Follow-Up After Surgery for Benign Nodular Thyroid Disease: Evidence-Based Approach

Total Thyroidectomy Versus Partial Thyroidectomy for Non-Toxic Multinodular Goiter: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Thyroid follicular nodular disease (non-toxic multinodular goiter), the commonest thyroid disorder, can be managed with different surgical methods, including total thyroidectomy (TT), near-total thyroidectomy (NTT), subtotal thyroidectomy (STT), and Dunhill operation (DO). This systematic review and meta-analysis aimed to provide an update on the role of TT versus NTT, STT, or DO in MNG concerning goiter recurrence, thyroid cancer incidence, and reported complications. We conducted a systematic literature search in Medline, EMBASE, and CENTRAL. We included randomized controlled trials (RCTs) that compared TT to partial thyroidectomy (NTT, STT, or DO) in the management of multinodular goiter (MNG). The following outcomes, goiter recurrence, cancer incidence, and adverse events (hypoparathyroidism and recurrent laryngeal nerve injury), were evaluated. We used the risk ratio (RR) to represent the dichotomous outcome. Subgroup analysis was performed based on the different types of partial thyroidectomy (NTT, STT, and DO). A total of 7 RCTs that included 1909 individuals were deemed eligible. TT showed significantly better results compared to PT in terms of goiter recurrence (RR = 0.05, 95% CI 0.02 to 0.13, P = 0.001; I 2  = 0%), whereas it showed similar results compared to PT in terms of thyroid cancer incidence (RR = 1.09, 95% CI 0.76 to 1.57, P = 0.63; I 2  = 0%). PT was significantly better than TT concerning transient adverse events (RR = 2.18, 95% CI 1.64 to 2.89, P = 0.001: I 2  = 63%). This meta-analysis showed that TT has a lower risk of goiter recurrence. TT is comparable to PT in terms of persistent adverse events but has a higher risk for transient adverse events.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-024-02057-y.

Radiofrequency ablation versus reoperation for benign thyroid nodules that developed after previous thyroid surgery

PURPOSE

To compare the clinical outcomes of radiofrequency ablation (RFA) versus reoperation for benign thyroid nodules that developed after previous thyroid surgery.

METHODS

A total of 53 patients with 53 benign nodules developed after previous thyroid surgery were evaluated in this retrospective study. Eighteen patients were treated by RFA (RFA group) and 35 patients underwent reoperation (reoperation group). The efficacy, safety, thyroid function, blood loss, hospitalization, total treatment time, and cost were compared between the two groups.

RESULTS

In the RFA group, the mean volume decreased significantly from 12.78 ± 17.57 ml to 0.94 ± 1.01 ml (p = 0.043) with a volume reduction rate of 85.27 ± 14.35% and significant improvement in symptom and cosmetic scores (all p = 0.001). Therapeutic efficacy was achieved with a single session in all thyroid nodules. The total treatment time (6.12 ± 3.17 min vs. 110.26 ± 44.41 min, p < 0.001), blood loss (0 ml vs. 82.58 ± 105.55 ml, p < 0.001) and hospitalization(0 days vs. 9.66 ± 4.28 days, p < 0.001) were significantly lower in the RFA group than those in reoperation group, but the costs of treatment were similar(2262.12 ± 221.54 USD vs. 2638.04 ± 1062.90 USD, p = 0.081). The incidence of complications was significantly higher in the reoperation group than in the RFA group(31.43 vs. 0%, p < 0.001). Furthermorre, 65.17% of patients developed hypothyroidism after reoperation, whereas the thyroid function of the patients in the RFA group was unaffected.

CONCLUSION

For patients with benign thyroid nodules developed after previous thyroid surgery, RFA can be considered as a safe and effective alternative to reoperation with advantages of maintenance of intact thyroid function and low incidence of complications.

Efficacy and safety of radiofrequency ablation for benign thyroid nodules in patients with previous thyroid lobectomy

Background

Radiofrequency ablation (RFA) is recommended for the treatment of benign thyroid nodules. However, data on the clinical role of RFA for benign thyroid nodules in patients with history of thyroid lobectomy are insufficient. The purpose of this study was to evaluate the efficacy and safety of radiofrequency ablation (RFA) for benign thyroid nodules in patients who had previously undergoing thyroid lobectomy.

