Response to “Does thyroxine suppression therapy help to rationalize surgery in benign euthyroid nodules”

Sir,

It is an interesting article[1] on clinical experimentation with thyroxine suppression of thyroid nodules (TN). Though, the study was done with good clinical intent and effort, many glaring drawbacks, prompted us to put forth few queries and comments. Firstly, size of the TN is not mentioned, as smaller nodules have been shown to regress or be static with longer follow-up.[2] Secondly, clinical palpation has a very low accuracy in assessing the size of goiter or TN compared to ultrasonography (USG),[3] as USG detects additional nodules in 50% of cases with an apparent solitary TN. How many of your cases had multinodular goiter? Thirdly, thyroxine suppression for TN is not recommended routinely, as it is shown that there can be rebound increase in their size after stopping it.[4]

Fourthly, natural history of TN is variable and dependent on many intrinsic and extrinsic factors such as iodine intake status, geography, genetic factors and growth factors like epidermal and fibroblast growth factors,[5] apart from thyroid-stimulating hormone alone. Fifthly, inclusion of groups A and C is not contributing much to be objectives of this study. When 3/29 cases in group B underwent surgery within 1 year follow-up, more cases might have required surgery with longer follow-up. The proposed 1 year cut-off for surgical decision appears to be shorter and overdoing in the absence of traditional indications for surgery such as malignancy, pressure symptoms, toxicity and sudden increase in TN size. What were the indications for surgery in your study?

Finally, the conclusion though interesting appears to be largely speculative as the methodology of study and objective documentation are not robust.