ABSTRACT Objective: Mutations in DICER1 are found in differentiated thyroid carcinoma (DTC) and in multinodular goiter (MNG) at a younger age with other tumors, which characterizes DICER1 syndrome. DICER1 is one driver to DTC; however, it is also found in benign nodules. We speculated that patients with mutations in DICER1 may present long-lasting MNG. Our aim was to investigate the frequency of DICER1 variants in patients with MNG. Subjects and methods: Patients who submitted to total thyroidectomy due to large MNG with symptoms were evaluated. DICER1 hotspots were sequenced from thyroid nodule samples. To confirm somatic mutation, DNA from peripheral blood was also analyzed. Results: Among 715 patients, 154 were evaluated with 56.2 ± 12.3 years old (28-79) and the thyroid volume was 115.7 ± 108 mL (16.2-730). We found 11% with six DICER1 variations in a homo or heterozygous state. Only rs12018992 was a somatic DICER1 variant. All remaining variants were synonymous and likely benign, according to the ClinVar database. The rs12018992 was previously described in an adolescent with DTC, measuring 13 mm. There were no significant differences according to gender, familial history of goiter, age, thyroid volume, TSH and TI-RADS classification between DICER1 carriers. Free T4 were lower in patients with DICER1 polymorphisms (13.77 ± 1.8 vs. 15.44 ± 2.4 pmol/L, p = 0.008), regardless of TSH levels. Conclusions: We conclude that germline DICER1 variants can be found in 11% of large goiters but no second-hit somatic mutation was found. DICER1 is one driver to thyroid lesion and a second-hit event seems unnecessary in the MNG development. Objective DICER DTC (DTC (MNG tumors syndrome however nodules longlasting long lasting methods samples analyzed Results 71 15 562 56 2 56. 123 12 3 12. 2879 28 79 (28-79 1157 115 7 115. 10 16.2730. 162730 16.2 730 . 16 (16.2-730) 11 state rs rs1201899 variant database 1 mm gender TIRADS TI RADS carriers T 13.77 1377 77 (13.7 18 8 1. vs 1544 44 15.4 24 4 2. pmolL pmol L pmol/L 0.008, 0008 0.008 , 0 008 0.008) levels Conclusions secondhit second hit development 5 287 (28-7 2730 16.2730 16273 162 16. 73 (16.2-730 rs120189 13.7 137 (13. 15. 000 0.00 00 (28- 273 16.273 1627 (16.2-73 rs12018 13. (13 0.0 (28 27 16.27 (16.2-7 rs1201 (1 0. (2 (16.2- rs120 ( (16.2 rs12 (16. rs1 (16

ABSTRACT Objective Hürthle cell carcinomas (HCCs) of the thyroid have been recently reclassified as a separate entity due to their distinct clinical and molecular profiles. Few studies have assessed the ability of preoperative characteristics in differentiating HCCs from Hürthle cell adenomas (HCAs) due to the low prevalence of both lesions. This study aimed to compare the preoperative features of HCCs and HCAs and evaluate the diagnostic performance of ultrasound in distinguishing between both. Subjetcs and methods Retrospective study including 101 patients (52 HCCs and 49 HCAs) who underwent thyroid surgery from 2000 to 2016. Clinical, ultrasonographic, and histological data were reviewed. Diagnostic performance of suspicious sonographic features was analyzed in 51 cases (24 HCCs and 27 HCAs). Results Hürthle cell neoplasms were predominant in females. Subjects ≥ 55 years represented 58% of the cases of HCCs and 53% of those of HCAs. Carcinomas were significantly larger (p < 0.001), and a tumor size ≥ 4 cm significantly increased the risk of malignancy (odds ratio 3.67). Other clinical, cytologic, and sonographic data were similar between HCCs and HCAs. Among the HCCs, the lesions were purely solid in 54.2%, hypoechoic in 37.5%, and had coarse calcifications in 12.5%, microcalcifications in 8.3%, irregular contours in 4.2%, and a taller-than-wide shape in 16.7%. Predominantly/exclusive intranodular vascularization was observed in 52.6%. Overall, 58% of the HCCs were classified as TI-RADS 4 or 5 compared with 48% of the HCAs. TI-RADS 4 or 5 had a specificity of only 51.8% and a positive likelihood ratio of 1.21. Conclusions Apart from the lesion size, no other preoperative feature adequately distinguished HCCs from HCAs. Sonographic characteristics raising suspicion for malignancy, which are mostly present in papillary carcinomas, were infrequent in HCCs. New tools must be developed to improve preoperative diagnosis and deferral of surgery in cases of adenomas.

