Total or near-total thyroidectomy versus subtotal thyroidectomy for multinodular non-toxic goitre in adults

Background Total thyroidectomy (TT) and subtotal thyroidectomy (ST) are worldwide treatment options for multinodular non-toxic goitre in adults. Near TT, defined as a postoperative thyroid remnant less than 1 mL, is supposed to be a similarly effective but safer option than TT. ST has been shown to be marginally safer than TT, but it may leave an undetected thyroid cancer in place. Objectives The objective was to assess the effects of total or near-total thyroidectomy compared to subtotal thyroidectomy for multinodular non-toxic goitre. Search methods We searched the Cochrane Library, MEDLINE, PubMed, EMBASE, as well as the ICTRP Search Portal and ClinicalTrials.gov. The date of the last search was 18 June 2015 for all databases. No language restrictions were applied. Selection criteria Two review authors independently scanned the abstract, title or both sections of every record retrieved to identify randomised controlled trials (RCTs) on thyroidectomy for multinodular non-toxic goitre for further assessment. Data collection and analysis Two review authors independently extracted data, assessed studies for risk of bias and evaluated overall study quality utilising the GRADE instrument. We calculated the odds ratio (OR) and corresponding 95% confidence interval (CI) for dichotomous outcomes. A random-effects model was used for pooling data. Main results We examined 1430 records, scrutinized 14 full-text publications and included four RCTs. Altogether 1305 participants entered the four trials, 543 participants were randomised to TT and 762 participants to ST. A total of 98% and 97% of participants finished the trials in the TT and ST groups, respectively. Two trials had a duration of follow-up between 12 and 39 months and two trials a follow-up of 5 and 10 years, respectively. Risk of bias across studies was mainly unknown for selection, performance and detection bias. Attrition bias was generally low and reporting bias high for some outcomes. In the short-term postoperative period no deaths were reported for both TT and ST groups. However, longer-term data on all-cause mortality were not reported (1284 participants; 4 trials; moderate quality evidence). Goiter recurrence was lower in the TT group compared to ST. Goiters recurred in 0.2% (1/425) of the TT group compared to 8.4% (53/632) of the ST group (OR 0.05 (95% CI 0.01 to 0.21); P < 0.0001; 1057 participants; 3 trials; moderate quality evidence). Re-intervention due to goitre recurrence was lower in the TT group compared to ST. Re-intervention was necessary in 0.5% (1/191) of TT patients compared to 0.8% (3/379)of ST patients (OR 0.66 (95% CI 0.07 to 6.38); P = 0.72; 570 participants; 1 trial; low quality evidence). The incidence of permanent recurrent laryngeal nerve palsy was lower for ST compared with TT. Permanent recurrent laryngeal nerve palsy occurred in 0.8% (6/741) of ST patients compared to 0.7% (4/543) of TT patients (OR 1.28, (95% CI 0.38 to 4.36); P = 0.69; 1275 participants; 4 trials; low quality evidence). The incidence of permanent hypoparathyroidism was lower for ST compared with TT. Permanent hypoparathyroidism occurred in 0.1% (1/741) of ST patients compared to 0.6% (3/543) of TT patients (OR 3.09 (95% CI 0.45 to 21.36); P = 0.25; 1275 participants: 4 trials; low quality evidence). The incidence of thyroid cancer was lower for ST compared with TT. Thyroid cancer occurred in 6.1% (41/669) of ST patients compared to 7.3% (34/465)of TT patients (OR 1.32 (95% CI 0.81 to 2.15); P = 0.27; 1134 participants; 3 trials; low quality evidence). No data on health-related quality of life or socioeconomic effects were reported in the included studies. Authors' conclusions The body of evidence on TT compared with ST is limited. Goiter recurrence is reduced following TT. The effects on other key outcomes such as re-interventions due to goitre recurrence, adverse events and thyroid cancer incidence are uncertain. New long-term RCTs with additional data such as surgeons level of experience, treatment volume of surgical centres and details on techniques used are needed

Pediatric thyroid disease: when is surgery necessary, and who should be operating on our children?

