Iodized salt improves the effectiveness of L-thyroxine therapy after surgery for nontoxic goitre: a prospective and randomized study.
ABSTRACT To investigate whether the addition of iodized salt to daily diet in thyroidectomized patients for nontoxic goitre could influence the effectiveness of nonsuppressive L-thyroxine (L-T4) therapy on thyroid remnant size, during 12 months' follow-up after thyroid surgery.
A consecutive series of selected 139 patients (26 males, 113 females; median age 45 years, range 30-69 years) living in a moderate iodine-deficient area, and undergoing thyroid surgery for nontoxic multinodular goitre, was enrolled. Patients were assigned randomly to two different therapeutic regimens: 70 patients received L-T4 therapy alone (Gr. L-T4), while the remaining 69 patients took iodized salt on a daily basis in addition to L-T4 treatment (Gr. L-T4 + I). In both groups, the initial L-T4 dose was 1.5 microg/kg/day, which, in our experience, has been shown to be intermediate between suppressive and replacement doses. To avoid the risks of mild thyrotoxicosis and to limit the excessive TSH stimulation of the thyroid remnant, the L-T4 dose was adjusted in those patients with serum TSH levels outside the lowest two-thirds of the normal range (0.3-2.5 mU/l). An ultrasound evaluation of thyroid remnant size was performed after thyroid surgery and 12 months later.
After surgery, the median thyroid remnant volume was 3.5 ml (range 0.4-13.9 ml) in Gr. L-T4 and 4.6 ml (range 0.5-12.7 ml) in Gr. L-T4 + I (P = 0.06). After 1 year of follow-up, the patients treated with L-T4 + I obtained a remnant volume reduction (-39.7%, range -87.0% to +91.2%) significantly (P = 0.006) greater than that observed in patients assuming L-T4 alone (-10.2%, range -89.4% to +85.0%). However, the percentage of patients showing an increase in remnant size in the months following surgery was higher in Gr. L-T4 than in Gr. L-T4 + I (22/60 vs. 9/66; P = 0.01). In Gr. L-T4 patients the thyroid remnant volume variation throughout 12 months of treatment was correlated significantly with the size of the thyroid remnant found at the first ultrasound evaluation (R(2) = 0.3; P < 0.001). No such correlation was found in Gr. L-T4 + I patients, for whom the therapy maintains a similar effectiveness in patients with either a large or a small postsurgery thyroid remnant. In patients treated with L-T4 alone, the remnant volume variation was correlated significantly with the median serum TSH values attained in the course of treatment (R2 = 0.4; P < 0.001). The highest reduction in remnant volume was observed only by lowering the serum TSH concentrations. In patients treated with L-T4 plus iodine, instead, the thyroid remnant volume reduction occurred independently of the plasma TSH levels attained in the course of treatment.
Our short-term prospective and randomized study leads us to conclude that, in patients living in a moderate iodine-deficient area and undergoing thyroid surgery for nontoxic goitre: (1) the iodine prophylaxis improves the effects of postsurgery nonsuppressive L-T4 therapy on thyroid remnant size. (2) In patients treated with L-T4 alone the therapeutic effectiveness decreases in the presence of a large postsurgery thyroid remnant. With the addition of iodine, the L-T4 maintains a similar efficacy in patients with either a large or a small remnant. (3) During treatment with L-T4 alone the highest therapeutic effectiveness is attained by lowering the plasma TSH concentration. With the addition of iodized salt to the daily diet the effects of L-T4 on remnant size are relevant independently of the TSH levels.
