Evidence-based Management of Toxic Multinodular Goiter (Plummer’s Disease)

Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
World Journal of Surgery (Impact Factor: 2.64). 08/2008; 32(7):1278-84. DOI: 10.1007/s00268-008-9566-0
Source: PubMed


Toxic multinodular goiter (Plummer's disease) has posed challenges to surgeons, endocrinologists, and radiation oncologists since its description in 1913. A literature review with evidenced-based methodology has not yet been reported.
A systematic review of the English literature from 1950 to 2007 and report of Mayo Clinic experience since 1950 was undertaken to establish evidence-based recommendations for management.
Surgery and radioactive iodine (RI) are both supported by level IV evidence in the treatment of solitary toxic nodules and toxic multinodular goiter, and treatment is determined by symptoms and co-morbidities. No evidence suggests a difference in treatment outcome based on pretreatment clinical or subclinical hyperthyroidism. Level IV evidence supports thyroidectomy over RI for large goiters. When compressive symptoms are present, level IV evidence supports thyroidectomy for maximal symptom relief in patients at moderate risk. Occult malignancies are found in 2-3% of thyroidectomy specimens for Plummer's disease. Despite technical reports of RI dose considerations, there are no prospective studies validating a dose formula. Ethanol ablation of toxic nodules in patients unfit for surgery is supported by level III evidence. Level V data suggest a cost benefit favoring surgery.
Treatment of Plummer's disease with antithyroid medications, ethanol ablation, RI ablation, or surgery must balance the goals of therapy, durability of cure, relief of symptoms, risk of malignancy, and risk of complications. Between 1950 and 2006, 948 (70%) of 1,356 patients with Plummer's disease have been treated surgically at Mayo Clinic.

75 Reads
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Thyroid Surgery - the "Adequate Postoperative Result" in Surgery, Endocri- nology and Nuclear Medicine. Arguments for an Individualized Strategy. Surgery of hyperfunctioning or malignant thyroid diseases has always been a radical procedure. The appropri- ate approach in benign, normofunctioning goitre is presently under discussion despite well-estab- lished guidelines in the past. A more radical strat- egy, mostly total thyroidectomy in every case, is advocated by some groups, but not generally ac- cepted. Moreover, in some reports even non-inva- sive thyroid cancer is treated by unilateral non-radi- cal operation only. There is a wide spectrum of ar- guments between these 2 landmarks. Individual decision-making is one main goal in endocrine sur- gery, providing a patient- and disease-related con- cept, tailored to each individual procedure. J Klin
    Preview · Article ·
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Thyroid gland carcinomas usually appear as afunctional and hypofunctional lesions on thyroid scintigrams, but some rare cases of thyroid carcinoma with scintigraphic hyperfunctional lesions have also been reported. The aim of our retrospective study was to elucidate the frequency of carcinomas in patients operated for solitary hyperfunctional thyroid nodules and to represent their demographic and clinical features. During one decade (1997/2006), 308 patients were operated for solitary hyperfunctional thyroid nodules in the Centre for Endocrine Surgery in Belgrade. Malignancy was revealed in 9 cases (about 3 %) by histopathological examination. In 6 cases papillary microcarcinomas were found adjacent to dominant hyperfunctional adenomas, while in 3 cases (about 1 %) real hyperfunctional carcinomas were confirmed. Follicular carcinoma was diagnosed in 2 cases and papillary carcinoma in one. All 3 patients were preoperatively hyperthyroid. In both patients with follicular carcinoma we performed lobectomies. In the third case we carried out a total thyroidectomy considering the intraoperative frozen section finding of a papillary carcinoma. According to our results the frequency of solitary hyperfunctioning thyroid carcinomas is about 1 %, so that the possibility that a hyperfunctional nodule is malignant should be considered in the treatment of such lesions.
    Full-text · Article · Nov 2010 · Zentralblatt für Chirurgie
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: A 37-year-old woman presented with palpitations, tremulousness, shortness of breath, and a 9-kg (20-lb) weight loss, and received a diagnosis of Graves' hyperthyroidism. At the time of diagnosis, she had mild proptosis, no diplopia, and no signs of eye inflammation. Her thyroid gland was two times the normal size and non-nodular. Her initial serum triiodothyronine (T(3)) concentration was 655 ng per deciliter (9.2 nmol per liter), and her free thyroxine (T(4)) concentration was 5.7 ng per deciliter (73 pmol per liter). She was treated with methimazole for a year, and her thyroid tests became normal. She discontinued the methimazole 10 weeks before the current presentation with recurrent palpitations and tremulousness. Her serum T(3) concentration is 345 ng per deciliter (5.4 nmol per liter), and her free T(4) concentration is 2.8 ng per deciliter (36.0 pmol per liter). The patient does not smoke. She has a 3-year-old daughter and wishes to become pregnant again. Her endocrinologist recommends radioiodine ablation of her thyroid.
    Preview · Article · Feb 2011 · New England Journal of Medicine
Show more