Thyroid nodule surgery: Difference between revisions

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==Overview==
==Overview==
==Surgery==
Surigical management of thyroid nodule is performed in case of non-diagnostic or suspicious biopsy, for removal of primary [[thyroid cancer]] or for [[thyroid cancer]] staging for [[radioactive]] ablation and [[serum]] [[thyroglobulin]] monitoring.
 
== Surgery==
Not all thyroid nodules require a surgical intervention, in fact surgical intervention goals for a thyroid nodule include:  
Not all thyroid nodules require a surgical intervention, in fact surgical intervention goals for a thyroid nodule include:  
* Provision of a diagnosis after a non diagnostic or suspicious biopsy  
* Provision of a diagnosis after a non-diagnostic or suspicious [[Biopsy forceps|biopsy]]
* Removal of the thyroid cancer  
* Removal of the [[thyroid cancer]]
* Thyroid cancer staging for radioactive ablation and serum Tg monitoring  
* [[Thyroid cancer]] staging for [[Radioactive iodine uptake|radioactive ablation]] and serum [[thyroglobulin]] monitoring  
==== Thyroid surgery definition terms ====
{| class="wikitable"
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Term
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Definition
|-
!
Hemithyroidectomy
|Unilateral lobectomy, removing only half of the [[thyroid]]
|-
!Isthmusectomy
|Excising only the [[thyroid]] [[isthmus]]
|-
!Near-total thyroidectomy
|Removal of all grossly visible [[thyroid]] [[Tissue (biology)|tissue]], leaving only a small amount (<1 g) of [[Tissue (biology)|tissue]] adjacent to the [[recurrent laryngeal nerve]] near the [[ligament]] of Berry
|-
!Total thyroidectomy
|Removal of all grossly visible [[thyroid]] [[Tissue (biology)|tissue]]
|-
!Subtotal thyroidectomy
|Leaving >1 g of [[Tissue (biology)|tissue]] with the posterior capsule on the uninvolved side, is an inappropriate operation for [[thyroid cancer]]
|}


==== Diagnostic and curative surgical interventions ====
==== Diagnostic and curative surgical interventions ====
Indications:  
Indications:  
* Repeatedly nondiagnostic aspirations of:  
* Repeatedly nondiagnostic [[Aspiration|aspirations]] of:  
** Partially cystic nodules  
** Partially cystic nodules  
** Solid nodules  
** Solid nodules  
* If molecular testing is unavailable and repeat aspirates continue to show atypical cells  
* If [[Molecular biology|molecular testing]] is unavailable and repeat [[Aspiration|aspirates]] continue to show atypical [[Cells (biology)|cells]]
* Cytology result is diagnostic of or suspicious for PTC
* [[Cytology]] result is diagnostic of or suspicious for [[papillary thyroid cancer]]
* Toxic adenoma  
* [[Toxic adenoma]]
* Features suggestive of but not definitive for papillary thyroid cancer  
* Features suggestive of but not definitive for [[papillary thyroid cancer]]
* Cytology diagnostic of malignancy (include papillary cancer, medullary thyroid cancer, thyroid lymphoma, anaplastic cancer, and metastatic thyroid cancer)  
* [[Cytology]] diagnostic of [[malignancy]] (include [[papillary thyroid cancer]], [[medullary thyroid cancer]], [[thyroid]] [[lymphoma]], [[anaplastic thyroid cancer]], and [[metastatic]] [[thyroid cancer]])  
* Larg solid nodules with sonographically suspicious features
* Large solid nodules with suspicious [[ultrasound]] findings
* If growth of the nodule (>20 percent in two dimensions on ultrasound) is detected during observation  
* If growth of the nodule (>20 percent in two dimensions on [[ultrasound]]) is detected during observation  
* Recurrent symptomatic cystic fluid accumulation
* Recurrent [[symptomatic]] cysts with associated fluid accumulation
** Generally hemithyroidectomy or percutaneous ethanol injection (PEI)
** Generally [[hemithyroidectomy]] or [[percutaneous]] [[ethanol]] [[Injection (medicine)|injection]]
** Decision should be made based on compressive symptoms and cosmetic concerns
** Decision should be made based on compressive [[symptoms]] and [[Cosmetic Surgery|cosmetic]] concerns
Surgery in these cases may be required for further evaluation.
 