Summary Total thyroidectomy, radioiodine (RAI) therapy, and TSH suppression are the mainstay treatment for differentiated thyroid carcinomas (DTCs). Treatments for metastatic disease include surgery, external-beam radiotherapy, RAI, and kinase inhibitors for progressive iodine-refractory disease. Unresectable locoregional disease remains a challenge, as standard therapy with RAI becomes unfeasible. We report a case of a young patient who presented with unresectable papillary thyroid carcinoma (PTC), and treatment with sorafenib allowed total thyroidectomy and RAI therapy. A 20-year-old male presented with severe respiratory distress due to an enlarging cervical mass. Imaging studies revealed an enlarged multinodular thyroid gland, extensive cervical adenopathy, severe tracheal stenosis, and pulmonary micronodules. He required an urgent surgical intervention and underwent tracheostomy and partial left neck dissection, as the disease was deemed unresectable; pathology revealed PTC. Treatment with sorafenib was initiated, resulting in significant tumor reduction allowing near total thyroidectomy and bilateral neck dissection. Postoperatively, the patient underwent radiotherapy for residual tracheal lesion, followed by RAI therapy for avid cervical and pulmonary disease. The patient's disease remains stable 4 years after diagnosis. Sorafenib has been approved for progressive RAI-refractory metastatic DTCs. In this case report, we describe a patient with locally advanced PTC in whom treatment with sorafenib provided sufficient tumor reduction to allow thyroidectomy and RAI therapy, suggesting a potential role of sorafenib as an induction therapy of unresectable DTC.

Vários consensos têm sido publicados acerca do diagnóstico e do tratamento de nódulos e câncer da tireoide. Entretanto, as recentes recomendações nem sempre são apropriadas para diferentes regiões ou países. O objetivo deste trabalho foi oferecer uma série de recomendações para a avaliação e conduta de pacientes portadores de nódulos tireoideos aplicáveis a todos os países da América Latina. O trabalho foi realizado por um comitê composto por 13 membros da Sociedade Latino-Americana de Tireoide envolvidos com pesquisa e manejo de pacientes portadores de nódulos e carcinoma diferenciado da tireoide, de diferentes centros médicos da América Latina. As recomendações foram estabelecidas, após consenso, utilizando as opiniões especializadas de cada membro e os princípios da medicina baseada em evidência. Após a primeira reunião do grupo, um primeiro documento foi elaborado e encaminhado a todos os membros para revisão. Posteriormente, o documento foi enviado aos membros da Sociedade Latino-Americana de Tireoide para avaliação, sugestões e comentários. A versão final, elaborada após refinada revisão de todos os autores, representa o estado da arte no diagnóstico e na conduta de nódulos tireoideos, aplicáveis a todos os países da América Latina.

Several guidelines on diagnosis and treatment of thyroid nodules and cancer have recently been published. However, recommended practices are not always appropriate to different settings or countries. The aim of this consensus was to develop Clinical Guidelines for evaluation and management of patients with thyroid nodules applicable to Latin American countries. The panel was composed by 13 members of the Latin American Thyroid Society involved with research and management of thyroid nodules and cancer from different medical centers in Latin America. The consensus was produced based on the expert opinion of the panel with use of principles of evidence-based medicine. Following a group meeting, a first draft based on the expert opinion of the panel was elaborated and later circulated among panel members for further revision. After revision, this document was submitted to all LATS members for commentaries and considerations and finally revised and refined by the authors. The final recommendations represent state of the art on management of thyroid nodules applied to all Latin American countries.

