Surgical Treatment of Graves’ Disease: Evidence-Based Approach
ABSTRACT The optimal treatment of Graves disease (GD) is still controversial. Surgery is one treatment option along with radioactive iodine (RAI) and antithyroid medication. In this evidence-based review, we examine four issues: (1) Is surgery better than RAI or long-term antithyroid medication? (2) What is the recommended surgical approach? (3) How does the presence of Graves' ophthalmopathy (GO) influence the role of surgery? (4) What is the role of surgery in children with GD?
We conducted a systematic review of the literature using evidence-based criteria regarding these four issues.
(1) There are no recommendations reaching any grade of evidence for which treatment to choose for adults with GD. (2) Total thyroidectomy has complication rates equal to those seen with lesser resections but it has higher cure rates and negligible recurrence rates (Level I-IV data leading to a grade A recommendation). (3) Data support surgery when severe GO is present, but RAI combined with glucocorticoids may be equally safe (Level II-IV data, grade B recommendation). The extent of thyroid resection does not influence the outcome of GO (Level II data, grade B recommendation). (4) Based on the available data, definitive treatment can be advocated for children (Level IV data, grade C recommendation) using either RAI or surgery. No recommendation can be given as to whether RAI or surgery is preferred owing to the lack of studies addressing this issue. Increased cancer risk with RAI in children below the age of 5 years supports surgery in this setting (Level I data, grade A recommendation).
If surgery is considered for definitive management, evidence-based criteria support total thyroidectomy as the surgical technique of choice for GD. Available evidence also supports surgery in the presence of severe endocrine GO. Children with GD should be treated with an ablative strategy. Whether this is achieved by total thyroidectomy or RAI may still be debatable. Data on long-term cancer risk are missing or conflicting; and until RAI has proven harmless in children, we continue to recommend surgery in this group.
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- "In another series of 15 pediatric patients who underwent thyroidectomy for benign thyroid disease (12 for Graves’), a hypothyroid state was achieved in all patients, with one case (6%) of permanent hypocalcemia, and no recurrent laryngeal nerve injuries (17). These results are similar to those in adult patients treated by high-volume endocrine surgeons (18). In a cross-sectional analysis of the Health Care Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS), an endocrine-specific complication rate of 5.9% was shown for children undergoing thyroidectomy for benign disease when the procedure was performed by high-volume thyroid surgeons (19). "
ABSTRACT: Surgical diseases of the thyroid in the pediatric population represent a diverse set of both benign and malignant conditions. Overall, incidence is rare. Benign conditions include Graves’ disease, toxic adenomas, congenital hyperthyroidism, and goiter. Differentiated thyroid cancer (DTC) and medullary thyroid carcinoma (MTC), with its related familial cancer syndromes, are the most common malignancies. Near-total or total thyroidectomy is the appropriate surgery for thyroid cancer, with/out central lymph node dissection. Emerging practice guidelines from professional societies are helpful, although they generally have not addressed surgical management of the pediatric patient. Thyroidectomy in children is associated with a higher rate of complications, such as recurrent laryngeal nerve injury and hypoparathyroidism, as compared to the surgery in adults. Therefore, it is essential that pediatric thyroidectomy be performed by high-volume thyroid surgeons, regardless of specialty. Case volume to support surgical expertise usually must be borrowed from the adult experience, given the relative paucity of pediatric thyroidectomies at an institutional level. These surgeons should work as part of a multidisciplinary team that includes pediatric endocrinologists and anesthesiologists, pediatricians, nuclear medicine physicians, and pathologists to afford children the best clinical outcomes. Conflict of interest:None declared.Journal of Clinical Research in Pediatric Endocrinology 11/2012; 5(Suppl 1). DOI:10.4274/jcrpe.817
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- "The general management of GD remains controversial. The issue of whether ATD, RAI, or surgery should be used has long been debated and the decision varies greatly depending on different parts of the world . For those with relapsed GD after an adequate course of ATD, the decision for either RAI or thyroidectomy mostly depends on the presence of absolute or relative surgical indication. "
ABSTRACT: Studies have evaluated the effect of thyroidectomy on the course of Graves' ophthalmopathy (GO) but it is unclear how GO as an indication might affect surgical outcomes. We aimed to evaluate the impact of this indication on surgical outcomes in Graves' disease (GD). From 1995 to 2008, 329 patients with GD underwent thyroidectomy. Patients were stratified into two groups, namely, those with GO as indication (GO) and those with non-GO indication (non-GO). Outcomes were compared between the groups and outcomes with significance were further analyzed by multivariate analyses to determine independent factors. The GO group was significantly older (P < 0.001), had more males (P < 0.001), and fewer relapses (P < 0.001) than the non-GO group. It also had a higher proportion of total/near-total thyroidectomy (P < 0.001), despite a shorter operating time (P = 0.024) and less blood loss (P = 0.010). When only total/near-total thyroidectomy was considered, the GO group had significantly more permanent hypoparathyroidism than the non-GO group (9.2 vs. 1.6%, P = 0.038), but the rate of permanent hypoparathyroidism was similar in the two groups when only those with parathyroid autotransplantation were considered. Other complications were similar between the two groups. By multivariate analysis, GO as indication was an independent risk factor for temporary (OR 1.97, P = 0.033) and permanent hypoparathyroidism (OR 4.76, P = 0.007). GO as a surgical indication (i.e., unstable or active GO requiring ophthalmic treatment or follow-up) was associated with increased risk of temporary and permanent hypoparathyroidism after bilateral thyroidectomy. Routine parathyroid autotransplantation may reduce the risk of permanent hypoparathyroidism in this select patient group.World Journal of Surgery 08/2011; 35(10):2212-8. DOI:10.1007/s00268-011-1236-y · 2.64 Impact Factor
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- "Its treatment includes antithyroid drug therapy to reduce the level of thyroid hormone, radioactive iodine I-131 and surgical excision of the thyroid (Brent, 2008; Stalberg et al, 2008). In Europe, drug therapy is preferred, while radioiodine and surgery are more often used in the United States (Stalberg et al, 2008). Therapy-related side effects include inflammation, agranulocytosis and risk of cancer as response to radioiodine treatment (Franklyn et al, 1999; Brent, 2008). "
ABSTRACT: The possibility of an association of Graves' disease (GD) with subsequent cancers raised by certain studies. Using a database on 18 156 hospitalised GD patients, subsequent cancers were ascertained. Increased risks of thyroid and parathyroid tumours were limited to the early follow-up period, which is probably a surveillance bias. Cancer sites with observed excess included the mouth and breast, in contrast to decreased risks of colon cancer, melanoma and non-Hodgkin's lymphoma. Increased subsequent cancers in GD patients appeared to be balanced by decreased risks at other sites; chance cannot be excluded.British Journal of Cancer 03/2010; 102(9):1397-9. DOI:10.1038/sj.bjc.6605624 · 4.84 Impact Factor