=== Surgical procedure based on tumor status ===
=== Surgical procedure based on tumor status ===
{| class="wikitable"
{| class="wikitable"
!Tumor criteria
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Tumor criteria
!Tumor siza
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Tumor size
!Surgical procedure
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Surgical procedure
!Note
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Note
|-
|-
| rowspan="2" |Tumor without extrathyroidal extension and no lymph nodes
! rowspan="2" |[[Tumor]] without extrathyroidal extension and no [[lymph nodes]]
| rowspan="2" |<1 cm
! rowspan="2" |<1 cm
|thyroid lobectomy
|[[Thyroid]] lobectomy
|unilateral intrathyroidal differentiated thyroid cancer <1 cm
|
* Unilateral intrathyroidal differentiated [[thyroid]] [[cancer]] <1 cm
|-
|-
|Total thyroidectomy
|Total [[thyroidectomy]]
|
|
* Evidence of thyroid cancer in the contralateral lobe
* Evidence of [[thyroid cancer]] in the contralateral lobe
* Previous history of head and neck radiation
* Previous history of head and neck [[radiation]]
* Family history of thyroid cancer
* Family history of [[thyroid cancer]]
* Imaging abnormalities suspicious of malignancies
* Imaging abnormalities suspicious of [[Thyroid cancer|malignancies]]
|-
|-
| rowspan="2" |Tumor without extra thyroidal extension and no lymph node
! rowspan="2" |[[Tumor]] without extra thyroidal extension and no [[lymph node]]
| rowspan="2" |1 to 4 cm  
! rowspan="2" |1 to 4 cm  
|Thyroid lobectomy
|[[Thyroid]] lobectomy
| rowspan="2" |Based on:
| rowspan="2" |Based on:
* Patient preference
* Patient preference
* Evidence of metastasis on imaging
* Evidence of [[metastasis]] on imaging
|-
|-
|Total thyroidectomy
|Total [[thyroidectomy]]
|-
|-
|Tumor, extrathyroidal extension, or metastases
![[Tumor]], extrathyroidal extension, or [[metastases]]
|≥4 cm
!≥4 cm
| colspan="2" |Total thyroidectomy
| colspan="2" |Total [[thyroidectomy]]
|-
|-
|Tumor in a patient with a history of childhood head and neck radiation
![[Tumor]] in a patient with a history of childhood head and [[neck]] [[radiation]]
|Any size
!Any size
| colspan="2" |Total thyroidectomy
| colspan="2" |Total [[thyroidectomy]]
|-
|-
| colspan="2" |Multifocal papillary microcarcinoma (fewer than five foci)
! colspan="2" |Multifocal [[Papillary carcinoma of the thyroid|papillary microcarcinoma]] (fewer than five foci)
| colspan="2" |Unilateral lobectomy and isthmusectomy
| colspan="2" |Unilateral lobectomy and isthmectomy
|-
|-
| colspan="2" |Multifocal papillary microcarcinoma (more than five foci)
! colspan="2" |Multifocal [[Papillary carcinoma of the thyroid|papillary microcarcinoma]] (more than five foci)
| colspan="2" |total thyroidectomy
| colspan="2" |Total [[thyroidectomy]]
|-
|-
| colspan="2" rowspan="2" |Indeterminate or suspicious thyroid nodules
! colspan="2" rowspan="2" |Indeterminate or suspicious thyroid nodules
|unilateral lobectomy and  
|unilateral lobectomy and  
isthmusectomy
isthmectomy
| rowspan="2" |Decision should be made based on the imaging suspicious  
| rowspan="2" |
 
* Decision should be made based on the imaging suspicious
to whether perform a total thyroidectomy or a unilateral lobectomu
to whether perform a total [[thyroidectomy]] or a unilateral lobectomy
|-
|-
|Total thyroidectomy
|Total [[thyroidectomy]]
|-
|-
|indeterminate thyroid nodules and DTC
! colspan="2" |Indeterminate thyroid nodules and DTC
|
| colspan="2" |Total [[thyroidectomy]]
|
|
|}
|}
{| class="wikitable"
|
idectomy
|Unilateral lobectomy, removing only half of the thyroid
|
|
|-
|isthmusectomy
|Excising only the thyroid isthmus
|
|
|-
|near-total thyroidectomy
|Removal of all grossly visible thyroid tissue, leaving only a small amount [<1 g] of tissue adjacent to the recurrent laryngeal nerve near the ligament of Berry
|
|
|-
|total thyroidectomy
|Removal of all grossly visible thyroid tissue
|
|
|-
|Subtotal thyroidectomy
|Leaving >1 g of tissue with the posterior capsule on the uninvolved side, is an inappropriate operation for thyroid cancer
|
|
|}
==== Pregnancy and surgical resection of tumors ====
Pregnant patients that are diagnosed with nodules as differentiated thyroid carcinoma (DTC) by FNA, can utilize a delayed surgery, with the surgery scheduled for after the delivery. Researches have shown that delayed surgery will not decrease their response to therapy and their survival rate. 9284711
Exception should be made in these cases, which the surgery should be done during the pregnancy:
* A nodule with cytology indicating PTC discovered early in pregnancy that grows during pregnancy by 24 weeks gestation
* Patients with more advanced disease
==== Table ====
summary recommendation:


For patients with thyroid cancer >1 cm, the initial surgical procedure should be a near-total or total thyroidectomy unless there are contraindications to this surgery. Thyroid lobectomy alone may be sufficient treatment for small (<1 cm), low-risk, unifocal, intrathyroidal papillary carcinomas in the absence of prior head and neck irradiation or radiologically or clinically involved cervical nodal metastases
=== Summary of surgical recommendations in thyroid nodules: ===
The best surgical options regarding thyroid nodules diagnosis are summarized in the table below:<ref name="pmid11038196">{{cite journal |vauthors=Duren M, Yavuz N, Bukey Y, Ozyegin MA, Gundogdu S, Açbay O, Hatemi H, Uslu I, Onsel C, Aksoy F, Oz F, Unal G, Duren E |title=Impact of initial surgical treatment on survival of patients with differentiated thyroid cancer: experience of an endocrine surgery center in an iodine-deficient region |journal=World J Surg |volume=24 |issue=11 |pages=1290–4 |year=2000 |pmid=11038196 |doi= |url=}}</ref><ref name="pmid12016468">{{cite journal |vauthors=Hay ID, Thompson GB, Grant CS, Bergstralh EJ, Dvorak CE, Gorman CA, Maurer MS, McIver B, Mullan BP, Oberg AL, Powell CC, van Heerden JA, Goellner JR |title=Papillary thyroid carcinoma managed at the Mayo Clinic during six decades (1940-1999): temporal trends in initial therapy and long-term outcome in 2444 consecutively treated patients |journal=World J Surg |volume=26 |issue=8 |pages=879–85 |year=2002 |pmid=12016468 |doi=10.1007/s00268-002-6612-1 |url=}}</ref><ref name="pmid9499265">{{cite journal |vauthors=Lin JD, Chao TC, Huang MJ, Weng HF, Tzen KY |title=Use of radioactive iodine for thyroid remnant ablation in well-differentiated thyroid carcinoma to replace thyroid reoperation |journal=Am. J. Clin. Oncol. |volume=21 |issue=1 |pages=77–81 |year=1998 |pmid=9499265 |doi= |url=}}</ref><ref name="pmid14583762">{{cite journal |vauthors=Rubino C, de Vathaire F, Dottorini ME, Hall P, Schvartz C, Couette JE, Dondon MG, Abbas MT, Langlois C, Schlumberger M |title=Second primary malignancies in thyroid cancer patients |journal=Br. J. Cancer |volume=89 |issue=9 |pages=1638–44 |year=2003 |pmid=14583762 |pmc=2394426 |doi=10.1038/sj.bjc.6601319 |url=}}</ref><ref name="pmid7483170">{{cite journal |vauthors=Mazzaferri EL, Jhiang SM |title=Differentiated thyroid cancer long-term impact of initial therapy |journal=Trans. Am. Clin. Climatol. Assoc. |volume=106 |issue= |pages=151–68; discussion 168–70 |year=1995 |pmid=7483170 |pmc=2376543 |doi= |url=}}</ref><ref name="pmid2380337">{{cite journal |vauthors=DeGroot LJ, Kaplan EL, McCormick M, Straus FH |title=Natural history, treatment, and course of papillary thyroid carcinoma |journal=J. Clin. Endocrinol. Metab. |volume=71 |issue=2 |pages=414–24 |year=1990 |pmid=2380337 |doi=10.1210/jcem-71-2-414 |url=}}</ref><ref name="pmid1517360">{{cite journal |vauthors=Samaan NA, Schultz PN, Hickey RC, Goepfert H, Haynie TP, Johnston DA, Ordonez NG |title=The results of various modalities of treatment of well differentiated thyroid carcinomas: a retrospective review of 1599 patients |journal=J. Clin. Endocrinol. Metab. |volume=75 |issue=3 |pages=714–20 |year=1992 |pmid=1517360 |doi=10.1210/jcem.75.3.1517360 |url=}}</ref><ref name="pmid16684830">{{cite journal |vauthors=Durante C, Haddy N, Baudin E, Leboulleux S, Hartl D, Travagli JP, Caillou B, Ricard M, Lumbroso JD, De Vathaire F, Schlumberger M |title=Long-term outcome of 444 patients with distant metastases from papillary and follicular thyroid carcinoma: benefits and limits of radioiodine therapy |journal=J. Clin. Endocrinol. Metab. |volume=91 |issue=8 |pages=2892–9 |year=2006 |pmid=16684830 |doi=10.1210/jc.2005-2838 |url=}}</ref><ref name="pmid18403624">{{cite journal |vauthors=Moon WJ, Jung SL, Lee JH, Na DG, Baek JH, Lee YH, Kim J, Kim HS, Byun JS, Lee DH |title=Benign and malignant thyroid nodules: US differentiation--multicenter retrospective study |journal=Radiology |volume=247 |issue=3 |pages=762–70 |year=2008 |pmid=18403624 |doi=10.1148/radiol.2473070944 |url=}}</ref><ref name="pmid15200043">{{cite journal |vauthors=Marchesi M, Biffoni M, Biancari F, Berni A, Campana FP |title=Predictors of outcome for patients with differentiated and aggressive thyroid carcinoma |journal=Eur J Surg Suppl |volume= |issue=588 |pages=46–50 |year=2003 |pmid=15200043 |doi= |url=}}</ref><ref name="pmid15283286">{{cite journal |vauthors=Ge JH, Zhao RL, Hu JL, Zhou WA |title=[Surgical treatment of advanced thyroid carcinoma with aero-digestive invasion] |language=Chinese |journal=Zhonghua Er Bi Yan Hou Ke Za Zhi |volume=39 |issue=4 |pages=237–40 |year=2004 |pmid=15283286 |doi= |url=}}</ref>


