Hemithyroidectomy for benign euthyroid asymmetric nodular goitre

Twenty-year follow-up of a randomized clinical trial of unilateral thyroid lobectomy with or without postoperative levothyroxine treatment

BACKGROUND

The aim of this study was to validate in 20-year follow-up (FU) the outcomes reported in World J Surg 2010; 34(6):1232-8 on recurrent nodular goiter in the contralateral thyroid lobe among patients after thyroid lobectomy (TL) for multinodular goiter (MNG) receiving versus not receiving postoperative prophylactic levothyroxine (LT4) treatment.

METHODS

Some 150 consenting patients underwent TL for MNG in 2000-2003. They were randomized to two groups, 75 patients each: (a) receiving prophylactic LT4 treatment postoperatively (dose range 75-125 microg/day to maintain thyroid-stimulating hormone values within 0.27-1.0 mU/L), and (b) not receiving LT4. Sixty-month FU was extended to 240 months for all the consenting patients. The primary outcome was prevalence of recurrent goiter. The secondary outcome was re-intervention rate for recurrent goiter. The outcomes were stratified according to individual iodine metabolism status assessed by urinary iodine excretion.

RESULTS

During the 5-year FU (5 patients were lost) recurrent goiter was found in patients receiving versus not receiving LT4 in 1.4% versus 16.7% (p = 0.001) whereas during 20-year FU (29 patients were lost) it was 3.3% versus 30.0% of patients, respectively (p = 0.031). During 20-year FU 4.9% versus 30.0%, respectively, of patients receiving versus not receiving LT4 required contralateral thyroid lobe treatment/surgery (p = 0.028). LT4 decreased recurrence rate among iodine-deficient patients (10.0% vs. 70.0%, respectively; p = 0.037) but not among iodine-sufficient patients (0.0% vs. 10.0%, respectively; p = 0.056).

CONCLUSIONS

Twenty-year FU data confirmed that prophylactic LT4 treatment significantly decreased the recurrence of nodular goiter and the need for completion intervention/surgery, mostly among patients with iodine deficiency.

Contemporary Thyroid Nodule Evaluation and Management

CONTEXT

Approximately 60% of adults harbor 1 or more thyroid nodules. The possibility of cancer is the overriding concern, but only about 5% prove to be malignant. The widespread use of diagnostic imaging and improved access to health care favor the discovery of small, subclinical nodules and small papillary cancers. Overdiagnosis and overtreatment is associated with potentially excessive costs and nonnegligible morbidity for patients.

EVIDENCE ACQUISITION

We conducted a PubMed search for the recent English-language articles dealing with thyroid nodule management.

EVIDENCE SYNTHESIS

The initial assessment includes an evaluation of clinical risk factors and sonographic examination of the neck. Sonographic risk-stratification systems (e.g., Thyroid Imaging Reporting and Data Systems) can be used to estimate the risk of malignancy and the need for biopsy based on nodule features and size. When cytology findings are indeterminate, molecular analysis of the aspirate may obviate the need for diagnostic surgery. Many nodules will not require biopsy. These nodules and those that are cytologically benign can be managed with long-term follow-up alone. If malignancy is suspected, options include surgery (increasingly less extensive), active surveillance or, in selected cases, minimally invasive techniques.

CONCLUSION

Thyroid nodule evaluation is no longer a 1-size-fits-all proposition. For most nodules, the likelihood of malignancy can be confidently estimated without resorting to cytology or molecular testing, and low-frequency surveillance is sufficient for most patients. When there are multiple options for diagnosis and/or treatment, they should be discussed with patients as frankly as possible to identify an approach that best meets their needs.