Surgical treatment of asymmetrical
multinodular goiter
Antonio Sitges-Serra, FRCS
EndocrineSurgery Unit
Hospital del Mar, Barcelona
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.”
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Asymmetric multinodular goiter
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.
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Asymmetric multinodular goiter
Prevalence of US-AMG in solitary thyroid nodules
50%
Tan G et al., Arch Int Med 1995
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Asymmetric multinodular goiter
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
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Lozano-Gómez MJ et al., CirEsp 2006
Asymmetric multinodular goiter
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
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Yetkin G et al., EndocrPract 2010
Asymmetric multinodular goiter
Decisionmaking in patientswith AMG
Whatis at stake?
Extensive thyroidectomy
+/+++
+
+
++
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Limited thyroidectomy
Recurrence
Hypothyroidism
Hypoparathyroidism
RLNparalysis
Incidental carcinoma
+++
+
+/+
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
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Asymmetric multinodular goiter
Studydesign:
Multicenter, randomizedclinical trial
comparingextensivevs. limitedsurgeryforAMG (18-65
yrs.)
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Asymmetric multinodular goiter
Studydesign:
Multicenter, randomizedclinical trial
comparingextensivevs. limitedsurgeryforAMG (18-65
yrs.)
Randomization
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Asymmetric multinodular goiter
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Asymmetric multinodular goiter
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Asymmetric multinodular goiter
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Asymmetric multinodular goiter
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Asymmetric multinodular goiter
118
randomized
65
Hemi -TX
53
Dunhill
2 Dunhill preferred
3 Randomization error
1 Papillary ca.
Intraop DX
3 Randomization error
59
Hemi -TX
49
IQ Dunhill
3 Papillary ca.
1 Follicular ca.
5 Papillary ca.
(3 follicular variant)
53
Benign
45
Benign
1 FU losses
7 FU losses
46
Evaluable
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1 Hemi-TX preferred
44
Evaluable
Asymmetric multinodular goiter
Group homogeneity
GLOBAL
HEMI TX
DUNHILL
(n=90)
(n=47)
(n=43)
7 (7.8%)
1(2.1%)
6 (14.0%)
83 (92.2%)
46 (97.9%)
37 (86.0%)
43.6 ± 10.6
41.4 ± 9.6
46 ± 11.2
Male
Sex
Female
Age (y)
Past medical history
Clinical features
LAB
Endemic goiter area
Compressive simptoms
TSH
Family history
Hyperfunction signs
Free T4
Estimated evolution
s-Ca / s-P
Smoking
Alcohol consumption
Beta blockers
Iodine intake
Hormonal therapy
Menopause
20
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P
0.51
0.038*
Auto antibodies
Asymmetric multinodular goiter
Grouphomogeneity
Size of thedominantnodule

N.S.

70
Nodule diameter (mm)
60
50
40
30
20
10
HEM I TX
21
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DUNHILL
Asymmetric multinodular goiter
Grouphomogeneity
Subclinical contralateral nodules
Global
Hemi TX
Dunhill
N =90
N = 47
N = 43
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
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P
Asymmetric multinodular goiter
The typical patient profile
• Woman
• 47 y/o.
• Normal thyroidfunction
5.8 mm
23
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36 mm
Asymmetric multinodular goiter
Operative time
N.S.
140
Operative time (min)
120
100
13’
80
60
40
20
0
HemiTX
24
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Dunhill
Asymmetric multinodular goiter
Identification of RLN
25
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Asymmetric multinodular goiter
Parathyroid gland identification
N of identified Parathryroids
4
P<0.0001
3,5
3
2,5
2
1,5
1
0,5
0
HemiTX
26
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Dunhill
Asymmetric multinodular goiter
Parathyroidglandidentification
Accidental PTX
N.S.
N.S.
25%
9%
8%
7%
6%
5%
4%
3%
3/47
3/43
2%
1%
% of patients with autotransplant
% of specimens with parathyroid gland
10%
20%
15%
10%
5/47
6/43
HemiTX
Dunhill
5%
0%
0%
HemiTX
27
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PT autotransplantation
Dunhill
Asymmetric multinodular goiter
Postoperativehypocalcemia (<8 mg/dL at 24h)
% Hypocalcemia
P<0.0001
28
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Treatment
Asymmetric multinodular goiter
Postoperative stay
P<0.005
3,5
Mean post-op stay (days)
3
2,5
2
1,5
1
0,5
0
HemiTX
29
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Dunhill
Asymmetric multinodular goiter
Thyroid function (last FU visit)
Onthyroxine:
Dunhill
41/43 (95%)
108 ± 24 mcg/day
HemiTX14/47 (30%)
66 ± 30 mcg/day
30
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P= 0.0001
Free T4 :
Dunhill:
HemiTX:
1.26 ± 0.4 ng/dL
1.07 ± 0.3 ng/dL
N.S.
TSH:
Dunhill:
HemiTX:
3.77 ± 4.5 UI/mL
3.03 ± 2.0UI/mL
N.S.
Asymmetric multinodular goiter
Long term parathyroid function
(no permanent hypoparathyroidism in either group)
31
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s-Ca:
Dunhill:
HemiTX:
8.9 ± 0.4 mg/dL
8.9 ± 0,4 mg/dLN.S.
iPTH:
Dunhill:
HemiTX:
32.3 ± 2.6 pg/mL
31.2 ± 1.8 pg/mLN.S.
Asymmetric multinodular goiter
Remnantsize at last FU visit(55 ± 34 mo)
P<0.0001
32
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Asymmetric multinodular goiter
Remnant size evolution (55 ± 34 mo)
≈ 20%
≈ 0%
BerghoutA et al., Am J Med 1990; 89:602-8.
33
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Asymmetric multinodular goiter
Reoperations
Early redo
(Intentiontotreat)
DuringFollow-Up
(Per protocol)
Overall
(Intentiontotreat)
HemiTX
Dunhill
P(1)
5/65
(7.7%)
1*/53
(1.8%)
0.22
1/53
(1.9%)
0/45
1.00
6/65
(9.2%)
1/53
(1.8%)
0.22
* 1 FTC (3 PTC detected but NOT reoperated)
(1) Fisher exact-test
35
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Asymmetric multinodular goiter
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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