Nontoxic Goiter Treatment & Management

http://emedicine.medscape.com/article/120392-treatment

 

Nontoxic Goiter Treatment & Management

Medical Care

Nontoxic goiters usually grow very slowly over decades without causing symptoms. Without evidence of rapid growth, obstructive symptoms (eg, dysphagia, stridor, cough, shortness of breath), or thyrotoxicosis, no treatment is necessary. Therapy is considered if growth of the entire goiter or a specific nodule is present, especially if intrathoracic extension of the goiter, compressive symptoms, or thyrotoxicosis exists. The intrathoracic extension of the goiter cannot be assessed by palpation or biopsy. The goiter, if significant in size, should be removed surgically.^[4] The currently available therapies include thyroidectomy, radioactive iodine therapy, and levothyroxine (L-thyroxine, or T4) therapy.

Radioactive iodine therapy - Radioiodine therapy of nontoxic goiters is often performed in Europe. It is a reasonable therapeutic option, particularly in patients who are older or have a contraindication to surgery.^{[5, 6, 7]}

Radioactive iodine therapy for nontoxic goiters was reintroduced in the 1990s. Careful studies have shown a reduction in thyroid volume in nearly all patients after a single dose of therapy.^[1]

Of patients with nontoxic diffuse goiter, 90% have an average of 50-60% reduction in goiter volume after 12-18 months, with a reduction in compressive symptoms. The decrease in goiter size has positively correlated with the dose of iodine-131 (¹³¹ I). Reduction in goiter size is greater in younger patients and in individuals who have only a short history of goiter or who have a small goiter. Baseline TSH is not a predictor of response to radioactive iodine.

Obstructive symptoms improved in most patients who received radioactive iodine.

Adverse effects, including thyroiditis, occurred, but no patient reported worsening of compressive symptoms requiring treatment. No long-term follow-up reports on patients treated with radioactive iodine exist. Patients should always be monitored clinically after¹³¹ I therapy, for evidence of goiter regrowth.

Transient hyperthyroidism is rare and typically occurs in the first 2 weeks after treatment.

Unlike patients with hyperthyroidism who are treated with radioactive iodine, only a small percentage of patients with nontoxic goiter develop hypothyroidism after radioactive iodine treatment

Recombinant human TSH (rhTSH) may have a role in radioactive iodine treatment for nontoxic goiter. Pretreatment with rhTSH 24 hours prior to therapy can reduce the amount of radioiodine needed to shrink the goiter (up to a 50% reduction).^{[8, 9, 10, 11]}

Thyroid hormone suppressive therapy - The use of T4 in a euthyroid individual to shrink a nontoxic goiter is controversial.

One study showed that T4 therapy for nontoxic goiter reduced thyroid volume in 58% of patients, compared with 4% of patients treated with a placebo. However, these results have not yet proven to be reproducible, and the benefit of using T4 needs to be weighed against the risk of the resultant subclinical hyperthyroidism associated with an increased risk of decreased bone mineral density and increased atrial fibrillation.

Goiter growth typically resumes after cessation of T4 therapy.

The American Thyroid Association and American Association of Clinical Endocrinologists have released guidelines for the management of hyperthyroid and other causes of thyrotoxicosis, including the use of radioactive iodine or surgery to treat toxic multinodular goiter.^[12]