Nodular goiter--is thyroxine medication of any value?

Investigation of TSH dependency, circulating thyroid autoantibody, and morphological features of recurrent nontoxic goitre

Pathogenetical factors possibly responsible for recurrence of nontoxic goitre in a nonendemic area are evaluated. A group of 22 female patients admitted for surgical treatment of recurrent nontoxic goitre was compared with a control group of 86 female nontoxic goitrous patients not operated upon before. Preoperative serum baseline thyrotrophin levels in the recurrent goitre group were low normal and did not differ significantly from those in the control group. Circulating thyroid microsomal autoantibodies, thyroglobulin antibody titers, and the densities of lymphocytic aggregation in goitrous tissue did not differ significantly in the two groups. Thus, none of the parameters studied were likely explanations of regrowth of goitre.

Extended Resection for Thyroid Disease has Less Operative Morbidity than Limited Resection

BACKGROUND

Theodor Kocher, surgeon and Nobel laureate, has influenced thyroid surgery all over the world: his treatment for multinodular goiter-subtotal thyroidectomy-has been the "Gold Standard" for more than a century. However, based on a new understanding of molecular growth mechanisms in goitrogenesis, we set out to evaluate if a more extended resection yields better results.

METHODS

Four thousand three hundred and ninety-four thyroid gland operations with 5,785 "nerves at risk" were prospectively analyzed between 1972 and 2002. From 1972 to 1990, the limited Kocher resections were performed, and from 1991 to 2002 a more radical resection involving at least a hemithyroidectomy was performed.

RESULTS

The incidence of postoperative nerve palsy was 3.6%; in the first study period and 0.9%; in the second (P < 0.001, Fisher's exact). Postoperative hypoparathyroidism decreased from 3.2%; in the first period to 0.64%; in the second (P < 0.01). The rate of reoperation for recurrent disease was 11.1%; from 1972 to 1990 and 8.5%; from 1991 to 2002 (P < 0.01).

CONCLUSIONS

Extended resection for multinodular goiter not only significantly reduced morbidity, but also decreased the incidence of operations for recurrent disease. Our findings in a large cohort corroborate the suggestions that Kocher's approach should be replaced by a more radical resection, which actually was his original intention more than 130 years ago.

[The role of intraoperative ultrasound in surgery for benign nodular goiter]

BACKGROUND

In treating benign nodular goiter, selective surgery taking into account morphology and function is better than standard subtotal resection for reducing the frequency of nodules in the thyroid remnant. Intraoperative ultrasound (IOPUS) may additionally influence operative radicality and also the incidence of remaining nodules.

METHODS

One hundred consecutive patients with benign nodular goiter were operated on with IOPUS; the specimens were compared with results of preoperative ultrasound and intraoperative palpation. Of these patients, 80 were reinvestigated after 3+/-1.6 years. A series of 80 patients with the same operative strategy but without IOPUS was used as control group, having been reinvestigated sonographically 1 year postoperatively, and was compared to the IOPUS group with respect to operative procedures, size of remnants, and sonography of lesions in thyroid remnants.

RESULTS

In 35% of the thyroid lobes, preoperatively undetected nodules could be identified additionally by IOPUS, which also provided information on extent and structure in a further 20%. It resulted in the indication for more radical surgery in 24% and greater tissue preservation in 10%. Compared to surgery without IOPUS, IOPUS-guided surgery was more radical (total lobectomy in 40% vs 24%, nonresected lobes in 16% vs 26%, P<0.05) and showed a lower incidence of nodules in remnants at follow-up (2.5% vs 12.5%, P<0.05).

CONCLUSIONS

With IOPUS, more nodules are detectable, size and structure of the remnants are optimized, and the number of nodular lesions in thyroid remnants is lower. Thus, an even lower risk of recurrence can be expected for long-term follow-up. All in all, the routine use of IOPUS can be advocated, with maintenance of the selective operative strategy.

Evolution de la chirurgie thyroïdienne vers la thyroïdectomie totale

OBJECTIVES

To study the place of the total thyroïdectomy compared to the sub-total thyroidectomy and the lobectomy in benign nodular thyroid pathology, about complications and prevention of the recurrence.

