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Surgery versus radioiodine therapy in the treatment of hyperthyroidism

If you are offered surgical intervention because you suffer hyperthyroidism (Graves) goitre, make sure that you are aware of another option.

I will first quote from Dr Peatfields book Your Thyroid and How to Keep it Healthy

“. . . Let it be said at once that growths or cysts in the thyroid must be treated by surgical removal or drainage procedure, and a much-enlarged thyroid which interferes with breathing or swallowing leaves no option. But partial thyroidectomy to reduce the amount of thyroid hormone forming tissue is a popular, if in some eyes, barbaric procedure. It is popular with surgeons if only because, their job done, they may then refer the patient back to the physician for subsequent management.

My view is that as a procedure it should be the last resort only; and not as is so often and regrettably the case, almost the first option. Apart from all the normal objections to surgery, and a lasting reminder from the scar that one has had ones throat cut, the objection has to be the same as with nuking; however, can one make a good enough guess to get it right? Well, usually it isnt possible. Too little means the surgery may have to be done again, or suppressant drugs continued with; too much, and one falls back on thyroxine replacement. Sometimes the abused thyroid tissue may recover some function, so that the result of an over-enthusiastic surgical removal may in time largely correct itself. But many patients who have passed through my surgery doors have found themselves under-active sooner or later. Once again the patient is obliged to join the seesaw of more or less replacement therapy, even after, being told that they are perfectly well whatever they say since the blood tests show they are.

The use of radioiodine therapy is slightly safer and somewhat more effective than is the use of surgery for hyperthyroidism. Radioiodine therapy is regarded as the treatment of choice.

Before the Second World War, surgery was the only definitive treatment for hyperthyroidism. When iodine-131 became available after the war, it rapidly replaced surgery as the therapy of choice. Today, surgery for hyperthyroidism is rarely performed in the US, but still is in the UK, but it is performed in third-world countries that cannot afford the radioiodine.

The surgical technique is to take out most, but not all, of the thyroid gland. This is done to avoid damage to the parathyroid arteries and the recurrent laryngeal nerves, which are easy to injure or destroy if one tries to remove every bit of the thyroid gland. The parathyroid arteries feed the parathyroid glands, which are necessary for blood calcium control and normal nerve and muscle function. If blood calcium levels are very low (such as from non-functional parathyroid glands), nerves and muscles do not function properly. Very low calcium levels can be fatal. The recurrent laryngeal nerves control speech. If one is cut, you will be permanently hoarse. If both are cut, you will be unable to speak at all. The other reason to leave a small amount of thyroid tissue is to allow the patient to have some thyroid function.

Other than the risks of anaesthesia and the risks to the parathyroid glands and laryngeal nerves discussed above, the remaining thyroid tissue tends to grow back, creating hyperthyroidism once again.

Radioactive iodine (131I, sodium iodide) is concentrated in thyroid glands, especially in hyperactive portions of the gland. For the type of hyperthyroidism called Graves’ disease, it is usual for about 40-80% of the administered activity to concentrate in the thyroid gland. For functioning adenomas (“hot nodules”), the uptake is closer to 20-30%. The kidneys excrete excess iodine-131 rapidly. The quantity of radioiodine used to treat hyperthyroidism is not enough to injure any tissue except the thyroid tissue, which slowly shrinks over a matter of weeks to months. If the first treatment is not enough to shrink the thyroid gland, you would be given another dose, usually about four months after the first. Radioactive iodine is either swallowed in a capsule or sipped in solution through a straw. It is an outpatient procedure. There are some simple radiation safety precautions necessary for about a week (it varies with the patient and the dose).

The goal of therapy in Graves’ disease is to destroy the whole gland and then take thyroid hormone pills (one a day) to maintain normal thyroid function. Untreated, Graves’ disease will “burn out” the thyroid gland (the disease is a chronic inflammation), so treatment with radioiodine merely accelerates the pathological process. The goal of therapy with “hot nodules” is to ablate the hyperthyroid areas, leaving normal areas to function normally afterwards, usually without the need for hormone replacement (unless the gland has numerous “hot nodules”).

I hope you now understand why most people believe that radioiodine therapy for hyperthyroidism is better than surgical therapy.


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