Surgery in simple
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
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.
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
Surgery was proposed when the algebric sum of positive and negative
criteria was = or > 2, according to Tab. 1.
|Score 3||citology indicative for maligancy|
| ||obstructive symptoms with goiter of volume < 40 ml|
|Score 2||citology suggestive for follicular neoplasm or Hurtle|
| ||cells (numerous)|
|Score 1||thoracic 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 -1||age < 80|
| ||high surgical risk|
| ||good response to previously instituted suppressive therapy|
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).
|1||malignant neoplasms papillary||11|
| ||malignant neoplasms follicular||3|
| ||malignant neoplasms medullary||3|
| ||malignant neoplasms Hurtle cells||2|
| ||malignant neoplasms anaplastic||1|
|2||diffuse goiter with foci of occult papillary carcinoma||3|
|6||micro-macro follicular goiter||84|
The follow-up of the 269 not operated subjects (12-112 months)
did not reveal any diagnostic failure (6 were lost to the
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.
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