Analysis Favours Surgery Over Radioiodine for paediatric Graves' Disease Treatment

Thyroidectomy appears statistically superior to radioiodine ablation (RAI) for achieving a definitive cure in children with hyperthyroidism. Historically, selecting a definitive paediatric Graves' disease treatment has been a fraught exercise, balancing the immediate physical risks of neck surgery against the long-term radiological concerns of iodine therapy. This hesitation has often left clinicians relying on patient preference rather than robust efficacy data.

Efficacy in paediatric Graves' Disease Treatment

The investigators compiled data from 29 studies, encompassing 1,861 children with a mean age of 13 years. The review, covering literature from 1985 to 2023, assessed 1,061 patients receiving RAI and 800 undergoing thyroidectomy. The pooled analysis measured a clear divergence in outcomes: RAI demonstrated a significantly lower cure rate (RR 0.89). Put simply, surgery was more effective at stopping the disease. Furthermore, the granularity of the surgical data offers a sharper insight. Within the surgical cohort, total thyroidectomy resulted in a recurrence rate of just 2%, compared to 13% for subtotal thyroidectomy. The evidence implies that if one chooses the knife, half-measures are ill-advised.

We must scrutinise the mechanical divergence between these therapies to understand the variance in failure rates. Radioiodine ablation functions as a biological suppression; it introduces a radioactive isotope that must be actively taken up by the thyroid to induce necrosis in hyperfunctioning cells. It relies on metabolic cooperation. If the tissue is resistant or uptake is uneven, the disease persists. Conversely, thyroidectomy is an anatomical deletion. The surgeon physically excises the glandular tissue. The meta-analysis indicates that this physical removal eliminates the variable of tissue responsiveness inherent to RAI. While RAI leaves tissue behind that may recrudesce, total surgery leaves nothing to reactivate. The biological variability of the isotope method cannot compete with the absolute nature of total excision.

Safety remains the primary counter-argument to surgery. However, the review found no significant difference in hypothyroidism rates between the two groups; thyroid failure is essentially the intended endpoint for both. Regarding adverse events, RAI showed no reported secondary malignancies, though this may reflect the limitations of follow-up duration. Surgical risks were present but low: permanent hypoparathyroidism occurred in 0.6% of cases, and temporary recurrent laryngeal nerve palsy in 5.1%. These are not negligible risks, yet they are quantifiable and immediate, unlike the theoretical long-term risks often associated with radiation.

The study authors note that while surgery appears more effective, access is not universal. High-volume thyroid surgeons are not available in every centre. Consequently, while the data supports thyroidectomy as the superior curative agent, logistical barriers may force RAI to remain a common second-line option.