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Laszlo Hegedüs - One of the best experts on this subject based on the ideXlab platform.
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time to reconsider nonsurgical therapy of benign non Toxic Multinodular Goitre focus on recombinant human tsh augmented radioiodine therapy
European Journal of Endocrinology, 2009Co-Authors: Soren Fast, Viveque Egsgaard Nielsen, Steen Joop Bonnema, Laszlo HegedüsAbstract:The treatment of benign Multinodular Goitre (MNG) is controversial, but surgery is recommended in large compressive Goitres. While some patients decline surgery others may have contraindications due to comorbidity, since MNG is prevalent in the elderly. Therefore, non-surgical treatment alternatives are needed. Until recently, levothyroxine therapy was the preferred non-surgical alternative, but due to low efficacy and potential side-effects, it is not recommended for routine use in recent international guidelines. Conventional radioiodine ( 131 I) therapy has been used for two decades as an effective and safe alternative to surgery in the treatment of symptomatic non-Toxic MNG. Since much higher activities of 131 I are employed when treating non-Toxic rather than Toxic MNG, there has been reluctance in many countries to use this treatment modality. Frequently, the 131 I -uptake in a non-Toxic MNG is low, which makes 131 I therapy less feasible. Another challenge is the negative correlation between the initial Goitre size and Goitre volume reduction (GVR). With its ability to more than double the thyroid 131 I-uptake, recombinant human TSH (rhTSH) increases the absorbed radiation dose and thus enhances the GVR by 35–56% at the expense of up to fivefold higher rate of permanent hypothyroidism. An alternative strategy is to reduce the administered 131 I-activity with a factor corresponding to the rhTSH induced increase in 131 I-uptake. Hereby, the extrathyroidal irradiation can be reduced without compromising efficacy. Thus, although in its infancy, and still experimental, rhTSH-augmented 131 I therapy may profoundly alter the non-surgical treatment of benign non-Toxic MNG.
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Radioiodine therapy in non-Toxic Multinodular Goitre. The possibility of effect-amplification with recombinant human TSH (rhTSH).
Acta oncologica (Stockholm Sweden), 2006Co-Authors: Steen Joop Bonnema, Viveque Egsgaard Nielsen, Laszlo HegedüsAbstract:There is no consensus regarding the optimum treatment of benign non-Toxic Goitre. L-thyroxine suppressive therapy is widely used, but there is poor evidence of its efficacy, and it may have serious adverse effects on health. Surgery is first choice in large Goitres or if malignancy is suspected. 131I therapy results in a one-year Goitre reduction of around 40% in Multinodular Goitres, usually with a high degree of patient satisfaction and improvement of the inspiratory capacity. The effect is attenuated with increasing Goitre size. The risk of hypothyroidism is 22–58% within 5–8 years. A sufficient thyroid 131I uptake is mandatory for 131I therapy to be feasible and pre-stimulation with recombinant human TSH (rhTSH) increases this considerably. This leads to an increased absorbed thyroid dose by approx.75%, mainly in those patients with the lowest thyroid 131I uptake, and a more homogeneous intrathyroidal isotope distribution. Pre-stimulation with even a small dose of rhTSH seems to allow a reduction of t...
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Differences between endocrine surgeons and endocrinologists in the management of non-Toxic Multinodular Goitre.
