3
INTRODUCTION Single thyroid nodules occur in 4–10% of the adult population and are more common in women than men. 1,2 In a randomly selected adult population in Finland, thyroid abnormalities were detected by ultrasonography in 27.3%, of which 57% were classified as single thyroid nodules. 3 Single thyroid nodules are often part of a multinodular goitre. 4,5 Patients who present with a single thyroid nodule that requires surgery will generally undergo hemithyroidec- tomy as definitive treatment. 6–9 However, if the subsequent histo- logical examination reveals that the single thyroid nodule was part of an unsuspected multinodular goitre, the risk of recur- rence in the remaining lobe exists. METHODS Patients Information on patients with a clinical single thyroid nodule, operated on with hemithyroidectomy and where multinodular goitre was diagnosed on subsequent histopathological examination were obtained from a prospective database at the Endocrine Sur- gical Unit at the Royal North Shore Hospital, Sydney, Australia. This database now contains information on 10 648 procedures. Information about clinical recurrence, the need for further treat- ment, and the use of thyroxine therapy was obtained by patient questionnaires, telephone contact or after contact with the local doctor. RESULTS A total of 4030 patients underwent surgery for a clinical single thyroid nodule over the study period (Table 1). There were 465 patients who fulfilled the criteria for the study (clinical single nodule; hemithyroidectomy; multinodular goitre on histopathology) and who were available for the study. Complete follow-up infor- mation was able to be obtained from 229 patients (49%); there were 204 women and 25 men. Mean age at the time of the operation was 47 years (range 4–84) and the mean follow-up time was 14 years (range 1–33). No clinical evidence of recurrence was documented in 201 patients (88%) but recurrence was reported in 28 patients (12%). Among the patients with recurrence, 14 (50%) have had further thyroid surgery, seven (25%) reported clinical recurrence but no further treatment, six (21%) patients received thyroxine medication Aust. N.Z. J. Surg. (1999) 69, 34–36 ORIGINAL ARTICLE MULTINODULAR GOITRE PRESENTING AS A CLINICAL SINGLE NODULE: HOW EFFECTIVE IS HEMITHYROIDECTOMY? CARL WADSTRÖM,* JAN ZEDENIUS, ANA GUINEA, TOM REEVE AND LEIGH DELBRIDGE *Karolinska Institute, Danderyd Hospital, Danderyd, Sweden, Karolinska Institute, Karolinska Hospital, Stockholm, Sweden and Endocrine Surgical Unit, University of Sydney, Royal North Shore Hospital, Sydney, New South Wales, Australia Background: Patients who present with a single thyroid nodule that requires surgery will generally undergo hemithyroidectomy. If, however, the subsequent histological examination shows unsuspected multinodular change, there is a risk of recurrence in the remain- ing lobe. The aim of this study was to determine the clinical outcome in patients who have had a hemithyroidectomy for a single thyroid nodule that was shown on subsequent histopathological examination to be part of a multinodular goitre. Methods: A survey was undertaken of patients who were identified from a thyroid surgery database with the following criteria: (i) hemithyroidectomy for clinical single nodule; and (ii) multinodular change on histopathology. Main outcome measures were clin- ical recurrence rate, the frequency of further thyroid surgery, and the efficacy of thyroxine treatment on recurrence. Results: In the 229 patients studied, the clinical recurrence rate was 12%. Fourteen of the 28 patients with recurrence required further surgery. Thyroxine therapy did not influence the recurrence rate. Conclusion: When surgery for a clinically benign single thyroid nodule is indicated, hemithyroidectomy is an adequate surgical pro- cedure in cases where the single nodule is subsequently found to be part of a multinodular goitre. Such patients can be reassured that the chance of clinical recurrence is low. Thyroxine replacement therapy appears not to prevent recurrence. Key words: hemithyroidectomy, multinodular, single thyroid nodule, thyroxine treatment. Correspondence: Dr L. Delbridge, Department of Surgery, Royal North Shore Hospital, Sydney, NSW 2065, Australia. Email: <[email protected]> Accepted for publication 5 May 1998. Table 1. Histopathological diagnoses of patients operated on for clinically single nodule at Endocrine Surgical Unit, Royal North Shore Hospital, Sydney, Australia (1957–95) Histopathology No. patients (%) Multinodular goitre 1232 (31) Follicular adenoma 1010 (25) Single colloid nodule 757 (19) Carcinoma 443 (11) Simple cyst 297 (7) Hashimoto’s thyroiditis 123 (3) Thyroglossal cyst 66 (1.5) Hürthle cell adenoma 20 (0.5) Miscellaneous 82 (2) Total 4030 (100)

