Five-Year Follow-up of a Randomized Clinical Trial of Unilateral Thyroid Lobectomy with or Without Postoperative Levothyroxine Treatment

Hypothyroidism after hemithyroidectomy: a systematic review and meta-analysis

BACKGROUND

The incidence of hypothyroidism following hemithyroidectomy and risk factors associated with its occurrence are not completely understood. This systematic review investigated the incidence and risk factors for hypothyroidism, thyroxine supplementation following hemithyroidectomy as well as the course of post-operative hypothyroidism, including the time to hypothyroidism and incidence of transient hypothyroidism.

METHODS

Searches were conducted in MEDLINE, EMBASE, Scopus, and Cochrane library for studies reporting the incidence of hypothyroidism or thyroxine supplementation following hemithyroidectomy.

RESULTS

Sixty-six studies were eligible for inclusion: 36 reported risk factors, and 27 reported post-operative course of hypothyroidism. Median follow-up was 25.2 months. The pooled incidence of hypothyroidism was 29% (95% CI, 25-34%; P<0.001). Transient hypothyroidism occurred in 34% of patients (95% CI, 21-47%; P<0.001). The pooled incidence of thyroxine supplementation was 23% (95% CI, 19-27%; P<0.001), overt hypothyroidism 4% (95% CI, 2-6%, P<0.001). Risk factors for development of hypothyroidism included pre-operative thyroid stimulating hormone (TSH) (WMD, 0.87; 95% CI, 0.75-0.98; P<0.001), TSH ≥ 2 mIU/L (RR, 2.87; 95% CI, 2.43-3.40; P<0.001), female sex (RR, 1.19; 95% CI, 1.08-1.32; P=0.007), age (WMD, 2.29; 95% CI, 1.20-3.38; P<0.001), right sided hemithyroidectomy (RR, 1.35; 95% CI, 1.10-1.65, P=0.003), the presence of autoantibodies anti-TPO (RR, 1.92; 95% CI, 1.49-2.48; P<0.001), anti-Tg (RR, 1.53; 95% CI, 1.40-1.88; P<0.001), and Hashimoto's thyroiditis (RR, 2.05; 95% CI, 1.57-2.68; P=0.001).

CONCLUSION

A significant number of patients will develop hypothyroidism or require thyroxine following hemithyroidectomy. An awareness of patient risk factors and postoperative thyroid function course will assist in counselling patients on their risk profile and guiding management.

Posthemithyroidectomy Hypothyroidism: Updated Meta-Analysis of Risk Factors and Rates of Remission

INTRODUCTION

The aim of this study was to determine the incidence and risk factors for hypothyroidism, both clinical and subclinical, following hemithyroidectomy in preoperatively euthyroid patients, as well as hypothyroidism remission and its time of remission.

MATERIALS AND METHODS

A search was performed in Medline (via PubMed), Web of Science, and the Cochrane Library using the keywords "hemithyroidectomy + postoperative + hypothyroidism" and "hemithyroidectomy + hormone supplementation".

RESULTS

Fifty-four studies with a total of 9,999 patients were included. After a mean follow-up interval of 48.2 mo, the pooled hypothyroidism rate was 29%. The subclinical hypothyroidism rate was 79% of patients with hypothyroidism (18 studies). Moreover, a meta-analysis of 12 studies indicated a pooled hypothyroidism remission rate after hemithyroidectomy of 42% (95% CI: 24%-60%). Older patient age (MD = -2.54, 95% CI = -3.99, -1.10, P = 0.0006), female gender (OR = 0.69, 95% CI = 0.58, 0.82, P < 0.0001), higher preoperative thyroid-stimulating hormone levels (MD = -0,81, 95% CI = -0.96, -0.66, P < 0.00001), pathological preoperative anti-thyroid peroxidase antibodies (OR = 0.37, 95% CI = 0.24, 0.57, P < 0.00001) and anti-thyroglobulin antibodies (OR = 0.52, 95% CI = 0.36, 0.75, P = 00,005), and right-sided hemithyroidectomy (OR = 0.54, 95% CI = 0.43, 0.68, P < 0.00001) were associated with postoperative hypothyroidism development. In metaregression analysis, Asia presented a significantly higher hypothyroidism rate after hemithyroidectomy (34.6%, 95% CI = 29.3%-9.9%), compared to Europe (22.9%, 95% CI = 16.2%-29.5%, P = 0.037) and Canada (1.8%, 95% CI = -22.6%-26.2%, P = 0.013).

