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Surgical treatment of asymmetrical multinodular goiter Antonio Sitges-Serra, FRCS EndocrineSurgery Unit Hospital del Mar, Barcelona.

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Presentation on theme: "Surgical treatment of asymmetrical multinodular goiter Antonio Sitges-Serra, FRCS EndocrineSurgery Unit Hospital del Mar, Barcelona."— Presentation transcript:

1 Surgical treatment of asymmetrical multinodular goiter Antonio Sitges-Serra, FRCS EndocrineSurgery Unit Hospital del Mar, Barcelona

2 Asymmetric 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.”

3 Asymmetric multinodular goiter Is the surgeon right? Why 15 mm.? Should he remove the contralateral lobe? What are the risks? What’s the chance of cancer? How often is hemiTX followed by hypothyroidism? How often is hemiTX followed by recurrence?

4 Asymmetric multinodular goiter Yes, thesurgeonwasright, said Dr. H. Chen Lessmorbidity of hemithyroidectomy (2 vs. 9%) Lesshypocalcemia (0 vs. 6%) Reasonablereoperationrate (11 vs 3% at 3-11 yrs) Recurrencedoesnotequalreoperation Reoperationdoesnotincreasemorbidity Olson SE, Starling J, Chen H. Symptomatic benign multinodular goiter: Unilateral or bilateral thyroidectomy? Surgery 2007;142(4):

5 Asymmetric 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

6 Asymmetric multinodular goiter Prevalence of US-AMG in solitary thyroid nodules 50% Tan G et al., Arch Int Med 1995

7 Asymmetric 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 rate Nodular 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

8 Asymmetric multinodular goiter Recurrence after hemithyroidectomy for benign TN Randomized trial of suppressive T4, 140 cases US-normal contralaterallobe Barczynski M et al., World J Surg year of follow-up data Nodular hyperplasia or follicular adenoma US-recurrence rate (NT>3mm): 13/145 (9%) 24% hypothyroidism (non-treated group) Seven (5%) reoperations during the interval Suspicious FNA: 4 cases Compressive symptoms: 3 cases Favors suppressive T4 in I-deficient patients Hemi-TX advisablefor US-unilateral benign TN

9 Asymmetric multinodular goiter Recurrence after hemithyroidectomy for benign TN (104 patients, prospective study) Yetkin G et al., EndocrPract 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 interval Suspicious FNA: 3 cases (follicular neoplasia) Hemi-TX advisablefor US-unilateral benign TN

10 Asymmetric multinodular goiter Limited thyroidectomy Extensive thyroidectomy /- Recurrence Hypothyroidism -+ Hypoparathyroidism +/-+ RLNparalysis +++ Incidental carcinoma Decisionmaking in patientswith AMG Whatis at stake?

11 Asymmetric 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 rates Permanent 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 2008 Erbil Y et al., Langenbeck’sArchSurg2006 Gibelin H et al., World J Surg2004

12 Asymmetric multinodular goiter Some data from the literature Farkas EA et al., AmSurg 2002

13 Asymmetric multinodular goiter Studydesign: Multicenter, randomizedclinical trial comparingextensivevs. limitedsurgeryforAMG (18-65 yrs.)

14 Asymmetric multinodular goiter Randomization Studydesign: Multicenter, randomizedclinical trial comparingextensivevs. limitedsurgeryforAMG (18-65 yrs.)

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19 Asymmetric multinodular goiter 118randomized 65 Hemi -TX 53 Dunhill 49 IQ Dunhill 1 Papillary ca. Intraop DX 53Benign 1 Hemi-TX preferred 2 Dunhill preferred 59 Hemi -TX 5 Papillary ca. (3 follicular variant) 45Benign 7 FU losses 44Evaluable 46Evaluable 3 Randomization error 3 Papillary ca. 1 Follicular ca. 1 FU losses

20 Asymmetric multinodular goiter 20 Group homogeneity GLOBAL (n=90) HEMI TX (n=47) DUNHILL (n=43) P Sex Male 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 ± ± ± * Past medical historyClinical featuresLAB 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

21 Asymmetric multinodular goiter 21 N.S. Size of thedominantnodule Grouphomogeneity

22 Asymmetric multinodular goiter 22 Global N =90 Hemi TX N = 47 Dunhill N = 43 P Number of nodules1.7±0.91.5±0.11.8± Maximum size (mm)6.8±2.26.6±2.26.9± Minimum size (mm)5.8±2.35.9±2.55.6± Subclinical contralateral nodules Grouphomogeneity

23 Asymmetric multinodular goiter 23 The typical patient profile 5.8 mm Woman 47 y/o. Normal thyroidfunction 36 mm

24 Asymmetric multinodular goiter 24 Operative time N.S. 13’

25 Asymmetric multinodular goiter 25 Identification of RLN

26 Asymmetric multinodular goiter 26 Parathyroid gland identification P<0.0001

27 Asymmetric multinodular goiter 27 N.S. Accidental PTX PT autotransplantation Parathyroidglandidentification 3/473/43 N.S. 5/476/43

28 Asymmetric multinodular goiter 28 Postoperativehypocalcemia (<8 mg/dL at 24h) P< % Hypocalcemia Treatment

29 Asymmetric multinodular goiter 29 Postoperative stay P<0.005

30 Asymmetric multinodular goiter 30 Thyroid function (last FU visit) Onthyroxine: Dunhill41/43 (95%)108 ± 24 mcg/day HemiTX14/47 (30%) 66 ± 30 mcg/day Free T4 : Dunhill:1.26 ± 0.4 ng/dL HemiTX: 1.07 ± 0.3 ng/dL TSH: Dunhill:3.77 ± 4.5  UI/mL HemiTX: 3.03 ± 2.0  UI/mL N.S. P= N.S.

31 Asymmetric multinodular goiter 31 Long term parathyroid function (no permanent hypoparathyroidism in either group) s-Ca: Dunhill:8.9 ± 0.4 mg/dL HemiTX: 8.9 ± 0,4 mg/dLN.S. iPTH: Dunhill:32.3 ± 2.6 pg/mL HemiTX: 31.2 ± 1.8 pg/mLN.S.

32 Asymmetric multinodular goiter 32 Remnantsize at last FU visit (55 ± 34 mo) P<0.0001

33 Asymmetric multinodular goiter 33 Remnant size evolution (55 ± 34 mo) ≈ 20%≈ 0% BerghoutA et al., Am J Med 1990; 89:602-8.

34 Asymmetric multinodular goiter 34 New nodules on remnant P= /47 6/43

35 Asymmetric multinodular goiter 35 Reoperations HemiTXDunhillP (1) Early redo (Intentiontotreat) 5/65 (7.7%) 1*/53 (1.8%) 0.22 DuringFollow-Up (Per protocol) 1/53 (1.9%) 0/ Overall (Intentiontotreat) 6/65 (9.2%) 1/53 (1.8%) 0.22 * 1 FTC (3 PTC detected but NOT reoperated) (1) Fisher exact-test

36 Asymmetric multinodular goiter 49 IQ Dunhill 1 Papillaryca. Intraop DX 53Benign 59 Hemi -TX 5 Papillaryca. 45Benign 7 FU losses 44Evaluable 46Evaluable 1TT 5TT 1 FTC 1 TT I 3 Micro PTC 1 MNG progression 42MNG SURVEILLANCE TX 1 FU losses 5 Micro PTC 39MNG 0 SURVEILLANCE TX 3 PTC

37 Asymmetric 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


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