MULTINODULAR GOITRE PRESENTING AS A CLINICAL SINGLE NODULE: HOW EFFECTIVE IS HEMITHYROIDECTOMY?

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Page 1: MULTINODULAR GOITRE PRESENTING AS A CLINICAL SINGLE NODULE: HOW EFFECTIVE IS HEMITHYROIDECTOMY?

INTRODUCTION

Single thyroid nodules occur in 4–10% of the adult population andare more common in women than men.1,2 In a randomly selectedadult population in Finland, thyroid abnormalities were detectedby ultrasonography in 27.3%, of which 57% were classified assingle thyroid nodules.3 Single thyroid nodules are often part ofa multinodular goitre.4,5 Patients who present with a single thyroidnodule that requires surgery will generally undergo hemithyroidec-tomy as definitive treatment.6–9 However, if the subsequent histo-logical examination reveals that the single thyroid nodule waspart of an unsuspected multinodular goitre, the risk of recur-rence in the remaining lobe exists.

METHODS

Patients

Information on patients with a clinical single thyroid nodule,operated on with hemithyroidectomy and where multinodulargoitre was diagnosed on subsequent histopathological examinationwere obtained from a prospective database at the Endocrine Sur-gical Unit at the Royal North Shore Hospital, Sydney, Australia.This database now contains information on 10 648 procedures.

Information about clinical recurrence, the need for further treat-ment, and the use of thyroxine therapy was obtained by patientquestionnaires, telephone contact or after contact with the localdoctor.

RESULTS

A total of 4030 patients underwent surgery for a clinical singlethyroid nodule over the study period (Table 1). There were 465patients who fulfilled the criteria for the study (clinical singlenodule; hemithyroidectomy; multinodular goitre on histopathology)and who were available for the study. Complete follow-up infor-mation was able to be obtained from 229 patients (49%); there were204 women and 25 men. Mean age at the time of the operation was47 years (range 4–84) and the mean follow-up time was 14 years(range 1–33).

No clinical evidence of recurrence was documented in 201patients (88%) but recurrence was reported in 28 patients (12%).Among the patients with recurrence, 14 (50%) have had furtherthyroid surgery, seven (25%) reported clinical recurrence but nofurther treatment, six (21%) patients received thyroxine medication

Aust. N.Z. J. Surg. (1999) 69, 34–36

ORIGINAL ARTICLE

MULTINODULAR GOITRE PRESENTING AS A CLINICAL SINGLENODULE: HOW EFFECTIVE IS HEMITHYROIDECTOMY?

CARL WADSTRÖM,* JAN ZEDENIUS,† ANA GUINEA,‡ TOM REEVE‡ AND LEIGH DELBRIDGE‡

*Karolinska Institute, Danderyd Hospital, Danderyd, Sweden, †Karolinska Institute, Karolinska Hospital, Stockholm,Sweden and ‡Endocrine Surgical Unit, University of Sydney, Royal North Shore Hospital, Sydney, New South Wales, Australia

