An analysis of clinical, subclinical features of graves’ patients before endoscopic thyroid surgery – Tran Doan Ket

Journal of military pharmaco-medicine n o 8-2018 199 AN ANALYSIS OF CLINICAL, SUBCLINICAL FEATURES OF GRAVES’ PATIENTS BEFORE ENDOSCOPIC THYROID SURGERY Tran Doan Ket1; Tran Ngoc Luong1; Kieu Trung Thanh2 SUMMARY Objectives: To analyse clinical, subclinical features of Graves’ patients indicated endoscopic surgery. Subjects and methods: A prospective study based on data of patients undergoing endoscopic thyroid surgery in National Hospital of Endocrinology from 1 - 2005 to 5 - 2017. Results: Rate of goiter’s size in grade II was 88.2%. Mean volume of thyroid gland was 30.48 ± 1.15. Mean number of vessel spots was 3.42 ± 0.87. Subclinical: Serum T3 level: 1.55 ± 0.39 nmol/L, serum FT4: 17.25 ± 2.73 pmol/L, serum TSH 1.13 ± 0.92 µIU/mL. Serum TRAb: 10.48 ± 3.85 U/L. Conclusion: Clinical and subclinical examinations prior to endoscopic surgery for Graves’ patient are essential for prognosis, aiming to evaluate surgery, ensuring surgical safety. * Keywords: Grave disease; Endoscopic thyroid surgery; Subclinical and clinical features. INTRODUCTION Graves’ disease was a common autoimmune disorder in our country and all the world. In Europe, the annual incidence was 20 cases per 100,000 people. In America, this figure was 40 cases per 100.000 people. This disease was predominant in females, the incidence in female was 4 - 6 times higher than in males. The common age was from 20 to 50 [5]. In Vietnam, there have been no a national statistics on Graves’ disease. According to Le Huy Lieu, Graves disease accounted for 45.8% of patients with endocrine disease and 2.6% of internal diseases in Bachmai Hospital. Currently, there were 3 treatment options for Graves’ patient: internal treatment, radioactive iodine therapy and surgery. Each method had its own strengths and weaknesses, which needs appropriate indication. Open surgery for Graves’ disease has been strongly developed since the 1990s and has achieved extremely high results: 95 - 97% curable, the low incidence of accidents and complications [1]. However, open surgery also revealed some disadvantages such as pain, paresthesia in the neck, ugly scars even keloids. Thyroid and parathyroid endoscopic surgery was initiated in 1997 by Gagnet and today, from the basic foundation of open surgery, open endoscopic thyroid surgery has been completed and widely used [6]. 1. National Hospital of Endocrinology 2. 103 Military Hospital Corresponding author: Tran Doan Ket (drtranket72@gmail.com) Date received: 15/08/2018 Date accepted: 02/10/2018 Journal of military pharmaco-medicine n o 8-2018 200 In Vietnam, endoscopic thyroid surgery was first applied at National Hospital of Endocrinology in 2003 and later developed in many major hospitals in the country such as 103 Military Hospital, Binh Dan Hospital, Nhan Dan Hospital Gia Dinh, Cho Ray Hospital, 175 Military Hospital... and thyroid endoscopic surgery have confirmed the advantages such as: hidden scar, avoiding the risk of scarring and postoperative paresthesia in the neck, significantly improving aesthetics. Thyroid endoscopy was more significantly complex than conventional surgery, but so far, no studies have been adequately evaluated and systematized. Clinical, subclinical examinations can support and help surgeon set up the best endoscopic surgery plan for Graves’ patients and help them to stay stable soon with normal thyroid function. Therefore, we conducted a study with the aim: To analyze clinical and subclinical features of Graves’ patients before thyroid endoscopic surgery at National Hospital of Endocrinology (2005 - 2017). SUBJECTS AND METHOD 1. Subjects. Graves’ patient had received treatment at the National Hospital of Endocrinology from January 2005 to May 2017. * Selection criteria: Patients received internal treatment for 3 - 6 months with normal function of clinical and subclinical thyroid. Age ranged from 14 to 50. Goiter grading was grade Ib, grade II (WHO classification 1995). Patients desired for endoscopic surgery and agreed to participate in research. 2. Method. This is a prospective study. * Size: Convenient size from January 2005 to May 2017 was 76 patients meeting the research standards. * Variable, index: - Physical examination: + History: Age, gender, duration of illness. + Thyroid examination: Evaluation of thyroid: size, density, mobility, thyroid classification by WHO (1995). - Subclinical examination: + Thyroid volume: Based on thyroid ultrasound, using two-dimensional black and white ultrasound, flat probe with frequency from 5 - 10 MHz to measure thyroid volume. + Number of vessel spots: Based on thyroid color Doppler ultrasound. Number of vessel spots per centimeter increased when it is higher than 2.5 spot (normal ≤ 2). + Heart rate: Measured by electrocardiogram. + Blood test: Thyroid hormone (T3, FT4) and TSH - pituitary hormone were measured by the spectrophotometric method. + TrAb: Measured TrAb by receptor radioimmunoassay (RRA). Normal value of labo: TRAb < 1.5 U/L. The thyroid hormone test was performed by the Ci 8,200 machine provided by ABBOTT, according to the spectrophotometric method. Normal: T3 from 1 to 3 nmol/L. FT4 from 9 to 25 pmol/L. TSH from 0.3 to 5.5 miU/mL. The thyroid hormone test and TRAb test were performed at Department of Journal of military pharmaco-medicine n o 8-2018 201 Biochemistry and Immunology Labo of National Hospital of Endocrinology. * Analyzing data: The results were recorded on the sample form. The data