1. 1. Dr. Trevor Angell of the Division of Endocrinology, Diabetes, and Hypertension at Brigham and Women’s Hospital and Harvard Medical School, in Boston, Massachusetts, will present a study called “Xpression Atlas Findings in the Genomic Sequencing Classifier (GSC) Clinical Validation Cohort.”

      The GSC used in this study classifies cytologically indeterminate thyroid nodules as either benign (B) or suspicious (S). The ability to detect genomic variants and fusions was recently expanded by the Xpression Atlas (XA), which identifies 761 nucleotide variants and 130 fusion gene pairs in 511 genes. In this study, researchers used XA to analyze the mutational spectrum of 190 nodules classified with standard histologic diagnoses (using microscopic studies of the tissues) as belonging to categories III and IV in the Bethesda System for Reporting Thyroid Cytopathology (BSRTC). The conclusion was that GSC is better than XA for ruling out cancers, while the two used together may provide additional insights into pathway activation and potential cancer treatment targets.

1. 1. Another study involving XA will be presented by Dr. Allan C. Golding of the Memorial Center for Integrative Endocrine Surgery in Hollywood, Florida. Titled “Xpression Atlas Variants and Fusions Found Among 4,742 Thyroid Nodules,” the study involved reanalyzing all clinical samples with complete XA profiles from July 2017 to April 3, 2018.

      Overall, fusions were detected less frequently than variants across all BSRTC categories. This analysis supported excluding XA reporting among GSC-benign nodules. However, markedly different genomic insights were found between cohorts at increased risk of cancer, specifically, those in categories III through VI of the BSRTC. Together, the GSC and XA contribute substantial genomic content to advance preoperative risk stratification.

1. 1. In a presentation by Dr. Christine Cherella of Boston Children’s Hospital (BCH), attendees will learn how “Malignancy Rates of Thyroid Nodules Differ Between Children and Adults Within Indeterminate Cytopathological Categories.” Thyroid nodules are more common in older individuals but are more likely to be malignant in younger ones. Although the BSRTC is widely used to interpret fine-needle aspiration (FNA) cytology, it is unclear whether BSRTC diagnostic categories suggest the same risk of malignancy in younger versus older patients.

      Researchers evaluated all consecutive patients who underwent FNA of a thyroid nodule ≥1 cm in diameter, at the BCH and the Brigham and Women’s Hospital between 1998 and 2016. They found that, in children and adults with clinically relevant thyroid nodules, malignancy rates differ within indeterminate BSRTC categories defined by similar morphologic features. This finding likely reflects true differences in nodule biology rather than variations in cytological classification.

1. 1. Dr. Yu-kun Luo of the Ultrasound Department, General Hospital of Chinese PLA, Beijing, China, will present a study titled “Artificial Intelligence-Assisted Ultrasound Diagnosis for Thyroid Nodules.” Due to uneven development of medical resources, diagnostic accuracy for thyroid nodules varies greatly. The aim of this study was to explore a novel AI-assisted ultrasound diagnostic system to improve the efficiency and accuracy of thyroid nodule diagnosis.

      To test the accuracy of the new system, 500 pathologically confirmed thyroid nodules were selected, including 208 benign and 292 malignant ones. The images of all nodules, acquired from 10 different types of ultrasound equipment, were dynamically stored in the form of consecutively longitudinal and transverse sections. The AI-assisted diagnostic system recognized and analyzed the features of the images and offered recommendations for diagnosis. The diagnostic accuracy of the system was then compared with that of junior and senior physicians. Results showed the diagnostic accuracy of the AI system alone was higher than that of junior physicians (77.6% vs. 70.5%); however, accuracy could reach 92.4% when junior physicians were assisted by the new AI system—higher than the accuracy of senior physicians (85.6%) unassisted by the system. For nodules of different sizes, testing showed no significant difference in diagnostic accuracy among the three groups.

1. 1. Another presentation will be given by Dr. Mingbo Zhang of the same department in Beijing’s General Hospital. Dr. Mingbo will describe a “Randomized controlled clinical trial of ethanol-sensitized radiofrequency ablation (RFA) for benign solid thyroid nodules” that took place between June 2016 and February 2018. While solid thyroid nodules are good candidates for RFA surgery, they often require high power and energy, which increase the incidence of complications. This study used ethanol as a sensitizer before RFA to explore whether that could achieve a safer, faster, and more effective result.