Background: Patients who present with a single thyroid nodule that requires surgery will generally undergo hemithyroidectomy.If, however, the subsequent histological examination shows unsuspected multinodular change, there is a risk of recurrence in the remain-ing lobe. The aim of this study was to determine the clinical outcome in patients who have had a hemithyroidectomy for a single thyroidnodule that was shown on subsequent histopathological examination to be part of a multinodular goitre.Methods: A survey was undertaken of patients who were identified from a thyroid surgery database with the following criteria:(i) hemithyroidectomy for clinical single nodule; and (ii) multinodular change on histopathology. Main outcome measures were clin-ical recurrence rate, the frequency of further thyroid surgery, and the efficacy of thyroxine treatment on recurrence.Results: In the 229 patients studied, the clinical recurrence rate was 12%. Fourteen of the 28 patients with recurrence required furthersurgery. Thyroxine therapy did not influence the recurrence rate.Conclusion: When surgery for a clinically benign single thyroid nodule is indicated, hemithyroidectomy is an adequate surgical pro-cedure in cases where the single nodule is subsequently found to be part of a multinodular goitre. Such patients can be reassured thatthe chance of clinical recurrence is low. Thyroxine replacement therapy appears not to prevent recurrence.

Key words: hemithyroidectomy, multinodular, single thyroid nodule, thyroxine treatment.

Correspondence: Dr L. Delbridge, Department of Surgery, Royal NorthShore Hospital, Sydney, NSW 2065, Australia.Email: <[email protected]>

Accepted for publication 5 May 1998.

Table 1. Histopathological diagnoses of patients operated on forclinically single nodule at Endocrine Surgical Unit, Royal NorthShore Hospital, Sydney, Australia (1957–95)

Histopathology No. patients (%)

Multinodular goitre 1232 (31)Follicular adenoma 1010 (25)Single colloid nodule 757 (19)Carcinoma 443 (11)Simple cyst 297 (7)Hashimoto’s thyroiditis 123 (3)Thyroglossal cyst 66 (1.5)Hürthle cell adenoma 20 (0.5)Miscellaneous 82 (2)

Total 4030 (100)

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only and one patient (4%) had received radio-iodine treatment(Table 2). Forty-eight (24%) patients without recurrence wereon thyroxine therapy for reasons other than recurrence, such ashypothyroidism. The complications for the 229 operations wheresurveys were completed are listed in Table 3.

DISCUSSION

In the industrialized world, the prevalence of single thyroidnodules increases linearly with age, and ranges between 4 and 10%in the adult population.1,2 Thyroid nodules in the elderly aremore frequent and are more often malignant. In autopsy studies, theprevalence of non-palpable thyroid nodules is between 30 and60%.10 A subset of these nodules is part of a multinodulargoitre. The recurrence rate of goitre in the remaining thyroidlobe in patients who have undergone hemithyroidectomy for asingle nodule that was part of a multinodular goitre is not wellknown. According to Kuma et al. at least 21% of untreatedmultinodular goitres increase in size over a 10-year period.11

Fine needle aspiration biopsy (FNAB) is a most importantpart of the pre-operative assessment of single thyroid nodulesand is the most cost-effective investigation in patients withthyroid nodules. It is preferred to radionucleotide scintigraphyand ultrasonography as the primary diagnostic procedure.12 For thatreason, ultrasonography is being performed less often in patientswith clinically single thyroid nodules. However, ultrasonogra-phy may provide assistance in performing FNAB of noduleswhich are difficult to localize by palpation.13 Otherwise it is of littlevalue in clinical decision-making.6–8

When the FNAB shows sign of a follicular thyroid neoplasm,the risk of malignancy is approximately 15–20%.10,14–16Malignantdevelopment in long-standing multinodular goitre is between 4 and8%.17,18 Fine needle aspiration biopsy of colloid nodules may behard to interpret and often several attempts are needed for theexclusion of neoplastic growth. Still, some single nodules must beremoved for histopathology and the exclusion of malignancyregardless of the FNAB results.19 In the authors’ experience,

about 31% of all patients undergoing surgery for single thyroidnodules are diagnosed histopathologically as having a multi-nodular thyroid goitre, which is in agreement with several otherstudies.2,5,20