PATIENTS AND METHODS

The evolution of the number and the type of thyroïdectomy among the total thyroidectomy, subtotal thyroidectomy and the lobectomy was analyzed in a retrospective study including 735 patients in the service of Head and Neck Surgery in the University Hospital in Amiens, France over a 12 years period, for a multinodular goiter, a toxic and a nontoxic solitary nodule. The post-operative transient and permanent recurrent nerve paralysis and hypocalcemia of the total thyroidectomies were studied and compared with the other surgical procedures of the study and in a review of the literature in order to study benefit and risks.

RESULTS

Multinodular goiters were the most thyroid pathologies (80%). The total thyroidectomy became gradually the most frequent surgical procedure, from 17% to nearly 70% of the surgical procedures over 12 years, with depend on the currently abandoned subtotal thyroidectomy and the lobectomy. No significant difference appeared concerning the recurrent and parathyroid complications between the 3 procedures.

CONCLUSION

The post-operative morbidity is not statistically different between the total thyroidectomy and the other procedures. The total thyroidectomy prevents moreover nodular recurrences whose surgical treatment is difficult without benefit of the L-thyroxine treatment prevention. It implies a substitute opotherapy that the other surgical techniques cannot nevertheless always avoid. Nowadays, the total thyroidectomy is the gold treatment for surgical treatment of multinodular benign goiters. Many factors must be considered concerning the solitary nodules: the size, the evolutivity, the fine needle aspiration the aspect of the contralateral lobe. In all the cases, the decision will have to be consensual between the patient, the endocrinologist and the surgeon.

Total versus subtotal thyroidectomy for the management of benign multinodular goiter in an endemic region

BACKGROUND

Because controversy still continuous to surround use of total thyroidectomy for the management of benign multinodular goiter, the present study aims to prospectively compare the safety and efficacy of total thyroidectomy with subtotal thyroidectomy.

METHODS

A total of 200 consecutive patients with benign multinodular goiter were assigned to have either total thyroidectomy (n = 105) or subtotal thyroidectomy (n = 95) based on preoperative evaluation, intraoperative macroscopic findings and nodular dissemination. The patients with no healthy tissue or nodules localized in the dorsal part of the gland, which are usually left during normal subtotal resection, were assigned to the total thyroidectomy group. Demographic details, biochemical findings, indications for operation, operating time, specimen weight, complications and hospital stay were noted.

RESULTS

There was no significant difference in the sex, hormonal status or duration of goiter between the two groups (P = 0.74, P = 0.59 and P = 0.59, respectively). The mean operating time was longer (148.52 min +/- 51.10 vs 135.10 min +/- 32.47, P = 0.03), and the mean weight of the specimens was greater (228.40 g +/- 229.91 vs 157.01 g +/- 151.23, P = 0.01) for total rather than subtotal thyroidectomy. Either temporary recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism occurred in 10 (9.3%) or 12 (11.4%) of the patients undergoing total compared with six (6.3%) or nine (9.5%) of the patients undergoing subtotal thyroidectomy (P = 0.40 and P = 0.65, respectively). Either permanent RLN palsy or hypoparathyroidism was observed in one patient undergoing total thyroidectomy (P = 0.34 for each comparison). The mean hospital stay was longer in the total thyroidectomy group (2.24 days +/- 1.18 vs 1.89 days +/- 0.72 for subtotal thyroidectomy, P = 0.01).

CONCLUSIONS

The present study shows that total thyroidectomy can be performed without increasing risk of complication, and it is an acceptable alternative for benign multinodular goiter, especially in endemic regions, where patients present with a huge multinodular goiter.

Predictive factors for recurrence after thyroid lobectomy for unilateral non-toxic goiter in an endemic area: Results of a multivariate analysis

BACKGROUND

The aim of the study was to identify the factors that are predictive of recurrence after thyroid lobectomy for unilateral non-toxic thyroid goiter in an endemic region through a multivariate analysis.

METHODS

Two hundred sixty-eight consecutive patients who underwent thyroid lobectomy and who were evaluated by the same endocrinologist were included. Univariate and multivariate analysis analyzed the relationship between sex, age, preoperative thyroid-stimulating hormone, duration of disease, duration of levothyroxine (LT4) preoperative therapy, cytologic results, histologic results, resected thyroid weight, numbers and diameters of thyroid nodules, morphologic alterations of the remnant lobe, follow-up length, postoperative LT4 therapy, ultrasonographic evidence of recurrence, and reoperation.

