Objective: Recently, small medullary thyroid carcinomas (smallMTCs; %1.5 cm) are frequently diagnosed, occasionally as incidental findings in surgical specimens. Their clinical course varies. We examined tumour size as a predictor of clinical behaviour. Design: A retrospective study. Methods: A total of 128 smallMTC patients (35.2% males and 45% familial) were followed up for 0.9-30.9 years. According to tumour size (cm), patients were classified into four groups: group 1, 0.1-0.5 (nZ33); group 2, 0.6-0.8 (nZ33); group 3, 0.8-1.0 (nZ29) and group 4, 1.1-1.5 (nZ33). Results: Pre-and post-operative calcitonin levels were positively associated with the tumour size (P!0.001). Capsular and lymph node invasion were more frequent in groups 3 and 4 (P!0.03); the stage was more advanced and the outcome was less favourable with an increasing tumour size (P!0.001). Groups 1 and 2 patients were more frequently cured (group 1, 87.8%; group 2, 72.7%; group 3, 68.9%; and group 4, 48.5%; PZ0.002). The 10-year probability of lack of disease progression according to the tumour size differed between patients with tumour sizes of 0.1-1.0 and 1.1-1.5 cm (96.6%, 81.3%, x 2 Z4.03, PZ0.045 for log-rank test). Post-operative calcitonin was the only predictor significantly associated with the 10-year progression of disease. Post-operative calcitonin levels R4.65 pg/ml predicted disease persistence (sensitivity 93.8% and specificity 90%) and R14.5 pg/ml predicted disease progression (sensitivity 100%, specificity 82%, receiver operating characteristic curve analysis). Conclusions: Tumour size may be of clinical importance only in patients with MTCs O1 cm in size. Post-operative calcitonin is a more important predictor than size for disease progression.

OBJECTIVE Environmental factors are involved in goiter development. An increased number of goitrous patients were identified among outpatients in Gyrocaster, a mountainous region in Southwestern Albania. We examined possible associations of thyroid enlargement with nutritional factors. DESIGN 112 consecutive patients, 104 females, aged 52.8 ±12.1 (mean±SD), who either were taking thyroxine (n=27) or were suspected to have thyroid disease were examined. Thyroid parameters and nutritional habits were recorded and serum selenium and urine iodine levels were determined; thyroid ultrasound was performed. RESULTS The median thyroid volume (TV) was 20.4ml (range 4.4-97.6). All consumed food was home-produced. TV correlated negatively with the frequency of lamb-goat meat and vegetables consumption (p=0.05 and p=0.03, respectively). Mean TV was significantly lower in those eating lamb-goat >1 times/week (21.4±13.3 vs 31.9±23 ml, p<0.01). The association of TV with lamb meat consumption was independent of sex, education or occupation (p<0.009). Selenium levels ranged from 30.6-138μg/L (reference range 43-190). There was no association between selenium levels and TV. 43% of the subjects had TSH<0.3 mU/L (those on thyroxine were excluded). Log TSH correlated negatively with TV and fT4 levels (p<0.007), indicating the presence of autonomy (TSHRab positive in two subjects). Mean urinary iodine excretion was 99.8±35.3μg/gr creatinine (normal >100). CONCLUSIONS Nutritional factors may be involved in the development of goiter in Southwestern Albania. No role of selenium was found. The higher consumption of lamb-goat meat and vegetables, all non-industrialized, appeared to be protective. This finding may reflect better socioeconomic status, although this was not identified. Unrecognized subclinical hyperthyroidism, probably due to thyroid autonomy, was quite common.