suppressive therapy with levothyroxine on the size of benign solitary solid nodules (SSN) and multinodular goiter (MNG) in a relatively low iodine intake area. In this study 136 euthyroid subjects with a benign solitary predominantly solid nodule (n = 54) confirmed by biopsy or with multinodular goiter (n = 47) received 200 µg of levothyroxine daily as a single morning tablet for 12 months. Thirty-five patients receiving no therapy were considered as controls (SSN-20, MNG=15). Patients were admitted to the study after evaluation of thyroid biochemical parameters (T4, free T4, T3, TSH, Tg), thyroid scanning, ultrasound examination and fine-needle aspiration biopsy. Every 3 months thyroid-function tests and every 6 months ultrasound examinations were repeated. Twelve months later 20/54 (37.1%) patients with a single solid nodule had 50% or more regression of the nodular volume (responders). Eleven of 54 (20.3%) patients had more than 20% but less than 49.9% reduction of nodular volume (partial responders). Non responders were 23/54 (42.5%). One third off subjects with multinodular goiter had 50% or more regression of the glandular volume whereas 46.8% were considered as non responsive. The mean serum Tg levels decreased significantly only in responders with solitary nodular disease or multinodular goiter. In the control group (no treatment) only 8/35 patients had a 50% reduction or a partial reduction after 12 mo. of observation. The authors concluded that levothyroxine may be effective, among other factors, in arresting the growth or in reducing the volume of the relatively small benign solitary solid thyroid nodule or the combined nodular volume of multinodular goiter. An unique case of solitary plasmacytoma of the thyroid was presented by Di Ninno and co-workers (Sào Paulo, Brazil). They report an unique case of a solitary plasmacytoma in a 58-year-old man who presented a 8-month history of a rapidly enlarging, nontender neck mass, with several nodules on physical examination; the neck ultra-sound demonstrated an enlarged thyroid with several solid nodules. A fine-needle aspiration showed numerous abnormal and atypical plasma cells consistent with a plasmacytoma; a cytometric analysis of the aspirate reveald monoclonal, kappa positive cells. TSH (1.2 mU/L, range 0.3-4.5) and fT4 (1 ng/mL, range 0.6-1.5) were normal; anti-thyroglobulin antibodies were positive in very high titer, 4,500,000 U/L (normal until 40) and anti-peroxidase antibodies were also positive, 150 U/L (normal <= 100). A serum protein electrophoresis and immunoelectrophoresis revealed a monoclonal peak in the delta-globulin region (1.5 g/dL) due to a monoclonal (IgG kappa) immunoglobulin. Urine protein electrophoresis and Bence Jones protein measurements were negative. Following confirmation of the diagnosis, the patient was submitted to a near total thyroidectomy and resection of 8 lymphonodes. Histologic sections of the specimen revealed sheets of atypical plasma cells, consistent with a malignant plasmacytoma positive for kappa light chain. In addition to the plasmacytoma cells, chronic lymphocytic thyroiditis was evident in the surrounding normal tissue. The authors seeded the plasmacytoma cells in culture and were able to demonstrate the production of anti-thyroglobulin antibodies by these cells in culture, result which strongly suggests that the very elevated anti-thyroglobulin antibodies present in serum were produced by tumor cells. In addition, B cell monoclonality of tumor samples was demonstrated by amplification of immunoglobulin chains by polymerase chain reaction (PCR). The patient subsequently received a full course of external beam radiotherapy and is doing very well 6 years after surgery. Serum monoclonal immunoglobulin and anti-thyroglobulin antibodies have declined and disappeared after 2 months and 2 years, respectively. Interestingly, as a demonstration of the presence of a chronic thyroiditis, anti-thyroperoxidase antibodies stayed positive during follow-up. Among 120 cases of plasma cell tumors of the thyroid from the literature, this case presented unique features, which include the diagnosis of a monoclonal plasmacytoma made by fine needle aspiration cytology, the molecular characterization of a monoclonal plasmacytoma by PCR and the demonstration of the production of anti-thyroglobulin antibodies by the thyroid monoclonal plasma cells. |