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ABSTRACT: This report examines outcomes in our series of patients who underwent surgery for recurrent goiter to assess the efficacy of thyroid-stimulating hormone (TSH)-suppressive therapy after the first less than total thyroidectomy. A further outcome was to understand whether redo surgery was burdened with a higher rate of complications. We evaluated 214 patients undergoing a completion thyroidectomy for recurrent goiter who had received, as their first surgery, a bilateral subtotal thyroidectomy. After the first operation, 84 patients were given TSH-suppressive therapy with levothyroxine, 32 were treated with antithyroid drugs, and 92 did not receive any suppressive treatment but only a substitutive therapy. The 84 patients who received levothyroxine at a suppressive dosage (group A) were compared with 92 patients who did not receive levothyroxine or received it only at substitutive dosage (group B). We further compared the complication rate of a similar group of 175 patients who had undergone a primary thyroidectomy. The average age at intervention for relapse in group A patients was significantly lower than that of group B patients: 54.18 vs 60.8 years (p < 0.001). The average interval between the first intervention and the intervention for relapse was significantly shorter in group A than in group B: 24 vs 27 years (p = 0.03). After the operation, temporary hypoparathyroidism occurred in 37.7 % of patients and definitive hypoparathyroidism in 7.2 %. Our results clearly show that the interval between the two surgical interventions was significantly reduced in patients undergoing TSH-suppressive therapy with levothyroxine. The incidence of hypoparathyroidism dramatically increased.Langenbeck s Archives of Surgery 11/2014; 400(2). DOI:10.1007/s00423-014-1258-7 · 2.16 Impact Factor
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ABSTRACT: The extent of thyroid resection in multinodular nontoxic goiter (MNG) is controversial. The aim of the present study was to evaluate results of various thyroid resection modes, with special emphasis put on the recurrence rate and morbidity rate, in a 5-year follow-up. From 01/2000 through 12/2003, 600 consenting patients with MNG qualified for thyroidectomy at our institution were randomized to three groups equal in size, n = 200 in each. Patients in group A underwent total thyroidectomy (TT); patients in group B underwent Dunhill operation (DO), whereas patients in group C underwent bilateral subtotal thyroidectomy (BST). All patients were subjected to ultrasonographic, cytological, and biochemical follow-up at least for 60 months postoperatively. The primary outcome measure was prevalence of recurrent goiter and need for redo surgery. The secondary outcome measure was the postoperative morbidity rate (hypoparathyroidism and recurrent laryngeal nerve injury). Recurrent goiter was found in 0.52% TT versus 4.71% DO versus 11.58% BST (p = 0.01 for TT versus DO, p = 0.02 for DO versus BST, p < 0.001 for TT versus BST), and completion thyroidectomy was necessary in 0.52% TT versus 1.57% DO versus 3.68% BST (p = 0.03 for TT versus BST). Transient postoperative hypoparathyroidism was present in 10.99% versus 4.23% versus 2.1% (p = 0.007 for TT versus DO, p < 0.001 for TT versus BST), whereas the recurrent laryngeal nerve injury rate was 5.49% and 1.05% TT versus 4.23% and 0.79% DO versus 2.1% and 0.53% BST (transient and permanent, respectively; p = 0.007 for transient events TT versus BST). Total thyroidectomy can be regarded as the procedure of choice for patients with MNG. It is associated with a significantly lower incidence of goiter recurrence and less frequent need for completion thyroidectomy than other more limited thyroid resections. However, TT involves a significantly higher risk of postoperative transient but not permanent hypoparathyroidism and recurrent laryngeal nerve paresis.World Journal of Surgery 02/2010; 34(6):1203-13. DOI:10.1007/s00268-010-0491-7 · 2.35 Impact Factor
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ABSTRACT: Hauptindikation fr Schilddrsenoperationen ist die Entfernung von knotigem, potenziell malignem oder hyperfunktionellem Schilddrsengewebe. Postoperativ ist je nach Restfunktion eine L-Thyroxinsubstitution erforderlich. Gleichzeitig ist bei multinodser Struma zur Rezidivprophylaxe eine Jodidsupplementation indiziert. Bei Patienten mit differenziertem SD-Karzinom schlieen sich im Regelfall eine Radioiodbehandlung und risikoadaptierte Nachsorge an. Trotz unbefriedigender Datenlage ist davon auszugehen, dass Patienten mit niedrigem Rezidivrisiko von einer kompletten Thyreoablation und lebenslangen Thyreosuppression prognostisch nicht profitieren. Werden die Nebenschilddrsen in ihrer Funktion beeintrchtigt oder bei Hyperparathyreoidismus gezielt entfernt, kann sich eine behandlungsbedrftige Hypokalzmie entwickeln. Bei unzureichender Effektivitt einer oralen Kalziumsubstitution mssen additiv Vitamin D-Derivate eingesetzt werden, die aufgrund ihrer geringen therapeutischen Breite regelmige Laborkontrollen erfordern.The main indication for surgery of the thyroid gland is the resection of nodular, suspicious or hyperfunctioning tissue. Following thyroidectomy, L-thyroxine therapy is initiated adjusted to the remnant thyroid function. To prevent recurrence of a multinodular goiter, supplementation with iodine is strongly recommended. The management of patients with differentiated thyroid cancer depends on risk stratification. Although large prospective studies are missing, low-risk patients probably do not benefit from total thyroid ablation and lifelong thyroxine suppression therapy. As a result of impaired parathyroid function or resection of the parathyroid glands for hyperparathyroidism, acute or chronic hypocalcaemia can develop. If treatment with oral calcium is insufficient, the addition of a vitamin D analogue is necessary. This requires close monitoring to avoid renal or other hypercalcaemic complications.Der Internist 05/2007; 48(6):569-577. DOI:10.1007/s00108-007-1834-9 · 0.27 Impact Factor