Methods

From May 2015 to October 2018, a total of 20 patients (19 females, 1 male, mean age 49.50 ± 14.26 years, range 22–74 years) with 20 benign thyroid nodules (mean volume 15.04 ± 21.17 ml, range 0.40–69.67 ml) who had undergone previous thyroid lobectomy were included in this retrospective study. Patients were followed up at 3, 6, 12 months after RFA and every 12 months thereafter by ultrasound, clinical evaluation and thyroid function. Volume, volume reduction rate (VRR), symptom score and cosmetic score were evaluated.

Results

During the mean follow-up time of 21.24 ± 16.41 months, the mean nodule volume decreased significantly from 15.04 ± 21.17 ml to 1.29 ± 1.17 ml (P = 0.018) with a mean VRR of 85.41 ± 12.17%. Therapeutic success was achieved in a single session for all thyroid nodules. The symptom score (P = 0.001) and cosmetic score (P = 0.001) were both significantly reduced at the last follow-up. The levels of free triiodothyronine (fT3), free thyroxine (fT4) and thyroid stimulating hormone were not significantly different at the last follow-up from those prior to treatment (all P > 0.05). No life-threatening complications or sequelae occurred after RFA.

Conclusions

As a minimally invasive modality, RFA was a safe, effective, and thyroid function-preserving option for patients with symptomatic benign thyroid nodules after a previous lobectomy.

Hemithyroidectomy for benign euthyroid asymmetric nodular goitre

BACKGROUND

There is no consensus on the optimal surgery extent for patients with benign euthyroid asymmetric nodular goitre (AMNG).

METHODS

We reviewed medical literature using the PubMed engine to address the following issues: definition and prevalence, rationale for hemithyroidectomy, long-term outcomes, follow-up, revision surgery and image-guided thermal ablation of contralateral benign thyroid nodules following hemithyroidectomy for AMNG.

RESULTS

In total, 102 articles were found in MEDLINE using a keyword search strategy; subsequently, we selected 36 articles with clinical pertinence.

CONCLUSIONS

AMNG is a common clinical and surgical problem. Depending on the extent of the disease and individual surgeon preferences, either unilateral or bilateral thyroidectomy can be performed. Hemithyroidecomy can be considered for some patients with AMNG and the low risk of recurrent disease as a safer alternative to total thyroidectomy but it requires life-long follow-up, is associated with a higher recurrence risk and a need for revision thyroidectomy in selected subjects.

[Update of the S2k guidelines : Surgical treatment of benign thyroid diseases]

Thyroid resections represent one of the most common operations with 76,140 interventions in the year 2016 in Germany (source Destatis). These are predominantly benign thyroid gland diseases. Recommendations for the operative treatment of benign thyroid diseases were last published by the CAEK in 2010 as S2k guidelines (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V. [AWMF] 003/002) against the background of increasingly more radical resection procedures. Hemithyroidectomy and thyroidectomy are routinely performed for benign thyroid disease in practice. The operation-specific risks show a clear increase with the extent of the resection. Therefore, weighing-up of the risk-indications ratio between unilateral lobectomy or thyroidectomy necessitates an independent evaluation of the indications for both sides. This principle in particular has been used to update the guidelines. In addition, the previously published recommendations of the CAEK for correct execution and consequences of intraoperative neuromonitoring were included into the guidelines, which in particular serve the aim to avoid bilateral recurrent laryngeal nerve paralysis. Moreover, the recommendations for the treatment of postoperative complications, such as hypoparathyroidism and postoperative infections were revised. The updated guidelines therefore represent the current state of the science as well as the resulting surgical practice.

Ten-Year Follow-Up of a Randomized Clinical Trial of Total Thyroidectomy Versus Dunhill Operation Versus Bilateral Subtotal Thyroidectomy for Multinodular Non-toxic Goiter

Background

The aim of this study was to validate in a 10-year follow-up the initial outcomes of various thyroid resection methods for multinodular non-toxic goiter (MNG) reported in World J Surg 2010;34:1203–13.

Materials and methods

Six hundred consenting patients with MNG were randomized to three groups of 200 patients each: total thyroidectomy (TT), Dunhill operation (DO), bilateral subtotal thyroidectomy (BST). Obligatory follow-up period of 60 months was extended up to 120 months for all the consenting patients. The primary outcome measure was the prevalence of recurrent goiter and need for revision thyroid surgery. The secondary outcome measure was the cumulative postoperative and post-revision morbidity rate.