RESULTS

The incidence of recurrence was 33.9% (91/268 patients) after a mean follow-up time of 79.9 months (range, 12-251 months), female sex ( P = .016), multiple nodules ( P = .017), and lack of postoperative LT4 therapy ( P = .0009) were predictive factors of recurrence. Reoperation was performed in 20 patients (7.4%); factors that were predictive of reoperation were the presence of multiple nodules ( P = .008), resected thyroid weight ( P = .00006), and lack of postoperative hormonal therapy ( P = .0005).

CONCLUSIONS

Thyroid lobectomy for unilateral non-toxic goiter, when combined with suppressive or substitutive thyroxin therapy, resulted in a low rate of recurrence and reoperation in an endemic area.

Iodized salt improves the effectiveness of L-thyroxine therapy after surgery for nontoxic goitre: a prospective and randomized study

OBJECTIVE

To investigate whether the addition of iodized salt to daily diet in thyroidectomized patients for nontoxic goitre could influence the effectiveness of nonsuppressive L-thyroxine (L-T4) therapy on thyroid remnant size, during 12 months' follow-up after thyroid surgery.

DESIGN AND PATIENTS

A consecutive series of selected 139 patients (26 males, 113 females; median age 45 years, range 30-69 years) living in a moderate iodine-deficient area, and undergoing thyroid surgery for nontoxic multinodular goitre, was enrolled. Patients were assigned randomly to two different therapeutic regimens: 70 patients received L-T4 therapy alone (Gr. L-T4), while the remaining 69 patients took iodized salt on a daily basis in addition to L-T4 treatment (Gr. L-T4 + I). In both groups, the initial L-T4 dose was 1.5 microg/kg/day, which, in our experience, has been shown to be intermediate between suppressive and replacement doses. To avoid the risks of mild thyrotoxicosis and to limit the excessive TSH stimulation of the thyroid remnant, the L-T4 dose was adjusted in those patients with serum TSH levels outside the lowest two-thirds of the normal range (0.3-2.5 mU/l). An ultrasound evaluation of thyroid remnant size was performed after thyroid surgery and 12 months later.

RESULTS

After surgery, the median thyroid remnant volume was 3.5 ml (range 0.4-13.9 ml) in Gr. L-T4 and 4.6 ml (range 0.5-12.7 ml) in Gr. L-T4 + I (P = 0.06). After 1 year of follow-up, the patients treated with L-T4 + I obtained a remnant volume reduction (-39.7%, range -87.0% to +91.2%) significantly (P = 0.006) greater than that observed in patients assuming L-T4 alone (-10.2%, range -89.4% to +85.0%). However, the percentage of patients showing an increase in remnant size in the months following surgery was higher in Gr. L-T4 than in Gr. L-T4 + I (22/60 vs. 9/66; P = 0.01). In Gr. L-T4 patients the thyroid remnant volume variation throughout 12 months of treatment was correlated significantly with the size of the thyroid remnant found at the first ultrasound evaluation (R(2) = 0.3; P < 0.001). No such correlation was found in Gr. L-T4 + I patients, for whom the therapy maintains a similar effectiveness in patients with either a large or a small postsurgery thyroid remnant. In patients treated with L-T4 alone, the remnant volume variation was correlated significantly with the median serum TSH values attained in the course of treatment (R2 = 0.4; P < 0.001). The highest reduction in remnant volume was observed only by lowering the serum TSH concentrations. In patients treated with L-T4 plus iodine, instead, the thyroid remnant volume reduction occurred independently of the plasma TSH levels attained in the course of treatment.

CONCLUSIONS

Our short-term prospective and randomized study leads us to conclude that, in patients living in a moderate iodine-deficient area and undergoing thyroid surgery for nontoxic goitre: (1) the iodine prophylaxis improves the effects of postsurgery nonsuppressive L-T4 therapy on thyroid remnant size. (2) In patients treated with L-T4 alone the therapeutic effectiveness decreases in the presence of a large postsurgery thyroid remnant. With the addition of iodine, the L-T4 maintains a similar efficacy in patients with either a large or a small remnant. (3) During treatment with L-T4 alone the highest therapeutic effectiveness is attained by lowering the plasma TSH concentration. With the addition of iodized salt to the daily diet the effects of L-T4 on remnant size are relevant independently of the TSH levels.

