Alternative to eventual surgery for simple goiters
Normal TSH, T4 is not a reason not to treat the goiter with T4. The thyroid hormone output of the goiter will be decreased to 30% and the thyroid hormone therapy will fill in the rest. This is because the goiter is inefficient and will always need more TSH to replace the damaged parts with new thyroid cells. The new cells and the old damaged parts result in progressive slow enlargement. An example is the lady with a goiter bigger than her head with normal TSH, T4, T3 and no antibodies. Located in this massive goiter was enough normal thyroid to keep the blood tests normal while progressive enlargement occurred by TSH stimulated new thyroid cell growth. The vast majority of her goiter was non-functional and causing obstructive symptoms not to mention a major cosmetic problem.
We first make sure there are no suspicious nodules growing already, and that the goiter is not simple but due the Hashimoto’s thyroiditis. A repeat biopsy would also include the latest Molecular markers BRAF RET/PTC and RAS, and classifier. etc.
First I try a 6 month trial of thyroid hormone suppression. A growth marker called thyroglobulin or TG is drawn before therapy and repeated after 6 months. TG is increased by an enlarging goiter. The TG usually decreases by 50% if the goiter is responsive to T4 therapy. I continue T4 in those patients who respond. The ones who do not respond with TG decrease are followed at 6 month intervals watching for the the onset of nodules and cancer by neck exams and endocrine neck ultrasound. TG was first used to follow thyroid cancer patients, but all thyroid cells make it so it is a cancer marker after thyroidectomy only. Normal thyroid glands and goiters make TG. The larger the goiter the higher the TG.
Complex Cyst formation can now be treated without surgery. However, your physician may only know about surgery. You need to refuse surgery and seek a thyroidologist to do ethanol ablation therapy PEI for a benign large cyst. I remove the cyst fluid and replace it with ethanol in a simple outpatient procedure. It saves you the morbidity of a thyroidectomy, hospital stay and recovery.
Before and after PEI. USG needle placed to remove the fluid and inject the ethanol.
Patient with a very large thyroid cyst treated with Ethanol ablation without surgery.
Large benign solid nodules can be treated with usually one visit for radiofrequency ablation RFA. An outpatient procedure that solves the symptoms and cosmetic problems of the nodule and reduces the size progressively over 4 years without a second RFA procedure in most cases. Again a simple non-surgical therapy for a simple goiter.
Solid visible benign thyroid nodule for RFA and ultrasound image
Thyroid RFA Probe in the nodule and after the image on contrast ultrasound is ablated.
Well your simple goiter is not so simple after all. That is why you must request a referral to a non-surgeon endocrine thyroidologist, sonologist who is certified in endocrine neck ultrasound ECNU by American College of Endocrinology. Check thyroid.org for one near you, or visit me for a overnight complete evaluation to see if you are a candidate for any of these therapy options instead of waiting for the eventual referral by your physician to have your goiter removed.
With the high rate of surgical complications by low volume surgeons, it is a breakthrough to have two simple goiter diseases of cysts and benign solid nodules treated with new first line treatment options replacing surgery after one hundred years.
Richard Guttler MD,FACE,ECNU