CONCLUSIONS

Hypothyroidism is a frequent and significant postoperative sequela of hemithyroidectomy, necessitating individualization of treatment strategy based on the underlying disease as well as the estimated risk of hypothyroidism and its risk factors.

Risk factors for hypothyroidism following hemithyroidectomy

OBJECTIVE

Hypothyroidism is the most common complication of hemithyroidectomy for thyroid nodules. This retrospective cohort study investigated the prognostic factors for hypothyroidism following hemithyroidectomy.

METHODS

We included patients who underwent hemithyroidectomy between 2016 and 2017, excluding those with history of preoperative hypothyroidism or malignancy on histopathological examination. The primary endpoint was development of hypothyroidism during follow-up (TSH≥2 above normal).

RESULTS

Twenty-six of the 128 included patients (20%) developed postoperative hypothyroidism. The following independent prognostic factors were found: preoperative TSH level>1.5 mIU/L (OR 2.11; P=0.013), and remaining thyroid volume adjusted for body surface area<4.0mL/m2 (OR 1.77; P=0.015). Twenty-one patients (81%) had first TSH values above the upper limit of normal. Postoperatively, first TSH level correlated significantly with the preoperative value (R=0.5779, P<0.001). Levothyroxine was prescribed to 16% of patients, with a mean dose of 0.92μg/kg/day.

CONCLUSION

Patients with TSH>1.5 mIU/or remaining thyroid volume adjusted for body surface area<4.0mL/m2 should have intensified clinical and biological follow-up in the first year after surgery.

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.

Long-term sequelae of the less than total thyroidectomy procedures for benign thyroid nodular disease

INTRODUCTION

Nodular goiter is the most common disorder of the thyroid gland. Less than total thyroidectomy procedures are considered the gold standard in the surgical management of nodular thyroid disease despite its propensity for recurrence. The aim of the study was to assess long-term sequelae of the less than total thyroidectomy procedures.

MATERIAL AND METHODS

In this single-center retrospective study, records of 154 patients that underwent less than total thyroidectomy, for nodular disease and/or hyperthyroidism between 1998 and 2013, were reviewed. Patients with malignant findings in the histology report and a follow-up of less than 5 years were excluded.

RESULTS

The mean age of the recorded patients was 65.1 ± 12.91 years of which 132 were females. Subtotal thyroidectomy was performed in 45.5% of the study population, 22.1% underwent partial thyroidectomy, while the remaining 32.5% underwent lobectomy. Long-term thyroxine supplementation was administered in 138 patients (89.6%). Recurrence of clinically important nodules (>1 cm) was observed in 68.2% of patients but only 11% of the population underwent completion thyroidectomy. In the univariate analysis, the duration of follow-up (p = 0.00005, C.I.: 0.903-0.965) as well as the type of operation (p = 0.035, C.I.: 1.031-2.348) appeared to have a significant correlation with nodular recurrence. The multivariate analysis identified the duration of follow-up (p = 0.0005, C.I.: 0.908-0.973) as the only significant predictive factor of nodular recurrence.

CONCLUSION

This is the first study with such a long duration of post-operative follow-up. The high rate of nodular recurrence in less than total thyroidectomy procedures along with the lifelong need for thyroxine supplementation suggest that a more conservative surgical approach is needed. When surgery is recommended, we suggest total thyroidectomy as the treatment of choice to avoid the recurrence of disease, the high cost associated with frequent follow-ups by means of sonography as well as thyroxine replacement therapy.