Long-term follow-up of contralateral lobe in patients hemithyroidectomized for solitary follicular adenoma

OBJECTIVES

Since there are no available conclusive studies on the long-term evolution of remnant thyroid tissue after hemithyroidectomy in patients who undergo surgery for solitary follicular adenomas, we searched for such cases in our records to elucidate this issue.

DESIGN

Search criteria were as follows: (i) presence of a single palpable thyroid nodule with the remainder of the gland normal on palpation; (ii) clinically euthyroid status at the time of surgery; (iii) histological diagnosis of nodule as follicular adenoma; (iv) a hemithyroidectomy operation, sparing the contralateral lobe; (v) normal macroscopic aspect of the contralateral lobe at the time of surgery; and (vi) at least 4 years of postoperative follow-up.

PATIENTS

Only 47 female cases were found to meet above criteria, with a mean age of 45.9 years (range: 23-79) at the time of surgery and a mean follow-up of 7.2 years (range: 4-32). Besides evaluating the presence or absence of antithyroid antibodies and the extranodular histology of tissue removed during surgery, a preoperative TRH test also allowed patients to be classified into two groups: normal extranodular thyroid (NET) (n = 32) and abnormal extranodular thyroid (AET) (n = 15).

RESULTS

Eleven of the 15 patients with AET had thyroid autoimmunity, with or without overt histological thyroiditis, and the remaining four had subclinical hypothyroidism with negative antithyroid antibody titres. In the entire study population, only 28 patients received treatment with L-T4 immediately after surgery, none of whom had any alterations in the contralateral lobe. However, six of the nineteen patients not treated with T4 (31.6%) developed overt abnormalities in the contralateral lobe, including the only three with AET who had not received L-T4 treatment. The remaining three were two patients with NET, who showed postoperative TSH hyper-responsiveness to TRH (peak TSH > 25 mU/l), and one who developed a new follicular adenoma 32 years later. To date, none of the patients with NET, who had a normal TRH test after surgery, have developed any kind of alterations in the contralateral lobe, even those who received no L-T4 prophylactic treatment.

CONCLUSIONS

The findings of this study suggest that: (i) there is a higher risk of follicular adenomas developing in a gland affected by thyroid autoimmunity than in a previously normal gland; (ii) L-T4 therapy may prevent the formation of new nodules or the development of goitre in the contralateral lobe; and (iii) in the absence of prophylactic treatment after surgery, the contralateral lobe of subjects with thyroid autoimmunity and/or previous subclinical hypothyroidism develops morphological abnormalities.

Postintervention serum TSH levels may be useful to differentiate patients who should undergo levothyroxine suppressive therapy after thyroid surgery for multinodular goiter in a region with moderate iodine deficiency

Recent studies have raised doubts about the efficacy of the postoperative use of levothyroxine (LT4) suppressive doses in patients who underwent thyroid surgery for multinodular goiter. The purpose of this retrospective study was to examine the efficacy of different doses of LT4 in preventing postsurgical recurrences of simple multinodular goiter and to identify a marker that could be useful in discriminating patients with a higher risk of developing recurrence. Two hundred thirty-two patients (57 male, 175 female) operated for nontoxic multinodular goiter were divided into two groups: (I) patients with normal postsurgery thyrotropin (TSH) levels (0.25 to 4.5 mU/L) and (II) patients with elevated postsurgery TSH levels (>4.5 mU/L). All patients were subjected to replacement (1.3 microg LT4/kg/day) or suppressive (1.7 microg LT4/kg/day) doses of LT4, and they were followed for a median period of 6 years (range 2 to 12). No statistical difference was found for sex, age, and postsurgery serum TSH between patients submitted to suppressive and replacement therapy. The ultrasound (US) detection of new postsurgery nodules of at least 0.5 cm maximum diameter was considered a recurrence of disease and was found in 10% of the cases studied. Patients with normal postsurgery serum TSH showed a high recurrence rate (30.4%) when submitted to lower daily doses of LT4. In patients with elevated postsurgery serum TSH, the rate of nodular goiter recurrence did not vary with different types of LT4 therapy. In conclusion, our results suggest that the postsurgical serum TSH is useful for prediction of nodular goiter recurrence, as it reflects the amount of residual functioning thyroid tissue in the cervical area. It may also be indicative of patients who might benefit from LT4 suppressive therapy.