The British journal of surgery, 2003Co-Authors: M.c. Bhagat, Steen Joop Bonnema, Laszlo Hegedüs, Satvinder S. Dhaliwal, John P. WalshAbstract:Background: It is not known whether the management of Multinodular Goitre differs between endocrinologists and endocrine surgeons. Methods: A questionnaire containing a hypothetical case (a 42-year-old euthyroid woman with a 50–80-g Multinodular Goitre) and 11 variations on the case was sent to endocrinologists and endocrine surgeons in Australia. Results: The response rate was 55 per cent, including 45 endocrine surgeons and 127 endocrinologists. For the index case, serum thyroid-stimulating hormone (TSH), fine-needle aspiration biopsy and ultrasonography were widely used by both groups. Thyroid antibodies and scintigraphy were ordered by a greater proportion of endocrinologists than surgeons, and computed tomography more frequently by surgeons than endocrinologists. Treatment recommendations differed significantly between specialties for the index case (endocrinologists: no treatment 65 per cent, thyroxine 22 per cent, surgery 10 per cent, radioiodine 3 per cent; surgeons: no treatment 67 per cent, thyroxine 2 per cent, surgery 31 per cent; P < 0·001) and for seven of the variations. In particular, for a patient with suppressed TSH, most endocrinologists (60 per cent) recommended radioiodine treatment, whereas there was no consensus among surgeons (surgery 40 per cent, no treatment 36 per cent, radioiodine 21 per cent). For a patient with a partly intrathoracic Goitre, most surgeons (88 per cent) recommended surgery, whereas there was no consensus among endocrinologists (surgery 45 per cent, no treatment 34 per cent, thyroxine treatment 13 per cent, radioiodine 8 per cent). Conclusion: There are clinically significant differences between endocrine surgeons and endocrinologists in the management of Multinodular Goitre. Copyright © 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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danish endocrinologists examination and treatment of non Toxic Multinodular goiter a questionnaire study
Ugeskrift for Læger, 2001Co-Authors: Steen Joop Bonnema, Finn Noe Bennedbaek, Laszlo HegedüsAbstract:AIM To assess the attitudes towards the management of the non-Toxic Multinodular Goitre by means of a questionnaire concerning on case history, which was circulated to all Danish endocrinologists ("A 42-year-old woman with an irregular, non-tender, bilaterally enlarged thyroid of 50-80 g and no clinical suspicion of malignancy"). DESIGN Eleven variations of the (basic) case report were proposed in order to evaluate the impact on the management of each alteration. In the index case, serum TSH was the routine choice of 100%, serum T4/free T4-index and T3/free T3-index were measured by 83% and 79%, serum TPOab and serum calcitonin by 49% and 4%, respectively. RESULTS The median number of blood tests was three (range 1-7). Thyroid scintigraphy was used by 96% and ultrasound by 94%, both methods were employed by 90% with scintigraphy most often having the first priority. Fine-needle aspiration biopsy was not routinely used, unless a scintigraphically dominant "cold" area was present; 70% used ultrasound guidance. Radioiodine was the preferred treatment of 51%, surgery 7%, L-T4 4%, and no treatment 38%. DISCUSSION In the case of young patients or factors predisposing to thyroid cancer, treatment preferences changed to surgery. The prevailing use of radioiodine in Denmark contrasts with the situation in most other European countries, but Danish endocrinologists also disagree about the optimum management of Multinodular non-Toxic Goitre.
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acute changes in thyroid volume and function following 131i therapy of Multinodular Goitre
Clinical Endocrinology, 1994Co-Authors: Birte Nygaard, J Faber, Laszlo HegedüsAbstract:Summary OBJECTIVE Many textbooks claim that radioIodine (131I) treatment should be given with care to a Goitre with substernal extension, for fear of acute swelling of the gland and thus respiratory problems. Since 131I Is used increasingly in the treatment of non-Toxic as well as Toxic Goitre we have evaluated the acute changes in thyroid volume following 131I therapy. DESIGN Evaluation of potential acute changes in thyroid volume and function after 131I treatment in patients with non-Toxic Goitre treated because of compression symptoms or for cosmetic reasons, as well as In patients with Toxic Goitre. PATIENTS Out-patients with Multinodular Goitre, either non-Toxic (n= 20) or Toxic (n= 10). Excluded were patients with a substernal Goitre. MEASUREMENTS Ultrasonically determined thyroid volume and standard thyroid function variables were Investigated before and 2, 7, 14, 21, 28 and 35 days after treatment. RESULTS In non-Toxic Goitres the thyroid volume did not increase significantly, the maximum increase in the median volume being 4% on day 7. Serum levels of free T3 and free T4 Indices increased by 20% (day 7) and 13% (day 14) (P= 0·002), respectively. Likewise thyroid volume in Toxic nodular Goitre did not change significantly after 131I treatment (maximum median increase was 2%). None of the patients presented symptoms of tracheal compression. CONCLUSIONS 131I treatment of non-Toxic as well as Toxic Multinodular Goitre does not seem to increase thyroid volume.
B J B Hamer - One of the best experts on this subject based on the ideXlab platform.