Unilateral benign multinodular versus solitary goiter: Long-term contralateral reoperation rates after lobectomy

BACKGROUND

Few long-term studies define the appropriate extent of surgery and recurrence rates for unilateral multinodular goiter. We compared the rate and time to reoperation in patients with multinodular goiter who underwent lobectomy to that of patients with benign solitary nodule.

METHODS

Retrospective study of a prospective database of all patients who underwent lobectomy for multinodular goiter or solitary nodule from 1991 to 2017. We analyzed reoperation rates and time to reoperation. Reoperation was defined as the need for completion thyroidectomy determined the following citeria: nodule greater than 3 cm, multiple nodules, nodule growth or suspicion for malignancy by ultrasound or fine-needle aspiration biopsy, or compressive symptoms.

RESULTS

Included in the study were 2,675 lobectomies; 852 (31.85%) for multinodular goiter. In total, 394 patients (14.7%) underwent reoperation: 261 (30.6%) with a previous multinodular goiter and 133 (7.29%) with solitary nodule (P < .0001). A total of 80% of the patients with multinodular goiter and 67.66% with solitary nodule recurred as multinodular goiter; 3.5% of all recurrences were carcinomas. The mean time to reoperation was 14.8 years, without difference between groups (P = .5765). Patients without reoperation were younger (47 ± 15 vs 54 ± 13 years of age, P < .0001) and more likely to be male (P < .0001).

CONCLUSION

Lobectomy for unilateral multinodular goiter is the procedure of choice given the length of time to reoperation. Patients and surgeons should be aware of the need for long-term surveillance.

Treatment of adult Graves' disease

Treatment strategy in Graves' disease firstly requires recovery of euthyroid status by antithyroid therapy. Treatment modalities, precautions, advantages and side-effects are to be discussed with the patient. No particular treatment modality has demonstrated superiority. Pregnancy or pregnancy project affects choice of treatment and monitoring. Graves' orbitopathy is liable to be aggravated by iodine-131 treatment and requires pre-treatment assessment. Iodine-131 treatment aims at achieving hypothyroidism. Thyroid surgery for Graves' disease should preferably be performed by an expert team. In case of recurrence of hyperthyroidism, the various treatment options should be discussed with the patient. Empiric treatment of thyroid dermopathy uses local corticosteroids in occlusive dressing.

Follow-up of differentiated thyroid cancer - what should (and what should not) be done

The treatment paradigm for thyroid cancer has shifted from a one-size-fits-all approach to more personalized protocols that range from active surveillance to total thyroidectomy followed by radioiodine remnant ablation. Accurate surveillance tools are available, but follow-up protocols vary widely between centres and clinicians, owing to the lack of clear, straightforward recommendations on the instruments and assessment schedule that health-care professionals should adopt. For most patients (that is, those who have had an excellent response to the initial treatment and have a low or intermediate risk of tumour recurrence), an infrequent assessment schedule is sufficient (such as a yearly determination of serum levels of TSH and thyroglobulin). Select patients will benefit from second-line imaging and more frequent assessments. This Review discusses the strengths and weaknesses of the surveillance tools and follow-up strategies that clinicians use as a function of the initial treatment and each patient's risk of recurrence.

Multinodular goiter in children: treatment controversies

BACKGROUND

Multinodular goiter (MG) is very common in adults. MG may occur in children in some exceptional circumstances. The objective of this study was to examine two cases of MG in children who relapsed soon after surgery and to discuss the treatment options in pediatric ages.

METHODS

Two girls consulted for euthyroid colloid goiter, uninodular goiter and bilateral MG. They were intervened by hemithyroidectomy and total thyroidectomy, respectively, due to the existence of local symptoms.

RESULTS

Goiters reappeared 3 years after intervention in both cases. They already appeared as bilaterally MG, and patients underwent a total thyroidectomy, in one case after 1 year of treatment with levothyroxine (LT4).

CONCLUSIONS

MG treatment remains controversial. There is an increasing trend to a more radical surgery decreasing recurrence risk. Treatment with LT4 may be tested but it is rarely effective. Regardless of the therapeutic option, these children should be followed up and they should know about the possibility of goiter regeneration and the need for reintervention.