Postoperative Suppressive Therapy for Thyroid Adenomas

Thyroid adenoma is a common disease. If partial thyroidectomy is performed, postoperative suppression therapy is often given to avoid nodule development in the remaining thyroid. It is unclear whether this treatment is warranted. Patients who underwent a partial thyroidectomy with a histologic diagnosis of follicular thyroid adenoma from January 1985 until February 1998 were studied retrospectively. Patients were analyzed on the basis of postoperative therapy, new thyroid nodule growth, and costs. Seventy-six patients were identified with a recurrence rate of 4 per cent (3/76). Sixty-one per cent (46/76) were treated with postoperative thyroid suppression therapy, and no difference in new nodule development was noted with at least 6 months of follow-up ( P = 0.274). No patients required reoperation. A large cost saving was shown for patients who were not treated with levothyroxine. We conclude that postoperative thyroid suppression may not be routinely indicated. A prospective, randomized study would be necessary to answer this question conclusively.

Assessing the effects of thyroid suppression on benign solitary thyroid nodules. A model for using quantitative research synthesis

Systematic review of the available information with a modified, largely quantitative method of research synthesis disclosed that an initial trial of thyroid hormone suppression therapy leads to clinically significant (> or = 50%) reduction of nodule size or arrest of nodule growth in a subset of patients with benign solitary thyroid nodules. In fact, in addition to objective improvements due to decreasing nodule size, L-T4 suppression therapy may benefit patients by reducing perinodular thyroid volume. Consequently, both pressure symptoms and cosmetic complaints may improve (9, 68). Additional studies for the assessment of the risks versus benefits of supraphysiologic doses of L-T4, the optimal level of thyroid suppression and the dose needed to achieve this magnitude of reduction, the optimal length of the initial trial, and the conditions for the continuation of L-T4 thyroid suppression therapy, as well as the identification of markers for patients most likely to respond to this therapy, are warranted. Finally, quantitative assessment of available evidence as described here may be applicable to the review of other controversial issues as well.

Effectiveness of prophylactic therapy on goiter recurrence in an area with low iodine intake--a sonographic follow-up study

There is no agreement as to whether or not drug treatment after surgery for nodular goiter is effective in preventing recurrence of goiter. Data about recurrences in areas of marginally low iodine intake (like Germany) vary widely. Therefore, we performed a retrospective study in 104 patients who had been treated surgically because of benign uninodular or multinodular goiter. The mean follow-up period was 6.4 years (minimal 1 year) with at least three examinations. Thyroid ultrasound with volumetric analysis was recorded in each patient. Thirty-two patients did not receive any prophylaxis, 50 patients were treated with L-thyroxine, 17 patients with a combination of L-thyroxine and iodine and 5 patients with iodine alone. Recurrence of goiter was documented in 28.0% of the untreated patients and in 8.9% of the patients on prophylaxis (P < 0.05). The mean increase of thyroid volume was 7.3 ml versus 3.1 ml in patients without versus with prophylactic drug treatment (not significant). No significant correlation was found between the increase of thyroid volume and age of the patients, follow-up time, or initial thyroid volume, respectively. These data clearly demonstrate the effectiveness of prophylactic drug therapy to prevent recurrence of goiter after thyroid surgery in an iodine-deficient area.

Preventive effect of levothyroxine in patients operated for non-toxic goitre: a randomized trial of one hundred patients with nine years follow-up

OBJECTIVE

Earlier reports have shown different effects of levothyroxine in the prevention of recurrence of non-toxic goitre after operation. These studies have been either retrospective or of short-term follow-up. This study was designed to evaluate the efficacy of long-term Eltroxin treatment (levothyroxine 0.1 mg daily) in the prevention of post-operative recurrence of non-toxic goitre.

DESIGN

Randomized prospective non-placebo controlled study with 9 years follow-up. Group A (n = 40) received levothyroxine and group B (n = 60) did not.