were collected and analyzed by using SPSS 16.0 statistical software. * Research ethics: The study was agreed by the selected patients and approved by Hospital Science Council and by National Hospital of Endocrinology. All information of the patients were kept confidential. RESULT AND DISSCUSSION 1. Features of patients. * Age distribution of 76 patients: ≤ 20 years old: 12 patients (15.8%); 21 - 30 years old: 47 patients (61.8%); 31 - 40 years old: 16 patients (21.1%); 41 - 50 years old: 1 patient (1.3%); average age: 26.38 ± 6.02. Group of patient from 21 to 30 occupied the highest proportion (61.8%). The majority was in the youth age, being the staffs who have high demand of aesthetics. In the study, one patient aged 46 who had a social place, frequent communication. Together with the development of the society, the application of endoscopic techniques is also of great necessity. * Duration of illness (n = 76): According to Nguyen Ngoc Trung, average internal treatment time was 17.0 ± 3.1 months; Nguyen Huu Binh: 20.3 ± 3.5 months. The shortest duration of illness in our study was 4 months, the longest one was 132 months, mean time 50.85 ± 37.06 [3, 4]. 2. Clinical and subclinical features. * Clinical features: - Classification of goiter grading according to WHO (1995) (n = 76): Grade Ia: 0 patient; grade Ib: 9 patients (11.8%); grade II: 67 patients (88.2%); grade III: 0 patient. - Grades of goiter: According to Do Trung Quan, goiter in Graves’ disease was a diffuse goiter, grade II occupied 70.62%, grade III occupied 13.03% [2]. Clinical examination of the thyroid’s size and ultrasonography evaluated thyroid volume as one of the factors determining the surgical decision. Authors often indicated open surgical treatment for Graves’ disease with goiter in grade II and grade III. However, the endoscopic surgery was performed in patients with too large goiter would be more difficult because of many limitations, so we chose goiters in grade Ib and grade II. * Subclinical features: - Volume of thyroid gland on ultrasound (n = 76): Thyroid volume was determined by conventional thyroid ultrasound, ultrasound was a necessary test and increasingly applied in clinical specialties, especially in diagnosis of thyroid disease. Ultrasound could measure volume and thyroid morphology and help surgeons indicate an endoscopic or open surgery. In our study of 76 patients, the patient had a minimum volume of 12.5 cm3 and a maximum of 65 cm3, with an average of 30.48 ± 1.15 cm3. If the volume was too large, the operation time would be longer. Journal of military pharmaco-medicine n o 8-2018 202 Table 1: Number of vessels before and after lugol treatment (n = 76). Vessel Min Max Mean Before 1 5 3.42 ± 0.87 After 0.5 3.5 1.89 ± 0.74 Number of vessel spots was determined by thyroid Doppler ultrasonography. We performed thyroid Doppler ultrasound to evaluate vessel spots and thyroid blood flow. The smallest number of spots in our study was 1.0 and the largest was 5 spots. After a 7-day treatment with lugol, the smallest number of spots was 0.5 and the largest was 3.5. We found that the higher number of vessel spots, the more the thyroid blood flow and the more difficult the surgery was , the more bleeding was. Table 2: Thyroid and pituitary hormone test before surgery (n = 76). Hormone Min Max Mean Normal T3 (nmol/L) 0.86 2.9 1.55 ± 0.39 1.0 - 3.0 FT4 (pmol/L) 10.22 21.72 17.25 ± 2.73 9.0 - 25.0 TSH (µIU/mL) 0.03 3.5 1.13 ± 0.92 0.3 - 5.5 TRAb (U/L) 1.0 21.0 10.48 ± 3.85 1 - 1.58 Thyroid and pituitary hormone: All 76 patients in the study group were tested for serum T3, FT4 and TSH levels before surgery. All patients had T3 levels, FT4 was within normal limits. 02 cases had higher TSH than normal and 3 cases were lower than normal but T3 and FT4 were within the normal range, accompanied by clinical symptoms without manifestations of hyperthyroidism or hypothyroidism. This could be explained by the thyroid hormone TSH secreted by the anterior pituitary gland, which regulates T3 and FT4 production in the thyroid without directly causing clinical manifestations of thyroid gland function. Hence, the TSH level was always fluctuated to remain production of thyroid hormones flat. Thus, all patients in our study were clinically normal. - TrAb antibody test: Cappelli. C showed that Graves’ disease was an autoimmune disorder, characterized by the presence of autoantibody TrAb that stimulates the thyroid gland. TRAb played a role in the diagnosis and follow-up of treatment based on disease. It helped identify the patients who are likely to be cured for short-term treatment, who should continue to maintain antithyroid drugs longer and who need optimal interventions such as surgery or radioiodine [7]. TRAb was an antibody against TSH receptor of thyroid cells, which had a diagnostic value as it is elevated and had a prognostic value in the treatment of disease, recurrence, and surgical indication in the Graves’ disease. CONCLUSION The average duration of internal treatment was 50.85 ± 37.06 months. Patients with grade II goiter had a major proportion (88.2%). Mean volume of thyroid gland was 30.48 ± 1.15. Mean number of vessel spots was 3.42 ± 0.87. Subclinical: serum T3 level: 1.55 ± 0.39 nmol/L, serum FT4: 17.25 ± 2.73 pmol/L, serum TSH 1.13 ± 0.92 µIU/mL. Serum TRAb: 10.48 ± 3.85 U/L. Journal of military pharmaco-medicine n o 8-2018 203 REFERENCES 1. Tạ Văn Bình. Bệnh Grave-Basedow. Bệnh học Tuyến giáp. NXB Y học. 2003, tr.111-154. 2. Đỗ Trung Quân. Basedow. 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