Belo Horizonte, Brazil
Belo Horizonte, Brazil

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The objective of this study was to screen for acromegaly by application of a simple questionnaire in patients seen at primary health care units. A total of 17,000 patients of both genders[18 and<70 years seen by general practitioner were interviewed. Patients with known pituitary disease and pregnant women were excluded. A simple questionnaire was applied to the patients: Has your shoe size increased over the last 5 years? Did you have to change your wedding ring or ring over the last 5 years because it became tight? In one patient, the diagnosis of acromegaly was suspected by the physician. Among the remaining patients, 178 (1%) responded positively to one of the items of the questionnaire and were submitted to IGF-1 measurement. Five patients had persistently elevated IGF-1 and inadequate suppression of GH in the OGTT (without other conditions associated with GH or IGF-1 elevation). One of these patients presented a normal pituitary upon magnetic resonance imaging and adenoma was detected in the other four; two presented the typical facies and two others reported changes in physiognomy (confirmed by the comparison of photographs), in addition to the enlargement of extremities. The present investigation suggests a much higher prevalence of acromegaly in the adult population than that reported traditionally. We propose that screening based on phenotypic alterations is costeffective since these changes occur early and almost universally in acromegaly and are uncommon in the general population. © Springer Science+Business Media, LLC 2012.


Rosario P.W.,Postgraduation Program | Furtado M.S.,Postgraduation Program | Mineiro Filho A.F.C.,Postgraduation Program | Lacerda R.X.,Postgraduation Program | Calsolari M.R.,Endocrinology Service
Thyroid | Year: 2012

Background: In patients with differentiated thyroid carcinoma considered to be free of the disease after initial therapy, the appropriate timing or necessity of subsequent stimulated thyroglobulin (Tg) testing is uncertain. The objective of this study was to determine the value of a repeat stimulated Tg in patients considered to be free of disease 6-12 months after thyroid ablation, and also who continued to have serum Tg <1 ng/mL while on thyrotropin suppressive doses of thyroxine (T4) (Tg/T4), negative anti-Tg antibodies (TgAb), and a normal clinical examination 5 years after their initial therapy. Methods: The study participants were 203 patients who had total thyroidectomy followed by ablation with 131I, who were considered to be free of disease 6-12 months after ablation (stimulated Tg <2 ng/mL in the absence of TgAb and negative diagnostic whole-body scanning), who had no recurrence, and who continued to have serum Tg/T4 of <1 ng/mL, negative TgAb and a normal clinical examination 5 years after initial therapy. These patients were evaluated with repeat stimulated Tg testing after 4 weeks of T4 withdrawal. Results: Repeat stimulated Tg values after 5 years were <2 ng/mL in 192 (94.6%) patients of whom 188 were <1 ng/mL. Subsequent follow-up after a mean of 102 months did not detect new cases of tumor recurrence in this subgroup. Eleven patients (5.4%) had stimulated Tg levels of >2 ng/mL. Neck ultrasonography (US) revealed metastases in three and other imaging methods detected metastases in five patients with negative US. In the other three patients, no metastases were detected initially or during follow-up. Gender, age, and tumor stage were not predictors of recurrence or elevated Tg upon repeat testing after 5 years. Conclusions: The present results favor repeating stimulated Tg 5 years after ablation in patients who were initially considered to be free of disease and who continued to have Tg/T4 values of <1 ng/mL and negative TgAb tests. A negative predictive value of 100% was obtained for patients who continued to have low stimulated Tg values. © Copyright 2012, Mary Ann Liebert, Inc.


Rosario P.W.,Postgraduation Program | Xavier A.C.M.,Postgraduation Program | Calsolari M.R.,Endocrinology Service
Thyroid | Year: 2010