Estas recomendações tiveram por objetivo o desenvolvimento de diretrizes para avaliação e manejo de pacientes com câncer diferenciado da tiroide em países latino-americanos. Um painel composto por 13 membros da Sociedade Latino-Americana de Tireoide (SLAT) - que estavam envolvidos em pesquisas, e eram peritos no cuidado do paciente com câncer da tiroide e provenientes de diferentes centros médicos latino-americanos - utilizou os princípios da Medicina Baseada em Evidências para produzir esse consenso. Após uma primeira reunião, um texto inicial foi elaborado, baseado em evidências e opiniões dos especialistas do painel e, posteriormente, circulado entre os membros do painel, para revisão. Após a revisão, o documento foi enviado aos membros da SLAT para comentários e considerações e, finalmente, revisado e refinado pelos autores. As recomendações finais aqui apresentadas demonstram o estado da arte no manejo do câncer diferenciado da tireoide aplicadas aos países latino-americanos.

The aims of these recommendations were to develop clinical guidelines for evaluation and management of patients with differentiated thyroid cancer applicable to Latin American countries. The panel was composed by 13 members of the Latin American Thyroid Society (LATS) involved with research and management of thyroid cancer from different medical centers in Latin America. The recommendations were produced on the basis of the expert opinion of the panel with use of principles of Evidence-Based Medicine. Following a group meeting, a first draft based on evidences and the expert opinions of the panel was elaborated and, later, circulated among panel members, for further revision. After, this document was submitted to the LATS members, for commentaries and considerations, and, finally, revised and refined by the authors. The final recommendations presented in this paper represent the state of the art on management of differentiated thyroid cancer applied to all Latin American countries.

OBJECTIVES: To evaluate the prevalence of thyroid dysfunction in elderly cardiac patients in an outpatient setting. SUBJECTS AND METHODS: A total of 399 consecutive patients (268 women, age range 60-92 years) who were followed at Heart Institute were evaluated for thyroid dysfunction with serum free T4, TSH, anti-Peroxidase antibodies, urinary iodine excretion measurements and thyroid ultrasound. RESULTS: Hyperthyroidism (overt and subclinical) was present in 29 patients (6.5%), whereas hypothyroidism (overt and subclinical) was found in 32 individuals (8.1%). Cysts were detected in 11 patients (2.8%), single nodules were detected in 102 (25.6%), and multinodular goiters were detected in 34 (8.5%). Hashimoto's thyroiditis was present in 16.8% patients, most of whom were women (83.6%). The serum TSH increased with age and was significantly higher (p= <0.01) in patients, compared to the normal control group. No significant differences in serum TSH and free T4 values were observed when patients with atrial fibrillation (AF) where compared with those without arrhythmia. The median urinary iodine levels were 210 µg/L (40-856 µg/L), and iodine levels were higher in men than in women (p<0.01). Excessive iodine intake (urinary iodine >300 µg/L) was observed in one-third of patients (30.8%). CONCLUSIONS: Elderly patients have a higher prevalence of both hypo- and hyperthyroidism as well as thyroid nodules when compared with the general population. About one-third of the older patients had elevated urinary secretion of iodine and a higher prevalence of chronic Hashimoto's thyroiditis. It is recommended that ultrasonographic studies, tests for thyroid function and autoimmunity should be evaluated in elderly patients.

OBJETIVO: Aprofundar a análise molecular da mutação intrônica IVS30+1G>T do gene tireoglobulina (TG) e relatar a clínica de pacientes portadores da mutação, acompanhados por 11 anos. MÉTODOS: Foram estudados dois irmãos com hipotireoidismo congênito grave com bócio fetal e bócio neonatal, portadores da mutação IVS30+1G>T. Foram coletadas amostras de tecido nodular e não-nodular. Avaliou-se a expressão de genes específicos da tireóide por PCR em tempo real e imunohistoquímica. RESULTADOS: A expressão de genes específicos da tireóide foi menor no tecido não-nodular que no tecido normal controle. Expressões de TPO e NIS foram extremamente baixas no tecido nodular. Verificou-se lúmen folicular aumentado com grandes vesículas de retículo endoplasmático, e detectou-se forte marcação de TG no citoplasma e fraca no lúmen folicular. No tecido não-nodular observou-se forte positividade de NIS intracelular e, TPO e TSHR na membrana plasmática. O acompanhamento em longo prazo dos pacientes mostrou adequado desenvolvimento, apesar de um deles ter recebido tratamento tardio. CONCLUSÕES: A mutação IVS30+1G>T não só promove alterações no retículo endoplasmático, como alterações na expressão de genes específicos da tireóide. A evolução clínica destes pacientes reforça o conceito da influência do meio ambiente, como o aporte nutricional de iodo, no fenótipo final.