Thyroid lobectomy is an effective option for unilateral benign nodular disease

OBJECTIVE

The use of thyroid lobectomy in the treatment of unilateral, benign nodules is limited by the potential of nodular recurrence in the remaining lobe. This study aimed to assess the rate and clinical impact of nodular recurrence in the contralateral lobe after thyroid lobectomy and to identify predictive factors of recurrence.

DESIGN

Single-centre retrospective study.

PATIENTS

Records of patients that underwent lobectomy for unilateral thyroid nodules between 1991 and 2010 were reviewed and 270 patients were included. Exclusion criteria were: presence of contralateral nodule(s) ≥5 mm on preoperative ultrasound, diagnosis of cancer necessitating completion thyroidectomy or pseudonodules. Recurrence was defined as the occurrence of nodule(s) ≥5 mm in the remaining lobe on at least one postoperative ultrasound. A set of clinical, imaging, histological and biochemical parameters was tested as predictors of recurrence using logistic regression.

RESULTS

After a median follow-up of 78 months (range, 12-277 months), the global recurrence rate was 42% and recurrence of nodules of a size ≥1 cm occurred in 19%. Reoperation rate was 1·1%. 90% of patients were treated postoperatively by levothyroxine. Median time to nodular recurrence was 4 years. Preoperative contralateral lobe volume and resected thyroid weight were identified as significant predictors of recurrence (P = 0·045 and P = 0·03 respectively).

CONCLUSIONS

Thyroid lobectomy is an effective therapeutic strategy for unilateral, benign nodules, resulting in a low rate of clinically relevant nodular relapse in a mildly iodine-deficient area. Patients with uninodular disease and a contralateral lobe of normal size are particularly good candidates for lobectomy.

Safety and Effectiveness of Total Thyroidectomy and Its Comparison with Subtotal Thyroidectomy and Other Thyroid Surgeries: A Systematic Review

Diseases associated with the thyroid gland are one of the most frequently seen endocrine disorders across the globe. Total thyroidectomy is currently the preferred treatment for many thyroid diseases. Controversies exist among surgeons regarding safety of total thyroidectomy due to the risk associated with it like postoperative hypoparathyroidism or recurrent laryngeal nerve damage. Since, in the recent years, the incidence of thyroidectomy is in increasing trend in south Indian population, this review aims to study the available data regarding the appropriateness and safety of total thyroidectomy and compares it with subtotal thyroidectomy and other thyroid surgeries. This is a retrospective comprehensive review of various articles and publications regarding total and partial thyroidectomy performed across the world. Many retrospective studies and few prospective studies suggest that the incidence of transient hypocalcemia is higher after total thyroidectomy than after subtotal thyroidectomy, but the incidence of other complications including recurrent laryngeal nerve palsy and postoperative hematoma is not significantly different between the two procedures. Hence in our review we found that total thyroidectomy is safe and cost effective with low complication rates and provides little significant advantage of being safer procedure compared to subtotal thyroidectomy.

Hypothyroidism after hemithyroidectomy

BACKGROUND

The risk of hypothyroidism after hemithyroidectomy is variable, and most estimates come from single institutional studies. The purpose of the present study was to determine the incidence of hypothyroidism at the population level, and to evaluate predictive factors for hypothyroidism after hemithyroidectomy.

METHODS

This retrospective study identified euthyroid patients who underwent hemithyroidectomy between 2000 and 2010 for benign disease in Kaiser Permanente Southern California regional hospitals. The incidence of hypothyroidism [thyroid stimulating hormone (TSH) levels >4 μIU/ml] was analyzed. The independent effect of age-quartile, gender, race, thyroiditis, and preoperative TSH level on the development of hypothyroidism was evaluated.