Background: Most patients with well-differentiated thyroid cancer (WDTC) are first treated by total thyroidectomy followed by remnant ablation (RA) with 131I. There are less data regarding the efficacy of recombinant human thyrotropin (rhTSH) for patients with WDTC at high risk of relapse than for low-risk patients. This study compared the efficacies of rhTSH and thyroid hormone withdrawal (THW) to prepare patients at high risk of relapse for RA. Methods: Post-thyroidectomy patients with WDTC and complete tumor resection (n=275) were studied. They were at high risk of recurrence (tumor size >4cm and/or extrathyroidal extension [pT3] and/or lymph node metastases), and they did not have antithyroglobulin (Tg) antibodies. Group A (n=77) received 0.9mg rhTSH for 2 consecutive days followed by RA on day 3. The remaining 198 patients (group B) were prepared by THW for 4 weeks. Patients in groups A and B received 3.7 or 5.5GBq 131I. Results: The groups were similar in terms of gender, age, histology, TNM (tumor-node-metastases) stage, 131I activity, and frequency of metastases on post-therapy whole-body scanning (RxWBS). Among patients without metastases on RxWBS, RA was successful (stimulated Tg <1ng/mL and negative diagnostic whole body scan and neck ultrasonography) in 56 of 70 patients in group A (80%) and in 135 of 169 patients in group B (79.9%). Among patients with Tg >1ng/mL immediately before RA, the comparable success rates were 68.4% and 67.4%, respectively. Among patients with metastases on the first RxWBS, no uptake was observed on the RxWBS 1 year later in 5 of 7 patients in group A (71.4%) and in 17 of 29 patients in group B (58.6%). The rhTSH stimulated serum Tg was <1ng/mL in 3 of 5 and in 12 of 17 patients with a second negative RxWBS in groups A and B, respectively. Persistent disease (stimulated Tg >1ng/mL and RxWBS continuing to show ectopic uptake) occurred in 2 of 7 patients in group A (28.5%) and in 12 of 29 patients in group B (41.3%). Conclusions: rhTSH is as effective as THW for RA in patients with WDTC who are at a high risk of relapse. © Copyright 2010, Mary Ann Liebert, Inc.


Mourao G.F.,Postgraduation Program | Mourao G.F.,Institute Ensino E Pesquisa Da Santa Casa Of Belo Horizonte | Rosario P.W.,Postgraduation Program | Rosario P.W.,Institute Ensino E Pesquisa Da Santa Casa Of Belo Horizonte | Calsolari M.R.,Institute Ensino E Pesquisa Da Santa Casa Of Belo Horizonte
Endocrine-Related Cancer | Year: 2016

This study evaluated the recurrence rate in patients with papillary thyroid carcinoma (PTC) who had low nonstimulated thyroglobulin (Tg), measured with a second-generation assay, after total thyroidectomy and who were not submitted to ablation with 131 I. The objective was to define whether low postoperative nonstimulated Tg can be used as a criterion to spare patients with PTC from therapy with 131 I. This was a prospective study including 222 patients with PTC (except for microcarcinoma restricted to the thyroid and tumor with extensive extrathyroid invasion (pT4), aggressive histology, extensive lymph node (LN) involvement, or known residual disease). After thyroidectomy, all patients had nonstimulated Tg!0.3 ng/ml, negative antithyroglobulin antibodies (TgAb) and neck ultrasonography (US) showing no anomalies. Because of this finding, the patients were not submitted to ablation with 131 I. The time of follow-up ranged from 15 to 102 months (median 62 months). Of the 222 patients, 217 (97.7%) continued to have nonstimulated Tg !0.3 ng/ml and negative US. Tg was undetectable in the last assessment in 185 of these patients and detectable in 32. Five patients (2.2%) exhibited an increase in Tg, and LN metastases were detected in 4 (structural recurrence). One patient progressed to an increase in Tg, but disease was not detected by the imaging methods (biochemical recurrence). The results obtained here suggest that patients with PTC who have low nonstimulated Tg (measured with a second-generation assay and in the absence of TgAb) and negative neck US after thyroidectomy do not require ablation with 131 I. © 2016 Society for Endocrinology.


Rosario P.W.,Postgraduation Program | Purisch S.,Endocrinology Service
Gynecological Endocrinology | Year: 2011

Objective. To evaluate the frequency of elevated TSH in pregnant women of low risk for thyroid dysfunction. Subjects and methods. TSH was measured in 838 pregnant women during the first trimester of gestation (from 6 to 14 weeks, median 9 weeks) and who were considered to be of low risk for thyroid dysfunction because they did not meet any of the following criteria: known or clinically suspected thyroid disease; history of head and neck radiotherapy; personal history of autoimmune diseases; family history of thyroid disease; history of abortion or prematurity. Results. The frequency of elevated TSH was 0.25%, 1.2% and 5.5% at cut-off values of 4, 3 and 2.5 mIU/l, respectively. These rates increase to 1.43%, 2.4% and 6.2% if cases of TSH > 2 mIU/l with TPOAb are included. TSH was undetectable in 18 women (2.1%), but only six (0.71%) had elevated T4. Conclusions. The definition of a TSH cut-off that defines subclinical hypothyroidism (SCH) should precede the decision of screening pregnant women without any risk factors for thyroid dysfunction. © 2011 Informa UK, Ltd.