OBJECTIVE: To extend the molecular analysis of the IVS30+1G>T intronic thyroglobulin (TG) mutation, and to report the eleven year follow-up of the affected patients. METHOSD: Two siblings with severe congenital hypothyroidism with fetal and neonatal goiter, harboring the IVS30+1G>T mutation were included. Nodular and non-nodular thyroid tissue specimens were collected. Specific thyroid genes expression was evaluated by real-timePCR and by immunohistochemistry. RESULTS: In non-nodular tissue specific thyroid genes mRNA were reduced when compared to normal thyroid sample. In the nodule, TPO and NIS expression was very low. Microscopic examinations showed very large follicular-lumina and swollen vesicles of endoplasmatic-reticulum. Strong cytoplasmatic and low follicular-lumen TG immunostaining were detected. Intracellular NIS, membrane TPO and TSHR immunostaining had higher positivity in non-nodular sample. Both patients had a long-term adequate developmental outcome, besides one patient have been lately-treated. CONCLUSIONS: IVS30+1G>T mutation not only lead to very enlarge endoplasmatic-reticulum, but also to alterations of specific thyroid genes expression. The clinical evolution of patients harboring these mutations strengthen the concept of the influence of environment, like iodine nutrition, to determine the final phenotypic appearance.

Esse artigo tem o objetivo de discutir o papel da tomografia por emissão de pósitrons (PET) com 18F-FDG na avaliação pré-operatória de pacientes com nódulos de tireóide com citologia indeterminada. Para o cálculo da sensibilidade, foram selecionados todos os estudos com pacientes com carcinoma de tireóide. Para o cálculo da especificidade, foram selecionados apenas estudos desenhados para avaliação dos pacientes com nódulos com citologia indeterminada. O achado de captação focal na PET-18F-FDG relacionou-se com a presença de carcinoma de tireóide na maioria dos estudos. A sensibilidade do exame foi bastante alta na detecção de malignidade tireoidiana, porém sua especificidade variou de 0% a 66%, sendo de 39% em estudo brasileiro. Concluindo, os estudos indicam que a PET-18F-FDG pode reduzir o número de tireoidectomias desnecessárias em pacientes com nódulos de tireóide com citologia indeterminada. Entretanto, o percentual relativamente elevado de resultados falso-positivos, o alto custo, a baixa disponibilidade do exame em países em desenvolvimento e a pouca experiência clínica ainda limitam o uso da PET-18F-FDG com essa finalidade.

The aim of this article is to discuss the role of 18F-FDG Positron Emission Tomography (PET) in the preoperative evaluation of patients with cytologically indeterminate thyroid nodules. All studies with patients with thyroid cancer were selected to the calculation of sensitivity. Only studies aiming to evaluate patients with thyroid nodules whose cytological result was indeterminate were selected to establish the specificity. The finding of focal 18F-FDG uptake at PET was associated with the presence of thyroid malignancy in most of the studies. The sensitivity of the exam to the detection of thyroid malignancy was extremely high, but the specificity varied from 0 to 66%. In our experience, the specificity was 39%. In conclusion, the studies suggest that 18F-FDG PET can reduce the number of unnecessary thyroidectomies performed in patients with cytologically indeterminate thyroid nodules. However, the relatively high percentage of false positive results, the high costs, the low availability of this exam in developing countries and the low clinical experience still restrict the use of 18F-FDG PET when recommended with this aim.

