This is best considered in two general settings:

1. When the lesion is clinically suspicious

2. When the lesion is not clinically suspicious

The first category normally presents no great difficulty since most physicians would have no hesitancy about recommending surgery for diagnosis and/or therapy in the case of lesions which are clinically suspicious for cancer as previously described.

However, the second category-that of the clinically nonsuspicious lesion-may pose quite a dilemma. One school of thought urges removal of all nodules (even though as many as 4% of the general population may have them), whereas the opposing camp advises surgery for virtually none.

The arguments pro and con are summarized as follows.

Should all nodular goiters he removed?

Yes

1. The incidence of cancer in surgically removed nodular goiters is quite high, perhaps 5 to 10%. Some quote figures up to twice as high, especially for clinically solitary nodules.

2. Preoperatively it is virtually impossible to distinguish with certainty a benign adenomatous goiter from one harboring cancer.

3. The diagnosis must be made as early as possible in the course of the disease. Speed is essential; the only sure way to accomplish this is by surgery.

4. Even if an adenomatous goiter is benign, it still must be regarded as a premalignant lesion. Its removal will prevent cancer from developing in it later.

5. Thyroid surgery of this nature carries a minimal hazard of morbidity and mortality.

No

1. The over-all incidence of cancer in nodular goiters is really quite low, probably less than 1%. The surgical statistics quoted represent a very selected sample. For every patient operated on (often because there is a clinical suspicion of cancer), there are several patients who never come to surgery, either because an operation has never been recommended or because they have refused it.

Clinical cancer of the thyroid is a relatively rare disease. If about 4% of the population harbor clinically detectable thyroid nodules, and if 5 to 10% of all adenomatous goiters were actually malignant, there should be over 500,000 cases of carcinoma of the thyroid in the United States today. Either these cancers do not exist, or they are actually present microscopically but never become a clinical problem. In either instance, the case for removing all such goiters is a poor one.

2. It is often possible to make a clinical differentiation between benign and malignant adenomatous goiters with some accuracy by taking the following into consideration:

(a) The age and sex of patient

(b) The physical characteristics of the lesion

(c) Radioiodine uptake

(d) Response to thyroid treatment

(e) Observation

The quoted statistics on the relatively high incidence of cancer in persons in whom adenomatous goiters were surgically removed contrasted with that found in the general population suggests that physicians are even now managing to exercise considerable selectivity in recommending operation. (This aspect is dealt with on p. 112.)

3. Thyroid cancer is either the fulminant, rapidly fatal type or the relatively sluggish variety which is readily amenable to surgery and other measures. The first variety is incurable. For the second type, speed of treatment appears to be of secondary importance.

4. There is little evidence that much, if any, thyroid cancer arises from a pre-existing benign nodule. It is either cancer from the beginning or is not cancer at all.

5. Although the risk may be slight, if the premises upon which the need for surgery are based are invalid, several hundred thousand unnecessary operations might be recommended annually. In all likelihood more people would die as a result of this surgery than would be expected to die from thyroid cancer.

Obviously, the physician must take into consideration many factors in arriving at a conclusion as to whether surgery should be recommended for a particular clinically nonsuspicious adenomatous goiter.

The following points should be considered (see Table 3):

1. Age of the patient. Although the absolute incidence of thyroid cancer does increase with age, the chances of a given nodule being malignant are greatly increased if the patient is under 30 years of age. Virtually all goiters in such patients should be removed.

2. Radiation therapy to the head and neck area in infancy or childhood is regarded as increasing the likelihood of cancer.

3. Single or multiple nodules. Many make a distinction between uninodular and multinodular goiters. It is said that cancer is more common in the clinically solitary nodule than in the gland with multiple adenomas. There is considerable difference of opinion as to just how great the difference is between the incidence of cancer in uninodular and multinodular goiters and just how useful this is in deciding when to advise operation. This is especially true since the clinically solitary nodule often proves to be multiple at the time of surgery.

Table 3. Nodular Goiter-Surgery Vs. Observation*

*The decision is rarely as clear-cut as this table might suggest. The final recommendation represents the clinical judgment of the physician after he has weighed all factors.

4. Pressure symptoms. Obviously if the patient has symptoms suggestive of pressure upon surrounding structures, such as the trachea, surgery is advisable.

5. Scintigram (see pp. 109 and 110). Although the scintigram technique errs both on the side of overdiagnosis and underdiagnosis of cancer, it may be useful in narrowing the field of surgical candidates.

6. Response to medication. A limited trial of therapy with thyroid extract is advocated by some in the case of clinically nonsuspicious nodules. This is given in dosage of 1 to 3 grains daily for eight to twelve weeks or longer and the response of the lesion (change in size and consistency) noted. A decrease in size is taken as an indication of a benign lesion.

7. Simple observation. Some prefer merely to examine the gland carefully, record the findings in detail, and have the patient return at intervals of one to two months for an extended period. Any increase in size, beginning induration, etc. is taken as an indication of possible cancer, and surgery is advised. In view of the biologic peculiarities of thyroid cancer previously referred to, these physicians feel that little is lost by the resulting delay-and many operations may be avoided.

8. General condition of the patient. As in most other situations involving quasi-elective surgery, this important factor must be given consideration. The likelihood of cancer, the estimated prognosis of the thyroid lesion with or without treatment, the surgical risk presented by the patient, and the patient's life expectancy as a result of co-existing disease and age-all must be assessed. Then the physician can decide whether good or harm is more likely to result from surgery in a particular patient if operation is recommended.

In general, it is our recommendation that, in the absence of significant contraindications, surgery be performed on all patients with discrete thyroid nodules. The physician's final decision should, of course, not be an arbitrary one based on "routine" or "policy." It should represent sound clinical judgment based on careful evaluation of all the evidence available in the particular patient under consideration.