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takotsubo cardiomyopathy following radioiodine therapy for Toxic Multinodular Goitre
Netherlands Journal of Medicine, 2009Co-Authors: N Van De Donk, Yves G. C. J. America, P M J Zelissen, B J B HamerAbstract:abstraCtwe report on a 73-year-old man with a Toxic Multinodular Goitre, which was treated with radioiodine therapy (i-131) without pretreatment with an antithyroid drug. four weeks later he presented with rapidly progressive dyspnoea and a significant increase in free thyroxin. the electrocardiogram showed st-segment elevation, and echocardiography demonstrated apical akinesia and a left ventricular ejection fraction of only 25%. however, direct coronary catheterisation showed no evidence of coronary artery disease. left ventricular angiography showed apical ballooning consistent with the diagnosis of takotsubo cardiomyopathy. following treatment of the cardiomyopathy and thyroToxicosis, he experienced a complete recovery. to the best of our knowledge, this is the first report of a takotsubo cardiomyopathy associated with thyroToxicosis resulting from radiation thyroiditis induced by radioiodine. three other cases of takotsubo cardiomyopathy associated with graves’ disease have been described in literature. KeywordsHeart failure, radioiodine therapy, takotsubo cardiomyopathy, Toxic Multinodular GoitreintroduCtionTakotsubo cardiomyopathy, also called stress-induced cardiomyopathy, consists of reversible apical or midventricular left ventricular dysfunction with sparing of the basal segments, without significant epicardial coronary artery stenosis. This entity is named after the round-bottomed narrow-necked Japanese fishing pot used for trapping octopus, because of the peculiar left ventricle apical ballooning evident on left ventriculogram. It is typically triggered by an acute medical illness such as sepsis,
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Takotsubo cardiomyopathy following radioiodine therapy for Toxic Multinodular Goitre
The Netherlands journal of medicine, 2009Co-Authors: N. Van De Donk, Yves G. C. J. America, P M J Zelissen, B J B HamerAbstract:We report on a 73-year-old man with a Toxic Multinodular Goitre, which was treated with radioiodine therapy (I-131) without pretreatment with an antithyroid drug. Four weeks later he presented with rapidly progressive dyspnoea and a significant increase in free thyroxin. The electrocardiogram showed ST -segment elevation, and echocardiography demonstrated apical akinesia and a left ventricular ejection fraction of only 25%. However, direct coronary catheterisation showed no evidence of coronary artery disease. Left ventricular angiography showed apical ballooning consistent with the diagnosis of takotsubo cardiomyopathy. Following treatment of the cardiomyopathy and thyroToxicosis, he experienced a complete recovery. To the best of our knowledge, this is the first report of a takotsubo cardiomyopathy associated with thyroToxicosis resulting from radiation thyroiditis induced by radioiodine. Three other cases of takotsubo cardiomyopathy associated with Graves' disease have been described in literature.
Steen Joop Bonnema - One of the best experts on this subject based on the ideXlab platform.
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time to reconsider nonsurgical therapy of benign non Toxic Multinodular Goitre focus on recombinant human tsh augmented radioiodine therapy
European Journal of Endocrinology, 2009Co-Authors: Soren Fast, Viveque Egsgaard Nielsen, Steen Joop Bonnema, Laszlo HegedüsAbstract:The treatment of benign Multinodular Goitre (MNG) is controversial, but surgery is recommended in large compressive Goitres. While some patients decline surgery others may have contraindications due to comorbidity, since MNG is prevalent in the elderly. Therefore, non-surgical treatment alternatives are needed. Until recently, levothyroxine therapy was the preferred non-surgical alternative, but due to low efficacy and potential side-effects, it is not recommended for routine use in recent international guidelines. Conventional radioiodine ( 131 I) therapy has been used for two decades as an effective and safe alternative to surgery in the treatment of symptomatic non-Toxic MNG. Since much higher activities of 131 I are employed when treating non-Toxic rather than Toxic MNG, there has been reluctance in many countries to use this treatment modality. Frequently, the 131 I -uptake in a non-Toxic MNG is low, which makes 131 I therapy less feasible. Another challenge is the negative correlation between the initial Goitre size and Goitre volume reduction (GVR). With its ability to more than double the thyroid 131 I-uptake, recombinant human TSH (rhTSH) increases the absorbed radiation dose and thus enhances the GVR by 35–56% at the expense of up to fivefold higher rate of permanent hypothyroidism. An alternative strategy is to reduce the administered 131 I-activity with a factor corresponding to the rhTSH induced increase in 131 I-uptake. Hereby, the extrathyroidal irradiation can be reduced without compromising efficacy. Thus, although in its infancy, and still experimental, rhTSH-augmented 131 I therapy may profoundly alter the non-surgical treatment of benign non-Toxic MNG.
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Radioiodine therapy in non-Toxic Multinodular Goitre. The possibility of effect-amplification with recombinant human TSH (rhTSH).
