Incidental carcinoma in multinodular goiter: risk factors

The aim of the study was to analyze the frequency of incidental thyroid carcinoma (unknown tumor smaller than or equal to 10 mm) in a consecutive series of 462 total thyroidectomies for multinodular goiter and to investigate the clinical risk factors for this type of malignancy. A retrospective, single-center study of outcome data collected from patients with preoperative diagnosis of multinodular goiter who underwent total thyroidectomy at the General Surgery Unit of Pavia (Italy) between January 2000 and December 2008 was performed. Possible risk factors for malignancy were: gender, age, time of evolution of goiter, presence of a dominant nodule in multinodular goiter, hyperthyroidism, history of radiation to the neck, residence in an area of endemic goiter, prior thyroid surgery, calcifications in the goiter detected by neck ultrasound or chest X-rays, and a family history of thyroid diseases. In a 9-year period, 462 patients underwent total thyroidectomy. We found 41 cases of incidental thyroid carcinoma; the most common histopathological type was papillary. The multivariable analysis demonstrated that the clinical variables associated with occult carcinoma were a personal history of radiation therapy to the neck, the presence of calcifications detected by ultrasound or neck X-rays, and a family history of thyroid diseases; residence in an area of endemic goiter was a protective factor. A personal history of radiation to the neck, detection of calcifications by ultrasound or by neck X-rays, and a family history of thyroid diseases should be considered clinical risk factors for malignancy in multinodular goiter.     

Incidental thyroid carcinoma in a large series of consecutive patients operated on for benign thyroid disease

BACKGROUND: The diagnosis of incidental thyroid carcinoma (ITC) in patients operated on for a benign disease is frequent. This study aims to determine both its clinical effect and the possibility of identifying this class of patients preoperatively. METHODS: A total of 998 consecutive patients (697 women and 301 men; mean age, 49.5 years) undergoing surgery for benign thyroid pathology in a single institution were studied. The mean time between first diagnosis of thyroid disease and operation was 9.0 years (range, 0-50 years). All patients underwent at least one ultrasonography before surgery, and 678 patients underwent fine-needle aspiration cytology. Patients with undetermined cytology or follicular nodules were excluded from the study. RESULTS: Histology revealed an ITC in 104 patients (10.4%): 99 had a papillary carcinoma. Mean and median diameters of ITC were 1.4 and 0.7 cm, respectively (range, 0.1-7.5 cm). In 43 patients, the tumour size was greater than 1 cm, whereas it exceeded 2 cm in 25 patients. Tumours were multicentric in 19.8% of the patients and occurred in 8.2% of patients with nodular toxic goiter, 8.7% of patients with toxic diffuse goiter and 13.8% of patients with multinodular goiter. DISCUSSION: The results confirm the high frequency of ITC. ITC was more frequent in euthyroid patients than in thyrotoxic patients (P < 0.03). Sex, age, thyroid volume and interval between diagnosis and surgery did not significantly influence its incidence. The majority of ITC was represented by microcarcinomas, but in approximately 25% of patients, the tumour size was greater than 2 cm. The role played by FNAC in excluding malignancies proved to be fairly inconclusive.     

Thyroid cancer in patients with Grave's Disease

OBJECTIVE: To evaluate the incidence of thyroid carcinoma in patients operated on for Graves' disease, to identify criteria which may predict malignancy, and to develop a practical approach to determine the extensiveness of thyroidectomy. PATIENTS AND METHODS: Retrospective study of all patients who underwent thyroidectomy for Graves' disease between 1995 and 2005. RESULTS: 547 patients underwent subtotal thyroidectomy for Graves' disease during this period. Post-operative pathology examination revealed six cases of thyroid cancer (1.1%). All six cases had differentiated thyroid carcinoma (papillary carcinoma in 3 cases, follicular carcinoma in 2 cases and papillo-follicular carcinoma in 1 case). The indication for initial thyroidectomy was a palpable thyroid nodule in 3 cases (50%), failure of medical treatment for Grave's disease in 2 cases (33%), and signs of goiter compression in 1 case (17%). Five patients underwent re-operative total thyroidectomy. CONCLUSION: This study shows that while malignancy in Grave's disease is uncommon, the presence of thyroid nodule(s) in patients with Grave's disease may be considered as an indication for radical surgery. The most adequate radical surgery in this situation is to perform a total thyroidectomy.     

