surgical treatment of asymmetrical multinodular goiter

Surgical treatment of asymmetrical multinodular goiter

Antonio Sitges-Serra, FRCSEndocrineSurgery UnitHospital del Mar, Barcelona

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Asymmetric multinodular goiterAsymmetric multinodular goiter

A chat in the internet:

“… well, I have been today to visit my surgeon. He told me that my

left thyroid lobe should be removed because of a 5 cm. benign

nodule but he said that the right lobe will be untouched because

only two 4 and 7 mm. nodules are there. He says that nothing has

to be done for nodules under 15 mm.”

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Starting with a definition:

Asymmetrical goiter is a clinically solitary unilateral

“benign” thyroid nodule which, in thyroid imaging,

shows evidence of contralateral subclinical (<10 mm)

nodular disease.

Manymethodologicalissues

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Prevalence of US-AMG in solitary thyroid nodules

50%Tan G et al., Arch Int Med 1995

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Recurrenceafterhemithyroidectomyforbenign TN(69 cases, US-normal contralaterallobe)

Lozano-Gómez MJ et al., CirEsp 2006

At least 10 yrs. of follow-up

Nodular hyperplasiaorfollicular adenoma

US-recurrence rateNodular hyperplasia: 70% (mean size 13 mm)

Follicular adenoma: 60% (mean size 9 mm)

No reoperations during the interval

50% treated with T4 (non-suppressive)

Hemi-TX advisablefor US-unilateral benign TN

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Recurrence after hemithyroidectomy for benign TN(104 patients, prospective study)

Yetkin G et al., EndocrPract 2010

39 mos. follow-up data

Nodular hyperplasia or follicular adenoma

US-recurrence rate (NT>3mm): 60/104 (60%)

Multinodularity as a risk factor

Three (2.9%) reoperations during the intervalSuspicious FNA: 3 cases (follicular neoplasia)

Hemi-TX advisablefor US-unilateral benign TN

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Limited thyroidectomyExtensive thyroidectomy

+ + ++/- Recurrence++ + + Hypothyroidism-+ Hypoparathyroidism

+/-+ RLNparalysis+++ Incidental carcinoma

Decisionmaking in patientswith AMGWhatis at stake?

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Some data from the literature

More recurrences with limited resections

Recurrence related to any residual tissue

Surgery for recurrence a mean of 18 yrs.

Higher hypocalcemia rates (T&P) after total thyroidectomy

Reoperation carries higher complication ratesPermanent hypopara: 0-22 vs 0-4%

Permanent RLN injury: 0-13 vs 0-4%

Factors for recurrence: young age and multiple nodules

Moalem J et al., World J Surg 2008Erbil Y et al., Langenbeck’sArchSurg2006

Gibelin H et al., World J Surg2004

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Studydesign:Multicenter, randomizedclinical trial comparingextensivevs. limitedsurgeryforAMG (18-65 yrs.)

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Randomization

Studydesign:Multicenter, randomizedclinical trial comparingextensivevs. limitedsurgeryforAMG (18-65 yrs.)

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118118randomizedrandomized

6565Hemi -TXHemi -TX

5353DunhillDunhill

4949IQ DunhillIQ Dunhill

11 Papillary ca. Papillary ca.Intraop DXIntraop DX

5353BenignBenign

11 Hemi-TX preferred Hemi-TX preferred22 Dunhill preferred Dunhill preferred

5959Hemi -TXHemi -TX

55 Papillary ca. Papillary ca.(3 follicular variant)(3 follicular variant)

4545BenignBenign

77 FU losses FU losses

4444EvaluableEvaluable

4646EvaluableEvaluable

33 Randomization error Randomization error33 Randomization error Randomization error

33 Papillary ca. Papillary ca.11 Follicular ca. Follicular ca.

11 FU losses FU losses

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20

Group homogeneity

GLOBAL

(n=90)

HEMI TX

(n=47)

DUNHILL

(n=43)P

SexMale

Female

7 (7.8%)

83 (92.2%)

1(2.1%)

46 (97.9%)

6 (14.0%)

37 (86.0%)

0.51

Age (y) 43.6 ± 10.6 41.4 ± 9.6 46 ± 11.2 0.038*

Past medical history Clinical features LAB

Endemic goiter area

Family history

Smoking

Alcohol consumption

Beta blockers

Iodine intake

Hormonal therapy

Menopause

Compressive simptoms

Hyperfunction signs

Estimated evolution

TSH

Free T4

s-Ca / s-P

Auto antibodies

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21

N.S.

