The choice of therapeutic tactics for nodal nontoxic goiter, despite the apparent simplicity, is one of the most complex and controversial issues. Many clinicians insist on mandatory surgical treatment of all, at least single, nodular formations in the thyroid gland, motivating such tactics by the danger of malignancy of single knots.
We are deeply convinced that the removal of nodular goiter should not be considered as a prophylaxis for thyroid cancer. Established in recent years, the trend towards mandatory surgical treatment of all nodular formations of the thyroid gland is alarming. There is no doubt that the testimony to the operation in such cases should be weighted reasonably. This is probably the most crucial and difficult question that a clinician should solve.
The task is primarily to “not miss” the differentiated cancer, which often proceeds clinically in the same way as the adenoma of the thyroid gland. Hence the importance of mandatory morphological verification of changes in the thyroid gland prior to surgery. Naturally, all nodal formations of the thyroid gland, according to clinical manifestations, are suspicious of the tumor, are subject to operational treatment. In such cases, the operation is also the last diagnostic method. The necessity of the operation is beyond doubt at large nodes, leading to neck deformation, displacing the trachea. Indications for surgery may be cosmetic considerations, especially when it comes to young patients.
The question of the scope of the operation concerning the nodular nontoxic goiter is ultimately decided depending on the results of the revision of the thyroid gland, which often changes the perception of the nature and scale of changes in the gland. Therefore, when speaking about the fundamental questions of tactics, it is first of all necessary to decide what the minimum amount of intervention should be a single site located within the proportion of the thyroid gland. Opinions on this issue are contradictory. A number of surgeons consider it possible to confine themselves in such cases to resection of a part of the lobe with a node or even enucleation of the node [14, 31]. It should be noted that advocates of mandatory surgical treatment of all single thyroid nodules adhere to such sparing tactics.
In this case, they clearly contradict themselves: on the one hand, the operation is necessary in all cases, since there is a risk of malignization of the node, on the other hand, one can confine oneself to the enucleation of the node, not being sure of its nature. It should be emphasized that the question of the minimum amount of intervention for single nodular formations of the thyroid gland is of a fundamental nature. It is all the more important because it is a very common disease.
It is safe to say that minimal surgical intervention for solitary adenoma of the thyroid gland should be hemithireoidectomy (removal of the affected part with an isthmus). Today most clinicians adhere to such tactics. The legality of such a tactical approach becomes obvious, if we proceed from clear indications for an operational intervention. As already noted, one of the most weighty indications for surgery for a single node in the thyroid gland is the inability to exclude the tumor nature of the process. Further it will be shown that differentiated carcinomas of the thyroid gland are often of a multifocal nature with localization of foci within one lobe. Therefore, if cancer is recognized when examining a remote share, hemithyroidectomy is sufficient in scope to interfere.
As for the enucleation of the solitary node, this is obviously a vicious operation, which inevitably leads to a relapse of the tumor and the development of implantation metastases. Therefore, it is necessary to abandon it in principle, and
Nucleation of the node is considered as a serious tactical error requiring obligatory repeated intervention if the operation was performed for a tumor.
With multinodal goiter, when there are changes in both lobes, the question of the scope of the operation can not be easily solved. In this case, it is essential to abstain from extirpation of the gland and try to preserve normal tissue as much as possible, more often in the region of the upper poles.
Another controversial issue is the technique of surgical intervention. How to operate – subfascial or extrafascial? As the discussion showed in the pages of the journal “Bulletin of Surgery. I. Grekova “in 1985, opinions on this issue are contradictory, but to a large extent are related to a not quite clear definition of the subject of the dispute. It is known that the thyroid gland has its own capsule in the form of a thin fibrous plate and the fascial vagina formed by the visceral leaf of the IV fascia. Between the capsule of the gland and its vagina there is a loose fiber, in which lie the arteries, veins, nerves and parathyroid glands. The fascial vagina of the gland is so tender and subtle that it is simply impossible to keep it, this would lead to the inevitable removal of parathyroid corpuscles.
