Surgical treatment of asymmetrical multinodular goiter
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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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Asymmetric multinodular goiterAsymmetric multinodular goiter
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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Asymmetric multinodular goiterAsymmetric multinodular goiter
Prevalence of US-AMG in solitary thyroid nodules
50%Tan G et al., Arch Int Med 1995
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Asymmetric multinodular goiterAsymmetric multinodular goiter
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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Asymmetric multinodular goiterAsymmetric multinodular goiter
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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Asymmetric multinodular goiterAsymmetric multinodular goiter
Limited thyroidectomyExtensive thyroidectomy
+ + ++/- Recurrence++ + + Hypothyroidism-+ Hypoparathyroidism
+/-+ RLNparalysis+++ Incidental carcinoma
Decisionmaking in patientswith AMGWhatis at stake?
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Asymmetric multinodular goiterAsymmetric multinodular goiter
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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Asymmetric multinodular goiterAsymmetric multinodular goiter
Studydesign:Multicenter, randomizedclinical trial comparingextensivevs. limitedsurgeryforAMG (18-65 yrs.)
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Asymmetric multinodular goiterAsymmetric multinodular goiter
Randomization
Studydesign:Multicenter, randomizedclinical trial comparingextensivevs. limitedsurgeryforAMG (18-65 yrs.)
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Asymmetric multinodular goiterAsymmetric multinodular goiter
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Asymmetric multinodular goiterAsymmetric multinodular goiter
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Asymmetric multinodular goiterAsymmetric multinodular goiter
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Asymmetric multinodular goiterAsymmetric multinodular goiter
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Asymmetric multinodular goiterAsymmetric multinodular goiter
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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Asymmetric multinodular goiterAsymmetric multinodular goiter
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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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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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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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The typical patient profile
5.8 mm
• Woman• 47 y/o.• Normal thyroidfunction
36 mm
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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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Identification of RLN
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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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Asymmetric multinodular goiterAsymmetric multinodular goiter
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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Postoperativehypocalcemia (<8 mg/dL at 24h)
P<0.0001
% Hypocalcemia Treatment
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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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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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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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Remnantsize at last FU visit(55 ± 34 mo)
P<0.0001
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Remnant size evolution (55 ± 34 mo)
≈ 20% ≈ 0%
BerghoutA et al., Am J Med 1990; 89:602-8.
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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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Asymmetric multinodular goiterAsymmetric multinodular goiter
• 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