1 / 31

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:.

michon
Télécharger la présentation

Surgical treatment of asymmetrical multinodular goiter

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related