PATIENTS

One hundred patients consecutively operated for non-toxic goitre. All clinically and biochemically euthyroid and none taking any thyroid and/or antithyroid medication.

MEASUREMENTS

T3, T4, TSH, thyroid antibodies (microsomal/thyroglobulin), weight and neck circumference were measured and thyroid palpation were done preoperatively, 3 and 12 months after surgery and thereafter yearly up to 9 years.

RESULTS

Sixty-nine patients completed 9 years follow-up. Incidence of recurrence in group A vs group B was 14.5 vs 21.8% (P < 0.05) irrespective of type of operation, pathoanatomical diagnosis, removed amount or remnant size of the thyroid gland and level of TSH.

CONCLUSION

No preventive effect on incidence of recurrence of goitre by Eltroxin 0.1 mg daily in patients operated for non-toxic sporadic goitre was observed.

Thyroid hormone suppressive therapy of sporadic nontoxic goiter

Thyroid hormone has been used to reduce the size of sporadic nontoxic goiter since 1894. Noncontrolled clinical studies suggest that about two thirds of goiters respond to therapy, and a recent randomized clinical trial confirms the efficacy of suppressive therapy for sporadic nontoxic goiter. Efficacy is at least partly correlated with suppression of pituitary TSH production, response is usually evident by 3 months, relapse occurs when therapy is withdrawn, and nodular goiters may be less responsive than diffuse goiters. Some, but not all, series suggest that postoperative use of thyroid hormone suppressive therapy prevents recurrence of benign goiter. Three recent randomized trials suggest that thyroid hormone administered for 6 months to 3 years does not reduce the size of solitary thyroid nodules. About one third of nodules regressed in both treatment and placebo groups. Long-term studies are needed to define the effects of thyroid hormone suppressive therapy on the growth of goitrous lesions based on their underlying pathophysiology.

Endemic goiter and endemic thyroid disorders

The primary role of iodine deficiency in goitrogenesis and the prevention and treatment of endemic goiter by iodine supplementation is firmly established. Unfortunately, implementation of iodine prophylaxis programs has met with considerable technical and socioeconomic difficulties. Besides, lack of knowledge concerning some of the other causative factors of endemic goiter has prevented development of appropriate measures for its complete eradication in those areas where goiter persists in spite of prolonged and adequate iodine supplementation. At present, no less than 5% of the world's population have goiters and associated disorders, resulting in a public health and socioeconomic problem of major proportions. Seventy-five percent of people with goiter live in less developed countries where iodine deficiency is prevalent. Goiter prevalence rates of more than 50% and the highest frequency of severe cases of iodine deficiency disorders, namely, cretinism, congenital hypothyroidism, and various degrees of impairment of growth and mental development are found in endemic areas with extreme iodine deficiency. Goiters are usually multinodular and of very large size, producing, on occasion, signs of compression that require surgery. Recurrence rates are as high as 25-30% and second surgery accounts for 16% of all thyroidectomies. Unfortunately, most of these goiters occur in areas with highly restricted medical and surgical facilities. Twenty-five percent of people with goiters live in more developed countries where goiter continues to occur in certain areas despite iodine prophylaxis. Iodine-sufficient goiters are associated with autoimmune thyroiditis, hypothyroidism, hyperthyroidism, and thyroid carcinoma. Goiter is of considerable surgical significance in iodine-sufficient endemic areas and, to a lesser degree, in nonendemic areas where it is called "sporadic" goiter. Recurrence rates of iodine-sufficient goiter are 10-19% following thyroidectomy. Since most of these goiters grow by mechanisms other than increased thyrotropin (TSH) stimulation, treatment with suppressive doses of L-thyroxine is inefficient and, because of possible complications, not recommended. Although Graves' hyperthyroidism is not directly related to endemic goiter, it does relate adversely with ingestion or administration of iodine. At present, Graves' disease is treated with 131I or antithyroid drugs in more than 90% of the cases. The incidence rates of papillary, follicular, and anaplastic thyroid carcinomas appear to be related to endemic goiter and iodine supplementation, with surgery being required in essentially all of these cases.

Is a more active attitude warranted in patients with subclinical thyrotoxicosis?