Hyperthyroidism and concurrent thyroid malignancies

In a 17-year period 1848 patients with hyperthyroidism were operated on. Fourteen (0.76%) had a coexisting thyroid malignancy. Preoperative scintiscan and pathologic diagnoses were compared: 10 malignancies were in cold nodules, two were unidentifiable preoperatively due to small size, and two were in hot areas. Five patients had papillary cancer, four follicular, three anaplastic, and two medullary. Patients with uninodular toxic goiter had a low rate of associated malignancy (0.27%, 3/1108). In contrast, patients with multinodular toxic goiter had an incidence of 1.63% (11/676). No patient with Graves' disease (n = 64) had a carcinoma. Extensive use of fine-needle aspiration biopsy enabled preoperative diagnosis in a majority of the cases (9/14, 64%). We conclude that the incidence of coexisting thyroid malignancy and hyperthyroidism is rare in our endemic iodine-deficiency goiter area.     

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??Coexisting nodular goiter and thyroid carcinoma: a retrospective analysis of 262 cases HE Liang, ZHANG Hao??DONG Wen-wu, et al. Department of General Surgery, the First Hospital, China Medical University, Shenyang 110001, China
Corresponding author: ZHANG Hao,E-mail: haozhang@mail.cmu.edu.cn
Abstract Objective To summarize the clinical characteristics and the highlight of diagnosis and treatment of nodular goiter in patients with coexistent thyroid carcinoma??Methods A total of 262 nodular goiter coexisting with thyroid carcinoma patients underwent operations from January 1998 to December 2007 at the First Hospital, China Medical University were retrospectively reviewed??Results Two hundreds and sixty-two patients accounted for 33.9% in thyroid carcinoma patients at the same time. The age mainly ranged from 40 to 59 years. The sex ratio was 1:5.2 (male:female). The clinical characteristics were manifested as nodular goiter. In addition to 25 patients who received secondary operation had a clear diagnosis before surgery. 70.0% of tumors were suspected as malignant lesions by preoperative ultrasound examination, in which 39.2% exhibited as microcalcification. The accuracy rate of intra-operative fast frozen section pathological examination was 93.2%. Tumor nodules less than 2.0 cm in diameter accounted for 62.9%, and microcarcinomas accounted for 40.1%. Clinical phase I cases accounted for 74%. The main pathological type was papillary carcinoma??93.1%??. The various styles of thyroidectomy were performed according to the different pathological results?? Neck dissection was performed in 122 patients, and 46 of them had cervical lymph node metastasis. Conclusion Most patients with coexisting thyroid carcinomas and nodular goiter have small tumor size and lower incidence of lymph node metastasis. The coexistent thyroid carcinoma was often well differentiated papillary cancer??The preoperative ultrasonography and the intra-operative fast frozen section examination are helpful for the diagnosis of thyroid carcinoma in nodular goiter?? Regular follow-up in patients with nodular goiter could improve the early diagnostic rate of coexisting thyroid carcinoma.     

Hyalinizing trabecular adenoma--an uncommon thyroid tumor frequently misdiagnosed as papillary or medullary thyroid carcinoma

