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Rapid restoration of bone mass after surgical management of hyperthyroidism: A prospective case control study in Southern India.
Karunakaran, P, Maharajan, C, Mohamed, KN, Rachamadugu, SV
Surgery. 2016;(3):771-6
Abstract
CONTEXT The rate and the extent of bone remineralization at cancellous versus cortical sites after treatment of hyperthyroidism is unclear. Few studies have examined the effect of operative management of hyperthyroidism on recovery of bone mass. OBJECTIVE To evaluate prospectively the bone mineral density (BMD), bone mineral content (BMC), and bone areal size at the spine, hip, and forearm before and after total thyroidectomy. DESIGN AND SETTING A prospective case control observational study from August 2011 to July 2014 in a single center. PARTICIPANTS This study evaluated 40 overt hyperthyroid patients and 31 age-matched euthyroid controls who were operative candidates. MAIN OUTCOME MEASURES Bone indices were measured at baseline and 6-month postoperatively using dual energy x-ray absorptiometry. Serum levels of alkaline phosphatase and 25-hydroxy vitamin D3 (25OHD) were assessed. RESULTS Baseline BMD of hyperthyroid subjects at the spine, hip, and forearm were less than euthyroid controls (P = .001) with concomitant increases in serum alkaline phosphatase (mean ± SD, 143 ± 72 vs 72 ± 23 IU/L control; P < .001). The 25OHD level was 24.3 ± 10.6 and 26.1 ± 14.6 ng/mL in patients and controls, respectively. Among hyperthyroid patients, posttreatment BMD expressed as g/cm(2) were 0.97 ± 0.12 (vs pretreatment 0.91 ± 0.14; P = .001) at the spine, 0.87 ± 0.12 (vs pretreatment 0.80 ± 0.13; P = .001) at the hip, and 0.67 ± 0.09 (vs pretreatment 0.64 ± 0.11; P = .191) at the forearm. The percent change in BMD was greatest at spine (8.3%) followed by the hip (7.6%) and forearm (3.0%). CONCLUSION Operative management with total thyroidectomy improved the bone loss associated with hyperthyroidism as early as 6 months postoperatively at the hip and spine despite concomitant vitamin D deficiency. Delayed recovery of bone indices at the forearm, a cortical bone, requires further long-term evaluation.
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Terminal ligature of inferior thyroid artery branches during total thyroidectomy for multinodular goiter is associated with higher postoperative calcium and PTH levels.
Cocchiara, G, Cajozzo, M, Amato, G, Mularo, A, Agrusa, A, Romano, G
Journal of visceral surgery. 2010;(5):e329-32
Abstract
PURPOSE To evaluate the impact of truncal versus terminal branch ligature of the inferior thyroid artery (ITA) on postoperative calcium and PTH plasma levels in patients undergoing total thyroidectomy for multinodular goiter. METHODS A prospective randomized study was performed comparing a group of patients that underwent either truncal ligature of the ITA (group 1) or terminal ligature of ITA branches (group 2). RESULTS A series of 126 consecutive patients with non-toxic euthyroid multinodular goiter underwent total thyroidectomy. Truncal ligature of the ITA was performed in 63 patients (group 1) and terminal branch ITA ligature in 63 patients (group 2). Postoperative ionized serum calcium (mmol/L) at 24 hours was significantly lower in group 1 than in group 2 patients (1.22 ± 0.06 vs. 1.25 ± 0.05, P<0.05) and at 48 hours (1.20 ± 0.05 vs. 1.23 ± 0.05, P<0.05). Mean postoperative PTH levels (pg/mL) at 4 hours after thyroidectomy were significantly lower in group 1 than in group 2 patients (22.32 ± 11.64 vs. 25.82 ± 12.87, P=0.044). Mean hospital stay (hours) was higher in group 1 than in group 2 patients (87.47 ± 41.04 vs. 70.34 ± 24.82, P<0.05). CONCLUSION This study shows that terminal ligature of ITA branches during total thyroidectomy for multinodular goiter is associated with higher mean postoperative calcium and PTH levels, and shorter hospital stay. However, no significant difference in terms of permanent hypoparathyroidism was observed between the two groups.
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3.
Surgery and radioablation therapy combined: introducing a 1-week-condensed procedure bonding total thyroidectomy and radioablation therapy with recombinant human TSH.