In 1985 one of the new sensitive thyroid stimulating hormone (TSH) assays was introduced as part of our laboratory routine for thyroid function testing. Consequently, we now routinely identify a small but not insignificant group of patients with 'subclinical thyrotoxicosis', i.e. a low serum TSH in conjunction with a normal serum free T4. We here present the results of a 2-year follow-up investigation, which includes 40 patients with subclinical thyrotoxicosis and 40 euthyroid control patients. The group with subclinical thyrotoxicosis was characterized by a mean age of 65 years and a high prevalence of nodular goitre. Twelve (30%) of the patients but none of the individuals in the control group were treated during the follow-up period because of clinical thyroid disease. Atrial fibrillation was found in 11 (28%) patients compared to four (10%) of the controls. Therapy should be considered more often than previously in patients with nodular goitre and subclinical thyrotoxicosis, particularly in conjunction with atrial fibrillation.

The long-term outcome of thyroidectomy for sporadic non-toxic goitre

To study the long-term outcome after thyroidectomy, 113 sporadic non-toxic goitre patients who underwent thyroidectomy in our hospital in the period 1974-1983, were studied. Five patients complained of recurrent goitre; a goitre was found on inspection and palpation in these five and in 15 others. There were no differences between the 20 patients with goitre and the 93 patients without goitre with regard to sex, age, duration of goitre, indication and type of thyroidectomy, postoperative thyroid hormone medication, period of follow-up, and T4, T3, or TSH plasma values at the time of follow-up examination. Twenty-three patients complained of voice changes since thyroidectomy. In a case control study, included in this follow-up study, 19 patients with goitre, i.e. thyroid size I and II as estimated by inspection and palpation (cases), and 16 patients without goitre, i.e. thyroid size OA and OB (controls), were studied in more detail. No difference between cases and controls was found in any of the above mentioned parameters that could explain the recurrence of goitre. Thyroid volume (median) was greater in the cases (34.1 ml, range 7.9-83.4) than in the controls (10.3 ml, range 2.5-48.7) (P less than 0.001), although a considerable overlap between the two groups was observed. One or more thyroid nodules were found in 89.5% of the cases and in 62.5% of the controls (NS). Serum thyroid growth stimulating immunoglobulin (TGI) was present both in cases (68%) and controls (50%). TGI was present in high titres in all five patients who complained about recurrent goitre.(ABSTRACT TRUNCATED AT 250 WORDS)

Recurrence of thyroid nodules after surgical removal in patients irradiated in childhood for benign conditions

To determine the incidence of benign thyroid nodules and the risk factors for their recurrence after surgical removal, we followed 511 patients for 1 to 40.6 years (median, 11.2) after surgery for benign thyroid nodules arising after local irradiation for unrelated benign diseases in childhood. Recurrent thyroid nodules developed in 100 patients (19.5 percent). The risk of recurrence correlated inversely with the amount of thyroid tissue removed. Women had a higher recurrence rate than men (28.4 percent vs. 10.3 percent; P less than 0.05). Among the 299 patients who had been treated with thyroid hormone at the discretion of their physicians to suppress thyroid-stimulating hormone, 25 had recurrences (8.4 percent), as compared with 72 of 201 patients who did not receive thyroid hormone (35.8 percent) (hazard ratio taking into account the extent of surgery and the patient's sex, 2.5; 95 percent confidence interval, 1.5 to 4.1). Histologic analysis of the 73 tissue samples from patients with recurrences showed that 14 samples (19.2 percent) were malignant. Thyroid hormone treatment had no effect on the rate of thyroid cancer. We conclude that radiation-associated benign thyroid nodules have a high recurrence rate, similar to that reported among nonirradiated patients with benign thyroid nodules. We also conclude that treatment with thyroid hormone decreases the risk of benign recurrences, particularly in women, but not the risk of cancer.