BACKGROUND: Hyalinizing trabecular adenoma (HTA) is an uncommon benign thyroid tumor that can present as a solitary thyroid nodule, a prominent nodule in a multinodular goiter, or as an incidental finding in a thyroidectomy specimen. The clinical significance of the lesion is that it is frequently misdiagnosed as papillary carcinoma on fine-needle aspiration cytology or as papillary or medullary carcinoma on histopathological section. We reviewed our recent experience with 7 patients diagnosed with HTA. METHODS: Fine-needle aspiration biopsy was performed in 7 patients presenting with a solitary thyroid nodule (n = 4) or a multinodular goiter (n = 3). The patients underwent total thyroidectomy (n = 6) or hemithyroidectomy (n = 1). RESULTS: In 4 patients, the preoperative cytology was suggestive of papillary carcinoma, in 2 patients suspicious, and in 1 patient positive for papillary carcinoma. On histopathological section, 2 patients had a microscopic HTA, 2 patients had HTA in 1 or 2 nodules of a multinodular goiter, and 3 patients had HTA in a solitary nodule. Except in 1 patient, who had a microscopic focus (3.2 mm) of papillary carcinoma, there was no evidence of malignancy in the surgical specimens on permanent histopathological section. CONCLUSIONS: Although HTA is a rare condition of the thyroid, the surgeon needs to be aware of this entity to be able to better discuss the pathological findings with the patient, particularly since some pathologists and endocrinologists believe that HTA may represent a malignant neoplasm of low metastatic potential.     

Incidental carcinoma in thyroid pathology: our experience and review of the literature

The diagnosis of incidental thyroid carcinoma in patients submitted to thyroidectomy for a benign disease is quite frequent. A retrospective analysis was performed on 240 patients submitted to surgical intervention in order to establish the incidence of the carcinoma. One hundred sixty five patients (68.75%) were affected by benign disease (132 multinodular goiter, 30 uninodular goiter, 2 Plummer and 1 Basedow) and 75 (31.25%) by carcinoma. In 30 of 165 patients (18.2 %), affected by benign disease, occurred a histological diagnosis of thyroid carcinoma, (18 papillary carcinoma, 6 follicular carcinoma, 5 papillary carcinoma follicular variant and 1 oncocytic carcinoma). In this study it's considered incidental thyroid carcinoma the one occurred in patients who never underwent FNA and there were no suspicious features in all exams that may suggest the presence of carcinoma. Fifteen of the 30 incidental carcinoma (50%) were microcarcinomas; in the other 13, dimensions were more than 1 cm, but less than 2 cm in 9 cases. Two patients had a synchronous carcinoma. Actually these patients are still in a follow up program and no recurrency of disease is occasionally observed. This study shows that the only way to put doubts on the real benignity of the disease is the fine needle aspiration; there are no other instruments that could let think about the occurrence of the carcinoma. Moreover in the majority of cases the incidental carcinoma is a microcarcinoma, it doesn't reach significant volume, may be not centered by a FNAB, but in must cases it's not really biologically aggressive.     

Thyroidectomy or radioiodine? The value of ultrasonography and cytology in the assessment of nodular lesions in Graves' hyperthyroidism

Although diffuse toxic goiter is a classical feature of Graves' disease (GD) nodular goiters are occasionally found in some patients. The aim of the present study was to investigate the ultrasonographic and corresponding cytological manifestations in GD patients with nodular lesions to decide on a therapeutic strategy. Twenty-seven consecutive GD patients with nodular goiter were included in this study (21 women and six men, mean age 41.2 years, range 22-77 years). All underwent thyroid ultrasonography and fine-needle aspiration cytology. Of the 27 patients eight underwent surgical intervention because papillary thyroid carcinoma or follicular neoplasm was diagnosed by cytology; five of these were shown to have papillary thyroid carcinomas. Ultrasonography revealed the malignant nodules to be hypoechogenic, heterogeneous, and with ill-defined margins in four of these five thyroid cancers, whereas the remaining sonogram showed a cystic change and cauliflower-like tumor formation with microcalcification. The volume and maximal diameter of cancerous nodules were significantly larger than those of benign nodules. In conclusion our results reveal that ultrasonography and fine-needle aspiration cytology are reliable and quick methods for diagnosing nodular goiters in GD patients. If thyroid neoplasms are found ablative therapy with thyroidectomy is indicated instead of radioactive iodine.     

