Evidence-based management of toxic multinodular goiter (plummer’s disease)

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.

Content Type Journal ArticleDOI 10.1007/s00268-008-9566-0Authors
John R. Porterfield, Mayo Clinic Department of Surgery 200 First Street SW Rochester MN 55905 USAGeoffrey B. Thompson, Mayo Clinic Department of Surgery 200 First Street SW Rochester MN 55905 USADavid R. Farley, Mayo Clinic Department of Surgery 200 First Street SW Rochester MN 55905 USAClive S. Grant, Mayo Clinic Department of Surgery 200 First Street SW Rochester MN 55905 USAMelanie L. Richards, Mayo Clinic Department of Surgery 200 First Street SW Rochester MN 55905 USA

Journal World Journal of SurgeryOnline ISSN 1432-2323Print ISSN 0364-2313 (Source: World Journal of Surgery)