Nodular thyroid disease surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Surgery and Device Based Therapy
- The extent of surgery is also controversial. Some surgeons advocate lobectomy and isthmectomy for papillary cancers < 2cm confined to one lobe, whereas others prefer complete thyroidectomy. Larger, multicentric or locally metastatic tumors are best managed with total thyroidectomy, regional lymph node and radical neck dissection.
- For nontoxic multinodular goiter, bilateral subtotal thyroidectomy is the standard of care.
- Lifelong thyroxine replacement has been shown to reduce tumor recurrence rate. The optimal range of suppression is not clear however. If the tumor is completely removed, most authors recommend keeping the TSH ~ 0.1 ug/ml, and even lower in metastatic disease.
- The use of thyroid hormone replacement to shrink or suppress the growth of a benign nodule is controversial. Reported effectiveness is between 0 – 68%, and it seems to work better in multinodular disease.
- A recent study from the Annals suggests that only 10-20% of nodules shrink in response to therapy. Additionally, they report that post-op replacement therapy does not prevent recurrence, except in patients with a history of radiation therapy. As thyroid replacement is associated with an increased risk of osteoporosis and heart disease, they do not recommend suppressive therapy.
- The use of thyroid hormone replacement to shrink or suppress the growth of a benign nodule is controversial. Reported effectiveness is between 0 – 68%, and it seems to work better in multinodular disease.
- For cystic lesions, FNA can be curative, whereas thyroxine replacement will usually not change the cyst at all.
Indications for Surgery
- The indications for surgery vary widely between institutions, with rates primarily determined by the accuracy of FNA, the threshold of individual surgeons, and differing views on whether all indeterminate FNA should be removed.
References