      Seventy-two patients with 84 nodules among them were enrolled in the study group and in a conventional RFA group, respectively, each with 42 nodules. The researchers concluded that ethanol can significantly improve the efficiency of RFA, reduce the time and energy of the ablation, and reduce the occurrence of complications.

1. In a presentation titled “Efficacy and Safety of Thermal Ablation of 200 Benign Thyroid Nodules: Comparison of Three Techniques (Radiofrequency, Laser, High Intensity Focused Ultrasound),” Dr. Adrien Ben Hamou of the Endocrinology Department at the University Hospital in Lille, France, will describe a bicentric retrospective study conducted between October 2013 and January 2018.

   The aim was to compare the three ablation methods for treating benign thyroid nodules. Two hundred nodules were treated in 176 patients with benign histology or cytology, all of whom refused surgery. Clinical, biological, and ultrasound evaluation was performed before treatment. Researchers compared variations in volume and symptoms as well as side effects at 6 weeks and 12 months after treatment. Volume reduction between radiofrequency (RFA) and laser (LA) ablation was significantly different at 6 weeks but not at 12 months. After adjustments, no significant difference was observed at either 6 weeks or 12 months between RFA and high-intensity focused ultrasound (HIFU) or between LA and HIFU. Clinical symptoms were reduced in all three groups. Very few transient but potentially serious side effects were reported, the causes of which should be analyzed.

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 The American Thyroid Association (ATA) is the leading worldwide organization dedicated to the advancement, understanding, prevention, diagnosis, and treatment of thyroid disorders and thyroid cancer. ATA is an international membership medical society with over 1,700 members from 43 countries around the world. Celebrating its 95^th anniversary, the ATA continues to deliver its mission of being devoted to thyroid biology and to the prevention and treatment of thyroid disease through excellence in research, clinical care, education, and public health.  These efforts are carried out via several key endeavors:

• The publication of the highly regarded professional journals Thyroid, Clinical Thyroidology, and VideoEndocrinology
• Annual scientific meetings
  
• Biennial clinical and research symposia
  
• Research grant programs for young investigators
  
• Support of online professional, public, and patient educational programs
  
• Development of guidelines for clinical management of thyroid disease and thyroid cancer

 The ATA promotes thyroid awareness and information online through Clinical Thyroidology for the Public and extensive, authoritative explanations of thyroid disease and thyroid cancer in both English and Spanish. The ATA website serves as the clinical resource for patients and the public who look for reliable information on the Internet. Every fifth year, the American Thyroid Association joins with the Latin American Thyroid Society, the European Thyroid Association, and the Asia and Oceania Thyroid Association to cosponsor the International Thyroid Congress (ITC).

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We will continue to monitor this situation and provide further information as it becomes available.

Pfizer Customer Letter (PDF File, 664 KB)

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What is the thyroid gland?

The thyroid gland is a butterfly-shaped endocrine gland that is normally located in the lower front of the neck. The thyroid’s job is to make thyroid hormones, which are secreted into the blood and then carried to every tissue in the body. Thyroid hormone helps the body use energy, stay warm and keep the brain, heart, muscles, and other organs working as they should.

What are the symptoms of a goiter?

The term “goiter” simply refers to the abnormal enlargement of the thyroid gland. It is important to know that the presence of a goiter does not necessarily mean that the thyroid gland is malfunctioning. A goiter can occur in a gland that is producing too much hormone (hyperthyroidism), too little hormone (hypothyroidism), or the correct amount of hormone (euthyroidism). A goiter indicates there is a condition present which is causing the thyroid to grow abnormally.

What causes a goiter?

One of the most common causes of goiter formation worldwide is iodine deficiency. While this was a very frequent cause of goiter in the United States many years ago, it is no longer commonly observed. The primary activity of the thyroid gland is to concentrate iodine from the blood to make thyroid hormone. The gland cannot make enough thyroid hormone if it does not have enough iodine. Therefore, with iodine deficiency the individual will become hypothyroid. Consequently, the pituitary gland in the brain senses the thyroid hormone level is too low and sends a signal to the thyroid. This signal is called thyroid stimulating hormone (TSH). As the name implies, this hormone stimulates the thyroid to produce thyroid hormone and to grow in size. This abnormal growth in size produces what is termed a “goiter.” Thus, iodine deficiency is one cause of goiter development. Wherever iodine deficiency is common, goiter will be common. It remains a common cause of goiters in other parts of the world.

