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Surgical treatment of asymmetrical multinodular goiter

Surgical treatment of asymmetrical multinodular goiter. Antonio Sitges-Serra, FRCS EndocrineSurgery Unit Hospital del Mar, Barcelona. A chat in the internet:.

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Surgical treatment of asymmetrical multinodular goiter

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  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. 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.

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

  5. 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

  6. 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

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

  8. 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

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

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

  11. 118 randomized 65 Hemi -TX 53Dunhill 1 Hemi-TX preferred 2 Dunhill 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 1 FU losses 7 FU losses 46 Evaluable 44 Evaluable

  12. Group homogeneity 20

  13. Grouphomogeneity Size of thedominantnodule N.S. 21

  14. Grouphomogeneity Subclinical contralateral nodules 22

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

  16. Operative time N.S. 13’ 24

  17. Identification of RLN 25

  18. Parathyroid gland identification P<0.0001 26

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

  20. Postoperativehypocalcemia (<8 mg/dL at 24h) Treatment % Hypocalcemia P<0.0001 28

  21. Postoperative stay P<0.005 29

  22. 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: 1.07 ± 0.3 ng/dL TSH: Dunhill: 3.77 ± 4.5 UI/mL HemiTX: 3.03 ± 2.0UI/mL P= 0.0001 N.S. N.S. 30

  23. 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. 31

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

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

  26. Reoperations * 1 FTC (3 PTC detected but NOT reoperated)(1) Fisher exact-test 35

  27. 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

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