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      Pertechnetate thyroid scan in Marine-Lenhart syndrome

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          Abstract

          Sir, Marine-Lenhart syndrome is a variant of Graves’ disease with incidentally functioning nodule(s) which are responsive to thyroid stimulating hormone but are not responsive to thyroid stimulating immunoglobulins. Here we present a classic case of Marine-Lenhart syndrome. A 65-year-old female, with hyperthyroidism diagnosed 6 years ago, was subjected to Tc-99m pertechnetate thyroid scan prior to I-131 ablation. At presentation, the patient was receiving propranolol and she stopped methimazole 10 days back. She was clinically hyperthyroid and complained of palpitations, tremors and loose motions. On clinical examination, a left-sided thyroid nodule was palpated. Thyroid functions tests were as follows: Thyrotropin (TSH) ≤0.01 uIU/mL (range, 0.27-4.20); free thyroxine (T4) ≥5.4 ng/dL (range, 0.7-1.6); triiodothyronine (T3) =4.6 ng/mL (range, 0.8-2.0). On ultrasound, the thyroid gland was asymmetrically enlarged with an isoechoic nodule surrounded by halo in the left lobe. There was no cervical lymphadenopathy. Tc-99m pertecnetate thyroid scan [Figure 1] showed diffuse homogeneously increased uptake throughout the gland with cold area in the infero-lateral part of the left lobe corresponding to the palpable nodule. Fine needle aspiration from thyroid nodule revealed features of colloid nodule. At that time the patient underwent successful ablation with 10 mCi of radioiodine-131. Figure 1 Tc-99m pertechnetate thyroid scan showing diffuse homogeneously increased uptake throughout the gland with cold area in the infero-lateral part of the left lobe corresponding to the palpable nodule. Fine needle aspiration from thyroid nodule revealed features of colloid nodule Marine-Lenhart syndrome, also known as nodular Graves’ disease, is the coincidence of Graves’ disease with TSH-sensitive functioning nodules. The syndrome was initially described in 1911 by Marine and Lenhart and is now considered a distinct sub entity of Graves’ disease.[1] Marine-Lenhart syndrome has been described as a variant of Graves’ disease with the following criteria: (i) The thyroid scan shows an enlarged gland and 1 or 2 poorly functioning nodules; (ii) the nodule is TSH dependent and the paranodular tissue is TSH independent; (iii) after endogenous or exogenous TSH stimulation, the return of function in the nodule can be demonstrated; and (iv) the nodule is histologically benign.[2] It is reported to be quite rare with a prevalence of 2.7-4.1% in patients with Graves’ disease.[3 4] Graves’ disease is an autoimmune disease in which stimulatory auto antibodies bind to TSH receptor and activate gland function, leading to hyperthyroidism. 25-30% patients of Graves’ disease are reported to harbour thyroid nodules.[5 6 7] Mostly these nodules are cold, benign and multiple,[8] but 1-2.5% are associated with hot autonomous nodules.[3] Thyroid scintigraphy shows the typical finding of increased activity with a decreased background, but with one or more cold nodules (suppressed by TSH). Following therapy with anti-thyroid drugs or I-131 radioablation, the nodules may accumulate radiotracer and appear like hot nodules as TSH level starts to rise.

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          Graves' disease with functioning nodules (Marine-Lenhart syndrome).

          N Charkes (1972)
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            Thyroid nodules in Graves' disease: classification, characterization, and response to treatment.

            Thyroid nodules in patients with Graves' disease are common and raise concern about coexistent thyroid malignancy. Alternative etiologies for such nodules are more frequent, and separation from thyroid malignancy is important for rational management. To characterize the types of thyroid nodules present in patients with Graves' disease, evaluate the response of these nodules to treatment, and stratify the risk of thyroid malignancy, we report on a retrospective single center study in an ambulatory setting of 468 Graves' patients ages (12-75) followed for 1-31 years (mean = 5.1) treated with radioiodine (n = 345), near total thyroidectomy (n = 19), thionamide antithyroid drugs (n = 88) or observation (n = 18). Sixty patients (12.8% of the total) had nodules and were classified as: (1) Graves' disease with a solitary hypofunctional nodule (n = 27, 5.8%); (2) Graves' disease with multiple nodules (n = 21, 4.5%); (3) Graves' disease with autonomous nodule (n = 4, 1%); or (4) patchy Graves' disease (n = 8, 1.7%). Six patients (1.3% of total or 10% of nodule patients) had cancer: 5 in group 1 and 1 in group 4. Based on the response to therapy or surgical and fine-needle aspirate pathology, the remaining patients demonstrated pseudo-nodules of autoimmune thyroid disease, autonomous nodules of Marine-Lenhart syndrome, colloid goiter, hyperplastic adenomatous disease, and Hashitoxicosis. In conclusion, Graves' patients present with or may develop nodules commonly (12.6%) and the majority of these are benign expressions of autoimmune changes and coexistent nodular goiter. Thyroid cancer occurs in 10% of all nodules, 19% of palpable solitary cold nodules and 1.3% of the total patients. If the fine-needle aspiration biopsy (FNAB) cytology is benign, it is reasonable to use nonsurgical therapy. Any single cold nodule that remains or develops after treatment needs careful re-examination due to the high risk of malignancy.
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              Prevalence of thyroid cancer in Graves' disease: a retrospective study of a cohort of 103 patients treated surgically.

              BACKGROUND: Thyroid nodules in patients with Graves' disease (GD) are common, and the incidence of coexisting thyroid carcinoma is a much debated subject, which is addressed in this study. METHODS: In order to determine the incidence rate of coexisting malignancy, a retrospective study was conducted on 103 patients who underwent surgery for GD between 1990 and 2000 at the Cliniques Universitaires Saint-Luc in Brussels, Belgium. The patients were classified into groups. Those in group I had a solitary palpable nodule (4.9%), those in group II multiple palpable nodules (12.6%), group IIIa had nodule(s) revealed by imaging techniques (incidentalomas: 17.5%), and group IIIb had diffuse non-nodular goiter (65%). RESULTS: Patients with nodules (groups I, II, and IIIa) were found to have significantly more thyroid carcinomas than those with diffuse non-nodular goiters (P=0.02), and the rate of malignancy was significantly increased when the nodules were palpable (groups I and II; P=0.03). Eight patients (7.8%) were diagnosed as having coexisting carcinomas, all but one being microcarcinomas. CONCLUSIONS: Well-differentiated papillary carcinomas are found to coexist with GD surgically treated (7.8%) and occur most frequently in GD with palpable nodular lesions (35%). Even though the majority (88%) of coexisting carcinomas are microcarcinomas, the presence of palpable nodules justifies further evaluation and follow-up.
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                Author and article information

                Journal
                Indian J Nucl Med
                Indian J Nucl Med
                IJNM
                Indian Journal of Nuclear Medicine : IJNM : The Official Journal of the Society of Nuclear Medicine, India
                Medknow Publications & Media Pvt Ltd (India )
                0972-3919
                0974-0244
                Apr-Jun 2013
                : 28
                : 2
                : 125-126
                Affiliations
                [1]Department of Nuclear Medicine and PET, Post Graduate Institute of Medical Education and Research, Chandigarh, India
                Author notes
                Address for correspondence: Dr. Bhagwant Rai Mittall, Department of Nuclear Medicine and PET, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012, India. E-mail: brmittal@ 123456yahoo.com
                Article
                IJNM-28-125
                10.4103/0972-3919.118261
                3800311
                24163525
                94a42d7d-e5cd-4720-9b0d-b48492ce75e1
                Copyright: © Indian Journal of Nuclear Medicine

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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