Rosario P.W.,Postgraduation Program | Xavier A.C.M.,Postgraduation Program | Calsolari M.R.,Endocrinology Service
Thyroid | Year: 2011

Background: This study investigated the value of postoperative stimulated thyroglobulin (Tg) combined with neck ultrasonography for the prediction of the posttherapy whole-body scanning (RxWBS) and the efficacy of ablation with 30 mCi 131I in patients with thyroid cancer and low risk of recurrence to identify those who do not require ablation or only need a low 131I activity. Methods: A total of 237 consecutive patients with well-differentiated thyroid cancer and low risk of recurrence who were initially treated by total thyroidectomy followed by remnant ablation with 1.1 or 3.7 GBq (30 or 100 mCi) 131I were studied. Neck ultrasonography, Tg after levothyroxine withdrawal, and anti-Tg antibodies (TgAb) were obtained before, and RxWBS was performed 7 days after 131I administration. Patients with TgAb were excluded. Results: Postoperative ultrasonography revealed lymph node metastases in 5/237 (2%) patients. RxWBS showed ectopic uptake in 3/232 (1.3%) patients with negative ultrasonography. The negative predictive value of postoperative stimulated Tg <1 ng/mL (n = 132) or <10 ng/mL (n = 213) combined with negative ultrasonography was 100%. Among patients with detectable postoperative stimulated Tg <10 ng/mL and negative ultrasonography, 50 received 1.1 GBq 131I and 31 received 3.7 GBq. In the control assessment, stimulated Tg <1 ng/mL and neck ultrasonography without anomalies were achieved in 47/50 (94%) and in 29/31 patients (93.5%). All patients with stimulated Tg ≤1 ng/mL, negative TgAb, and normal ultrasonography before ablation continued to show the same results 8-12 months after initial therapy as expected, irrespective of the administration of 1.1 GBq (n = 82) or 3.7 GBq 131I (n = 50). Conclusions: Measurement of stimulated Tg combined with neck ultrasonography after total thyroidectomy may exclude the need for ablation in 56% of low-risk patients without TgAb (Tg <1 ng/mL) and permit the administration of an activity of 1.1 GBq 131I in another 34% with low Tg levels. © Copyright 2011, Mary Ann Liebert, Inc. 2011.


The objective of this study was to evaluate the frequency of acromegaly in adults with diabetes mellitus (DM) or glucose intolerance (GI) and to estimate its prevalence in the general population. A total of 2,270 patients with DM or GI and age from 20 to 70 years were studied. Patients with known pituitary disease and pregnant women were excluded. Serum IGF-1 was measured in all subjects and, if elevated, a new measurement was obtained together with the measurement of GH in the oral glucose tolerance test (OGTT). Patients with persistently elevated IGF-1 and inadequate suppression of GH were submitted to magnetic resonance imaging (MRI). Acromegaly was not suspected by the assistant physician in any of the patients. Six patients had persistently elevated IGF-1 and inadequate suppression of GH in the OGTT (without other conditions associated with GH or IGF-1 elevation). Pituitary adenoma was detected by MRI in three patients, and two subjects presented an acro-megalic phenotype. Two patients were submitted to trans-sphenoidal surgery, with immunohistochemistry confirming immunoreactivity for GH. Another patient was treated with octreotide LAR which resulted in the normalization of IGF-1 and GH. Considering a prevalence of DM or GI of 20% in adults and the occurrence of these co-morbidities in 55% of patients with acromegaly, the frequency of 3/2,270 found in this study permits to estimate 480 cases/1,000,000 adults. The present results suggest that the prevalence of acromegaly is underestimated and further studies are needed to evaluate the cost-effectiveness of biochemical screening in certain groups of patients. © Springer Science+Business Media, LLC 2010.


Rosario P.W.S.,Postgraduation Program | Dos Santos J.B.N.,Postgraduation Program | Calsolari M.R.,Postgraduation Program
Hormone and Metabolic Research | Year: 2013

The importance of thyroglobulin (Tg) stimulation after ablation in patients with papillary thyroid carcinoma (PTC) and undetectable basal Tg measured with sensitive assays has been questioned. However, there is a need for prospective studies that evaluate the evolution of these patients when stimulated Tg is omitted and this was the objective of the present investigation. One hundred twenty-two consecutive patients with PTC with the following characteristics were evaluated: submitted to total thyroidectomy and remnant ablation; low risk for recurrence; undetectable basal Tg (functional sensitivity of 0.1 ng/ml) 6 months after initial therapy; anti-Tg antibodies (TgAb) negative, and neck ultrasound (US) showing no abnormalities. These patients were not submitted to Tg stimulation. After follow-up for 24-78 months, only one patient (0.8%) presented apparent disease (lymph node metastases). TgAb were detected at low titers and without progression in 1 patient (0.8%). Tg became detectable and continued to be detectable in 3 patients (2.4%), but at concentrations ≤0.3 ng/ml in the absence of further increases, with stimulated Tg < 1.4 ng/ml. A total of 117 patients (96%) coursed with no apparent disease throughout follow-up and had undetectable Tg at the end of the study. Of these, 111 showed undetectable Tg in all measurements and 6 showed detectable Tg in some of them, although Tg later returned spontaneously to an undetectable range. After ablation, the risk of recurrence is very low in patients with low-risk PTC who show undetectable basal Tg measured with a sensitive assay, negative TgAb and negative US. © Georg Thieme Verlag KG Stuttgart, New York.


