In this concluding part of the series on Multinodular Goitre (MNG), ARCHANA JYOTI speaks with DR SUNIL CHUMBER and his team from the Department of Surgical Discipline at AIIMS, Delhi about critical factors for intervention and available management strategies
Treatment Indications and Options
MNG is essentially a non-cancerous enlargement of the thyroid. Not all people with this condition will need treatment and your doctor will advise you with a treatment plan based on certain indications which are described below.
Indications
Patients with hyperthyroidism: All MNG patients who also have hyperthyroidism (increased thyroid hormones) on blood tests will need some form of treatment.
Patients without hyperthyroidism: Goitre causing compressive symptoms such as difficulty in breathing, difficulty in swallowing, cough, difficulty sleeping, etc. needs to be treated. Also, if your doctor suspect’s thyroid cancer based on size/rate of growth/ scans or needle test, he will advise urgent treatment. Lastly, patients may choose to receive treatment for MNG due to cosmetic reasons.
Treatment Options
Surgical treatment: The surgeon removes the whole or a part of the thyroid gland. This is the treatment of choice in patients with compressive symptoms, suspicion of thyroid cancer, and large goitre. A lifelong thyroid hormone supplementation is needed when the entire thyroid gland is removed.
Medical treatment: All patients with hyperthyroidism are started on "antithyroid medications" like carbimazole, and methimazole till hormone levels become normal, after which surgery can be done. However, if patients who do not want surgery or are not fit to undergo surgery, they can be kept on these medicines for a long time as an alternative but is not very effective in decreasing the size of the goitre.
Radioiodine treatment: "Radioactive iodine" is a solution containing I131which is given to patients either as an oral liquid to drink or as a capsule. It gets taken up by the thyroid alone and destroys it from within in a few weeks. It is recommended by doctors as an alternative to surgery in patients who are unfit or unwilling to undergo surgery. Pregnant ladies and lactating mothers have to be very careful and inform your doctor immediately as this method is not safe for them.
Ablative procedures: These are ultrasound-guided procedures that involve injection of medical alcohol or the use of radiofrequency (RFA) or laser to destroy diseased thyroid tissue. These procedures are relatively new and not readily available.
Annual surveillance: For people with goitre but no other symptoms, not having hyperthyroidism, and not being suspicious of cancer, annual surveillance is an option. For this, the doctor conducts a yearly checkup, checks thyroid function test, and neck ultrasound. If an indication for treatment arises or the patient desires, appropriate treatment is provided.
Operations in MNG
Indications for surgery in MNG are local compressive symptoms (difficulty in swallowing and shortness of breath), suspicious malignancy features on imaging, large substernal development, drug-resistant hyperthyroidism, and cosmetic concerns.
If MNG is limited to one lobe of the thyroid, the standard surgical procedure is a hemithyroidectomy where only the lobe with nodule(s) is removed and the other half thyroid is left intact.
In these cases, it is crucial to assess the other lobe not being removed, for any involvement through an ultrasound scan before surgery, and feeling with hands during the surgery that it does not have any nodules.
Two main categories of surgeries can be performed for MNG cases involving both lobes. First category is more limited and includes “bilateral subtotal thyroidectomy” where both lobes of the thyroid are removed but small pieces of normal thyroid from both are left behind. This method will be performed by your surgeon to decrease the risks associated with the other procedures, such as injury to nerve and parathyroid gland.
The second type includes total and near-total thyroidectomy, which tends to be a more aggressive approach. In these again both the lobes of thyroid are removed, but minimal-to-no thyroid is left behind. This group of surgery is recommended to reduce the need for repeat operation which might be required to remove the left-behind thyroid if the disease appears again or if carcinoma is found in the removed thyroid. As these procedures are known to have higher risks of injury, only specialized doctors in these procedures perform them at adequately equipped centers.
All surgeries on the thyroid have some degree of risk of damage to important structures in the neck like the nerve that controls our voice, the parathyroid gland which controls calcium levels in the body, or even the food pipe and the airway especially if the thyroid has become very large and both side surgeries have to be done. Also if both thyroid lobes are removed you will require taking thyroxine hormone supplements lifelong and based on Thyroid Function Tests reports doses will be adjusted by your doctor. Indications for surgery in MNG are local compressive symptoms (difficulty in swallowing and shortness of breath), suspicious malignancy features on imaging, large substernal development, drug-resistant hyperthyroidism, and cosmetic concerns.
If MNG is limited to one lobe of the thyroid, the standard surgical procedure is a hemithyroidectomy where only the lobe with nodule(s) is removed and the other half thyroid is left intact.
In these cases, it is crucial to assess the other lobe not being removed, for any involvement through an ultrasound scan before surgery, and feeling with hands during the surgery that it does not have any nodules.
Two main categories of surgeries can be performed for MNG cases involving both lobes. First category is more limited and includes “bilateral subtotal thyroidectomy” where both lobes of the thyroid are removed but small pieces of normal thyroid from both are left behind. This method will be performed by your surgeon to decrease the risks associated with the other procedures, such as injury to nerve and parathyroid gland.
The second type includes total and near-total thyroidectomy, which tends to be a more aggressive approach. In these again both the lobes of thyroid are removed, but minimal-to-no thyroid is left behind. This group of surgery is recommended to reduce the need for repeat operation which might be required to remove the left-behind thyroid if the disease appears again or if carcinoma is found in the removed thyroid. As these procedures are known to have higher risks of injury, only specialized doctors in these procedures perform them at adequately equipped centers.
All surgeries on the thyroid have some degree of risk of damage to important structures in the neck like the nerve that controls our voice, the parathyroid gland which controls calcium levels in the body, or even the food pipe and the airway especially if the thyroid has become very large and both side surgeries have to be done. Also if both thyroid lobes are removed you will require taking thyroxine hormone supplements lifelong and based on Thyroid Function Tests reports doses will be adjusted by your doctor.
Conclusion
MNG is a widely occurring disease of thyroid gland where small nodules form inside the thyroid causing it to become bigger and produce problems of cosmesis, difficulty in breathing, eating, and sleeping.
Not having enough Iodine in food is an important cause of this problem, but due to government efforts of iodisation of salt, the large goitres seen before the 90s have largely come down. The nodules are mostly non-cancerous but anytime any such enlargement is seen in front of your neck, you should contact a nearby doctor.
