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 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

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).

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
3 follicular adenomas 4
4 lymphocytic thyroiditis 20
5 simple cysts 12
6 micro-macro follicular goiter 84

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.

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