Emmanouilidis, N, Müller, JA, Jäger, MD, Kaaden, S, Helfritz, FA, Güner, Z, Kespohl, H, Knitsch, W, Knapp, WH, Klempnauer, J, et al
European journal of endocrinology. 2009;(5):763-9
Abstract
OBJECTIVE The objective of this study was to determine whether the use of recombinant human TSH (rhTSH) to stimulate radioiodine uptake after thyroidectomy is as efficacious as a period of withholding thyroid hormones, while at the same time avoiding hypothyroidism, reducing sick leave time and shortening the hospital stay. DESIGN Our aim was to compare the standard procedure of differentiated thyroid cancer treatment, which consists of thyroidectomy followed by 4 weeks of hypothyroidism and a conclusive ablative activity of (131)iodine, with a new shortened treatment in which l-thyroxine (T(4)) medication is initiated a day after thyroidectomy, followed by application of rhTSH stimulation and subsequent ablation a few days after surgery. We presumed our treatment to represent the most sophisticated strategy for the reduction in sick leave days overall without any reduction in safety or the efficacy of ablative therapy. METHODS Patients (n=25) were randomized either for surgery and rhTSH stimulation or surgery and l-T(4) abstinence before the first application of radioiodine. Ablation success was determined by neck ultrasound and serum thyroglobulin during follow-up. RhTSH receivers were monitored for an average of 635 days (s.d.+/-289) and patients in l-T(4) abstinence for an average of 624 days (s.d.+/-205). Both groups were statistically compared for significant differences in treatment efficacy, safety and overall time of sick leave. RESULTS AND CONCLUSIONS Our shortened treatment proved to be equally efficacious and safe in comparison with the conventional therapy regimen. At the same time, it showed economic advantages through the reduction in average sick leave time from approximately 29 days (l-T(4) abstinence) down to approximately 6 days (rhTSH stimulation) as well as sustaining the patient's quality of life by the complete avoidance of hypothyroidism.
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High-calcium mineral water as a calcium supplementing measure for post-thyroidectomy hypocalcemia.
Coiro, V, Zanardi, G, Saccani Jotti, G, Rubino, P, Manfredi, G, Chiodera, P
Minerva endocrinologica. 2008;(1):7-13
Abstract
AIM: The aim of this study was to test the possibility of enhancing blood calcium levels in totally thyroidectomized patients by supplementation with 1 L/d carbonate-bicarbonate-high-calcium mineral water. METHODS This study enrolled 95 outpatients, totally thyroidectomized four months earlier, and hence treated with oral calcium and vitamin-D. At recruitment, ionized blood calcium was either below (Group A; N. 55) or above (Group B; N. 40, randomly divided in Group B1 [N. 20] and Group B2 [N.20]) the lower limit of the normal range (1.12 mmol/L). For one month, Group A was treated with 1 L/d high-calcium (483 mg/L) mineral water and continued the usual therapy with Ca and vitamin-D. In contrast, Group B1 and Group B2 substituted their Ca and vitamin-D therapy with 1 L/d high-calcium mineral water (Group B1) or 1 L/d of placebo mineral water (Ca:80 mg/L) (Group B2). RESULTS After one month, a significant 7.5% increase in blood ionized-calcium levels was observed in Group A, no change in Group B1 and a significant drop below normality in Group B2 (Group B2 vs Group B1, P<0.001). Thereafter, 1 L/d of the high-calcium mineral water, given to Group B2 instead of placebo for an additional month, significantly enhanced ionized-calcium levels above the lower limit of normality (Group B2 vs Group B1, NS). CONCLUSION These experiments show that calcium supplementation as 1 L/d of a high-calcium mineral water may efficaciously enhance blood calcium levels in thyroidectomized patients. This complementary treatment might at least in part contribute to the prevention and/or treatment of hypocalcemia and substitute vitamin-D and calcium therapies after thyroidectomy.
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Routine oral calcium and vitamin D supplements for prevention of hypocalcemia after total thyroidectomy.
Roh, JL, Park, CI
American journal of surgery. 2006;(5):675-8
Abstract
BACKGROUND The purpose of this study was to evaluate the clinical usefulness of routine oral calcium and vitamin D supplements in the prevention of hypocalcemia after total thyroidectomy. METHODS Ninety patients who underwent total thyroidectomy were randomly assigned to routinely receive or not receive a supplement containing oral calcium (3 g/d) and vitamin D (1 g/d) for 2 weeks. Hypocalcemic signs and symptoms, serum calcium, and parathyroid hormone (PTH) levels were monitored and compared between the 2 groups. RESULTS The incidences of symptomatic and laboratory hypocalcemia were significantly lower in the oral calcium/vitamin D group than in the group not receiving the supplement: 3 of 45 patients (7%) versus 11 of 45 (24%) and 6 of 45 (13%) versus 16 of 45 (36%), respectively (P < or = .02). The hypocalcemic symptoms were minimal in the supplement group but more severe in the group not receiving the supplement. Serum calcium levels decreased in both groups after surgery but recovered earlier in the supplement group. No hypercalcemia or PTH inhibition developed in the supplement group. CONCLUSION Routine administration of a supplement containing oral calcium and vitamin D is effective in reducing the incidence and severity of hypocalcemia after total thyroidectomy.
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A prospective clinical trial to assess the efficacy of radioiodine ablation as an alternative to completion thyroidectomy in patients with differentiated thyroid cancer undergoing sub-total thyroidectomy.