Surgical diseases of the thyroid in the pediatric population represent a diverse set of both benign and malignant conditions. Overall, incidence is rare. Benign conditions include Graves' disease, toxic adenomas, congenital hyperthyroidism, and goiter. Differentiated thyroid cancer (DTC) and medullary thyroid carcinoma (MTC), with its related familial cancer syndromes, are the most common malignancies. Near-total or total thyroidectomy is the appropriate surgery for thyroid cancer, with/out central lymph node dissection. Emerging practice guidelines from professional societies are helpful, although they generally have not addressed surgical management of the pediatric patient. Thyroidectomy in children is associated with a higher rate of complications, such as recurrent laryngeal nerve injury and hypoparathyroidism, as compared to the surgery in adults. Therefore, it is essential that pediatric thyroidectomy be performed by high-volume thyroid surgeons, regardless of specialty. Case volume to support surgical expertise usually must be borrowed from the adult experience, given the relative paucity of pediatric thyroidectomies at an institutional level. These surgeons should work as part of a multidisciplinary team that includes pediatric endocrinologists and anesthesiologists, pediatricians, nuclear medicine physicians, and pathologists to afford children the best clinical outcomes

Functional radical cervical dissection for differentiated thyroid cancer: the experience of a single center

There is ongoing debate regarding the role of neck dissection in differentiated thyroid cancer, about its usefulness in elective settings, and the increased costs regarding morbidity and operative time. This retrospective study aimed to determine the rate of metastases in cervical lymph nodes, to examine the morbidity of this surgery, and to assess whether a pattern of distribution of tumor cells concerning neck lymphatic compartments exists. The most frequent type of cancer to metastasize was papillary cancer, the majority of patients were young with a median of 30 years, predominantly females. Differentiated thyroid cancer frequently metastasizes to the central and lateral compartments of the neck. The morbidity is minimal in a high-volume center. Radical neck dissection is safe and feasible in selected patients with confirmed invaded or enlarged lymph nodes due to differentiated thyroid cancer, and postoperative complications are minimal if the anatomy is correctly identified and the cases strictly selected

A case report of thyroid carcinoma confined to ovary and concurrently occult in the thyroid. Is conservative treatment always advised?

Introduction: Struma ovarii is an ovarian teratoma, represented in more than 50% by thyroid tissue. Five percent of struma ovarii cases have been proven to be malignant and, as in the thyroid gland, papillary thyroid carcinoma is the most common histotype arising in struma ovarii. Because of the unusual occurrence of this tumor, its management and follow-up after pelvic surgery is still controversial. Usually, total thyroidectomy followed by radioiodine treatment is the choice treatment in metastatic malignant struma ovarii, while these procedures are still controversial in non-metastatic thyroid cancer arising in struma ovarii. Case Presentation: We report a female with follicular variant of papillary thyroid carcinoma arising in struma ovarii. After pelvic surgery, thyroid morphofunctional examinations were performed and a single nodular lesion in the left lobe was discovered. The patient underwent total thyroidectomy and histological examination showed a papillary carcinoma. Radioiodine-ablation of residual thyroid tissue was performed and levothyroxine mildly-suppressive treatment was started. Conclusions: A more aggressive treatment should not be denied for malignant struma ovarii without any evidence, even when apparently confined into the ovary. However, in selected cases, aggressive treatment may be advisable to decrease the risk of recurrence and to allow an accurate follow-up

Non recurrent laryngeal nerve with right aberrant subclavian artery in recurrent case of papillary carcinoma of thyroid: an interesting clinical entity.