{| class="wikitable"
{| class="wikitable"
!
! colspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Surgical procedure
!
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Comment
!
!
|-
|-
![[Lobectomy|'''Thyroid lobectomy''']]
! rowspan="2" |'''Nondiagnostic biopsy, a biopsy suspicious for [[Papillary thyroid cancer|papillary cancer]] or suggestive of [[Follicular thyroid cancer|follicular neoplasm]]'''
|
|
|Surgical options to address the primary tumor should be limited to
* For patients with an isolated indeterminate solitary nodule who prefer a more limited surgical procedure
 
* Recommended as initial surgical approach
Duren M, Yavuz N, Bukey Y, Ozyegin MA, Gundogdu S, Ac¸bay O, Hatemi H, Uslu I, Onsel C, Aksoy F, Oz F, Unal G, Duren E 2000 Impact of initial surgical treatment on survival of patients with differentiated thyroid cancer: experience of an endocrine surgery center in an iodinedeficient region. World J Surg 24:1290–1294
|
|
|-
|-
|nondiagnostic biopsy, a biopsy suspicious for papillary cancer or suggestive of ‘‘follicular neoplasm’’
! rowspan="2" |[[Thyroidectomy|'''Total thyroidectomy''']]
|For patients with an isolated indeterminate solitary nodule who prefer a more limited surgical procedure, thyroid lobectomy is the recommended initial surgical approach
|Indicated in :
total thyroidectomy is indicated in patients with indeterminate nodules who have large tumors (>4 cm), when marked atypia is seen on biopsy, when the biopsy reading is ‘‘suspicious for papillary carcinoma,’’ in patients with a family history of thyroid carcinoma, and in patients with a history of radiation exposure
* Patients with indeterminate nodules who have large [[tumors]] (>4 cm)
 