Os nódulos tireóideos são encontrados em grande parte da população, mas somente 5 a 10% são malignos. A ultra-sonografia da tireóide, por ser um método simples, não-invasivo e apresentar boa correlação com os aspectos macroscópicos da glândula tireóide, é cada vez mais utilizada para identificar os nódulos que apresentam maior risco de malignidade. A presença de algumas características ultra-sonográficas como hipoecogenicidade, microcalcificações, contornos irregulares e vascularização central ao Doppler, aumenta o risco de malignidade da lesão. Por outro lado, nódulos que apresentam características ultra-sonográficas benignas, como hiperecogenicidade e aspecto misto semelhante a uma esponja, apresentam concordância com a citologia, com valor preditivo negativo de 96,6%. É importante, pois, examinarmos e classificarmos todas as lesões nodulares para selecionarmos aquelas suspeitas para a biópsia, principalmente em uma tireóide multinodular. A ultra-sonografia também apresenta alta sensibilidade para identificar gânglios cervicais suspeitos no seguimento de pacientes com carcinoma da tireóide, mesmo quando a PCI é negativa e a tireoglobulina (Tg) sérica, indetectável. É recomendável a dosagem da Tg no lavado da agulha da punção, pois esta tem-se mostrado mais sensível que a citologia no diagnóstico de metástase cervical, principalmente quando existe conteúdo líquido, e não é afetada pela presença de anticorpos anti-Tg.

Thyroid nodules are found in the vast majority of the population, but only 5 to 10% are malignant. Ultrasonography of the thyroid, by virtue of being a straightforward, non-invasive method presenting strong correlation with macroscopic aspects of the thyroid gland, is being increasingly used to identify nodules that present a higher risk of malignancy. The presence of certain ultrasonographic characteristics such as hypoechogenicity, microcalcifications, irregular contours and central vascularization on Doppler, increase the risk of the lesion being malignant. Conversely, nodules presenting benign ultrasonographic characteristics such as hyperechogenicity and a mixed sponge-like aspect, and a concordant cytology, have a negative predictive value of 96.6%. It is, thus, important to examine all nodular lesions and to identify suspicious lesions that need biopsy, especially in multinodular glands. Ultrasonography is also highly sensitive in the identification of suspicious cervical lymph nodes during the follow-up of patients with thyroid carcinoma, even when PCI is negative and serum thyroglobulin (Tg) levels are undetectable. Tg measurement in the needle wash-out content is recommended as this has proven to be more sensitive than cytology in the diagnosis of cervical metastasis, especially where there is liquid content, and it is not affected by the presence of anti-Tg antibodies.

OBJETIVO: Avaliar a possibilidade de diagnóstico pré-operativo de nódulos da tireóide (de diâmetro superior a 10mm) usando ultra-sonografia da glândula tireóide e citologia de punção aspirativa por agulha fina guiada pela ultra-sonografia. CASUÍSTICA E MÉTODOS: Nódulos tireóideos (maiores que 10mm) foram classificados ultra-sonograficamente em graus de I a IV e escores numéricos de 1 a 4, de acordo com crescente possibilidade de malignidade. O exame citológico, subseqüentemente, classificou os nódulos como benigno (escore 1) indeterminado (escore 2) suspeito (escore 3) e maligno (escore 6). Somando-se os escores obtidos nas duas metodologias obtém-se um índice considerado benigno (índice combinado 2-4), duvidoso (índice combinado 5) suspeito para malignidade (índice combinado 6) e elevada probabilidade de malignidade (índice combinado 7 a 10). Cirurgia da Tireóide foi realizada em 274 pacientes, dos quais 64 apresentavam índice de 2-4; destes, apenas 2 pacientes (3,1%) apresentaram comprovação histológica de câncer. Em pacientes com índice 5 (n= 51), 11,8% apresentaram câncer de tireóide e, em 61 pacientes com índice 6, (n= 31), 51% tiveram diagnóstico confirmado de malignidade. O índice combinado de 7-10 (n= 98) apresentou 99% de pacientes com câncer de tireóide. CONCLUSÕES: O índice combinado apresentou sensibilidade de 94,1% e especificidade de 77,5%. A precisão desta metodologia foi de 85,8%. Concluímos que o índice combinado pode ser útil no diagnóstico pré-cirúrgico do nódulo tireóideo, mormente se associado com outras metodologias como a ecografia com Doppler colorido, nível elevado de TSH sérico, análise de expressão de galectina-3 e imagens por FDG/PET.