结节性甲状腺肿合并甲状腺癌25例

目的：探讨结节性甲状腺肿中甲状腺癌的临床特征和预后。方法：回顾性分析手术治疗结节性甲状腺肿合并甲状腺癌２５例临床资料。结果：２５例结节性甲状腺肿合并甲状腺癌,男６例,女１９例,年龄１２～６５（３６．８±１３．１）岁,占同期手术治疗３９５５例结节性甲状腺肿的０．６３％。术前、术中诊断甲状腺癌的占３２％,６８％为术后病理检查发现。甲状腺微小癌占４８％。结论：结节性甲状腺肿合并甲状腺癌预后较好。不能简单地认为结节性甲状腺肿是良性病变而忽略对其的处理,也不应过分强调甲状腺癌在治疗结节性甲状腺肿中的地位随意放宽手术指征,或扩大手术。     

The Prevalence of Incidental Thyroid Carcinoma in Patients Who Underwent Thyroidectomy for Multinodular Goiter

The incidence of an incidental carcinoma following surgical treatment for MNG varies from 3 to 16%. The aims of this study are to determine the incidence of an incidental thyroid carcinoma (ITC) in patients with multinodular goiter (MNG) and to evaluate the primary surgical treatment modality for these patients. Between January 2010 and July 2015, a total of 3311 patients who underwent surgery for goiter were retrospectively evaluated. Demographic characteristics of the patients, previous medical history, thyroid hormone profiles, thyroid ultrasonography findings, fine-needle aspiration biopsy (FNAB) findings, thyroid scintigraphy findings, surgical techniques, early postoperative complications, and histopathological diagnoses were recorded. The patients were divided into two groups: those who were incidentially diagnosed with a thyroid carcinoma (ITC group; n = ?) and those with MNG (MNG group; n = ?). Of 3311 patients, FNAB was performed in 1524 (46%) patients. Of these, 1790 underwent total thyroidectomy (TT) or near total thyroidectomy (NTT), 1066 underwent bilateral subtotal thyroidectomy (BSTT), 354 underwent the Dunhill procedure, and 101 underwent unilateral lobectomy (ULL) due to the presence of unilateral MNG. Postoperative histopathological examinations revealed an incidental thyroid carcinoma (ITC) in 283 (8.54%) patients, papillary carcinoma in 201 patients (201/3311, 6%), follicular cancer in 68 patients (68/3311, 2%), medullary cancer in 13 patients (13/3311, 0.3%), follicular carcinoma in four patients (4/923, 0.4%), and anaplastic cancer in one patient (1/3311, 0.03%). Our study results suggest that TT should be the primary surgical treatment modality to avoid the complications of a complementary thyroidectomy.     

Surgical diseases of thyroid gland

Medical reports of 8,768 patients with various diseases of thyroid gland were analyzed. There were 1,563 (17.8) male and 7,201 (82.2%) female patients aged 6 to 86 years. One-nodular goiter was diagnosed at 13.85% patients, multinodular goiter - at 67.2%, diffuse toxic goiter - at 5.85%, thyreotoxic adenoma - at 4.91%, Hashimoto's thyroiditis - at 8.16% patients. Thyroid cancer was revealed at 1.56 patients with nodular goiter, at 8.45% - with multinodular goiter, at 2.72% - with diffuse toxic goiter, at 3.71% - with thyreotoxic adenoma, and at 27.09% patients with Hashimoto's thyroiditis. Totally thyroid cancer was diagnosed at 741 (8.45%) patients including 71.12% papillary cancer, 26.47% follicular cancer and 2.42% medullar (anablastic) cancer. Some patients had metastases. It is concluded that all the patients with goiter should be operated. At diffuse toxic goiter the surgical treatment is indicated at the patients with recurrences or after 6 - 12 months of conservative treatment without clinical improvement.     

