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Management of Toxic Multinodular Goiter - Role of surgery Shi LAM Queen Mary Hospital Joint Hospital Surgical Grandround.

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Presentation on theme: "Management of Toxic Multinodular Goiter - Role of surgery Shi LAM Queen Mary Hospital Joint Hospital Surgical Grandround."— Presentation transcript:

1 Management of Toxic Multinodular Goiter - Role of surgery Shi LAM Queen Mary Hospital Joint Hospital Surgical Grandround

2 ..two distinct types of thyroid intoxication… – H.S Plummer 1913 Hyperplastic (Graves) Hyperplastic (Graves) Non-hyperplastic (Plummers) Non-hyperplastic (Plummers) Solitary toxic nodule Solitary toxic nodule Toxic multinodular goiter Toxic multinodular goiter Two major causes (> 80%) of hyperthyroidism worldwide Two major causes (> 80%) of hyperthyroidism worldwide

3 Multinodular Goiters (MNG) Commonly adopted definition Commonly adopted definition thyroid volume > 20ml thyroid volume > 20ml nodular lesions > 5 – 10mm nodular lesions > 5 – 10mm Prevalence determined by iodine intake Prevalence determined by iodine intake palpation: 3 – 5% palpation: 3 – 5% USG screening: % USG screening: % endemic in regions of low iodine intake endemic in regions of low iodine intake risk factors: age, female, parity, smoking, obesity risk factors: age, female, parity, smoking, obesity

4 Hong Kong is a region of borderline iodine deficiency Chinese Nutrition Society Recommendation Chinese Nutrition Society Recommendation adolescent / adult : 150 ug / day adolescent / adult : 150 ug / day pregnant / lactating women: 250 ug / day pregnant / lactating women: 250 ug / day upper limit 1000 ug/day upper limit 1000 ug/day Center for food safety report 2011 Center for food safety report 2011 median daily food iodine content 44 ug/day median daily food iodine content 44 ug/day 59% of population has iodine intake < 50 ug / day 59% of population has iodine intake < 50 ug / day iodine rich food: seaweed > crustaceans > eggs > milk > fish iodine rich food: seaweed > crustaceans > eggs > milk > fish iodine scarce food: grains, meat, vegetable, tea / coffee iodine scarce food: grains, meat, vegetable, tea / coffee

5 Natural history – nodule growth Alexander et al. Ann Intern Med 2003 Alexander et al. Ann Intern Med 2003 USG follow-up of 330 benign nodules USG follow-up of 330 benign nodules 39% nodules increase volume by 15% in 35 months 39% nodules increase volume by 15% in 35 months cystic nodules tend to remain static cystic nodules tend to remain static age, gender and TSH level were not predictive of nodule growth age, gender and TSH level were not predictive of nodule growth Papini et al. J Clin Endocrinol Metab Papini et al. J Clin Endocrinol Metab % increase volume, 25% in nodule number in 5 years 45% increase volume, 25% in nodule number in 5 years

6 Natural history - thyrotoxicosis Prospective cohorts Prospective cohorts Elte et al. Postgrad Med J 1990 Elte et al. Postgrad Med J 1990 Wiener et al. Clin Nucl Med Wiener et al. Clin Nucl Med euthyroid MNG patients with autonomous functioning thyroid 158 euthyroid MNG patients with autonomous functioning thyroid mean follow-up 4 – 12.2 years mean follow-up 4 – 12.2 years 10% patients develop thyrotoxicosis 10% patients develop thyrotoxicosis Factors associated with hyperthyroidism Factors associated with hyperthyroidism older age older age hyperfunctional nodules size > 3cm hyperfunctional nodules size > 3cm autonomously functioning thyroid volume > 16ml autonomously functioning thyroid volume > 16ml

7 Spectrum & course of Plummers disease Age Goiter/ nodularity

8 Spectrum & course of Plummers disease Age Goiter/ nodularity Automaticity

9 Spectrum & course of Plummers disease Age Goiter/ nodularity AutomaticityThyrotoxicosis

10 Spectrum & course of Plummers disease Age Goiter/ nodularity AutomaticityThyrotoxicosis adolescent+ non- autonomous euthyroid

11 Spectrum & course of Plummers disease Age Goiter/ nodularity AutomaticityThyrotoxicosis adolescent+ non- autonomous euthyroid 40++autonomouseuthyroid

12 Spectrum & course of Plummers disease Age Goiter/ nodularity AutomaticityThyrotoxicosis adolescent+ non- autonomous euthyroid 40++autonomouseuthyroid Plummers disease

13 Spectrum & course of Plummers disease Age Goiter/ nodularity AutomaticityThyrotoxicosis adolescent+ non- autonomous euthyroid 40++autonomouseuthyroid autonomous autonomous subclinical hyperthyroidism

14 Spectrum & course of Plummers disease Age Goiter/ nodularity AutomaticityThyrotoxicosis adolescent+ non- autonomous euthyroid 40++autonomouseuthyroid autonomous autonomous subclinical hyperthyroidism Toxic multinodular goiter

15 Age Goiter/ nodularity AutomaticityThyrotoxicosis adolescent+ non- autonomous euthyroid 40++autonomouseuthyroid autonomous autonomous subclinical hyperthyroidism > 60 mass effect autonomous autonomous overt hyperthyroidism Spectrum & course of Plummers disease Iodine exposure

