Nontoxic, Nodular Goiter: New Management Paradigms

Abstract

Treatment options for patients with nontoxic, nodular goiter are thyroidectomy, L-thyroxine treatment, and radioiodine therapy. Thyroidectomy leads to rapid decompression of vital structures and provides tissue for pathologic examination. The efficacy of L-thyroxine treatment in patients with nontoxic, nodular goiter is, at best, modest and lifelong L-thyroxine treatment may cause bone loss and cardiac adverse effects. Radioiodine treatment is effective in more than 90% of patients with nontoxic, nodular goiter and results in a mean thyroid volume reduction of 40% after 1 year and of 50% to 60% after 3 to 5 years. In most patients compressive symptoms improve. Early side effects (radiation thyroiditis and esophagitis) are usually mild and transient. Exacerbation of compressive symptoms after radioiodine administration is rare. The development of autoimmune hyperthyroidism is the most important late complication, occurring several months after radioiodine therapy in approximately 5% of patients. The incidence of posttreatment hypothyroidism is 20% to 50% at 5 years. For each individual patient the estimated risks of both surgery and radioiodine therapy should be weighed carefully. At the moment surgery is preferred for younger patients, especially when the amount of radioiodine to be administered is high. However, for elderly patients, especially those with cardiopulmonary disease, the profits of radioiodine treatment will outweigh the lifetime risk for this mode of therapy. Recent data strongly suggest that recombinant human TSH may become a useful adjunct to radioiodine therapy, allowing a considerable reduction of the radioiodine dose needed to reduce thyroid volume. It is expected that administration of recombinant human TSH before radioiodine therapy will extend the indication for radioiodine therapy for nontoxic, nodular goiter to younger patients.