Operation for hyperthyroidism. Methods and rationale

Five hundred patients with hyperthyroidism underwent operation between 1970 and 1984. Sixty-nine percent had Graves' disease, 19 percent had toxic thyroid adenoma, and 12 percent had multinodular toxic goiter. Good results were achieved in the 275 patients most recently treated. These results may be attributed to the following: good personal contact between the surgeon and the patient at the first meeting, 1 month of preoperative management with carbimazole and propranolol without interruption of work, operation adapted to the type of goiter, and treatment of postoperative tachycardia by propranolol. The mean duration of hospital stay was 5 days. Sequelae were rare. In the patients with Graves' disease, results at 2 years were as follows: 74 percent of operated patients were euthyroid, 23 percent required substitutive treatment, and surgical treatment failed or early relapse occurred in 3 percent. There were no recurrences after operation in patients with solitary or multinodular toxic goiter, but 30 percent of the former and 98 percent of the latter had to be treated with L-thyroxine. Seventy-two percent of the patients who presented with atrial fibrillation had return of normal cardiac rhythm after operation.     

Results of Surgery for Toxic Multinodular Goiter

Purpose We analyzed the clinical and histological features of patients operated on for toxic multinodular goiter (TMG) to determine the clinical profile and evaluate the surgical results. Methods We reviewed 672 patients who underwent surgery for multinodular goiter (MG), 112 (17%) of whom had hyperthyroidism, and analyzed the epidemiological, clinical, and surgical variables. Results The patients with TMG tended to be older than those with nontoxic MG, with a greater evolution time of the goiter and a higher rate of positive antithyroid antibodies. In the multivariate analysis, the only feature characteristic of TMG, as opposed to nontoxic MG, was the evolution time. Morbidity was 34%, representative of the fact that that most of the patients were seen before the establishment of our endocrine surgical unit. The hyperthyroid symptoms resolved in all patients, but 4 of 17 patients who underwent partial surgical resection showed signs of relapse within a follow-up period of 98 ± 71 months. Conclusions TMG is characterized by a long evolution time and is most effectively treated by total thyroidectomy, which achieves complete remission from symptoms, without relapse, and is necessary if there is associated carcinoma. However, the incidence of complications may be high if this procedure is not carried out by surgeons with experience in endocrine surgery.     

Outcome of Patients Surgically Treated for Various Forms of Hyperthyroidism with Differentiated Thyroid Cancer: Experience at an Endocrine Center in Italy

Purpose The incidence and aggressiveness of thyroid cancer associated with hyperthyroidism remains a subject of much controversy. The aim of this study was to analyze the frequency of coexisting hyperthyroidism and thyroid cancer, and to determine whether cancer becomes more aggressive with different forms of hyperthyroidism. Methods We retrospectively studied 2 449 patients assessed for hyperthyroidism between 1985 and 2001. All patients with a “cold” nodule on scintigraphy, such as those with Graves' disease and a concomitant solid nodule, underwent fine-needle aspiration biopsy (FNAB). Criteria for surgery were cytological findings indicative of malignancy, goiter with signs of tracheal or esophageal compression, side effects of antithyroid drug therapy, or Graves' disease with multiple relapses after therapy withdrawal or responsiveness to antithyroid drugs. Results Thyroid cancer was diagnosed more frequently in patients with Graves' disease (6.5%) than in those with uninodular toxic goiter (UTG) (4.4%) or multinodular toxic goiter (MTG) (3.9%). Lymph node involvement was found in 56% of the patients with Graves' disease, in 23% of those with MTG, and in none of those with UTG. Distant metastases were found in one patient with Graves' disease. Conclusions Cancers associated with Graves' disease seems to be more aggressive than those associated with MTG or UTG. Thus, we suggest that patients with Graves' disease be carefully monitored for the detection of thyroid nodules. Ultrasonography seems to be the best modality to detect such nodules.     