Hashimoto’s thyroiditis is a more common cause of goiter formation in the US. This is an autoimmune condition in which there is destruction of the thyroid gland by one’s own immune system. As the gland becomes more damaged, it is less able to make adequate supplies of thyroid hormone. The pituitary gland senses a low thyroid hormone level and secretes more TSH to stimulate the thyroid. This stimulation causes the thyroid to grow, which may produce a goiter.

Another common cause of goiter is Graves’ disease. In this case, one’s immune system produces a protein, called thyroid stimulating immunoglobulin (TSI). As with TSH, TSI stimulates the thyroid gland to enlarge producing a goiter. However, TSI also stimulates the thyroid to make too much thyroid hormone (causes hyperthyroidism). Since the pituitary senses too much thyroid hormone, it stops secreting TSH. In spite of this the thyroid gland continues to grow and make thyroid hormone. Therefore, Graves’ disease produces a goiter and hyperthyroidism.

Multinodular goiters are another common cause of goiters. Individuals with this disorder have one or more nodules within the gland which cause thyroid enlargement. This is often detected as a nodular feeling gland on physical exam. Patients can present with a single large nodule or with multiple smaller nodules in the gland when first detected (see Thyroid Nodule brochure). Thus, in early stages of a multinodular goiter with many small nodules, the overall size of the thyroid may not be enlarged yet. Unlike the other goiters discussed, the cause of this type of goiter is not well understood.

In addition to the common causes of goiter, there are many other less common causes. Some of these are due to genetic defects, others are related to injury or infections in the thyroid, and some are due to tumors (both cancerous and benign tumors).

How do you diagnose a Goiter?

As mentioned earlier, the diagnosis of a goiter is usually made at the time of a physical examination when an enlargement of the thyroid is found. However, the presence of a goiter indicates there is an abnormality of the thyroid gland. Therefore, it is important to determine the cause of the goiter. As a first step, you will likely have thyroid function tests to determine if your thyroid is underactive or overactive (see Thyroid Function Tests brochure). Any subsequent tests performed will be dependent upon the results of the thyroid function tests.

If the thyroid is diffusely enlarged and you are hyperthyroid, your doctor will likely proceed with tests to help diagnose Graves’ Disease (see Graves’ Disease brochure). If you are hypothyroid, you may have Hashimoto’s Thyroiditis (see Hypothyroidism brochure) and you may get additional blood tests to confirm this diagnosis. Other tests used to help diagnose the cause of the goiter may include a radioactive iodine scan, thyroid ultrasound, or a fine needle aspiration biopsy (see Thyroid Nodule brochure).

How is a goiter treated?

The treatment will depend upon the cause of the goiter. If the goiter was due to a deficiency of iodine in the diet (not common in the United States), you will be given iodine supplementation given in preparations to take by mouth. This will lead to a reduction in the size of the goiter, but often the goiter will not completely resolve.

If the goiter is due to Hashimoto’s Thyroiditis, and you are hypothyroid, you will be given thyroid hormone supplement as a daily pill. This treatment will restore your thyroid hormone levels to normal, but does not usually make the goiter go completely away. While the goiter may get smaller, sometimes there is too much scar tissue in the gland to allow it to get much smaller. However, thyroid hormone treatment will usually prevent it from getting any larger. Although appropriate in some individuals, surgery is usually not routine treatment of thyroiditis.

If the goiter is due to hyperthyroidism, the treatment will depend upon the cause of the hyperthyroidism (see Hyperthyroidism and Graves’ disease brochures). For some causes of hyperthyroidism, the treatment may lead to a disappearance of the goiter. For example, treatment of Graves’ disease with radioactive iodine usually leads to a decrease or disappearance of the goiter.

Many goiters, such as the multinodular goiter, are associated with normal levels of thyroid hormone in the blood. These goiters usually do not require any specific treatment after the appropriate diagnosis is made. If no specific treatment is suggested, you may be warned that you are at risk for becoming hypothyroid or hyperthyroid in the future. However, if there are problems associated with the size of the thyroid per se, such as the goiter getting so large that it constricts the airway, your doctor may suggest that the goiter be treated by surgical removal.