RESULTS

Of 1,240 euthyroid patients identified, 417 (34 %) developed hypothyroidism, and 314 (25 % of total group) needed levothyroxine. Hypothyroidism was more common in age-quartile 2 (32 %), age-quartile 3 (37 %), and age-quartile 4 (42 %) than in age-quartile 1 (25 %) [adjusted odds ratio (OR) = 1.87; 95 % confidence interval (CI) 1.27-2.76, p = 0.002; age-quartile 4 compared to age-quartile 1]. Hypothyroidism was more frequent with increasing preoperative TSH levels 36, 72, and 92 % in patients with TSH levels of 1.0-2, 2.01-3, and 3.01-4 μIU/ml, respectively, compared to 17 % in those with TSH levels <1 μIU/ml [adjusted OR = 45.1; 95 % CI 13.5-151, p < 0.0001; 3.01-4 μIU/ml compared to <1 μIU/ml]. Thyroiditis was also an independent predictor of hypothyroidism.

CONCLUSIONS

About one third of euthyroid patients who undergo hemithyroidectomy develop hypothyroidism. The most significant predictor is the preoperative TSH level, with an approximate doubling of risk for each 1 unit of TSH increase over 1 μIU/ml. Our categorical scale is simple and allows for easy recall when counseling patients preoperatively.

Nodular recurrence and hypothyroidism following partial thyroidectomy for benign nodular thyroid disease in children and adolescents

OBJECTIVES

Diagnostic and therapeutic processing of a thyroid nodule in children and adolescents may require lobectomy-isthmusectomy (LI) or nodule-resection (NR). Very few data in the literature report the long-term evolution of the remaining thyroid lobe in a defined pediatric population. In this study, we aimed to answer the following questions: Does a nodule recurrence occur in the remainder lobe? Is a post-operative thyroxine treatment necessary?

MATERIAL AND METHODS

This retrospective study describes 28 patients under 18 who underwent LI (22 cases) or NR (6 cases) from January 2004 to March 2012. Ten of them were lost to follow up, 18 could be assessed (4 NR (22%) and 14 LI (78%) - mean follow-up 45±31 months). All patients benefited of post-operative thyroid ultrasonography, and regular endocrinologic follow-up. The following data were analysed: emergence of new thyroid nodules, evolution of pre-existing nodules, occurrence of post-operative hypothyroidism and requirement for completion thyroidectomy.

RESULTS

The mean age at the time of surgery was 14.3±1.9 years. Two patients (11%) had pre-existing nodules in the remaining thyroid gland, none of which showed an increase in size after surgery. De novo nodules developed in five patients (27.8%). Three patients who underwent LI (21.4%) needed thyroxine treatment for post-operative hypothyroidism. One patient (5.5%) needed completion thyroidectomy.

CONCLUSIONS

In this children and adolescents population, after performing LI or NR, remaining thyroid tissue stays free of nodules in 72.2% of the cases. A post-operative thyroxin treatment is necessary in 21.4% of cases after LI.

A randomized trial of hemithyroidectomy versus Dunhill for the surgical management of asymmetrical multinodular goiter

OBJECTIVE

To assess the immediate and long-term clinical results of 2 different surgical procedures for the treatment of asymmetrical multinodular goiter (AMG).

BACKGROUND

Half of the patients presenting with a single benign thyroid nodule have contralateral subclinical disease. There is a controversy whether these patients should be treated with hemithyroidectomy (HMT) or with a more extensive procedure.

METHODS

Adult patients with a benign unilateral dominant nodule and contralateral nodule(s) with a diameter of less than 10 mm detected on neck ultrasonography were randomized to HMT or Dunhill (DUN). Rates of complications, remnant growth, incidental carcinoma, and reoperation were assessed.

