Need for an Individualized and Aggressive Management of Multinodular Goiters of Endemic Zones by Specially Trained Surgeons: Experience in Western Nepal

Excerpt

The optimal treatment for endemic goiter is to prevent its development by treating its underlying cause of iodine deficiency. There has been substantial progress in the last decade towards the elimination of iodine deficiency with the introduction of universal salt iodization programs although goiter prevalence remains high.1 In addition, nodular goiter remains a common disorder, even in non-endemic areas, indicating that goitrogenic mechanisms are rather complicated. Apart from a high prevalence and a severe form of diseases, endemic goiter is also associated with the development of more aggressive and advanced forms of thyroid cancer. Compared with endemic goiter, the relative contributory role of iodine deficiency and socioeconomic factor remains uncertain.2,3 Low socioeconomic status seems to account for the high prevalence of advanced stage and anaplastic carcinomas while iodine deficiency should play a specific role in the increased prevalence of follicular thyroid carcinoma.3 There is no doubt that management of endemic goiter with its inherited complexity and socioeconomic background is still a challenge to the endocrine surgeons. The paper presented by Mukta and colleagues allude to the challenge by evaluating their experience in surgical management of multinodular goiter in Western Nepal where iodine deficiency prevails despite iodization. Majority of goiters (> 60%) is large (Grade III) according to World Health Organization Classification associated with a high incidence of thyrotoxicosis and aggressive thyroid cancer. Despite many patients defaulting investigations, treatment and follow-up, surgical treatment for this selective group of patients illustrates the unique clinical pattern and disease spectrum of thyroid disease encountered, which is distinctly different from that managed in many developed countries.4 …