Presentation on theme: "Surgical treatment of asymmetrical multinodular goiter"— Presentation transcript:
1Surgical treatment of asymmetrical multinodular goiter Antonio Sitges-Serra, FRCSEndocrineSurgery UnitHospital del Mar, Barcelona
2A 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.”
3Is 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?
4Yes, thesurgeonwasright, said Dr. H. Chen Lessmorbidity of hemithyroidectomy (2 vs. 9%)Lesshypocalcemia (0 vs. 6%)Reasonablereoperationrate (11 vs 3% at 3-11 yrs)RecurrencedoesnotequalreoperationReoperationdoesnotincreasemorbidityOlson SE, Starling J, Chen H.Symptomatic benign multinodular goiter: Unilateral or bilateral thyroidectomy?Surgery 2007;142(4):
5Manymethodologicalissues 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.
6Prevalence of US-AMG in solitary thyroid nodules 50%Tan G et al., Arch Int Med 1995
7(69 cases, US-normal contralaterallobe) Recurrenceafterhemithyroidectomyforbenign TN(69 cases, US-normal contralaterallobe)At least 10 yrs. of follow-upNodular hyperplasiaorfollicular adenomaUS-recurrence rateNodular hyperplasia: 70% (mean size 13 mm)Follicular adenoma: 60% (mean size 9 mm)No reoperations during the interval50% treated with T4 (non-suppressive)Hemi-TX advisablefor US-unilateral benign TNLozano-Gómez MJ et al., CirEsp 2006
8Recurrence after hemithyroidectomy for benign TN Randomized trial of suppressive T4, 140 casesUS-normal contralaterallobe5-year of follow-up dataNodular hyperplasia or follicular adenomaUS-recurrence rate (NT>3mm): 13/145 (9%)24% hypothyroidism (non-treated group)Seven (5%) reoperations during the intervalSuspicious FNA: 4 casesCompressive symptoms: 3 casesFavors suppressive T4 in I-deficient patientsHemi-TX advisablefor US-unilateral benign TNBarczynski M et al., World J Surg 2010
9Recurrence after hemithyroidectomy for benign TN (104 patients, prospective study)39 mos. follow-up dataNodular hyperplasia or follicular adenomaUS-recurrence rate (NT>3mm): 60/104 (60%)Multinodularity as a risk factorThree (2.9%) reoperations during the intervalSuspicious FNA: 3 cases (follicular neoplasia)Hemi-TX advisablefor US-unilateral benign TNYetkin G et al., EndocrPract 2010
10Decisionmaking in patientswith AMG Whatis at stake?Extensive thyroidectomyLimited thyroidectomy+ + ++/-Recurrence++ + +Hypothyroidism-+Hypoparathyroidism+/-+RLNparalysis+++Incidental carcinoma
11Some data from the literature More recurrences with limited resectionsRecurrence related to any residual tissueSurgery for recurrence a mean of 18 yrs.Higher hypocalcemia rates (T&P) after total thyroidectomyReoperation 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 nodulesMoalem J et al., World J Surg 2008Erbil Y et al., Langenbeck’sArchSurg2006Gibelin H et al., World J Surg2004
12Some data from the literature Farkas EA et al., AmSurg 2002
22Grouphomogeneity Subclinical contralateral nodules Global N =90 Hemi TX N = 47DunhillN = 43PNumber of nodules1.7±0.91.5±0.11.8±0.20.11Maximum size (mm)6.8±2.26.6±2.26.9±2.30.95Minimum size (mm)5.8±2.35.9±2.55.6±2.10.5322
37Conclusions Hemi TX and Dunhill have a similar intra and postop course Reoperation rate higher in hemiTXThe presence of unsuspected carcinoma favors DunhillGrowth of remnant significant for hemiTX (4% per year)No remnant growth after DunhillAccidental PTX same for both procedures30% of HemiTX end up on thyroxine