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

The treatment of benign multinodular goitre (MNG) is controversial. but. Surgery is recommended ill large compressive goitres. While sonic 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(I-131) therapy has been used for two decades as all effective and safe alternative to surgery in the treatment of symptomatic non-toxic MNG. Since much higher activities of I-131 are employed when treating non-toxic rather than toxic NING, there has been reluctance ill many Countries to use this treatment modality. Frequently the I-131-uptake in a non-toxic MNG is low, which makes I-131 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 I-131-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 I-131-activity with a factor corresponding to the rhTSH induced increase in I-131-uptake. Hereby the extrathyroidal irradiation can be reduced without compromising efficacy. Thus, although in its infancy, and still experimental, rhTSH-augmented I-131 therapy may profoundly after the non-surgical treatment of benign non-toxic MNG.