* Patients with marked [[atypia]] is seen on [[biopsy]]
Patients with indeterminate nodules who have bilateral nodular disease, or those who prefer to undergo bilateral thyroidectomy to avoid the possibility of requiring a future surgery on the contralateral lobe, should also undergo total or near-total thyroidectomy
* Patients with a [[biopsy]] reading ‘‘suspicious for [[Papillary carcinoma of the thyroid|papillary carcinoma]]’’
|
* In patients with a [[family history]] of [[Thyroid cancer|thyroid carcinoma]]
|
* In patients with a history of [[radiation]] exposure
* Patients with indeterminate nodules who had bilateral nodular disease
* Patients who prefer to undergo bilateral [[thyroidectomy]] to avoid the possibility of requiring a future surgery on the [[contralateral]] lobe
|-
|-
|Surgery for a biopsy diagnostic for malignancy
!'''Surgery for a biopsy diagnostic for [[malignancy]]'''
|Neartotal or total thyroidectomy is recommended if the primary thyroid carcinoma is >1 cm (156), there are contralateral thyroid nodules present or regional or distant metastases are present, the patient has a personal history of radiation therapy to the head and neck, or the patient has first-degree family history of DTC. Older age (>45 years) may also be a criterion for recommending near-total or total thyroidectomy even with tumors <1–1.5 cm, because of higher recurrence rates in this age group
|Near-total or total [[thyroidectomy]] if:
Hay ID, Thompson GB, Grant CS, Bergstralh EJ, Dvorak CE, Gorman CA, Maurer MS, McIver B, Mullan BP, Oberg AL, Powell CC, van Heerden JA, Goellner JR 2002 Papillary thyroid carcinoma managed at the Mayo Clinic during six decades (1940–1999): temporal trends in initial therapy and long-term outcome in 2444 consecutively treated patients. World J Surg 26:879–885. 123.
* The primary [[Thyroid cancer|thyroid carcinoma]] is >1 cm (156)
 
* There are contralateral thyroid nodules present or regional or distant [[metastases]] are present
Lin JD, Chao TC, Huang MJ, Weng HF, Tzen KY 1998 Use of radioactive iodine for thyroid remnant ablation in welldifferentiated thyroid carcinoma to replace thyroid reoperation. Am J Clin Oncol 21:77–81
* The patient has a personal history of [[radiation therapy]] to the head and neck
 
* The patient has first-degree family history of differentiated [[Thyroid Cancer|thyroid carcinoma]]
Rubino C, de Vathaire F, Dottorini ME, Hall P, Schvartz C, Couette JE, Dondon MG, Abbas MT, Langlois C, Schlumberger M 2003 Second primary malignancies in thyroid cancer patients. Br J Cancer 89:1638–1644
* Older age (>45 years) may also be a criterion for recommending near-total or total [[thyroidectomy]] even with [[tumors]] <1–1.5 cm, because of higher recurrence rates in this age group
|
|
|-
|-
|central-compartment (level VI) neck dissection
! colspan="2" |'''Central-compartment (level VI) neck dissection'''
|
|Therapeutic central-compartment (level VI) neck dissection:
* Therapeutic central-compartment (level VI) neck dissection:
* For patients with clinically involved central or lateral neck [[lymph nodes]] should accompany total [[thyroidectomy]] to provide clearance of disease from the central neck
** For patients with clinically involved central or lateral neck lymph nodes should accompany total thyroidectomy to provide clearance of disease from the central neck.
Prophylactic central-compartment neck [[dissection]] (ipsilateral or bilateral):
* Prophylactic central-compartment neck dissection (ipsilateral or bilateral):
* Consider in patients with [[Papillary thyroid cancer|papillary thyroid carcinoma]] with clinically uninvolved central neck [[lymph nodes]], especially for advanced primary tumors (T3 or T4)
** Consider in patients with papillary thyroid carcinoma with clinically uninvolved central neck lymph nodes, especially for advanced primary tumors (T3 or T4)
Near-total or total [[thyroidectomy]] without [[Prophylaxis|prophylactic]] central neck dissection:
* Near-total or total thyroidectomy without prophylactic central neck dissection:
* Consider in small (T1 or T2), noninvasive, clinically node-negative [[Papillary thyroid cancer|papillary thyroid cancers]] and most [[Follicular cancer of the thyroid|follicular cancer]]
** Consider in small (T1 or T2), noninvasive, clinically node-negative PTCs and most follicular cancer
|
|
|-
|-
|lateral neck compartmental lymph node dissection  
! colspan="2" |'''Lateral neck compartmental lymph node dissection'''
|For patients with biopsyproven metastatic lateral cervical lymphadenopathy. Recommendation rating
|
|
|
* For patients with biopsy proven [[metastatic]] lateral cervical [[lymphadenopathy]]
|-
|-
|Completion thyroidectomy
! colspan="2" |'''Tumors invade the upper aerodigestive tract'''
|should be offered to those patients for whom a near-total or total thyroidectomy would have been recommended had the diagnosis been available before the initial surgery. This includes all patients with thyroid cancer except those with small (<1 cm), unifocal, intrathyroidal, node-negative, low-risk tumors
|Techniques ranging from shaving tumor off the [[trachea]] or [[esophagus]] for superficial invasion, to more aggressive techniques when the [[trachea]] is more deeply invaded (e.g., direct intraluminal invasion) including:
|
* [[Trachea|Tracheal]] resection and [[anastomosis]]
|
* Laryngopharyngoesophagectomy
|-
|-
! colspan="2" |Comprehensive compartmental lateral and/or central neck dissection
|
|
|
* Should be performed for patients with persistent or recurrent disease confined to the [[neck]]
|
* Sparing uninvolved vital structures
|
|-
|Tumors invade the upper aerodigestive tract
|techniques ranging from shaving tumor off the trachea or esophagus for superficial invasion, to more aggressive techniques when the trachea is more deeply invaded (e.g., direct intraluminal invasion) including tracheal resection and anastomosis or laryngopharyngoesophagectomy
|
|
|}
|}
Increased extent of primary surgery may improve survival for high-risk patients and low-risk patients