Bal, CS, Kumar, A, Chandra, P, Dwivedi, SN, Pant, GS
Acta oncologica (Stockholm, Sweden). 2006;(8):1067-72
Abstract
We conducted a prospective clinical trial to evaluate whether radioiodine ablation can be an effective alternative to completion thyroidectomy in patients undergoing sub-total thyroidectomy and if yes, the optimum activity of 131I and frequency of ablation. A total of 85 patients (F--63; M--22) with mean age of 37.9+/-12.3 years were recruited in this study. The pre-ablation mean 24 hour radioiodine neck uptake, effective half-life, residual thyroid tissue weight and TSH values were 13.9+/-8.5%, 4.5+/-0.9 days, 9.6+/-3.6 g and 11.7+/-6.4 microIU/ml, respectively. Thyroid tissue was completely ablated in 50 patients (58.8%, 95% CI:50-68%) after mean 1st administered activity of 32.3+/-10.7 mCi of 131I and the cumulative ablation rate was 91.8% after two doses of 131I. During mean follow-up duration of 49 months no local/distant recurrence has been observed so far in this cohort. It appears that radioiodine ablation may be an attractive alternative to completion thyroidectomy and an activity as low as 35 mCi may achieve reasonable ablation.
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The advantage of total thyroidectomy to avoid reoperation for incidental thyroid cancer in multinodular goiter.
Giles, Y, Boztepe, H, Terzioglu, T, Tezelman, S
Archives of surgery (Chicago, Ill. : 1960). 2004;(2):179-82
Abstract
HYPOTHESIS To investigate the impact of total thyroidectomy on the rate of completion thyroidectomy for incidentally found thyroid cancer in euthyroid multinodular goiter. DESIGN A randomized, prospective clinical trial. SETTING A tertiary referral center. PATIENTS Patients with euthyroid multinodular goiter without any preoperative suspicion of malignancy, history of familial thyroid cancer, or previous exposure to radiation were randomized (according to a random table) to total or near-total thyroidectomy leaving no remnant tissue or less than 1 g (group 1; n = 109) or bilateral subtotal thyroidectomy leaving 5 g or more of remnant tissue (group 2; n = 109). Patients with preoperative or perioperative suspicion of malignancy were excluded. MAIN OUTCOME MEASURES We compared the complication rates and the incidence of thyroid cancer requiring radioactive iodine ablation and completion thyroidectomy between groups. RESULTS There were no permanent complications. The rates of temporary unilateral vocal cord dysfunction and hypoparathyroidism showed no significant difference between groups 1 and 2 (0.9% vs 0.9% and 1.8% vs 0.9%, respectively; P>.05). Papillary cancer was found in 10 group 1 patients (9.2%) and 8 group 2 patients (7.3%) (P =.80). Of the 9 patients requiring radioactive iodine ablation, reoperation was avoided in 5 group 1 patients; the remaining 4 group 2 patients underwent completion thyroidectomy (P =.007). CONCLUSION We recommend total or near-total thyroidectomy in multinodular goiter to eliminate the necessity for early completion thyroidectomy in case of a final diagnosis of thyroid cancer.
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Radioiodine lobar ablation as an alternative to completion thyroidectomy in patients with differentiated thyroid cancer.
Bal, CS, Kumar, A, Pant, GS
Nuclear medicine communications. 2003;(2):203-8
Abstract
This study seeks to evaluate the role of radioiodine in the ablation of the remaining thyroid lobe, following a histopathological diagnosis of minimally invasive follicular carcinoma or papillary carcinoma of > or =1.5 cm size in patients undergoing hemithyroidectomy. There were 93 patients (69 females and 24 males) with an average age of 37.3+/-12.5 years (range, 16-70 years) and a mean follow-up duration of 46 months. Sixty-six of the patients had papillary cancer and remaining 27 had follicular thyroid cancer. The mean 24 h radioiodine neck uptake at the first visit was 17.2+/-7.3% (4.4-34%). In view of the large amount of thyroid tissue to be ablated, which may produce radiation induced thyroiditis, low doses of radioiodine (15-60 mCi) were administered to the patients. The patients were evaluated 6 months after radioiodine therapy with a 131I whole-body scan and 48 h radioiodine neck uptake, and a thyroglobulin assay after 4-6 weeks of levothyroxine withdrawal. The thyroid lobe was completely ablated in 53 patients (56.9%) after one dose of I and the remaining patients had partial thyroid ablation, with the mean radioiodine neck uptake being reduced to 3.1+/-2.4%. The mean first dose of 131I was 31.8+/-11.7 mCi; the estimated mean absorbed dose was 251.3+/-149.3 Gy (range, 120-790 Gy). Around 30% patients, in each of whom a remnant thyroid lobe was ablated with a single dose of radioiodine, received < or =200 Gy. The cumulative ablation rate was 92.1% after two doses of 131I. Only seven patients needed a third dose of 131I. In our cohort, 15 patients (16.1%) complained of throat discomfort and neck pain. All of them were managed with mild analgesics except three patients who needed additional oral prednisolone for 7-10 days to overcome neck oedema. We conclude that, although completion thyroidectomy remains the standard treatment after hemithyroidectomy in cases of differentiated thyroid cancer, radioiodine ablation of an intact thyroid lobe is possible and it can be achieved with much smaller doses of radioiodine than previously believed. Lobar ablation is an attractive alternative to surgery for those who refuse to undergo completion thyroidectomy or had complications during initial surgery. However, the long-term outcome in this subset of patients remains to be determined.