PURPOSE:To evaluate the preoperative assessment of thyroid nodules using ultrasound studies and cytology of nodular aspirates. SUBJECTS AND METHODS: 2,468 patients with thyroid nodules were examined from 1999 to 2005. All patients were clinically examined and underwent ultrasonography followed by fine-needle aspiration biopsy (FNAB) and cytology. RESULTS:Nodules larger than 10 mm were classified ultrasonographically in a 4-tier system and received a score according to the criterion of possible malignancy. Cytological examinations were conducted independently by 2 cytologists and classified as benign (score 1), indeterminate (score 2), suspicious (score 3), and malignant (score 6). Combining both scores, an index was generated that would indicate a higher probability of malignancy (benign, doubtful, suspicious, and malignant). Thyroid surgery was performed in 274 patients. Of those, 115 patients had a score of 2 to 5 and only 8 had a histological diagnosis of thyroid cancer (6.9%). For patients with a score of 5 (n = 51), 11.5% had a malignant lesion, and 51% of the 61 patients with a score of 6 had confirmed thyroid cancer. Of the 98 patients with a combined score of 7 to 10, 99% had a histological confirmation of malignancy. CONCLUSIONS: The index score had a sensitivity of 94.1% and specificity of 77.5%. The overall accuracy was 85.8%. Therefore, we concluded that this methodology may improve the preoperative diagnosis of thyroid cancer in nodules larger than 10 mm. Association with other methods such as color Doppler echography, serum TSH concentration, galectin-3 expression analysis, and FDG/PET scan would be useful in avoiding the higher costs of thyroid surgical procedures.

OBJETIVO: Analisar a prevalência populacional de tireoidite crônica autoimune (tireoidite de Hashimoto) na área vicinal ao Polo Petroquímico de Capuava comparativamente a área controle em São Bernardo Campo. CASUÍSTICA E MÉTODOS: Em ambas as áreas urbanas foram incluídos, aleatoriamente, indivíduos adultos que, de forma voluntária, concordaram em participar do estudo, estratificado por idade (20 a > 70 anos) e sexo (mulheres 80%, homens 20%). Na área Polo foram incluídos 409 indivíduos e na área controle (São Bernardo Campo) 420 pessoas (sem diferenças significativas quanto a idade e sexo). Na área Polo 15,6% apresentava sinais ecográficos e de positividade para anticorpos anti TPO, confirmando tireoidite crônica autoimune (TCA) comparativamente a 19,5% na área controle (p > 0,05, NS). A presença de hipotiroidismo foi confirmada em 4,9% da população na área Polo e 8,3% na área controle (São Bernardo Campo) (p = 0,046, significativo). No conjunto 6,63% dos pacientes com TCA apresentavam hipofunção tireóidea. A excreção urinária de iodo ultrapassou 300 mcg Iodo/L de urina em 58,5% de ambas populações. O sal coletado nas casas dos examinados apresentava concentração normal de iodo (35,5 + 6,6 mg I/Kg de sal). CONCLUSÕES: A maior prevalência de tireoidite crônica autoimune em ambas as áreas é, provavelmente, decorrente da elevada ingestão nutricional de iodo durante o quinqüênio que precedeu esta pesquisa (1998-2004). A suposta conexão epidemiológica de maior prevalência epidemiológica de TCA com vicinidade com o Polo Petroquímico de Capuava é improvável.

