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Age is no contraindication to thyroid surgery

Age and Ageing, July, 1999 by Richard Bliss, Nirmal Patel, Ana Guinea, Thomas S. Reeve, Leigh Delbridge

Introduction

Thyroid disease is common in the elderly population [1]. The incidence of hypothyroidism and multinodular goitre gradually increases with age [2]. Although the frequency of carcinoma of the thyroid remains similar, there is a higher incidence of anaplastic carcinoma of thyroid [3] in elderly patients. Age may be a poor independent prognostic factor when managing differentiated carcinomas of the thyroid [4].

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Indications for thyroid surgery include carcinoma of the thyroid, the suspicion of carcinoma requiring histological diagnosis in a thyroid nodule, hyperthyroidism and, most commonly, local obstructive symptoms or the presence of a retrosternal extension of a goitre. Surgeons and endocrinologists may avoid thyroid surgery in older subjects because of perceived risks associated with operative treatment, and have either managed these problems medically or deferred treatment if the patient was not at risk of death. The timing of surgery is important, however, as a deferred procedure may carry increased risks. This is particularly so when managing differentiated thyroid cancer, as a high cure rate is possible if it is treated before local invasion, distant metastases or anaplastic transformation occur [4].

Surgery in elderly patients is considered to be more hazardous than in the young. The age at which this becomes important is debated--some authorities believe that the risk increases with all ages [5], while others claim that surgical risk increases only over the age of 70 [6].

The management of thyroid disorders has become increasingly specialized, and techniques of safe anaesthesia and operative skills have led to an increase in the proportion of these patients being managed in specialized endocrine surgical units. This has led to increasingly safe surgical management, to the extent where age alone may be dismissed as a contraindication to surgery. Very little has been written on the safety and efficacy of thyroid surgery in older people. We have retrospectively compared surgery in patients aged 75 years and older with surgery in younger groups to determine whether or not age should be a factor when considering the optimal time for surgery.

Patients and methods

Patients

During the 11-year period from 1986 to 1996, 1631 patients aged 50 years and over underwent 1673 thyroid procedures in the endocrine surgical unit at Royal North Shore Hospital. The three groups compared were: patients aged 50-60 years, patients aged 61-74 years and patients aged 75 years and over. All patients were aged above the limit set as a prognostic factor for thyroid cancer as defined by the AGES, AMES or MACIS [4] methods of prognostication. The elderly group was defined as 75 years and over to enable comparison with other published results, particularly for parathyroid surgery [7], although some authors have described patients as young as 64) years as `elderly' [8].

All patients had been previously assessed by an endocrinologist or family practitioner and any pre-existing disorders had been optimised prior to surgery. No patients in any of the groups were excluded from surgery without medical advice to enable maximum function.

The 50-60-year group contained 725 consecutive patients undergoing 738 thyroid procedures, the 61-74-year group contained 685 patients undergoing 704 operations and the elderly age group consisted of 221 patients undergoing 231 procedures. The elderly patients were predominantly female, with a female:male ratio of 4:1 (180:41). The ages in the over-75 group ranged from 75 to 94 years: 152 were aged 75-79, 43 were aged 80-84 and 25 were aged 85 or over.

Indications for surgery, surgical procedures performed, pathology and complications were compared between the three groups to determine whether morbidity or mortality were different between the age groups.

All statistics were calculated by the [chi square] test and were determined using SPSS for Windows95.

Results

Indications for surgery

Figure 1 shows the distribution of indications for surgery between the three groups. The only statistically significant difference in the indications for surgery across all three groups (P = 0.0003) was retrosternal goitre causing compression symptoms.

[Figure 1 ILLUSTRATION OMITTED]

Procedures performed

Figure 2 shows the distribution of operative procedures performed. Comparisons between the groups demonstrated a higher incidence of secondary procedures (previous thyroid surgery having been performed) on the elderly patients (P = 0.003) and also a significant difference between the proportions of total and hemi-thyroidectomies (P [is less than] 0.0001). The latter was significantly more common in the younger 50-60-year group than in either of the other two groups (P [is less than] 0.01).

[Figure 2 ILLUSTRATION OMITTED]

Pathology

Figure 3 demonstrates the pathology in each of the three groups. As expected, there was significantly more cancer in the 75 and over group (P = 0.0007) and benign follicular adenomas (which require a histological diagnosis) were more commonly found in the 50-60-year group (P [is less than] 0.01).

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Age is no contraindication to thyroid surgery

Age and Ageing, July, 1999 by Richard Bliss, Nirmal Patel, Ana Guinea, Thomas S. Reeve, Leigh Delbridge

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