Suppressive therapy with levothyroxine for solitary thyroid nodules. A double-blind controlled clinical study

Thyroid nodules are present in up to 50 percent of adults in the fifth decade of life. Patients are often treated with thyroxine in order to reduce the size of the nodule, but the efficacy of thyrotropin-suppressive therapy with thyroxine remains uncertain. In this study, 53 patients with a colloid solitary thyroid nodule confirmed by biopsy were randomly assigned in a double-blind manner to receive placebo (n = 25) or levothyroxine (n = 28) for six months. Before treatment, pertechnetate-99m thyroid scanning showed that 22 percent of the nodules were functional, 25 percent hypofunctional, and 53 percent nonfunctional. High-resolution (10-MHz) sonography was used to measure the size of the nodules before and after treatment. Suppression of thyrotropin release was confirmed in the levothyroxine-treated group by the administration of thyrotropin-releasing hormone; thyrotropin release was normal in the placebo group. Six months of therapy did not significantly decrease the diameter or volume of the nodules in the levothyroxine group as compared with the placebo group. We conclude that the efficacy of levothyroxine therapy in reducing the size of colloid thyroid nodules is not apparent within six months, despite effective suppression of thyrotropin.

Thyroid function after surgery for autonomous and non-autonomous nodular endemic goitre--effect of iodide-substitution

The aim of this study was to evaluate the influence of postoperative iodide-substitution on the function of thyroid remnants of different quality and quantity in order to define the appropriate prophylaxis (iodide or thyroid hormone) to prevent recurrent goitre. In a prospective, randomized clinical trial, the following patients were examined: group I: simple, non-autonomous nodular goitre, bilateral thyroidectomy (n = 40); group II: simple, non-autonomous nodular goitre, "selective" (unilateral) thyroidectomy (n = 40); group III: autonomous nodular goitre, bilateral thyroidectomy (n = 40); group IV: autonomous nodular goitre, "selective" (unilateral) thyroidectomy (n = 35). The following parameters were measured 6 and 12 weeks postoperatively. Serum-total-T4, -T3, -TSH, TRH-test, 99mTc-Thyroid-Uptake (TcTU). Six weeks postoperatively the 4 groups were separately randomized into controls and treatment groups, who received 200 micrograms iodide/day orally. Six weeks postoperatively, patients in group I had lower T4 levels and both basal and stimulated TSH were higher than in the other groups, however no significant differences were observed in T3, T4/T3 ratio and TcTU. Twelve weeks postoperatively patients from groups I, II and III, who had been treated with iodide, had lower T3 and TcTU values but higher T4 and T4/T3 than the appropriate controls. Basal and stimulated TSH showed no differences between controls and iodide-treated patients in these groups. In group IV, T4 and T3 showed a tendency to elevation (n.s.), and basal and stimulated TSH as well as TcTU were lower in patients with iodide.(ABSTRACT TRUNCATED AT 250 WORDS)

Recurrence of nontoxic goitre with and without postoperative thyroxine medication

The incidence of postoperative recurrence of nontoxic goitre was evaluated in 175 patients. The average observation period was 8.8 years. Levothyroxine (Eltroxin) had been taken by 104 of these patients as long-term prophylaxis against goitre recurrence. Ten (9.5%) of the 104 had recurrence. The other 71 patients received no or only brief thyroxine medication postoperatively. In this group there were eight recurrences (11.3%). The difference was not significant, nor did the two groups differ significantly in regard to sex and age distribution, pathologic anatomy and observation time. Routine long-term administration of thyroxine after thyroid resection is not justified from the results of this study.

Thyroid nodules indeterminate by needle biopsy

In our experience with 121 patients 18 (15 percent) thyroid nodules studied by needle biopsy were considered indeterminate relative to the presence of a low-grade, well-differentiated carcinoma. For 11 of the 18 patients, operation was performed with carcinoma identified in two (18 percent). Although experience reduced this problem, the frequency of carcinoma justifies operation for patients with indeterminate thyroid nodules by needle biopsy, unless other factors dictate otherwise. Inadequate results of fine-needle aspiration biopsy requires a determination of therapy on the basis of other clinical factors. However, permanent disappearance or great reduction in size following aspiration of cystic nodules, repeat biopsy, and biopsy with large needles are important in supporting nonoperative therapy. The indeterminate and inadequate cases must be considered in assessing reports of the use of needle biopsy of thyroid nodules. The large size of a thyroid nodule and previous external radiation therapy are factors supporting operative treatment. Improved selection of patients with benign thyroid nodules for thyroid hormone suppression therapy is needed--thyroid-releasing hormone testing may be of help.