PURPOSE: To evaluate the prevalence of chronic autoimmune thyroiditis in 2 urban areas of metropolitan São Paulo (Brazil): Polo Area neighboring a large petrochemical complex and São Bernardo Campo Area (control area). SUBJECTS AND METHODS: Subjects were randomly included from the adult population (20 to 70 years of age) of both genders (women 80%, men 20%) who voluntarily agreed to participate. From the Polo Area, in the vicinity of a large petrochemical industrial complex, 409 subjects were included; from the control area (São Bernardo Campo Area) 420 individuals were included. All subjects were clinically examined, and a detailed record of past thyroid illness and medications was obtained. Ultrasonographic studies were performed using a portable GE Medical Systems apparatus. Blood samples were obtained for free T4, serum TSH, and serum anti-thyroid peroxidase autoantibodies. Urine specimens were collected in Monovette syringes for assaying iodine content. Salt samples were collected at households, and the iodine content was measured. RESULTS: Chronic autoimmune thyroiditis was diagnosed both echographically (marked hypoechogenicity) and immunologically (presence of autoantibodies against thyroid peroxidase). In the Polo Area, 15.6% of the examined population had chronic autoimmune thyroiditis, and in the control area (São Bernardo Campo Area), 19.5% of the population had evidence of chronic autoimmune thyroiditis (P > 0.057, not significant). The prevalence of hypothyroidism was 4.9% in the Polo Area and 8.3% in the São Bernardo Campo Area (P = 0.0461 significant). Taking the 2 populations together, 6.6% had hypothyroidism (about one third of these patients were on L-T4 treatment). The mean thyroid volume was 11.2 mL. Domestic salt had a normal concentration of iodine (35.5 + 6.61 mg/kg). Urinary excretion of iodine was above 300 µg Iodine/L in 58.5% of the total population. CONCLUSION: The high iodine intake (above 300 µg Iodine/L of urine) that was present from 1998 through 2005 may be related to a higher prevalence of chronic autoimmune thyroiditis in both areas that were studied. There was no apparent or documented relationship of chronic autoimmune thyroiditis prevalence to the proximity to the petrochemical complex.

A incidência do câncer diferenciado da tiróide vem aumentando há várias décadas no Brasil, assim como em todo o mundo. A popularização de métodos diagnósticos sensíveis e de uso relativamente simples tem contribuído para o diagnóstico cada vez mais freqüente de carcinomas de pequeno tamanho. Uma parte destes tumores ocorre em pacientes denominados de baixo risco, que poderiam se beneficiar de estratégias de conduta menos agressivas. Entretanto, a definição de baixo risco ainda é confusa e não existem meios seguros para distinguir os pacientes que evoluirão de forma pior dos demais. Por outro lado, o uso de novos métodos de acompanhamento vem mudando a maneira de conduzir estes casos. Um grupo multidisciplinar que inclui pesquisadores básicos, endocrinologistas, médicos nucleares, cirurgiões e patologistas endócrinos reviu a literatura pertinente e, com base em sua experiência, propõe algumas normas de conduta no carcinoma diferenciado da tiróide chamado de baixo risco em nosso meio.

The trend of increasing thyroid cancer has been recognized in Brazil as well as all over the world for several decades. The large use of simple and effective diagnostic tools has significantly contributed to this trend. It is estimated that small carcinomas found at surgery for benign thyroid disorders and by ultrasonography will be identified at grater frequency in the further years. Part of these tumors occurs in low-risk patients that may benefit of less aggressive management strategies. However, the characterization of low-risk patient is still confusing and we lack adequate markers to tell apart patients that may present a troublesome progression of the disease. Furthermore, the use of new follow-up methods has recently changed some guidelines. A multidisciplinary team, including basic scientists, endocrinologists, nuclear medicine physicians, thyroid surgeons and endocrine pathologists reviewed the pertinent literature and, based on their experience, propose some management guidelines for Brazilian patients with low-risk thyroid carcinomas.

O objetivo do presente estudo foi avaliar esquema terapêutico medicamentoso para aumentar a aderência ao tratamento da moléstia de Graves-Basedow (MGB) em Hospital Público Universitário. Os pacientes foram selecionados segundo critérios rigorosos, que incluíam volume glandular inferior a 60cm³, origem da área urbana de São Paulo e não submetidos a terapia prévia da MGB. Receberam gratuitamente a medicação, eram avisados antecipadamente da data da consulta e acompanhados por um único médico durante todo o tratamento. Foram incluídos 229 pacientes, tratados inicialmente com metimazol (MMI - 60mg/dia) em dose única diária, seguindo-se com combinação de MMI (20mg) com LT4 (100µg) em dose única diária por 24 meses. Apenas 83 pacientes (36,2%) completaram o protocolo quando foram subdivididos em 2 grupos, após a suspensão do MMI+LT4: Grupo 1 (n= 34), que permaneceram em remissão por 3 anos, e Grupo 2 (n= 49), que apresentaram recidiva da doença entre 2 e 36 meses. Os fatores preditivos associados à remissão foram: decréscimo do volume glandular, tireoglobulina sérica < 40ng/ml e valores séricos normais de anticorpos anti-receptor de TSH. Constatamos que apesar do planejamento cuidadoso, mais de 60% dos portadores de MGB não completaram o protocolo e foram encaminhados a tratamento com radioiodo. Admitimos que esse baixo êxito terapêutico poderia ser melhorado mediante identificação dos fatores capazes de indicar quais pacientes estariam propensos a seguir um tratamento de longa duração.