Background/objectives: A nonrecurrent laryngeal nerve is a rare anatomical variant and a routine preoperative imaging studies are not indicated. NRLN is related with absence of the brachiocephalic trunk and aberrant (mainly retroesophageal) course of theright subclavian artery which is evident on contrast enhanced CT scan of the chest.Case report: The patient presented with a swelling in the neck for 4 months which is slowly increasing in size. Patient gives history of a surgery done in the neck with an old midlinesuprasternal scar which was done 40 years earlier.laryngoscopic mirror examinartion was normal with moving vocal cords. Rest of the oral and oropharyngeal examination along with completeblood picture and biochemical investigations were normal. The patient was not a known diabetic or hypertensive.Conclusion: Accurate knowledge of frequent variations of the nerve along with the non recurrent variant reduces the risk of intraoperative injury. A nonrecurrent laryngealnerve(NRLN) is a rare anatomical variant and a routine preoperative imaging studies are not indicated. NRLN is related with absence of the brachiocephalic trunk and aberrant(mainly retroesophageal) course of the right subclavian artery which is evident on contrast enhanced CT scan of the chest.

Follicular nodules (Thy3) of the thyroid: is total thyroidectomy the best option?

BACKGROUND: Identification of the best management strategy for nodules with Thy3 cytology presents particular problems for clinicians. This study investigates the ability of clinical, cytological and sonographic data to predict malignancy in indeterminate nodules with the scope of determining the need for total thyroidectomy in these patients. METHODS: The study population consisted of 249 cases presenting indeterminate nodules (Thy3): 198 females (79.5%) and 51 males (20.5%) with a mean age of 52.43 ± 13.68 years. All patients underwent total thyroidectomy. RESULTS: Malignancy was diagnosed in 87/249 patients (34.9%); thyroiditis co-existed in 119/249 cases (47.79%) and was associated with cancer in 40 cases (40/87; 45.98%). Of the sonographic characteristics, only echogenicity and the presence of irregular margins were identified as being statistically significant predictors of malignancy. 52/162 benign lesions (32.1%) and 54/87 malignant were hypoechoic (62.07%); irregular margins were present in 13/162 benign lesions (8.02%), and in 60/87 malignant lesions (68.97%). None of the clinical or cytological features, on the other hand, including age, gender, nodule size, the presence of microcalcifications or type 3 vascularization, were significantly associated with malignancy. CONCLUSIONS: The rate of malignancy in cytologically indeterminate lesions was high in the present study sample compared to other reported rates, and in a significant number of cases Hashimoto’s thyroiditis was also detected. Thus, considering the fact that clinical and cytological features were found to be inaccurate predictors of malignancy, it is our opinion that surgery should always be recommended. Moreover, total thyroidectomy is advisable, being the most suitable procedure in cases of multiple lesions, hyperplastic nodular goiter, or thyroiditis; the high incidence of malignancy and the unreliability of intraoperative frozen section examination also support this preference for total over hemi-thyroidectomy

Mucosa associated lymphoid tissue lymphoma of the thyroid gland: a case report and literature review = MALT linfoma della tiroide: caso clinico e revisione della letteratura

Mucosa associated lymphoid tissue (MALT) lymphomas are low-grade, non-Hodgkin’s B cell lymphomas, mainly occurring in the gastrointestinal tract, but also in other tissues. We describe the management of a patient with hypothyroidism, tracheoesophageal compressive symptoms and chest tightness affected by a thyroid MALT lymphoma. The patient underwent debulking thyroidectomy and temporary tracheostomy in order to reduce dysphonia and dysphagia, followed by adjuvant chemotherapy and subsequently radiation therapy. A CT scan performed at the end of radiotherapy 6 months after surgery revealed remnants of residual tissue from the thyroidectomy without any pathological findings. I linfomi MALT sono dei linfomi non-Hodgkin a cellule B a basso grado che in genere insorgono a livello del tratto gastrointestinale, ma anche in altri tessuti. Descriviamo in questo articolo il management clinico-chirurgico di un paziente con ipotiroidismo, sintomi da compressione tracheo-esofagea e senso di oppressione toracica, affetto da linfoma MALT della tiroide. Il paziente è stato sottoposto a parziale asportazione della massa tiroidea e tracheostomia allo scopo di ridurre i sintomi compressivi ed in seguito a trattamento chemioterapico e radioterapico. L’esame TC effettuato una volta conclusa la radioterapia, circa 6 mesi dopo l’intervento, ha evidenziato gli esiti della tiroidectomia parziale in assenza di altri reperti patologici