Results

The primary outcomes were twice as inferior at 10 years when compared to 5-year results for DO and BST, but not for TT. Recurrent goiter was found at 10 years in 1 (0.6%) TT versus 15 (8.6%) DO versus 39 (22.4%) BST (p < 0.001), and revision thyroidectomy was necessary in 1 (0.6%) TT versus 5 (2.8%) DO versus 14 (8.0%) BST patients (p < 0.001). Any permanent morbidity at 10 years was present in 5 (2.8%) TT patients following initial surgery versus 7 (4.0%) DO and 10 (5.7%) BST patients following initial and revision thyroidectomy (nonsignificant differences). At 10 years, 23 (11.5%) TT versus 25 (12.5%) DO versus 26 (13.0%) BST patients were lost to follow-up.

Conclusions

Total thyroidectomy can be considered the preferred surgical approach for patients with MNG, as it abolishes the risk of goiter recurrence and need for future revision thyroidectomy when compared to more limited thyroid resections, whereas the prevalence of permanent morbidity is not increased at experienced hands.

Registration number:

NCT00946894 (http://www.clinicaltrials.gov).

Guidelines of the French society of endocrinology for the management of thyroid nodules

The present document is a follow-up of the clinical practice guidelines of the French Society of Endocrinology, which were established for the use of its members and made available to scientific communities and physicians. Based on a critical analysis of data from the literature, consensuses and guidelines that have already been published internationally, it constitutes an update of the report on the diagnostic management of thyroid nodules that was proposed in France, in 1995, under the auspices of the French National Agency for Medical Evaluation (l'Agence nationale d'évaluation médicale). The current guidelines were deliberated beforehand by a number of physicians that are recognised for their expertise on the subject, coming from the specialities of endocrinology (the French Thyroid Research Group) and surgery (the French Association for Endocrine Surgery), as well as representatives from the fields of biology, ultrasonography, cytology and nuclear medicine. The guidelines were presented and submitted for the opinion of the members of the Society at its annual conference, which was held in Nice from 7-10 October 2009. The amended document was posted on the website of the Society and benefited from additional remarks of its members. The final version that is presented here was not subjected to methodological validation. It does not claim to be universal in its scope and will need to be revised in concert with progress made in technical and developmental concepts. It constitutes a document that the Society deems useful for distribution concerning the management of thyroid nodules, which is current, efficient and cost effective.

Splenic volume model constructed from standardized one-dimensional MDCT measurements

OBJECTIVE

The purposes of this study were to construct a model for estimation of splenic volume from standardized one-dimensional diameters of the spleen and to compare that model with the ellipsoid model for estimation of splenic volume.

MATERIALS AND METHODS

In this retrospective study, segmentation software was used for semiautomated quantification of splenic volume by counting CT voxels in 193 consecutively registered patients. For standardization of one-dimensional measurements, the software was used to measure transaxial diameter in the slice with the largest splenic cross-sectional area. By incorporation of splenic volume and the product of width, thickness, and length into the linear regression equation, a model for estimation of splenic volume was constructed, and its performance was externally assessed. Splenic volume also was calculated with the formula for a prolate ellipsoid. The ellipsoid volume and best-fit volumes were compared with segmented splenic volume by use of Bland-Altman plot and Lin concordance correlation. A value of p < 0.05 denoted statistical significance.

RESULTS

Splenic width was the best one-dimensional predictor of splenic volume (r = 0.84, p < 0.05). The linear regression fitted model for estimation of splenic volume (V(R)) in the initial 100 patients was V(R) = (0.36 × W × T × L) + 28, where W is width, T is thickness, and L is length (R(2) = 0.91, p < 0.05) and was externally validated by estimation of splenic volume in the other 93 patients. Compared with that observed with use of the ellipsoid formula, mean bias decreased from 22.57% to 0.93%, and the Lin coefficient increased from 0.81 to 0.96 with application of the best-fit model for calculation of splenic volume.

CONCLUSION

The best-fit model V(R) = (0.36 × W × T × L) + 28 is more optimized than the ellipsoid formula and is associated with less bias for estimation of splenic volume.