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Time to reconsider nonsurgical therapy of benign non-toxic multinodular goitre: focus on recombinant human TSH augmented radioiodine therapy

Department of Endocrinology and Metabolism, Odense University Hospital, DK-5000 Odense C, Denmark

(Correspondence should be addressed to S Fast; Email: soeren.fast{at}ouh.regionsyddanmark.dk)

Abstract

The treatment of benign multinodular goitre (MNG) is controversial, but surgery is recommended in large compressive goitres. While some patients decline surgery others may have contraindications due to comorbidity, since MNG is prevalent in the elderly. Therefore, non-surgical treatment alternatives are needed. Until recently, levothyroxine therapy was the preferred non-surgical alternative, but due to low efficacy and potential side-effects, it is not recommended for routine use in recent international guidelines. Conventional radioiodine (¹³¹I) therapy has been used for two decades as an effective and safe alternative to surgery in the treatment of symptomatic non-toxic MNG. Since much higher activities of ¹³¹I are employed when treating non-toxic rather than toxic MNG, there has been reluctance in many countries to use this treatment modality. Frequently, the ¹³¹I -uptake in a non-toxic MNG is low, which makes ¹³¹I therapy less feasible. Another challenge is the negative correlation between the initial goitre size and goitre volume reduction (GVR). With its ability to more than double the thyroid ¹³¹I-uptake, recombinant human TSH (rhTSH) increases the absorbed radiation dose and thus enhances the GVR by 35–56% at the expense of up to fivefold higher rate of permanent hypothyroidism. An alternative strategy is to reduce the administered ¹³¹I-activity with a factor corresponding to the rhTSH induced increase in ¹³¹I-uptake. Hereby, the extrathyroidal irradiation can be reduced without compromising efficacy. Thus, although in its infancy, and still experimental, rhTSH-augmented ¹³¹I therapy may profoundly alter the non-surgical treatment of benign non-toxic MNG.