Whatever the cause, it is important to have regular (annual) monitoring when diagnosed with a goiter.

Further Information

Further details on this and other thyroid-related topics are available in the patient information section on the American Thyroid Association^® website at www.thyroid.org.

Goiter Brochure for Saving and Printing (PDF File, 390 KB)

Goiter Brochure for Saving and Printing (PDF File, 156 KB)

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Graves’ disease (GD) is the most common form of thyrotoxicosis in North America and affects 1-2% of the population. Other causes of thyrotoxicosis, characterized by excessively high levels of thyroid hormone in the blood, include toxic multinodular goiter (TMG)—which is more common in Europe—autonomous thyroid nodular disease, and gestational thyrotoxicosis, which occurs during pregnancy.

A task force representing the ATA and AACE reviewed the medical literature and current standards of care and developed new guidelines that include recommendations for the following: initial evaluation and management of thyrotoxicosis; treatment of GD using radioactive iodine, antithyroid drugs, or surgery; management of GD in children, adolescents, and pregnant women; and subclinical hyperthyroidism. The lead author of the guidelines is Task Force Chair Rebecca Bahn, MD, Mayo Clinic, Rochester, MN.

“These guidelines combine the vast experience of the expert panel with the latest scientific literature and provide practical guidance for the clinician managing patients with hyperthyroidism,” says Gregory A. Brent, MD, Professor of Medicine and Physiology, David Geffen School of Medicine at the University of California Los Angeles and President of the ATA.

A related Editorial in this issue of Thyroid by Elizabeth Pearce, MD, MSc (ATA Board of Directors and Boston University School of Medicine) and colleagues highlights the key features and shortcomings of the new guidelines, noting that they are more comprehensive and more modern in format—providing levels of evidence to support individual recommendations—than previous versions.

Geraldo Medeiros-Neto, MD (Executive Council, Latin American Thyroid Society and Senior Professor, University of São Paulo Medical School, Brazil), and coauthors of another Editorial accompanying the guidelines highlight recommendations developed and accepted equally by members of the task force from America and from Europe.

As the prevalence of thyrotoxicosis and its various forms and causes vary across the globe, as do preferred methods of therapy and patient management, this issue of Thyroid also includes an article by George Kahaly, MD, PhD (European Thyroid Association and Gutenberg University Medical Center, Mainz, Germany) and coauthors that presents a European perspective on the new guidelines, and Shunichi Yamashita, MD (Member of the council of the Asia & Oceania Thyroid Association, and Director, Atomic Bomb Disease Institute, Nagasaki University Graduate School of Biomedical Sciences, Japan), providing several expert viewpoints from Japan and Korea.

“Hyperthyroidism affects both genders and people of all ages. These state-of-the-art guidelines highlight treatments and practices that improve patient outcomes. Clinicians that follow these guidelines are likely to immediately improve the care of their patients,” says Richard T. Kloos, MD, Professor, The Ohio State University and Secretary/Chief Operating Officer of the ATA.

Thyroid, the Official Journal of the American Thyroid Association is an authoritative peer-reviewed journal published monthly in print and online. The Journal publishes original articles and timely reviews that reflect the rapidly advancing changes in our understanding of thyroid physiology and pathology, from the molecular biology of the cell to clinical management of thyroid disorders. A complete table of contents and free sample issue may be viewed online.

The American Thyroid Association (ATA) is the leading worldwide organization dedicated to the advancement, understanding, prevention, diagnosis, and treatment of thyroid disorders and thyroid cancer. ATA is an international membership medical society with over 1,400 members from 43 countries around the world. Celebrating its 88th anniversary, ATA delivers its mission through several key endeavors: the publication of highly regarded monthly journals, Thyroid, Clinical Thyroidology and Clinical Thyroidology for Patients; annual scientific meetings; biennial clinical and research symposia; research grant programs for young investigators, support of online professional, public, and patient educational programs; and the development of guidelines for clinical management of thyroid disease. The ATA has extensive online information at their website on thyroid disease for patients in both English and Spanish and serves as the clinical resource for patients and the public who look for reliable information on the Internet.

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