Multicentre study of thyroid nodules in patients with Graves' disease

BACKGROUND: The association of Graves' disease with thyroid nodules and thyroid carcinoma is rarely reported. The incidence seems to be increasing according to recent literature. The aim of this multicentre study was to review patients who had surgery for Graves' disease associated with thyroid nodules, and to evaluate the risk of thyroid carcinoma. METHODS: A retrospective study was made of 557 consecutive patients who underwent operation for Graves' disease between 1991 and 1997 in five endocrine surgery departments. Each patient underwent clinical, biochemical, ultrasonographic and scintigraphic evaluation. None of the patients had had previous radioactive iodine therapy or external irradiation. Surgery consisted of either a subtotal or total thyroidectomy. RESULTS: Nodules were observed before operation in 140 patients (25.1 per cent). Thyroid carcinoma was diagnosed in 21 patients (15.0 per cent), always inside a nodule. The incidence of thyroid carcinoma associated with Graves' disease was 3.8 per cent (21 of 557 patients): 20 papillary and one follicular carcinoma. The carcinoma was multifocal in two patients. Tumour diameter ranged from 2 to 25 mm. A nodule was palpable in four patients. CONCLUSION: This multicentre study of patients having thyroidectomy for Graves' disease showed that 3.8 per cent had a carcinoma; the rate of carcinoma in cold nodules was 15.0 per cent. Surgery should be advised in any patient with Graves' disease and a thyroid nodule; the operation should be total thyroidectomy.     

全民普遍食盐加碘后广西地区甲状腺疾病谱的变迁

目的分析实行全民普遍食盐加碘前后广西沿海、山区等不同碘环境下甲状腺疾病谱变迁的特点,探讨普遍食盐加碘对甲状腺疾病谱的影响。方法收集广西南宁、桂林、百色及北海4城市的解放军三。三医院、解放军一八一医院、广西右江民族医学院附属医院及北海市人民医院1991年1月至2006年12月期间经手术治疗的甲状腺疾病患者共5998例,所有病例均有病理诊断并检测了尿碘水平;另检测同期1000位甲状腺正常人群的尿碘水平作对照。分析普遍食盐加碘前后碘环境的改变与甲状腺疾病谱变迁的关系。结果普遍食盐加碘后,结节性甲状腺肿患者的构成比较加碘前下降（尸〈0．05）,而毒性结节性甲状腺肿、慢性淋巴细胞性甲状腺炎及甲状腺乳头状癌患者的构成比较加碘前增高（P〈0．053;同时,结节性甲状腺肿、毒性弥漫性甲状腺肿、毒性结节性甲状腺肿、慢性淋巴细胞性甲状腺炎及甲状腺乳头状癌患者尿碘水平较加碘前明显增高（P〈0．05）,并且甲状腺疾病患者的尿碘水平高于对照组（P〈0．05）,甲状腺疾病患者及对照组的尿碘水平均较加碘前增高（P〈0．05）。结论全民普遍食盐加碘10年来,广西所调查地区平均尿碘水平及甲状腺疾病谱均发生了明显变化,碘过量可能是导致毒性结节性甲状腺肿、慢性淋巴细胞性甲状腺炎、慢性淋巴细胞性甲状腺炎合并乳头状癌及甲状腺乳头状癌发病率增高的环境因素之一。     

Characteristics of thyroid carcinoma in Grave's disease Hashimoto's thyroiditis and nodular goiter

The biology of thyroid cancer represents a spectrum of behavior ranging from well-differentiated lesions with an excellent prognosis to anaplastic carcinoma, which is almost fatal. For this reason, it is important that clinicians have methods at their disposal to asses the characteristics of patient's thyroid malignancy. In this work we discuss the behavior of differentiated thyroid cancer in associated diseases of thyroid as: Graves' disease, chronic lymphocytic thyroiditis--Hashimoto and nodular goiter. This is retrospectively reviewing of 50 patients treated for differentiated thyroid carcinoma at Department of surgery, Clinical Centre of Montenegro in Podgorica from 1998 until 2003. We evaluated occurrence, as well as the role of this diseases in patients with thyroid cancer. We found a more favorable course of thyroid cancer in the presence of chronic lymphocytic thyroiditis and nodular goiter, a contrary Graves' disease. In associated diseases of thyroid, a significantly greater proportion of patients with thyroid cancer, have modular goiter.     

