Tuesday, May 27, 2008

Why I Need to Know About Alternatives to Surgery for my Large Simple Goiter

There are not many therapy alternatives to surgery if you have a goiter. The large goiter may be causing obstructive symptoms, or harbor a cancer.
The obstructive component can be evaluated by MR, and pulmonary function testing, including flow loop to see if there is any upper airway obstruction. Any suspicious nodules found on ultrasound need to be biopsied. If no obstruction or cancer is found, then alternatives are available. The most widely used is low dose Radio-iodine therapy.
In Europe and special centers, Laser has been used to shrink goiters. However, experience with this method is limited at present, although it seems promising.
Thyroid hormone is effective if the goiter responds to suppression.However, it usually dose not work on very large goiters. Ethanol Injections, PEI, are not for treatment of a whole gland, but for single cystic nodules. The best method now is Radio-iodine therapy.

Case Presentation:

69 Y/O female with coronary artery disease, bypass surgery, and mild heart failure was noted to have a large goiter causing tracheal deviation, and symptoms of obstruction. The MR showed mild tracheal narrowing, and the breathing test showed an abnormal flow loop consistent with upper airway obstruction due to the enlarged goiter. The treatment of choice is surgery, but because of her heart condition, alternatives were sought. Thyroid hormone was considered dangerous with heart disease. She was referred to me for consideration for ethanol, laser, or Radio-iodine. As listed above RAI was the best alternative for her. The goiter was visible from across the room.The trachea was deviated, and the ultrasound found two suspicious nodules in the goiter.They were biopsied and were benign colloid nodules. Thyroid blood testing was normal for TSH, T4, and Antibodies. The thyroid uptake was not elevated, but was to the lower normal range of 11% at 24 hours. Normal 8-32. After informed consent, including all about off label use of Thyrogen, rhTSH stimulation to boost the low uptake, she was put on a low iodine diet for two weeks. The single injection of rhTSH was given, and the TSH rose to 32. A repeat Thyrogen Stimulated thyroid uptake was positive for a significant increase in uptake to 56%. The image showed diffuse increased uptake throughout the goiter. The radiation safety instructions were reviewed with the patient and her urinary continence was assessed. There were no children in her house and she was told to stay away from her grandchildren. The arrival of the iodine dose was followed by confirming the correct dose was sent, checking for leaks, and preparing a paper for her to keep with her when she traveled by air to see her brother in 3 weeks. This will explain to the security at the airport that see has been treated with radiation, and is not a terrorist! The 30 Millicuries was given in my office as an outpatient and she was sent home. She was told to suck on lemon drops, and drink water, and avoid close contact with people for 5 days. She could go for her morning walks as usual. She could watch TV with her husband if she sat 3-5 feet away from him. She returned in one week and her thyroid goiter was firmer, but not tender.Thyroid blood tests revealed slight decrease in TSH, but no change in T4, or T3. By 12 weeks there was an obvious decrease in goiter size. Thyroid tests returned to normal, and the goiter had continued to decrease at 6 months. Repeat MR confirmed shrinkage, and the Flow loop study improved. The trachea was not narrowed, and the mild obstructive pattern on the flow loop was also better. She has noted improvement in her symptoms as well. She is followed twice yearly, and is doing well without ever having thyroid surgery.

When Surgery is offered as a treat option for your goiter, consider looking into alternative therapy with radio-iodine.

Good Luck,


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