16 Management of toxic MNG Goals Goals correct dysfunction – mass / thyrotoxicosis correct dysfunction – mass / thyrotoxicosis exclude / treat malignancy exclude / treat malignancy Options Options medical medical radio-active iodine radio-active iodine surgery surgery percutaneous ablations percutaneous ablations

17 Overt thyrotoxicosis in toxic MNG Preferred treatment options Preferred treatment options surgery surgery total / near-total thyroidectomy total / near-total thyroidectomy immediate restoration of euthyroidism immediate restoration of euthyroidism retrosternal goiters, weight > 90g retrosternal goiters, weight > 90g <1% retreatment rate <1% retreatment rate <2% permanent recurrent laryngeal nerve injury <2% permanent recurrent laryngeal nerve injury <2% permanent hypoparathyroidism <2% permanent hypoparathyroidism contraindications: pregnancy (1 st and 3 rd trimester) contraindications: pregnancy (1 st and 3 rd trimester)

18 Overt thyrotoxicosis in toxic MNG Preferred treatment options Preferred treatment options 131 I 131 I avoids surgical / anaesthetic risk avoids surgical / anaesthetic risk euthyroidism: 3 months – 60%, 6 months – 80% euthyroidism: 3 months – 60%, 6 months – 80% hypothyroidism: 1 year – 3%, 24 years – 64%; hypothyroidism: 1 year – 3%, 24 years – 64%; 40% size reduction 40% size reduction contraindications: contraindications: lactating lactating pregnant / planning pregnant in 6 months pregnant / planning pregnant in 6 months

19 Overt thyrotoxicosis in toxic MNG Other treatment options Other treatment options Anti-thyroid medications Anti-thyroid medications does not induce remission does not induce remission for patients not fit for surgery, limitted life expectancy for patients not fit for surgery, limitted life expectancy Percutaneous ablation (ethanol / radio-frequency / high intensity focused ultrasound ) Percutaneous ablation (ethanol / radio-frequency / high intensity focused ultrasound ) lack of long-term experience lack of long-term experience

20 Subclinical thyrotoxicosis Common in toxic multinodular goiter Common in toxic multinodular goiter Porterfield et al. World J Surg 2008 Porterfield et al. World J Surg / 586 (82%) patients with toxic nodular goiter 438 / 586 (82%) patients with toxic nodular goiter Long-term consequence Long-term consequence Sawin et al. NEJM 1994 Sawin et al. NEJM 1994 prospective cohort of 2007 subjects > 60 years old prospective cohort of 2007 subjects > 60 years old follow-up: 10 years follow-up: 10 years subjects with subclinical hyperthyroidism (TSH < 0.1 mU/L) have 3-fold increased risk in developing atrial fibrillation subjects with subclinical hyperthyroidism (TSH < 0.1 mU/L) have 3-fold increased risk in developing atrial fibrillation

21 Risk of malignancy Incidental carcinoma in toxic multinodular goiter: Incidental carcinoma in toxic multinodular goiter: Review by Pazaitou et al. Horm Metab Res 2012 Review by Pazaitou et al. Horm Metab Res retrospective cohorts of toxic nodular goiter 7 retrospective cohorts of toxic nodular goiter 1611 subjects 1611 subjects Cancer in 1.6 – 8.8% Cancer in 1.6 – 8.8% Microcarcinoma (<10mm): 35 – 88% of tumors Microcarcinoma (<10mm): 35 – 88% of tumors Excellent prognosis compared with euthyroid patients Excellent prognosis compared with euthyroid patients QMH (unpublished) QMH (unpublished) Toxic multinodular goiter operated for non-suspicious causes Toxic multinodular goiter operated for non-suspicious causes Excluded FNAC confirmed or suspicious nodules Excluded FNAC confirmed or suspicious nodules 16/178 (9%) found to have carcinoma 16/178 (9%) found to have carcinoma 15 papillary carcinoma, 1 Hurthle cell carcinoma 15 papillary carcinoma, 1 Hurthle cell carcinoma Mean diameter 12mm Mean diameter 12mm

22 Risk of malignancy ? Clinical significance ? Clinical significance higher reported prevalence due to more detailed pathological examination ? higher reported prevalence due to more detailed pathological examination ? hyperthyroidism not previously identified as risk factors for manifesting carcinoma of thyroid hyperthyroidism not previously identified as risk factors for manifesting carcinoma of thyroid ? Pre-operative risk stratification ? Pre-operative risk stratification cold nodules on scintigraphy cold nodules on scintigraphy family history family history exposure to neck irradiation exposure to neck irradiation USG findings USG findings > 50% carcinomas found outside of dominant / cold nodules > 50% carcinomas found outside of dominant / cold nodules

23 Summary Toxic multinodular goiter is the manifesting stage of a chronic process of hyperplasia and acquisition of automaticity in the thyroid gland. Toxic multinodular goiter is the manifesting stage of a chronic process of hyperplasia and acquisition of automaticity in the thyroid gland. Hyperthyroidism, overt or subclinical, is an indication for definitive interventions, in the form of thyroidectomy or radio-active iodine ablation. Hyperthyroidism, overt or subclinical, is an indication for definitive interventions, in the form of thyroidectomy or radio-active iodine ablation. In the absence of suspicion of malignancy, surgery is probably still a safer offer in younger patients in view of the accumulated life-time risk for an incidental carcinoma to progress into a manifesting cancer. In the absence of suspicion of malignancy, surgery is probably still a safer offer in younger patients in view of the accumulated life-time risk for an incidental carcinoma to progress into a manifesting cancer.

24 Acknowledgement Dr. Brian Lang

25 Thank you!


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