结节性甲状腺肿合并甲状腺微小癌72例临床分析

目的总结结节性甲状腺肿合并甲状腺微小癌的临床特点及其诊断和治疗要点。方法回顾分析1993-01—2010-01手术治疗并病理证实的72例结节性申状腺肿合并甲状腺微小癌患者的临床资料。结果该组72例,占同期手术治疗结节性甲状腺肿患者的6.2%。术前彩超检查可疑恶性者占20.8%。术中快速冰冻检查诊断准确率为98.6%。病理类型以乳头状癌为主(93.1%)。手术方式主要是患侧腺叶+峡部切除+对侧腺叶次全/部分切除。结论结节性甲状腺肿合并甲状腺微小癌以乳头状癌为主,淋巴结转移发生率低。术中快速冰冻检查是诊断结节性甲状腺肿合并甲状腺微小癌的关键。对结节性甲状腺肿合并甲状腺微小癌不做预防性淋巴结清扫是安全的。     

Total Thyroidectomy for Benign Thyroid Disorders in an Endemic Region

Total thyroidectomy is increasingly being accepted as a treatment of choice for differentiated thyroid cancer. However, because of presumed increased morbidity associated with this procedure, it is still not considered a viable option for management of benign thyroid disorders. To assess the safety and efficacy of total thyroidectomy for management of benign thyroid disorders, we analyzed our data from 127 total thyroidectomies performed for benign thyroid disorders. Demographic details, biochemical findings, indications for operation, specimen weight, and complications were noted. Among these patients, 52 had a toxic goiter and 75 had a nontoxic goiter. The mean duration of the goiters being present was 6.08 ± 6.06 years (0.9–26.0 years), and the mean weight of the specimens was 136.88 ± 120.68 g. The incidence of occult malignancy was 6.3% (n= 8), and those of permanent hypothyroidism and permanent recurrent laryngeal nerve palsy were 1.6% and 0.8%, respectively. Total thyroidectomy should be considered a treatment of choice for multinodular goiter and Graves' disease in a setting of palpable nodule(s) or ophthalmopathy (or both). It is particularly relevant in endemic regions where patients present with a long-standing, large nodular goiter with virtually no normal thyroid tissue. Reoperation for recurrent goiter in such a setting would be fraught with distressing complications.     

Isthmectomy: A Conservative Operation for Solitary Nodule of the Thyroid Isthmus

Purpose : To assess the results obtained in patients with nontoxic uninodular goiter confined to the isthmus undergoing isthmectomy.

Methods : Between April 1994 and June 2006, 330 consecutive patients with nontoxic uninodular goiter underwent thyroidectomy at our institution. In 31 patients, lesions were limited to the thyroid isthmus with evidence of benign or undetermined pathology on ultrasound-guided fine-needle aspiration biopsy. Total isthmectomy was performed. Results : Preoperatively, thyroid nodules on ultrasonography were solid in 26 patients and mixed with cystic and solid components in 2. The mean size of nodules was 2.43 (± 0.88) cm. No intraoperative or postoperative complications occurred. Histological examination showed nodular hyperplasia in 29 cases, follicular adenoma in 1 and papillary thyroid carcinoma in 1. The patient with papillary carcinoma underwent bilateral lobectomy 7 days later. A total of 24 patients (77.4%) attended clinical visits at follow-up (mean 70, 57 months). Ultrasonographic scanning revealed thyroid nodules in 17 patients, in 16 of which nodules range from one to five (0.5 to 2 cm in size) and further surgery was not indicated. One patient with a 4-cm nodule and tracheal displacement found at ultrasonography 2 years after isthmectomy had inconclusive results of FNAB. This patient was re-operated for completion thyroidectomy, which was successfully performed without technical difficulties. The detection of recurrent nodules was independent of the time elapsed since thyroid isthmectomy.

Conclusions : These findings document the feasibility and efficacy of isthmectomy in solitary thyroid nodules confined to the isthmus.