Surgical Intervention in Chronic (Hashimotoʼs) Thyroiditis

Abstract

The incidence of chronic (Hashimoto's) thyroiditis in surgical specimens is relatively high, i.e., 13% in collected studies, for a disease with clinical and laboratory characteristics that are sufficiently specific, that thyroidectomy should rarely be required for diagnosis or treatment. This incidence is presumably related to the difficulty in distinguishing between thyroiditis and a thyroid neoplasm. Experience with 260 thyroidectomies at the North Carolina Memorial Hospital performed between 1875 and 1980 for a dominant thyroid mass was reviewed to determine the reliability of criteria for diagnosis and the indications for surgical treatment. Using the criteria of clinical findings, complemented by laboratory studies, e.g., free thyroxine index, thyroid autoantibodies, TSH level, thyroid scan, in addition to the judicious use of the cutting (core) needle biopsy procedure, the incidence of Hashimoto's thyroiditis in this series was 3% and cancer-27%. Four patients had Hashimoto's thyroiditis coincidental to another disease for which thyroidectomy was performed. In seven patients Hashimoto's thyroiditis alone constituted the indications for operation. The indications for operation in these patients were: autonomous function with mild hyperthyroidism (2 patients); associated cold nodule (2 patients); thyromegaly unresponsive to suppressive therapy (2 patients); and rapidly enlarging mass simulating a neoplasm (1 patient). Only one of 71 patients with well differentiated carcinoma had Hashimoto's thyroiditis. One patient with Hashimoto's thyroiditis had associated lymphoma. In most patients, Hashimoto's thyroiditis can be identified using appropriate clinical and laboratory criteria without resorting to thyroidectomy to differentiate between thyroiditis and a neoplasm. Operations are indicated in patients with suspected or established chronic thyroiditis for: 1) the presence of a dominant mass with incomplete regression on suppressive therapy. 2) Progression of thyromegaly despite suppressive therapy. 3) Historic or physical findings suggest a malignancy, e.g., irradiation, multiple endocrine adenomatosis (MEA) syndrome, nerve paralysis, pain, tracheal compression, stipple calcification and cervical lymph node enlargement. 4) Indeterminant findings on cutting needle biopsy, e.g., lymphoma versus thyroiditis. Rarely, an operation is required for an oppressive goiter or associated hyperthyroidism.

Surgical Indications for Goiter with Background Hashimoto’s Thyroiditis: Institutional Experience

“…Similar study was conducted by Thomas and Rutledge [24] who reported a 3% incidence of HT in their case series operated for nodular goiter and in whom the indications of surgery for HT were narrower. The comprehensive list of indications for surgery in HT based on this study and related review of the literature is as follows: 1) Dominant nodule or large solitary thyroid nodule (>3 cm) 2) Large MNG (>3 cm/retrosternal extension) 3) Compressive symptoms 4) Proven or suspicious associated malignancy 5) Persistent goiter not responsive to full-dose thyroxine replacement 6) Associated Graves' disease (Hashitoxicosis) 7) Painful thyroiditis 8) Incisional biopsy for suspicious lymphoma 9) Cosmetic reasons 10) Patient's wishes…”

“…We had high HT incidence of 22.8% among cases operated for goiter compared with many surgical series, which range from 3% to 33% [21,24,25]. Schlicke [21] reported a similar incidence of 23% of HT amongst 713 operated cases of nodular goiter, although from a different geographic zone.…”

Hashimoto's Thyroiditis: Celebrating the Centennial Through the Lens of the Johns Hopkins Hospital Surgical Pathology Records

“…Its treatment is symptomatic and based on the administration of synthetic thyroxine to correct the hypothyroidism when present and/or to decrease thyroid volume by lowering serum thyrotropin concentrations. In contemporary practice, pathology is rarely needed to establish a diagnosis of Hashimoto's thyroiditis, and surgery is seldom used as a form of treatment (29)(30)(31). Yet, analysis of surgical pathology records over a prolonged period of time provides insights about the natural history of the disease, as well as the practice of medicine.…”

Is thyroidectomy in patients with Hashimoto thyroiditis more risky?

“…Patients with HT are usually treated conservatively with levothyroxine (L-T4) therapy in an attempt to decrease thyroid volume and supplement thyroid hormone 5,11,12 . However, there are certain circumstances in which patients with HT are referred for surgery.…”

“…However, there are certain circumstances in which patients with HT are referred for surgery. In general, the indications for surgery in HT patients include suspicion of malignancy, persistent symptoms associated with the disease, or a goiter that is increasing in size 5,13–15 .…”