A possible role for selenoprotein glutathione peroxidase (GPx1) and thioredoxin reductases (TrxR1) in thyroid cancer. Our experience in thyroid surgery

Abstract Background: Oxidative stress is responsible for some alterations in the chemical structure and, consequently, in the function of proteins, lipids, and DNA. Recent studies have linked oxidative stress to cancers, particularly thyroid cancer, but the mechanisms remain unclear. Here, we further characterize the role of oxidative stress in thyroid cancer by analyzing the expression of two selenium antioxidant molecules, glutathione peroxidase (GPx1) and thioredoxin reductase (TrxR1) in thyroid cancer cells. Methods: Samples of both healthy thyroid tissue and thyroid tumor were taken for analysis after total thyroidectomy. The expression of GPx1 and TrxR1 was revealed by Western blot analysis and quantified by densitometric analyses, while the evaluation of free radicals was performed by Electron Paramagnetic Resonance (EPR)-spin trapping technique. Results: Our results show a decrease in the expression of GPx1 and TrxR1 (− 45.7 and − 43.2% respectively, p < 0.01) in the thyroid cancer cells compared to the healthy cells. In addition, the EPR technique shows an increase of free radicals in tumor tissue, significantly higher than that found in healthy thyroid tissue (+ 116.3%, p < 0.01). Conclusions: Our findings underscore the relationship between thyroid cancer and oxidative stress, showing the imbalance of the oxidant/antioxidant system in thyroid cancer tissue. These results suggest that either the inability to produce adequate antioxidant defense or an increased consumption of antioxidants, due to the hyper-production of free radicals, may play a crucial role in thyroid cancer. Keywords: Oxidative stress, Thyroid cancer, Glutathione peroxidase (GPx1), Thioredoxin reductases (TrxR1), Selenium enzyme

Risk stratification of neck lesions detected sonographically during the follow-up of differentiated thyroid cancer

Context: The European Thyroid Association (ETA) has classified post-treatment cervical ultrasound findings in thyroid cancer patients based on their association with disease persistence/recurrence. Objective: To assess this classification's ability to predict the growth and persistence of such lesions during active post-treatment surveillance of patients with differentiated thyroid cancer (DTC). Design: Retrospective, observational study Setting: Thyroid cancer center, large Italian teaching hospital. Patients: Center referrals (2005–2014) were reviewed and patients selected with pathologically confirmed DTC; total thyroidectomy, with or without neck dissection and/or radioiodine remnant ablation; abnormal findings on ≥2 consecutive post-treatment neck sonograms; subsequent follow-up consisting of active surveillance. Baseline ultrasound abnormalities (thyroid bed masses, lymph nodes) were classified according to the ETA system. Patients were divided into group S (those with ≥1 lesion classified as ‘suspicious’) and group I (‘indeterminate’ lesions only). We recorded baseline and follow-up clinical data through 30 June 2015. Main Outcomes: Patients with growth (> 3 mm, largest diameter) of ≥1 lesion during follow-up, patients with ≥1 persistent lesion at the final visit. Results: The cohort included 58 (9%) of the 637 DTC cases screened. A total of 113 lesions were followed (18 thyroid bed masses, 95 lymph nodes). During surveillance (median 3.7 years), group I had significantly lower rates than group S of lesion growth (8% vs. 36%, p=0.01) and persistence (64% vs. 97%, p=0.014). Median time to scan normalization: 2.9 years. Conclusions: The ETA's evidence-based classification of sonographically detected neck abnormalities can help identify PTC patients eligible for more relaxed follow-up