The aim of the present study was to evaluate a new proposal for increasing compliance to the clinical management of patients with Graves’ disease (GD) in a large and public University Hospital. The patients were carefully selected (no previous GD treatment, goiter volume less than 6mL must be living in the metro area of São Paulo), received medication at no cost, were contacted frequently by the social worker and alerted for the date of consultation and only referred to a single endocrinologist during all phases of treatment. We recruited 229 patients with GD that were initially treated with methimazole (MMI - 60mg q.d) in a single daily dose followed by a combination of MMI (20mg) plus L-T4 (100µg) daily for 24 months. Only 83 patients (36.2%) completed the protocol and were subdivided in: Group 1 (n= 34) that were in remission for 3 years after discontinuation of the MMI and Group 2 (n= 49) that presented recurrence of GD between 2 and 36 months without MMI. Predictive factors associated with remission were: decrease of the glandular volume, serum TG< 40ng/mL and normal TRAb values. We concluded that in spite of a careful protocol planned to increase compliance, more than 60% of patients with GD did not complete the therapeutic trial and were referred for radioiodine treatment. The solution for this low therapeutic success for GD should be the possible identification of factors that would indicate patients that are not inclined to follow a long period of clinical therapy.

A iodação do sal é eficiente no combate às doenças decorrentes da deficiência de iodo, sendo empregada em todo território nacional desde 1995. O Estado de São Paulo é considerado uma área ioda-suficiente. Para avaliar a ingesta de iodo, foram selecionados aleatoriamente 844 escolares entre 6 e 14 anos, de seis regiões do Estado. Foram avaliados, sob o ponto de vista ecográfico da tireóide, 423 meninos e 421 meninas. Os volumes da glândula tireóide elevaram-se progressivamente com a idade, guardando correlação positiva e significativa com a superfície corporal. Cerca de 1,6% dos escolares apresentava bócio. Nódulos, cistos, hemiagenesia foram detectados em 1,4% dos examinados. Notamos excessiva excreção urinária de iodo nesta população, cerca de 53% eliminou acima de 300<FONT FACE=Symbol>µ</FONT>g Iodo/L e valores acima de 600<FONT FACE=Symbol>µ</FONT>gI/L foram encontrados em 21% dos escolares. As amostras de sal doméstico apresentavam valores entre 28,1 e 63,3mg Iodo/kg de sal. Concluímos que a população escolar do Estado de São Paulo apresenta excessiva ingestão diária de iodo, a qual, extrapolada para a população em geral, pode induzir várias alterações da função tireóidea, como hipertiroidismo subclínico (em idosos) e tireoidite crônica autoimune na população adulta, em geral.

We have examined, by ultrasonographic studies, the thyroid gland of 844 schoolchildren, aged between 6 and 14 years old (423 girls, 421 boys). There was a progressive increase of the thyroid volume with aging with a positive and significant correlation with the body surface area. The presence of enlarged thyroid gland was rarely seen, being present in only 1.6% of the studied cohort. A few thyroid gland abnormalities were noticed such as hemiagenesia (4 children), nodules and cysts and hypoechogenicity (total: 1.4% of all subjects examined). It was clearly demonstrated that the urinary excretion of iodine was elevated being above 300ug Iodine/L in 53% of the schoolchildren examined. Assays for the iodine concentration in the domestic salt samples revealed values between 28.1 and 63.3mgI/kg of salt. We concluded that the schoolchildren population of the State of Sao Paulo may be under an excessive daily ingestion of iodine. This may induce, if extrapolated to the general population, subclinical hyperthyroidism in the elderly and possibly an increment in the prevalence of chronic autoimmune thyroiditis.