Surgical Treatment of Nodular Thyroid Pathology in Women of Reproductive Age

The dissertation is devoted to the surgical treatment of nodular thyroid formations in women of reproductive age. It examines the clinical features of nodular thyroid pathology at a young age, the comparative frequency of complications after operations for benign and malignant lesions, and the factors influencing the development of postoperative complications, primarily postoperative hypothyroidism and recurrences. Particular attention is paid to improving the preoperative differential diagnosis of nodular colloid goiter, chronic thyroiditis, and neoplastic lesions using radionuclide, ultrasound, and morphological methods, including a developed two-needle biopsy technique. The clinical variants of the combination of nodular thyroid pathology and pregnancy are analyzed separately, and on this basis a diagnostic and treatment algorithm is proposed that defines the justification and timing of surgical intervention.

Relevance of the problem

Over the past century, the problem of thyroid diseases has remained relevant. Traditionally, there has been ongoing discussion regarding the indications for surgical treatment and its extent, while surgical techniques continue to be improved, leading to a decrease in specific complications. Despite many years of studying this problem, new scientific data on the course of thyroid diseases continue to emerge every year. Issues related to nodular lesions of this organ are particularly relevant, since no less than 4 - 7 % of the world's population have nodular thyroid neoplasms [52].

The collaboration of leading European and American researchers resulted in the development, in 2005 - 2006, of recommendations for the diagnosis and treatment of nodular goiter and thyroid cancer. In these works, thyroidectomy is regarded as the principal method of surgical treatment of thyroid diseases [32, 130]. Undoubtedly, this approach reduces the risk of disease recurrence, but it brings to the forefront the problem of postoperative hypothyroidism.

Hypothyroidism plays an important role in the unfavorable course of a number of common diseases. These include cardiovascular and pulmonary diseases, neuropsychiatric disorders, gastroenterological diseases, and certain oncological conditions [28]. Thyroid insufficiency exerts a particularly notable influence on reproductive function [200, 212, 244, 316]. Pregnancy in women with hypothyroidism is rare, and when it does occur, the child is frequently born prematurely or stillborn [17, 28], with malformations observed in 10.7 - 11.6 % of newborns [260]. Even subclinical forms of hypothyroidism are often accompanied by miscarriage [17, 64].

The aforementioned effects of surgical treatment of nodular thyroid pathology determine the relevance of studying this problem in pregnant women and young women planning pregnancy. Leading domestic and international thyroidologists note that the problem of the combination of nodular goiter and, especially, thyroid cancer with pregnancy remains insufficiently studied [15, 31, 32, 130]. The question of the possibility of preserving pregnancy during or after surgical treatment of thyroid cancer remains debatable. The opinions of researchers on this problem differ: from categorical prohibition of pregnancy in this situation [6, 7, 65] to its preservation with simultaneous surgical treatment of the cancer [30, 112].

One of the state programs of Russia is the stabilization of the demographic situation, which requires the medical sector to reduce the number of pregnancy terminations. This can be achieved by refusing unjustified abortions in various thyroid diseases and by preventing postoperative hypothyroidism. At the same time, the extent of surgical intervention must be sufficient from the standpoint of oncology and the prevention of recurrence.

What niche should organ-preserving operations occupy? The answer to this question may help to refine the modern principles of radical surgical treatment of nodular thyroid pathology [32, 130], which is particularly relevant for pregnant women and women of young age.

Aim of the study

The aim of the present study is to improve the immediate and long-term results of surgical treatment of various forms of nodular thyroid pathology in women of reproductive age.

Objectives of the study

To achieve this aim, the following objectives must be addressed:

1. To identify the clinical features of nodular thyroid lesions in women of reproductive age.

2. To compare the frequency of complications after operations for benign and malignant thyroid tumors.

3. To study the factors influencing the occurrence of postoperative complications.

4. To expand the possibilities of preoperative differential diagnosis of nodular colloid goiter, chronic thyroiditis, and neoplastic thyroid lesions.

