Treatment of Goitre

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No consensus exists regarding the optimum treatment of benign non-toxic goitre. L-thyroxine suppressive therapy is widely used for treatment of goitre, but there is poor evidence of its efficacy, and the suppression of serum TSH may have serious adverse effects on health. Iodine supplementation is no better than L-thyroxine in comparative trials. Surgery is first choice in large goitres or if malignancy is suspected. Post-surgery, risk of goitre recurrence is inversely correlated with the extent of the operation. 131I therapy results in a one-year goitre reduction of around 50 % in multinodular and 70 % in diffuse goitres, usually with a high degree of patient satisfaction and improvement of the inspiratory capacity. The effect is attenuated with increasing goitre size. The risk of hypothyroidism is 22-58 % within 5-8 years. A sufficient thyroid 131I uptake is mandatory for 131I therapy to be feasible. Prestimulation with recombinant human TSH (rhTSH) may increase the thyroid 131I uptake considerably. This leads to an increased absorbed thyroid dose by approx. 75 %, mainly in those patients with the lowest thyroid 131I uptake. In addition, rhTSH results in a more homogeneous intrathyroidal isotope distribution. Recent studies with rhTSH stimulation before 131I therapy are encouraging. Pre-stimulation with even a small dose of rhTSH allows a reduction of the 131I activity while still achieving a mean goitre reduction of approximately 40 % within the first 12 months. A significantly lower extrathyroidal radiation is achieved by this approach. With an unchanged 131I activity, rhTSH pre-stimulation seems to improve the goitre reduction by up to 50 %. However, this is at the expense of a higher rate of hypothyroidism in addition to other side effects like cervical pain and transient thyrotoxicosis. Of particular concern is the observation made in healthy persons, that rhTSH results in a transient average thyroid volume increase of 35 %. A similar goitre swelling may cause problems in susceptible patients during rhTSH-augmented 131I therapy. Thus, this concept still needs a closer evaluation before routine use.