Size of thedominantnodule

Grouphomogeneity

HEMI TX DUNHILL

10

20

30

40

50

60

70

Nod

ule

dia

me

ter

(mm

)

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22

Global

N =90

Hemi TX

N = 47

Dunhill

N = 43

P

Number of nodules 1.7±0.9 1.5±0.1 1.8±0.2 0.11

Maximum size (mm) 6.8±2.2 6.6±2.2 6.9±2.3 0.95

Minimum size (mm) 5.8±2.3 5.9±2.5 5.6±2.1 0.53

Subclinical contralateral nodules

Grouphomogeneity

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23

The typical patient profile

5.8 mm

• Woman• 47 y/o.• Normal thyroidfunction

36 mm

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24

Operative time

0

20

40

60

80

100

120

140

HemiTX Dunhill

Op

era

tiv

e ti

me

(m

in)

N.S.

13’

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25

Identification of RLN

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26

Parathyroid gland identification

0

0,5

1

1,5

2

2,5

3

3,5

4

HemiTX Dunhill

N o

f id

enti

fied

Par

ath

ryro

ids

P<0.0001

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0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

HemiTX Dunhill

% o

f s

pec

imen

s w

ith

par

ath

yro

id g

lan

d

27

0%

5%

10%

15%

20%

25%

HemiTX Dunhill

%

of

pa

tie

nts

wit

h a

uto

tra

nsp

lan

t

N.S.

Accidental PTX PT autotransplantation

Parathyroidglandidentification

3/47 3/43

N.S.

5/47 6/43

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28

Postoperativehypocalcemia (<8 mg/dL at 24h)

P<0.0001

% Hypocalcemia Treatment

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29

Postoperative stay

0

0,5

1

1,5

2

2,5

3

3,5

HemiTX Dunhill

Mea

n p

ost

-op

sta

y (d

ays)

P<0.005

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30

Thyroid function (last FU visit)

Onthyroxine:Dunhill 41/43 (95%) 108 ± 24 mcg/dayHemiTX14/47 (30%) 66 ± 30 mcg/day

Free T4 :Dunhill: 1.26 ± 0.4 ng/dLHemiTX: 1.07 ± 0.3 ng/dL

TSH:Dunhill: 3.77 ± 4.5 UI/mLHemiTX: 3.03 ± 2.0UI/mL

N.S.

P= 0.0001

N.S.

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31

Long term parathyroid function (no permanent hypoparathyroidism in either group)

s-Ca:Dunhill: 8.9 ± 0.4 mg/dLHemiTX: 8.9 ± 0,4 mg/dLN.S.

iPTH:Dunhill: 32.3 ± 2.6 pg/mLHemiTX: 31.2 ± 1.8 pg/mLN.S.

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32

Remnantsize at last FU visit(55 ± 34 mo)

P<0.0001

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33

Remnant size evolution (55 ± 34 mo)

≈ 20% ≈ 0%

BerghoutA et al., Am J Med 1990; 89:602-8.

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35

Reoperations

HemiTX Dunhill P(1)

Early redo(Intentiontotreat)

5/65

(7.7%)

1*/53

(1.8%)0.22

DuringFollow-Up(Per protocol)

1/53

(1.9%)0/45 1.00

Overall(Intentiontotreat)

6/65

(9.2%)

1/53

(1.8%)

0.22

* 1 FTC (3 PTC detected but NOT reoperated)(1) Fisher exact-test

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• Hemi TX and Dunhill have a similar intra and postop course

• Reoperation rate higher in hemiTX

• The presence of unsuspected carcinoma favors Dunhill

• Growth of remnant significant for hemiTX (4% per year)

• No remnant growth after Dunhill

• Accidental PTX same for both procedures

• 30% of HemiTX end up on thyroxine

Conclusions

surgical treatment of asymmetrical multinodular goiter

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