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Evidence-based Management of Toxic Multinodular Goiter (Plummer’s Disease)

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Abstract

Background

Toxic multinodular goiter (Plummer’s disease) has posed challenges to surgeons, endocrinologists, and radiation oncologists since its description in 1913. A literature review with evidenced-based methodology has not yet been reported.

Methods

A systematic review of the English literature from 1950 to 2007 and report of Mayo Clinic experience since 1950 was undertaken to establish evidence-based recommendations for management.

Results

Surgery and radioactive iodine (RI) are both supported by level IV evidence in the treatment of solitary toxic nodules and toxic multinodular goiter, and treatment is determined by symptoms and co-morbidities. No evidence suggests a difference in treatment outcome based on pretreatment clinical or subclinical hyperthyroidism. Level IV evidence supports thyroidectomy over RI for large goiters. When compressive symptoms are present, level IV evidence supports thyroidectomy for maximal symptom relief in patients at moderate risk. Occult malignancies are found in 2–3% of thyroidectomy specimens for Plummer’s disease. Despite technical reports of RI dose considerations, there are no prospective studies validating a dose formula. Ethanol ablation of toxic nodules in patients unfit for surgery is supported by level III evidence. Level V data suggest a cost benefit favoring surgery.

Conclusions

Treatment of Plummer’s disease with antithyroid medications, ethanol ablation, RI ablation, or surgery must balance the goals of therapy, durability of cure, relief of symptoms, risk of malignancy, and risk of complications. Between 1950 and 2006, 948 (70%) of 1,356 patients with Plummer’s disease have been treated surgically at Mayo Clinic.

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References

  1. Plummer H (1913) The clinical and pathologic relationship of hyperplastic and nonhyperplastic goiters. JAMA 61:650

    Google Scholar 

  2. Vitti P, Rago T, Tonacchera M et al (2002) Toxic multinodular goiter in the elderly. J Endocrinol Invest 25:16–18

    PubMed  CAS  Google Scholar 

  3. Sackett DL (1989) Rules of evidence and clinical recommendations on the use of antithrombotic agents. Chest 95:2–4

    Article  Google Scholar 

  4. Wahl RA, Rimpl I, Saalabian S et al (1998) Differentiated operative therapy of thyroid autonomy (Plummer’s disease). Exp Clin Endocrinol Diabetes 106(Suppl 4):S78–S84

    Article  PubMed  CAS  Google Scholar 

  5. Sawin CT, Geller A, Wolf PA et al (1994) Low serum thyrotropin concentrations as a risk factor for atrial fibrillation in older persons. N Engl J Med 331:1249–1252

    Article  PubMed  CAS  Google Scholar 

  6. Iervasi G, Molinaro S, Landi P et al (2007) Association between increased mortality and mild thyroid dysfunction in cardiac patients. Arch Intern Med 167:1526–1532

    Article  PubMed  Google Scholar 

  7. Erdogan MF, Kucuk NO, Anil C et al (2004) Effect of radioiodine therapy on thyroid nodule size and function in patients with toxic adenomas. Nucl Med Commun 25:1083–1087

    Article  PubMed  Google Scholar 

  8. Hamburger J, Hamburger S (1985) Diagnosis and management of large toxic multinodular goiters. J Nucl Med 26:888–892

    PubMed  CAS  Google Scholar 

  9. Alexopoulou O, Beguin C, Buysschaert M et al (2004) Predictive factors of thyroid carcinoma in non-toxic multinodular goitre. Acta Clin Belg 59:84–89

    PubMed  CAS  Google Scholar 

  10. Clerc J, Dagousset F, Izembart M et al (1995) Radioiodine therapy of the autonomous thyroid nodule in patients with or without visible extranodular activity. J Nucl Med 36:217–223

    PubMed  CAS  Google Scholar 

  11. Lippi F, Ferrari C, Manetti L et al (1996) Treatment of solitary autonomous thyroid nodules by percutaneous ethanol injection: results of an Italian multicenter study. The Multicenter Study Group. J Clin Endocrinol Metab 81:3261–3264

    Article  CAS  Google Scholar 

  12. Zingrillo M, Modoni S, Conte M et al (2003) Percutaneous ethanol injection plus radioiodine versus radioiodine alone in the treatment of large toxic thyroid nodules. J Nucl Med 44:207–210

    PubMed  CAS  Google Scholar 

  13. Vidal-Trecan GM, Stahl JE, Eckman MH (2004) Radioiodine or surgery for toxic thyroid adenoma: dissecting an important decision. A cost-effectiveness analysis. Thyroid 14:933

    Google Scholar 

  14. Jensen MD, Gharib H, Naessens JM et al (1986) Treatment of toxic multinodular goiter (Plummer’s disease): surgery or radioiodine? World J Surg 10:673–680

    Article  PubMed  CAS  Google Scholar 

  15. Erickson D, Gharib H, Li H et al (1998) Treatment of patients with toxic multinodular goiter. Thyroid 8:277–281

    Article  PubMed  CAS  Google Scholar 

  16. Kang AS, Grant CS, Thompson GB et al (2002) Current treatment of nodular goiter with hyperthyroidism (Plummer’s disease): surgery versus radioiodine. Surgery 132:916–923

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

Special thanks to Linda L. Haigh and Michelle A. Neseth for their assistance in preparing the final manuscript.

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Authors and Affiliations

  1. Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA

    John R. Porterfield Jr., Geoffrey B. Thompson, David R. Farley, Clive S. Grant & Melanie L. Richards

Authors
  1. John R. Porterfield Jr.
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  2. Geoffrey B. Thompson
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  3. David R. Farley
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  4. Clive S. Grant
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  5. Melanie L. Richards
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Correspondence to Melanie L. Richards.

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Porterfield, J.R., Thompson, G.B., Farley, D.R. et al. Evidence-based Management of Toxic Multinodular Goiter (Plummer’s Disease). World J Surg 32, 1278–1284 (2008). https://doi.org/10.1007/s00268-008-9566-0

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  • DOI: https://doi.org/10.1007/s00268-008-9566-0

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