RESULTS

A total of 118 patients (F/M:110/8, mean age 43 years) were included and randomized: 65 to HMT and 53 to DUN. After randomization, 28 patients were excluded leaving 47 HMT and 43 DUN long-term (55 ± 35 months) evaluable patients. Mean nodule size was 38 and 6 mm for the dominant and contralateral nodules, respectively. No differences were found in operative time, accidental parathyroidectomy, parathyroid autotransplantation, or wound complications. Transient hypocalcemia was more common in DUN (30% vs 8%; P < 0.001). No permanent complications were observed. At the last follow-up visit, thyroid-stimulating hormone was similar in both groups. Remnant growth (20 vs 0%; P < 0.001), appearance of new nodules (55 vs 14%; P < 0.001), and overall reoperation rate (9.2 vs 1.8%, P = 0.2) were more common in HMT, mostly because of undiagnosed cancer requiring completion thyroidectomy. Thirty percent of HMTs developed hypothyroidism and required long-term T4 supplementation.

CONCLUSIONS

DUN appears superior to HMT for the treatment of AMG in terms of early reoperation for missed carcinomas and disease progression. Both procedures have a similarly uneventful postoperative course.

Minimally invasive video-assisted thyroidectomy: seven-year experience with 240 cases

Introduction

Minimally invasive video-assisted thyroidectomy (MIVAT) has gained acceptance in recent years as an alternative to conventional thyroid surgery.

Aim

Assessment of our 7-year experience with MIVAT.

Material and methods

A retrospective study of 240 consecutive patients who underwent MIVAT at our institution between 01/2004 and 05/2011 was conducted. The inclusion criterion was a single thyroid nodule below 30 mm in diameter within the thyroid of 25 ml or less in volume. The exclusion criteria were previous thyroid or parathyroid surgery, T2 or higher thyroid cancer, N1 stage, and thyroiditis. The Miccoli technique was used. The analysis included indications, eligibility rate, operative time, morbidity and cosmetic effects.

Results

Of 6,574 patients referred for thyroid surgery, 240 (3.6%) were eligible for MIVAT. In the final pathology report, there were 206 follicular adenomas, 21 papillary thyroid cancers, 9 cases of Graves’ disease and 4 follicular cancers. Reasons for exclusion were as follows: thyroid volume above 25 ml in 5401 (85.3%), thyroid cancer larger than stage T1 in 392 (6.2%), thyroiditis in 358 (5.6%), and previous neck surgery in 183 patients (2.9%). Minimally invasive video-assisted thyroidectomy operations consisted of 210 lobectomies and 30 total thyroidectomies, including 15 one-stage parathyroidectomies. Mean operative time was 38.6 ±15.1 min. Transient versus permanent recurrent laryngeal nerve injury was found in 8 (3.0%) vs. 2 (0.7%) nerves at risk, respectively. Cosmetic effects were assessed after 1 and 6 months of follow-up as very good or excellent by 89.6% and 95.8% of patients, respectively.

Conclusions

Minimally invasive video-assisted thyroidectomy is suitable for surgeons experienced in thyroid and video-assisted surgery. It is feasible for well-selected patients including cases of T1 thyroid cancer, Graves’ disease and concomitant parathyroid adenoma.

Quality of life is not influenced by the extent of surgery in patients with benign goiter

INTRODUCTION

The surgical approach to benign goiter is becoming increasingly radical due to the risk of recurrent goiter. The aim of this prospective study was to evaluate the impact of surgery on health-related quality of life (HRQoL) of patients with benign goiter.

MATERIAL AND METHODS

HRQoL data from 115 patients with benign goiter were analyzed. Thirty-three patients (group 1) had a hemithyroidectomy. Sixty-five patients (group 2) had a so-called Dunhill operation (hemithyroidectomy + near-total thyroidectomy of the opposite side), and in 17 patients, a total resection of the goiter was performed. The validated HRQoL instrument, the EuroQol-5D, was applied to measure the health-related quality of life.

RESULTS

With an overall complication rate of 10% and no permanent recurrent laryngeal nerve palsy, it was shown that surgery for benign goiter is safe. In the validated HRQoL questionnaire (EQ-5D), no significant variance could be found between different surgical procedures such as thyroidectomy, hemithyroidectomy, or Dunhill procedure. Further, no significant differences in QoL were found in EQ-5D questionnaire compared to normal population.

CONCLUSION

Thyroid surgery can be done safely and without impairment of life quality, regardless of the extent of the operation.