Acta oncologica (Stockholm Sweden), 2006Co-Authors: Steen Joop Bonnema, Viveque Egsgaard Nielsen, Laszlo HegedüsAbstract:There is no consensus regarding the optimum treatment of benign non-Toxic Goitre. L-thyroxine suppressive therapy is widely used, but there is poor evidence of its efficacy, and it may have serious adverse effects on health. Surgery is first choice in large Goitres or if malignancy is suspected. 131I therapy results in a one-year Goitre reduction of around 40% in Multinodular Goitres, usually with a high degree of patient satisfaction and improvement of the inspiratory capacity. The effect is attenuated with increasing Goitre size. The risk of hypothyroidism is 22–58% within 5–8 years. A sufficient thyroid 131I uptake is mandatory for 131I therapy to be feasible and pre-stimulation with recombinant human TSH (rhTSH) increases this considerably. This leads to an increased absorbed thyroid dose by approx.75%, mainly in those patients with the lowest thyroid 131I uptake, and a more homogeneous intrathyroidal isotope distribution. Pre-stimulation with even a small dose of rhTSH seems to allow a reduction of t...
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Differences between endocrine surgeons and endocrinologists in the management of non-Toxic Multinodular Goitre.
The British journal of surgery, 2003Co-Authors: M.c. Bhagat, Steen Joop Bonnema, Laszlo Hegedüs, Satvinder S. Dhaliwal, John P. WalshAbstract:Background: It is not known whether the management of Multinodular Goitre differs between endocrinologists and endocrine surgeons. Methods: A questionnaire containing a hypothetical case (a 42-year-old euthyroid woman with a 50–80-g Multinodular Goitre) and 11 variations on the case was sent to endocrinologists and endocrine surgeons in Australia. Results: The response rate was 55 per cent, including 45 endocrine surgeons and 127 endocrinologists. For the index case, serum thyroid-stimulating hormone (TSH), fine-needle aspiration biopsy and ultrasonography were widely used by both groups. Thyroid antibodies and scintigraphy were ordered by a greater proportion of endocrinologists than surgeons, and computed tomography more frequently by surgeons than endocrinologists. Treatment recommendations differed significantly between specialties for the index case (endocrinologists: no treatment 65 per cent, thyroxine 22 per cent, surgery 10 per cent, radioiodine 3 per cent; surgeons: no treatment 67 per cent, thyroxine 2 per cent, surgery 31 per cent; P < 0·001) and for seven of the variations. In particular, for a patient with suppressed TSH, most endocrinologists (60 per cent) recommended radioiodine treatment, whereas there was no consensus among surgeons (surgery 40 per cent, no treatment 36 per cent, radioiodine 21 per cent). For a patient with a partly intrathoracic Goitre, most surgeons (88 per cent) recommended surgery, whereas there was no consensus among endocrinologists (surgery 45 per cent, no treatment 34 per cent, thyroxine treatment 13 per cent, radioiodine 8 per cent). Conclusion: There are clinically significant differences between endocrine surgeons and endocrinologists in the management of Multinodular Goitre. Copyright © 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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danish endocrinologists examination and treatment of non Toxic Multinodular goiter a questionnaire study
Ugeskrift for Læger, 2001Co-Authors: Steen Joop Bonnema, Finn Noe Bennedbaek, Laszlo HegedüsAbstract:AIM To assess the attitudes towards the management of the non-Toxic Multinodular Goitre by means of a questionnaire concerning on case history, which was circulated to all Danish endocrinologists ("A 42-year-old woman with an irregular, non-tender, bilaterally enlarged thyroid of 50-80 g and no clinical suspicion of malignancy"). DESIGN Eleven variations of the (basic) case report were proposed in order to evaluate the impact on the management of each alteration. In the index case, serum TSH was the routine choice of 100%, serum T4/free T4-index and T3/free T3-index were measured by 83% and 79%, serum TPOab and serum calcitonin by 49% and 4%, respectively. RESULTS The median number of blood tests was three (range 1-7). Thyroid scintigraphy was used by 96% and ultrasound by 94%, both methods were employed by 90% with scintigraphy most often having the first priority. Fine-needle aspiration biopsy was not routinely used, unless a scintigraphically dominant "cold" area was present; 70% used ultrasound guidance. Radioiodine was the preferred treatment of 51%, surgery 7%, L-T4 4%, and no treatment 38%. DISCUSSION In the case of young patients or factors predisposing to thyroid cancer, treatment preferences changed to surgery. The prevailing use of radioiodine in Denmark contrasts with the situation in most other European countries, but Danish endocrinologists also disagree about the optimum management of Multinodular non-Toxic Goitre.
