Surgery in simple goiter



Autori: E. Maestri, P. P. Puviani *, F. Pirondi *, G. L. Liera *, 
A. Lucchini *, A. Savioli *, M. Franzini *

Ospedale Comprensoriale di Guastalla (Reggio Emilia)
* Divisione di Chirurgia Generale
Primario: Dr. M. Franzini Servizio di Endocrinologia

SUMMARY

The Authors reevaluate the therapeutic decision between suppressive treatment (or merely observation) and surgery in the rational approach to simple goiter.
Clinical and instrumental findings are integrated in order to elaborate a score useful in clinical practice. The application of the protocol to 411 patients referred for simple goiter led to surgery 142 patients.
The follow-up of the remaining 269 (12-112 months) did not reveal any diagnostic failure.

INTRODUCTION

Medical therapy is not fully recognized as effective in the treatment of simple goiter. Thyroxine is prescribed on a theoretical ground to suppress TSH stimulation but several papers evaluating thyroid volume with reproducible method failed to confirm the efficacy of the traditional suppressive therapy (2).
On the other side surgery can eliminate thyroid tissue but it does not cure the etiopathogenetic cause of glandular growth.
The choice among medical treatment, surgery or simple surveillance of non toxic goiter is frequent matter of discussion.
The problem is to avoid unnecessary surgery without overlooking potentially curable tumors.
The employ of new diagnostic tools: ultrasound imaging (8) and fine needle aspiration citology (5) gave consistent help in clinical decision but only the critical evaluation of numerous parameters can lead to the best choice (1,3-7).
The Authors report an analysis of their experience in the evaluation of several elements in the therapeutic decision of the patient affected by simple goiter.

MATERIAL AND METHODS

We studied 411 (312 F and 99 M) subjectes referred for thyroid enlargement (age 10-81).
All were clinically euthyroid with hormonal determinations comprised in the normal range. T3 and T4 were assayed by RIAs (Serono); TSH was determined by IRMA (Menarini).
Fine needle aspiration cytologic examination was performed in all patients at the time of the first visit and repeated if required in the follow up.
Ultrasound scan was performed (Toshiba Real Time Ultrasound Scanner 10 MHz) before the diagnosis and after the institution of suppressive therapy in the patients not operated (with a 4-12 months interval).
A score is proposed to choose between medical treatment or surgery in order to evaluate simultaneously several clinical and instrumental parameters.
Surgery was proposed when the algebric sum of positive and negative criteria was = or > 2, according to Tab. 1.

Score 3citology indicative for maligancy
 obstructive symptoms with goiter of volume < 40 ml
Score 2citology suggestive for follicular neoplasm or Hurtle
 cells (numerous)
Score 1thoracic goiter
 volumetric increase by US (increase < 5 mm or 50%
of precedent volume) during suppressive therapy
 regional lymph node enlargement
 history of neck irradiation (6)
 airways obstruction (x-ray documented)
 intolerance to thyroxine
 clinical clues suggestive for malignancy
Score -1age < 80
 high surgical risk
 good response to previously instituted suppressive therapy

Tab.1

RESULTS AND CONCLUSIONS

Following the described criteria 142 patients underwent surgery. The patological examination confirmed the cytologic suspect of malignant neoplasm in 20 patients (11 papillary, 3 follicular, 3 medullary, 2 Hurtle cells, 1 anaplastic carcinoma).
Three patients with diffuse goiter operated to relieve airways obstruction showed multiple foci (< 10 mm in diameter) of occult papillary carcinoma.
Four patients showed histological findings diagnostic for lymphocytic thyroiditis. Twelve patients had simple thyroid cysts; the remaning 84 showed pathologic findings of micro-macro follicular goiter (Tab. 2).

1malignant neoplasms papillary11
 malignant neoplasms follicular3
 malignant neoplasms medullary3
 malignant neoplasms Hurtle cells2
 malignant neoplasms anaplastic1
2diffuse goiter with foci of occult papillary carcinoma3
3follicular adenomas4
4lymphocytic thyroiditis20
5simple cysts12
6micro-macro follicular goiter84

Tab.2

The follow-up of the 269 not operated subjects (12-112 months) did not reveal any diagnostic failure (6 were lost to the follow-up).
Thirty-two were reevaluated by fine needle aspiration cytology with results confirming the precedent examination.
The described approach can be proposed as a useful diagnostic tool to evaluate simultaneously multiple factors in order to take appropriate diagnostic decisions.

REFERENCES
  1. DEGROOT L. J., LARSEN P. R., REFOTOFF S., STANBURY J. B.: The thyroid and its diseases. 5th edition. New York, John Wiley, 1984.
  2. FOSTER Jr R.R.: Morbidity and mortality after thyroidectomy. Surg. Gynecol. Obstet., 146: 423-429, 1978.
  3. GRIFFIN J. E.: Southwestern internal medicine conference: management of thyroid nodules. Am. J. Med. Sci., 296: 336-347, 1988.
  4. HOFFMAN G. L., THOMPSON N. W., HEFFRON C.: The solitary thyroid nodule. A reassessment. Arch. Surg., 105: 379-385, 1984.
  5. LOWHAGEN T., WILLEMS J. S., LUNDELL G., SUNBLAD R., GRANBERG P. O.: Aspiration biopsy citology in diagnosis of thyroid cancer. World J. Surg., 5: 61-73, 1981.
  6. MAXON H. R., THOMAS S. R., SAENGER E. L., BUNCHER C. R., KEREJAKES J. G.: Ionizing irradiation and induction of clinically significant disease in human thyroid gland. Am. J. Med., 63: 967-978, 1977.
  7. MAZZAFERRI E. L., DELOSSANTOS E. T., ROFAGHA-KEYHANI S.: Solitary thyroid nodule: diagnosis and management. Med. Clin. North Am., 72: 1177-1211, 1978.
  8. YOKOYAMA N., NAGAYAMA Y., KAKEZONO F.: Detemination of the volume of the thyroid gland by a high resolutional ultrasonic scanner. J. Nucl. Med., 27: 1475-1479, 1986.