Rosario P.W.,Postgraduation Program | Furtado M.D.S.,Postgraduation Program | Mourao G.F.,Postgraduation Program | Calsolari M.R.,Endocrinology Service
Thyroid | Year: 2015

Background: According to American Thyroid Association (ATA), all patients with papillary thyroid carcinoma (PTC) should initially be classified regarding the risk of tumor recurrence. If a very high postoperative thyroglobulin (Tg) classifies patients as high risk of recurrence, it is reasonable to hypothesize that, at the other extreme, a low Tg may reclassify patients from intermediate to low risk. The objective of this study was to evaluate the rate of persistent/recurrent disease in intermediate-risk patients with low postoperative (before 131I) Tg, thereby evaluating whether these patients can be reclassified as low risk based on this finding already at the time of initial therapy rather than one to two years after radioiodine therapy. Methods: A total of 181 patients with the following characteristics were evaluated: (i) diagnosis of PTC; (ii) submitted to total thyroidectomy with lymph node dissection in the case of a suspicion of metastases based on preoperative ultrasonography (US) or perioperative evaluation (cN1); (iii) apparently without persistent tumor after surgery; (iv) a postoperative stimulated Tg (sTg) ≤2 ng/mL and negative anti-Tg antibodies (TgAb); and (v) considered to be at intermediate risk by ATA criteria. Results: When evaluated 9-12 months after radioiodine therapy, 170 patients (94%) had a sTg <1 ng/mL and negative TgAb and a negative neck US (excellent response). Ten patients (5.5%) had a sTg >1 ng/mL (≤2 ng/mL) in the absence of apparent disease detected by imaging methods (indeterminate response). US detected cervical lymph node metastases (not detected at the time of 131I therapy) in one patient (incomplete structural response). During follow-up, recurrence was observed in 5/180 (2.7%) patients without apparent disease in the initial assessment. Thus, persistent or recurrent disease occurred in only 3.3% of cases. The 175 patients without tumor persistence/recurrence were not submitted to any additional therapy, and all had a Tg/thryoxine <1 ng/mL in the last assessment. There was no case of death related to the disease. Conclusions: This study suggests that intermediate-risk patients (according to ATA criteria) with a postoperative sTg ≤2 ng/mL can be reclassified as low risk already at the time of initial therapy. © Copyright 2015, Mary Ann Liebert, Inc..


Rosario P.W.,Postgraduation Program | Santos J.B.N.,Postgraduation Program | Nunes N.S.,Postgraduation Program | Da Silva A.L.,Postgraduation Program | Calsolari M.R.,Postgraduation Program
Hormone and Metabolic Research | Year: 2014

The objective of this prospective study was to compare the results of color flow Doppler sonography (CFDS) and radioiodine scintigraphy in patients with thyrotoxicosis. A total of 176 patients, 102 with clinical thyrotoxicosis and 74 with subclinical dysfunction, were included. Pregnant and breast-feeding women, patients using amiodarone or recently exposed to iodinated contrast, and patients treated with antithyroid drugs were excluded. Total T3, free T4, TSH, and anti-TSH receptor antibodies were measured before scintigraphy and CFDS. Excluding one patient whose etiology of thyrotoxicosis remained undefined, CFDS showed 100% specificity. In fact, in all 10 cases in which scintigraphy and CFDS provided discordant results, the diagnosis suggested by the latter was correct. In patients with clinical thyrotoxicosis, the sensitivity of CFDS was 96% for diffuse toxic goiter, 95% for the absence of hyperfunction, and 100% for toxic nodular disease. In patients with subclinical dysfunction, the sensitivity of CFDS was 72.7% for diffuse toxic goiter, 90% for toxic adenoma, and 86.6% for toxic multinodular disease. CFDS was inconclusive in patients with parenchymal blood flow with patchy uneven distribution or with macronodules in which nodule vascularity compared to the remaining parenchyma did not permit to establish the diagnosis with certainty. CFDS can be used instead of scintigraphy not only in situations in which the latter is contraindicated or of limited value to define the etiology of thyrotoxicosis. © Georg Thieme Verlag KG Stuttgart. New York.

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