5. To determine the treatment tactics in cases combining nodular thyroid pathology and pregnancy.

Scientific novelty of the research

Features of the course of nodular thyroid pathology at a young age have been identified.

A close relationship has been demonstrated between late complications of surgical treatment of this pathology and the volume of the thyroid remnant.

Clinical variants of the combination of nodular thyroid pathology and pregnancy have been distinguished, and on the basis of their study a diagnostic and treatment algorithm has been developed.

A device for minimally invasive histocytological examination of the thyroid gland has been proposed.

Practical significance of the work

In the present study, a unified tactical algorithm is proposed that makes it possible to determine the justification and timing of surgical treatment in cases combining nodular thyroid lesions and pregnancy. Its use makes it possible to minimize the existing risk to the life of the mother and the fetus.

A device for puncture histocytological examination of the thyroid gland has been created, making it possible to improve the results of preoperative diagnosis of various forms of nodular thyroid lesions.

Implementation of the results

The results of the study have been implemented in the practice of the Center for Endocrine Surgery based at the Clinic of Faculty Surgery named after S.R. Mirotvortsev of Clinical Hospital No. 3 of Saratov State Medical University.

Since 2005, the developed tactical algorithm has been used in cases combining nodular thyroid pathology and pregnancy (rationalization proposal certificate No. 2702 of 19.12.2006, issued by Saratov State Medical University).

Since 2006, the method of two-needle morphological examination of thyroid nodules has been introduced (rationalization proposal certificate No. 2703 of 19.12.2006, issued by Saratov State Medical University).

The materials of the dissertation are used in lectures and practical classes of the Department of Faculty Surgery of the Medical Faculty of Saratov State Medical University.

Approbation of the work

The materials of the dissertation were presented at the 61st Conference of the Scientific Society of Students and Young Scientists of Saratov State Medical University (Saratov, 2000); the Jubilee Student Scientific Conference dedicated to the 75th anniversary of Saint Petersburg State Pediatric Medical Academy (Saint Petersburg, 2000); the 62nd Scientific and Practical Conference dedicated to the 100th anniversary of the birth of Professor N.P. Pyatnitsky (Krasnodar, 2001); the X (XII) All-Russian Symposium on Surgical Endocrinology (Smolensk, 2002); a meeting of the Saratov Society of Endocrinologists (2004); and the International Symposium on Surgical Endocrinology (Kiev, 2006).

The materials of the dissertation were discussed at a joint meeting of the Departments of Faculty Surgery of the Medical Faculty, Hospital Surgery of the Medical Faculty, Hospital Surgery of the Pediatric Faculty, and Pathological Anatomy (Saratov, 7.04.2007) and served as the basis for the publication of 9 printed works.

Main propositions submitted for defense

1. The clinical picture and treatment of nodular thyroid lesions at a young age have specific features.

2. The risk of developing postoperative hypothyroidism is related to the nosological form of the disease and to the volume of the remaining thyroid tissue. The presence of this complication leads to deterioration of reproductive function.

3. The proposed method of two-needle biopsy of the thyroid gland has advantages over fine-needle aspiration biopsy.

4. The frequency of true recurrence of differentiated thyroid cancer after adequate surgical treatment does not exceed the corresponding figure for benign lesions.

5. In women radically operated on for differentiated thyroid cancer, the onset and/or continuation of pregnancy is permissible.

Scope and structure of the work

The work is set out on 157 pages of typewritten text and consists of an introduction, a review of the literature, 3 chapters of original research, a conclusion, conclusions, and practical recommendations. The work contains 31 tables and 11 figures. The bibliographic list contains 208 domestic and 120 foreign sources.

The work was carried out at the Department of Faculty Surgery of the Medical Faculty of the State Educational Institution of Higher Professional Education "Saratov State Medical University of the Russian Federal Agency for Health and Social Development" (Head of the Department: Doctor of Medical Sciences, Professor A.S. Slesarenko), based at the Clinic of Faculty Surgery named after S.R. Mirotvortsev of Clinical Hospital No. 3 of Saratov State Medical University.