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

2. 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. 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. 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. Manymethodologicalissues
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.

6. Prevalence 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-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
Lozano-Gómez MJ et al., CirEsp 2006

8. Recurrence after hemithyroidectomy for benign TN
Randomized trial of suppressive T4, 140 cases
US-normal contralaterallobe
5-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
Barczynski M et al., World J Surg 2010

9. Recurrence after hemithyroidectomy for benign TN
(104 patients, prospective study)
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 interval
Suspicious FNA: 3 cases (follicular neoplasia)
Hemi-TX advisablefor US-unilateral benign TN
Yetkin G et al., EndocrPract 2010

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

11. 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. Some data from the literature
Farkas EA et al., AmSurg 2002

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

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

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

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 ± 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 20

21. Grouphomogeneity
Size of thedominantnodule
N.S. 21

22. Grouphomogeneity Subclinical contralateral nodules 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 22

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

24. Operative time
N.S.
13’ 24

25. Identification of RLN 25

26. Parathyroid gland identification26

27. Parathyroidglandidentification
Accidental PTX
PT autotransplantation
N.S.
N.S.
3/47
3/43
5/47
6/43 27

28. Postoperativehypocalcemia (<8 mg/dL at 24h)
Treatment
P<0.0001
No cal afegir la P de gràficaesquerra? 28

29. Postoperative stay
P<0.005 29

30. Thyroid function (last FU visit)
Onthyroxine:
Dunhill 41/43 (95%) 108 ± 24 mcg/day
HemiTX14/47 (30%) 66 ± 30 mcg/day
Free T4 :
Dunhill: 1.26 ± 0.4 ng/dL
HemiTX: ± 0.3 ng/dL
TSH:
Dunhill: 3.77 ± 4.5 UI/mL
HemiTX: ± 2.0UI/mL P=
N.S.
Aquí invertirial’odrecoalsaltresllocs. Primer hemo i desprésdun
N.S. 30

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: ± 2.6 pg/mL
HemiTX: ± 1.8 pg/mLN.S. 31

32. Remnantsize at last FU visit(55 ± 34 mo)
P<0.0001 32

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

34. New nodules on remnant
P=0.0001
26/47
6/43 34

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 FTC (3 PTC detected but NOT reoperated) (1) Fisher exact-test 35

36. 59 Hemi -TX 49 IQ Dunhill 1TT 3 131I 5TT 1 TT 53 Benign 45 Benign 46
1 Papillaryca.
Intraop DX 59
Hemi -TX 49
IQ Dunhill
1TT
5 Papillaryca.
3 PTC
3 131I
5TT
1 FTC
1 TT 53
Benign 45
Benign
7 FU losses
1 FU losses 46
Evaluable 44
Evaluable 3
Micro PTC
1 MNG progression 42
MNG
SURVEILLANCE TX 5
Micro PTC 39
MNG
SURVEILLANCE TX

37. Conclusions 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