M. R. Pelizzo - One of the best experts on this subject based on the ideXlab platform.
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Prevalence of activating thyrotropin receptor and Gsα gene mutations in paediatric thyroid Toxic adenomas: a multicentric Italian study
Clinical Endocrinology, 2013Co-Authors: P. Agretti, M. Segni, G. De Marco, E. Ferrarini, C. Di Cosmo, A. Corrias, G. Weber, D. Larizza, V. Calcaterra, M. R. PelizzoAbstract:Toxic thyroid adenomas or functioning nodules are rare in children\ud and adolescents, representing less than 3% of all causes of\ud hyperthyroidism.1 Somatic gain-of-function mutations of the\ud TSHr gene (accession number NM_00369) have been identified\ud as a cause of Toxic thyroid adenomas and functioning nodules of\ud Toxic Multinodular Goitre in the adult.2 In patients with Toxic\ud thyroid adenomas coming from an area of iodine deficiency,\ud activating somatic mutations in the TSHr gene have been\ud detected in up to 80% and in the Gsa gene up to 25%, suggesting\ud that these genetic anomalies may play a role in the pathogenesis\ud of functioning nodules in adults. In contrast, the\ud incidence of gain-of-function somatic mutations of the TSHr or\ud Gsa genes in rare Toxic thyroid adenoma in the paediatric population\ud is poorly understood.3 In this study, we searched for\ud somatic mutations of TSHr and Gsa genes in a group of nine\ud children affected by Toxic thyroid adenomas or functioning\ud nodules that had undergone surgery
Carsten Kirkegaard - One of the best experts on this subject based on the ideXlab platform.
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Serum TSH and the response to radioiodine treatment of Toxic Multinodular Goitre
2015Co-Authors: Ulrik Pedersen-bjergaard, Carsten KirkegaardAbstract:A retrospective analysis of data from 73 consecutive patients with Toxic Multinodular Goitre treated with iodine-131 (131I) during a 2-year period was performed to investigate if serum TSH at the time of 131I treatment influences the outcome. The dose of 131I was calculated according to a model compensating for thyroid size estimated by palpation and 24-h 131I uptake. Serum TSH was determined by a third-generation assay with a functional sensitivity of 0.03 mU/l. A significantly more pronounced response to 131I treatment was observed in patients with TSH> 0.0 mU/l than in patients with TSH=0.0 mU/l (P 0.0006). This difference resulted in a threefold lower frequency of non-responders and a fivefold higher rate of early hypothyroidism in the group with detectable serum TSH. While the high frequency of hypothyroidism among patients with measurable serum TSH can be explained by destruction of normal thyroid tissue, the high frequency of treatment failure in the group with serum TSH 0.0 mU/l suggests that autonomous thyroid tissue may also be sensitized to a deleterious effect of 131I through stimulation by TSH. We conclude that serum TSH has a significant influence on the outcome of 131I treatment of Toxic Multinodular Goitre. The results of 131I treatment may be improved by adjustment of the dose of 131I according to the serum TSH level, in addition to adjustment for Goitre size and 24-h 131I uptake. European Journal of Endocrinology 137 365–36
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Serum TSH and the response to radioiodine treatment of Toxic Multinodular Goitre
European journal of endocrinology, 1997Co-Authors: Ulrik Pedersen-bjergaard, Carsten KirkegaardAbstract:A retrospective analysis of data from 73 consecutive patients with Toxic Multinodular Goitre treated with iodine-131 ( 131 I) during a 2-year period was performed to investigate if serum TSH at the time of 131 I treatment influences the outcome. The dose of 131 I was calculated according to a model compensating for thyroid size estimated by palpation and 24-h 131 I uptake. Serum TSH was determined by a third-generation assay with a functional sensitivity of 0.03 mU/l. A significantly more pronounced response to 131 I treatment was observed in patients with TSH > 0.0 mU/l than in patients with TSH=0.0 mU/l (P o 0.0006). This difference resulted in a threefold lower frequency of non-responders and a fivefold higher rate of early hypothyroidism in the group with detectable serum TSH. While the high frequency of hypothyroidism among patients with measurable serum TSH can be explained by destruction of normal thyroid tissue, the high frequency of treatment failure in the group with serum TSH o 0.0 mU/l suggests that autonomous thyroid tissue may also be sensitized to a deleterious effect of 131 I through stimulation by TSH. We conclude that serum TSH has a significant influence on the outcome of 131 I treatment of Toxic Multinodular Goitre. The results of 131 I treatment may be improved by adjustment of the dose of 131 I according to the serum TSH level, in addition to adjustment for Goitre size and 24-h 131 I uptake.
