Tiroid Nodüllerine Yaklaşım - Multinodüler Guatr ve Retrosternal Guatr

Oncologist. 2008 Feb;13(2):105-12.

Management of the solitary thyroid nodule.
Yeung MJ, Serpell JW.

Thyroid nodules are common, with up to 8% of the adult population having palpable nodules. With the use of ultrasound, up to 10 times more nodules are likely to be detected. Increasing numbers of nodules are being detected serendipitously because of the rising use of imaging to investigate unrelated conditions. The primary aim in investigating a thyroid nodule is to exclude the possibility of malignancy, which occurs in about 5% of nodules. This begins with a thorough history, including previous exposure to radiation and any family history of thyroid cancer or other endocrine diseases. Clinical examination of the neck should focus on the thyroid nodule and the gland itself, but also the presence of any cervical lymphadenopathy. Biochemical assessment of the thyroid needs to be followed by thyroid ultrasound, which may demonstrate features that are associated with a higher chance of the nodule being malignant. Fine-needle aspiration biopsy is crucial in the investigation of a thyroid nodule. It provides highly accurate cytologic information about the nodule from which a definitive management plan can be formulated. The challenge remains in the management of nodules that fall under the "indeterminate" category. These may be subject to more surgical intervention than is required because histological examination is the only way in which a malignancy can be excluded. Surgery followed by radioactive iodine ablation is the mainstay of treatment for differentiated thyroid cancers, and the majority of patients can expect high cure rates.

Laryngoscope. 2000 Feb;110(2 Pt 1):183-93.

Controversies in the management of thyroid nodule.
Shaha AR.

BMJ. 2009 Mar 13;338:b733.

Investigating the thyroid nodule.
Mehanna HM, Jain A, Morton RP, Watkinson J, Shaha A.

J Am Coll Surg. 2008 Aug;207(2):259-64. Epub 2008 May 12.

PET-associated incidental neoplasms of the thyroid.
Katz SC, Shaha A.

Cancer Cytopathol. 2010 Nov 8. [Epub ahead of print]

Diagnostic criteria and risk-adapted approach to indeterminate thyroid cytodiagnosis.
Abele JS, Levine RA.

Significant numbers of overdiagnoses of thyroid needle biopsies as "indeterminate" create a risk of surgery for benign disease. Overdiagnoses can be reduced by appropriate criteria and a risk-adapted approach to cytodiagnosis.

Thyroid. 2009 Nov;19(11):1167-214.

Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer.

American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman SI, Steward DL, Tuttle RM.

BACKGROUND: Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the publication of the American Thyroid Association's guidelines for the management of these disorders was published in 2006, a large amount of new information has become available, prompting a revision of the guidelines.

METHODS: Relevant articles through December 2008 were reviewed by the task force and categorized by topic and level of evidence according to a modified schema used by the United States Preventative Services Task Force.

RESULTS: The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to optimal surgical management, radioiodine remnant ablation, and suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using ultrasound and serum thyroglobulin as well as those related to management of recurrent and metastatic disease.

CONCLUSIONS: We created evidence-based recommendations in response to our appointment as an independent task force by the American Thyroid Association to assist in the clinical management of patients with thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.

World J Surg. 2008 Jul;32(7):1301-12.

Treatment and prevention of recurrence of multinodular goiter: an evidence-based review of the literature.
Moalem J, Suh I, Duh QY.

BACKGROUND: Reportedly, 10-15% of patients with goiters ultimately require operative intervention, and recurrences of multinodular goiter (MNG) account for up to 12% of all thyroid operations.

METHODS: We performed an evidence-based review of articles published in the English language between January 1987 and October 2007 relevant to the subject. RESULTS: Medical treatment with T4 appears to be associated with a greater proportion of patients whose nodules decreased in size by more than 50% (22% vs. 10%; range = 14-39% vs. 0-20%). Recurrence rates of benign nodular goiter after total thyroidectomy were essentially nonexistent (range = 0-0.3%) compared with those after subtotal thyroidectomy (range = 2.5-42%) and more limited resections (range = 8-34%). There was no difference between total and less-than-total thyroidectomy with respect to temporary recurrent laryngeal nerve (RLN) injury (1-10% vs. 0.9-6%, respectively) or permanent RLN palsy (0-1.4%). There was, however, a significantly higher rate of transient hypocalcemia after total thyroidectomy than less extensive operations (9-35% vs. 0-18%, respectively). In relation to redo surgery, permanent hypoparathyroidism appeared to be far more common in the redo group (0-22% vs. 0-4%) Moreover; the redo group had more frequent RLN injury, both temporary (0-22% vs. 0.5-18%) and permanent (0-13% vs. 0-4%). About half the studies examined conclude that postoperative TSH suppression is effective in reducing recurrences, while the other half state that it is not.

CONCLUSION: The definitive management and prevention of recurrence of benign nodular goiter is primarily surgical. Total thyroidectomy essentially eliminates the risk of recurrence without an accompanying increased risk of permanent hypoparathyroidism or RLN injury. Therefore, total thyroidectomy should be considered the procedure of choice for benign multinodular goiter whenever possible, especially considering that reoperations for goiter are significantly more morbid than any initial operation.

World J Surg. 2008 Jul;32(7):1285-300.

Evidence-based surgical management of substernal goiter.
White ML, Doherty GM, Gauger PG.

BACKGROUND: A number of reports have been published concerning the surgical treatment of substernal goiters; however, there is yet to be a comprehensive review of this body of literature using evidence-based methodology.

METHODS: This article is a systematic review of the literature using evidence-based criteria and a review of unpublished data from our institution.

RESULTS: Issue 1. Limited level III/IV data suggest that the incidence of cancer in substernal goiters is not higher than the incidence of cancer in cervical goiters. Risk factors for malignancy in substernal goiters may include a family history of thyroid pathology, a history of cervical radiation therapy, recurrent goiter, and the presence of cervical adenopathy (grade C recommendation). Issue 2. Prospective level V data suggest that, for most patients, expert endocrine surgeons utilize an extracervical approach approximately 2% of the time to remove a substernal goiter safely; a sternotomy or thoracotomy appears more likely in cases of a primary substernal goiter or a mass larger than the thoracic inlet (no recommendation). Issue 3. There may be a higher rate of permanent hypoparathyroidism and unintentional permanent recurrent laryngeal nevre injury when total thyroidectomy is performed for removal of a substernal goiter than for removal of a cervical goiter alone (grade C recommendation). Injury of the external branch of the superior laryngeal nerve was not specifically addressed and is almost certainly underreported. Issue 4. The presence of a substernal goiter, especially being present more than 5 years and causing significant tracheal compression, is likely a risk factor for tracheomalacia and tracheostomy (grade C recommendation). Tracheomalacia with substernal goiter is an infrequent occurrence, and many cases of tracheomalacia can be managed without tracheostomy (no recommendation). Issue 5. Prospective level V data suggest that about 5% to 10% of operations for substernal goiters are performed because of recurrent or persistent disease, although retrospective level V data report an even higher rate, up to 37%. The most common initial operations with recurrence or persistence appear to be subtotal or hemithyroidectomy (no recommendation).

CONCLUSION: Evidence-based recommendations provide reliable information regarding the pathologic findings and operative management of substernal goiters in expert hands.