Non-surgical approach to the benign nodular goiter: new opportunities by recombinant human TSH-stimulated 131I-therapy

Abstract

The optimal treatment strategy in a goiter patient depends--among other factors--on goiter size, the degree of cosmetic or compressive symptoms, the age of the patient, the impact on the upper airways, the wish to maintain normal thyroid function, the ability of the thyroid gland to take up (131)I, and the possibility of thyroid malignancy. When treatment is warranted in a patient with benign goiter, the choice usually stands between surgery and (131)I-therapy. Focal destructive treatment, by ethanol sclerotherapy or interstitial laser photocoagulation, may be considered in patients with a solitary benign nodule. If thyroid hyperfunction due to nodular autonomy is the dominant problem, life-long anti-thyroid drug treatment may be relevant in elderly individuals. With the advent of recombinant human TSH (rhTSH) stimulation the goiter reduction following (131)I-therapy is significantly enhanced and this treatment is of particular benefit, as compared with conventional (131)I-therapy, in patients with a low baseline thyroid (131)I uptake and a large goiter. If the rhTSH dose does not exceed 0.1 mg the risk of temporary hyperthyroidism and acute thyroid swelling is low. Since patient satisfaction seemingly is not improved by the greater goiter reduction obtained by rhTSH-stimulated (131)I-therapy, and permanent hypothyroidism is more frequent, it may be more relevant to reduce the administered radioactivity equivalent to the rhTSH-induced increase in the thyroid (131)I uptake. Future large-scale well-controlled studies should explore this strategy, with focus on cost-benefit and quality of life. A major hindrance of widespread and routine use of rhTSH-stimulated (131)I-therapy is its present status as an off-label treatment.

Thyroid nodules and differentiated thyroid cancer: update on the Brazilian consensus

“…Focal destruction by means of sclerotherapy with ethanol or laser photocoagulation can be considered in patients with benign solitary nodules (59,60). When the main problem is thyroid hyperfunction caused by an autonomous nodule, long-term anti-thyroid drug treatment is an interesting option in elderly patients (60).…”

“…When the main problem is thyroid hyperfunction caused by an autonomous nodule, long-term anti-thyroid drug treatment is an interesting option in elderly patients (60).…”

“…As such areas concentrate 131 I very weakly, the efficacy of this treatment is compromised. The use of low doses of recombinant TSH significantly increases 131 I uptake in such patients and allows even low activities to efficiently reduce the goiter size by 30 to 50% in one year (60)(61)(62).…”

THERAPY OF ENDOCRINE DISEASE: Recombinant human TSH and radioactive iodine therapy in the management of benign multinodular goiter

“…Pretreatment with methimazole before 131 I therapy for TMNG is indicated in patients who are at an increased risk for complications due to worsening of hyperthyroidism, including elderly and those with cardiovascular disease or severe hyperthyroidism (35). rhTSH can at least double thyroid RAIU (12,18,36,37,38), depending on the baseline RAIU, and it determines a more homogeneous distribution of 131 I in MNG (22). During the last decade, and based on the above observations, rhTSH has been evaluated as an adjuvant to 131 I therapy, in an attempt to improve the efficacy of this treatment for MNG (18,39,40).…”

The calcium–phosphate balance, modulation of thyroid autoimmune processes and other adverse effects connected with thyroid arterial embolization

“…Anti-thyroid drugs intake during pregnancy sometimes results in congenital malformations and hypothyroidism of the fetus [3]. Effectiveness of the radioiodine intake may be easily reduced by earlier use of amiodarone, contrast agents, fast iodine metabolism or low iodine uptake in the thyroid [8–13]. In addition, there is a risk of orbitopathy development or deterioration during the radioiodine treatment [14, 15].…”