Therefore, we are talking about extracapsular and intracapsular methods of thyroid secretion. The subfascial method of OV Nikolaev’s operation, which has become widespread in our country, suggests subcapsular isolation of the lobe with the leaving of a thin plate of the thyroid parenchyma in the “dangerous zone”, along the posterior surface of the lobe. Such a technique, according to its supporters, protects from severe postoperative complications – damage to the parathyroid glands and recurrent nerves. It should be noted, however, that this technique has a number of significant drawbacks.
First of all, the ablasticity of the operation is violated, and therefore such a technique is fundamentally unsuitable for a tumor process. The intracapsular technique of isolating the thyroid gland with the retention of the thyroid parenchyma on the glandular capsule, on the one hand, creates conditions for a possible recurrence of the disease, and on the other hand, disadvantageous conditions for repeated intervention.
Our experience suggests that the extracapsular technique of thyroid mobilization is preferable regardless of the nature of the pathological process. Technically perfect execution of it, careful hemostasis with an isolated dressing of blood vessels allows to minimize the danger of postoperative complications.
Thus, the need for surgical intervention for nodal non-toxic goiter should be argued. And how to deal with a small knot that does not cause the patient no worries and whose benign nature is beyond doubt? Small (up to 2 cm) soft nodes in the thyroid gland are subject to observation and hormone therapy. It should be noted that the issues of conservative treatment of nodal nontoxic goiter are not well understood. Numerous publications on the use of thyroid hormones in these patients lead to conflicting, often negative results. The clinical effect of suppressive therapy ranges from 0 to 68%. Some clinicians even consider that hormones of the thyroid gland should not be used for independent treatment of nodular nontoxic goiter.
It should be noted that sometimes the lack of clinical effect of hormone therapy in single nodal formations in the thyroid gland is undoubtedly associated with an erroneous determination of indications for its conduct. As already noted, the concept of “nodal nontoxic goiter” includes a number of completely different in nature processes – from focal hyperplasia and true adenomas to pronounced dystrophic changes. Naturally, one can not expect the effect of hormone therapy in the presence of pronounced degenerative-dystrophic changes with fibrosis and calcinosis of thyroid tissue. On the contrary, the likelihood that focal proliferates or adenoma will be hormonally sensitive is very high.
Therefore, when solving the problem of the possibility of hormone therapy in the case of a nodal nontoxic goiter, it is necessary to try to clarify (with the help of ultrasound and puncture biopsy) the essence of the process. The daily dose of the drug is selected individually, taking into account the age, concomitant diseases, the body weight of the patient and the individual tolerability of the drug, and for levothyroxine averages 50-100 μg. If the reception of thyroidin (levothyroxine) is accompanied by tachycardia, then it is necessary to prescribe adrenoblockers (anaprilin, inderal, obzidan). The effect of hormone therapy can be expected only after 3-5 months. Reducing the size of the node, as well as the lack of signs of its growth are an indication for the continuation of hormone therapy.
If the drug is well tolerated, treatment should be long (at least a year). T. Morita believes that the determination of the serum thyroglobulin (TG) content can be used as an indicator of the effectiveness of hormone therapy. The authors showed that in patients with a single node in the thyroid gland with effective use of thyroxine, the level of TG blood decreased sharply. In the absence of the effect of hormone therapy, the concentration of TG in the blood did not change appreciably.
Conservative measures can be cured of small cysts of the thyroid gland. Produce repeated puncture cysts with the removal of its contents. Usually 2-3 punctures are enough. Some authors recommend that after removing the contents of the cysts, 1-2 ml of tetracycline solution or 95% ethyl alcohol should be injected into the cavity. Ethanol destruction is successfully used for the treatment of toxic adenomas. We limited ourselves to repeated punctures with good clinical effect.