title: Should the Prevalence of Incidental Thyroid Cancer Determine the Extent of Surgery in Multinodular Goiter?
abstract: BACKGROUND
  The most appropriate surgical procedure for multinodular goiter (MNG) remains under debate. Incidental thyroid carcinoma (ITC) is often identified on histopathological examination after thyroidectomy performed for presumed benign MNG.
  
  
  OBJECTIVE
  The aim of the study was to determine the value of radical surgery for MNG patients considering the prevalence of ITC diagnosed postoperatively.
  
  
  METHODS
  We conducted retrospective analysis of the medical records of 2,306 patients surgically treated for MNG between 2008 and 2013 at one center. None of the patients presented with any suspicion of malignancy, history of familial thyroid cancer, multiple endocrine neoplasia syndrome or previous head or neck radiation exposure.
  
  
  RESULTS
  Among the 2,306 MNG patients, ITC was detected in 49 (2.12%) (44 women and 5 men, with average ages of 52.2 (21-79) and 55.6 (52-62), respectively). Papillary thyroid carcinoma was significantly more frequently observed than other types of ITC (p<0.00001). Among the MNG patients, 866 (37.5%) underwent total/near total surgery, 464 (20.1%) received subtotal thyroidectomy, and 701 (30.3%) received the Dunhill operation. The remaining 275 (11.9%) patients underwent a less radical procedure and were classified as "others." Among the 49 (100%) patients with ITC, 28 (57.1%) underwent radical surgery. Another 21 (42.9%) patients required completion surgery due to an insufficient primary surgical procedure. A total of 21 (2.42%) patients in the total/near total surgery group were diagnosed with ITC, as well as 16 (2.48%) in the subtotal thyroidectomy group and 12 (1.71%) in the Dunhill operation group; 21 (100%), 4 (25%) and 3 (25%) of these patients, respectively, underwent radical surgery; thus, 0 (0%), 12 (75%) and 9 (75%) required completion surgery. The prevalence rates of ITC were comparable between the radical and subtotal surgery groups (2.42% and 3.44%, respectively, p = 0.4046), and the prevalence was higher in the radical surgery group than in the Dunhill operation group (2.42% and 1.71%, respectively, p = 0.0873). A significant difference was observed between the group of patients who underwent total/near total surgery, among whom all of the patients with ITC (100%) received primary radical surgery, and the groups of patients who received the subtotal and Dunhill operations, among whom only 25% of the patients with ITC in each group received primary radical surgery (p<0.0001).
  
  
  CONCLUSIONS
  More radical procedures for MNG result in a lower risk of reoperation for ITC. The prevalence of ITC on postoperative histopathological examination should determine the extent of surgery in MNG patients. In the future, total/near total thyroidectomy should be considered for MNG patients due to the increased prevalence of ITC to avoid the necessity for reoperation.
authors.affiliation: 1st Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland.
authors.forename: Krzysztof
authors.initials: K
authors.lastname: Kaliszewski
authors.affiliation: 1st Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland.
authors.forename: Marta
authors.initials: M
authors.lastname: Strutyńska-Karpińska
authors.affiliation: Department of Endocrinology and Diabetology for Children and Adolescents, Wroclaw Medical University, Wroclaw, Poland.
authors.forename: Agnieszka
authors.initials: A
authors.lastname: Zubkiewicz-Kucharska
authors.affiliation: 1st Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland.
authors.forename: Beata
authors.initials: B
authors.lastname: Wojtczak
authors.affiliation: 1st Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland.
authors.forename: Paweł
authors.initials: P
authors.lastname: Domosławski
authors.affiliation: 1st Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland.
authors.forename: Waldemar
authors.initials: W
authors.lastname: Balcerzak
authors.affiliation: 1st Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland.
authors.forename: Tadeusz
authors.initials: T
authors.lastname: Łukieńczuk
authors.affiliation: 1st Department and Clinic of General, Gastroenterological and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland.
authors.forename: Zdzisław
authors.initials: Z
authors.lastname: Forkasiewicz
mesh_terms: D018263:Adenocarcinoma, Follicular / Q000453:epidemiology* / Q000209:etiology; D000328:Adult; D000368:Aged; D002291:Carcinoma, Papillary / Q000453:epidemiology* / Q000209:etiology; D005260:Female; D006044:Goiter, Nodular / Q000601:surgery*; D006801:Humans; D033162:Incidental Findings; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011044:Poland / Q000453:epidemiology; D015995:Prevalence; D011379:Prognosis; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D013964:Thyroid Neoplasms / Q000453:epidemiology* / Q000209:etiology; D013965:Thyroidectomy / Q000009:adverse effects* / Q000592:standards*