(21.07) Recurrent Multinodular Goiter: Is a Third Thyroidectomy the Charm?: A Case Report

A 73-year-old female with a history of recurrent goiter presented to the endocrinology clinic for neck compressive symptoms. She had undergone a near-total thyroidectomy in 1983 for benign goiter with compressive symptoms of dysphagia and voice hoarseness (leaving < 1 cm of left thyroid lobe tissue). This was followed by a completion thyroidectomy in 2003 for recurrent symptoms of worsening dysphagia. The surgical pathologies excluded malignancy, and the patient was on levothyroxine for post-operative hypothyroidism. In 2010, she developed iatrogenic hyperthyroidism for which levothyroxine was stopped. Thyroid uptake scan confirmed recurrence of thyroid lobes both measuring approximately 6 cm in longitudinal dimension. A fine needle aspiration revealed benign thyroid cells. She was monitored annually for thyroid nodules and then 17 years later, she developed compressive symptoms with difficulty swallowing. Laboratory results showed normal thyroid-stimulating hormone (TSH) and free thyroxine (FT4) levels. Ultrasound findings revealed an enlarged multinodular thyroid (6.5 cm right lobe and 7 cm in the left lobe) with coarse echogenicity and a slight deviation of the trachea to the right. There were benign-appearing lymph nodes in the cervical neck. After extensive discussion between the patient, endocrinologist, and surgeon, the patient was scheduled for a third thyroidectomy procedure despite the presence of fibrous scar tissue and increased risk of surgical complications.


Discussion :

This case underscores the importance of comprehensive evaluation and individualized management in cases of recurrent goiter. Before 1984, bilateral subtotal thyroidectomy was the predominant surgical approach for benign goiter but carried a potential risk of recurrent disease in up to 23% of cases. Total thyroidectomy (TT) has been the standard of care since, with recurrence rates ranging from 0.33%-33% attributed to remaining microscopic thyroid cells.

It is unclear why this regrowth occurs in a minority of patients. Up to 10% of thyroid surgeries are reoperations and present with unique challenges due to altered anatomy and postoperative tissue changes. These have higher rates of complications but can be safely considered in experienced hands. There is a paucity of data on a third thyroid surgery for recurrent multinodular goiter, with a few case reports in the literature. Further studies are warranted to refine surgical approaches and minimize complications in these cases. The authors look forward to presenting and discussing this case’s surgical findings and outcomes at the annual meeting.