The aim of the present study was to estimate the risk of recur-rence of nodular goitre in patients who had been treated withhemithyroidectomy for a single thyroid nodule, but who eventuallyhad a multinodular goitre as proven by histopathological investi-gation. The recurrence rate among the 229 patients available forfollow-up was 12%, half of whom had further surgery. Althoughonly approximately 50% of the patients who fulfilled the criteria forthe study were available for follow-up, we believe the resultsare representative for the whole group. The authors’ experience inprevious studies is that symptomatic patients or patients withsigns of recurrence are more prone to respond and report anyeventual symptoms. These results indicate that hemithyroidec-tomy is sufficient to cure the vast majority of patients, although alonger follow-up may increase the recurrence rate. As benignsingle nodules are preferably treated by hemithyroidectomy,6,9

we advocate that this should be adequate treatment even in the pres-ence of unsuspected background multinodular change, providedthat the multinodularity is not clinically apparent. Clearly, inpatients with a dominant nodule in a clinically apparent multi-nodular goitre, we continue to recommend total thyroidectomy asthe preferred option.

Thyroxine treatment is still used to try to prevent or reducegrowth of thyroid nodules and multinodular goitre. However,adequate suppressive doses of thyroxine do not seem to alter thenatural course of benign nodules.21,22 Instead, such nodules maywell decrease in size regardless of treatment.11,23 The use of thy-roxine suppressive therapy, once considered a cornerstone ofconservative management of goitre, has lately been questioned onits limited utility and potential side-effects.24,25 In the presentstudy, 21% of the patients with recurrence and 24% of thosewithout recurrence had received thyroxine medication. Despite theretrospective nature of these data and the lack of randomizedgroups, these figures support the hypothesis that thyroxine treat-ment does not reduce recurrence of multinodular goitre, althoughone thyroid lobe is left after initial surgery.

The youngest patient in this series was a 4-year-old girl whopresented with a solitary nodule as part of a multinodular goitre. She was later shown to suffer from congenital goitreous hypo-thyroidism (Pendred’s syndrome). This syndrome is associatedwith dyshormogenesis due to peroxidase deficiency.26,27 Becauseof the risk of malignant development total thyroidectomy is rec-ommended. Ten years after the initial hemithyroidectomy, she was reoperated because of recurrence. The remaining lobe was resected,and showed follicular adenoma but no signs of malignancy.

Unsuspected multinodular change is common in patients withclinical single thyroid nodules. Despite the risk of later develop-ment of nodular disease in the remaining lobe, hemithyroidec-tomy appears to be adequate treatment for these patients, as onlyfew will require future treatment for clinically significant recur-rence. Patients can thus be reassured that recurrence is unlikely tooccur and that thyroxine treatment is not necessary as it does notseem to reduce the recurrence rate.

ACKNOWLEDGEMENTS

At the time of the study, CW was appointed as the Mary JoReeve Research Fellow and JZ as the T. S. Reeve InternationalClinical Fellow in Endocrine Surgery.

MULTINODULAR GOITRE PRESENTING AS SINGLE NODULE 35

Table 2. Clinical details of the 28 patients with recurrent goitrefollowing hemithyroidectomy for single thyroid nodule

Table 3. Complications for the 229 operations where surveys werecompleted

Clinical course No. patients (%)

Further thyroid surgery 14 (50)0No treatment 7 (25)0Thyroxine medication only 6 (21)0Radio-iodine treatment 1 (4)00

Total 28 (100)

Complications No.

Re-operation for haemorrhage 2Temporary hypocalcaemia 3Permanent hypocalcaemia 0Temporary vocal cord dysfunction 1Permanent vocal cord dysfunction 0Wound infection 7

Total 13

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36 WADSTRÖM ET AL.

The study was supported by grants from the Swedish CancerFoundation, the Swedish Institute, the Swedish Medical Associa-tion and the Marcus and Marianne Wallenberg Foundation.

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