Mazzaferri EL, Young RL 1981 Papillary thyroid carcinoma: a 10 year follow-up report of the impact of therapy in 576 patients. Am J Med 70:511–518. 159.  
==== Pregnancy and surgical resection of tumors<ref name="pmid9284711">{{cite journal |vauthors=Moosa M, Mazzaferri EL |title=Outcome of differentiated thyroid cancer diagnosed in pregnant women |journal=J. Clin. Endocrinol. Metab. |volume=82 |issue=9 |pages=2862–6 |year=1997 |pmid=9284711 |doi=10.1210/jcem.82.9.4247 |url=}}</ref> ====
[[Pregnancy|Pregnant patients]] that are diagnosed with nodules as differentiated thyroid carcinoma by [[FNA]], can utilize a delayed surgery, with the surgery scheduled for after the [[delivery]]. Researches have shown that delayed surgery will not decrease their response to [[therapy]] and their survival rate.


DeGroot LJ, Kaplan EL, McCormick M, Straus FH 1990 Natural history, treatment, and course of papillary thyroid carcinoma. J Clin Endocrinol Metab 71:414–424. 160.
Exception should be made in these cases, which the surgery should be done during the [[pregnancy]]:
 
* A nodule with [[cytology]] indicating [[papillary thyroid carcinoma (PTC)]], discovered early in [[pregnancy]] that grows during [[pregnancy]] by 24 weeks [[gestation]]
Samaan NA, Schultz PN, Hickey RC, Goepfert H, Haynie TP, Johnston DA, Ordonez NG 1992 The results of various modalities of treatment of well differentiated thyroid carcinomas: a retrospective review of 1599 patients. J Clin Endocrinol Metab 75:714–720
* Patients with more advanced disease
 
Therapeutic comprehensive compartmental lateral and=or central neck dissection, sparing uninvolved vital structures, should be performed for patients with persistent or recurrent disease confined to the neck.
 
Limited compartmental lateral and=or central compartmental neck dissection may be a reasonable alternative to more extensive comprehensive dissection for patients with recurrent disease within compartments having undergone prior comprehensive dissection and=or external beam radiotherapy
 
Durante C, Haddy N, Baudin E, Leboulleux S, Hartl D, Travagli JP, Caillou B, Ricard M, Lumbroso JD, De Vathaire F, Schlumberger M 2006 Long term outcome of 444 patients with distant metastases from papillary and follicular thyroid carcinoma: benefits and limits of radioiodine therapy. J Clin Endocrinol Metab 92:450–455
 
Noguchi S, Yamashita H, Murakami N, Nakayama I, Toda M, Kawamoto H 1996 Small carcinomas of the thyroid. A long-term follow-up of 867 patients. Arch Surg 131: 187–191. 328.
 
Marchesi M, Biffoni M, Biancari F, Berni A, Campana FP 2003 Predictors of outcome for patients with differentiated and aggressive thyroid carcinoma. Eur J Surg Suppl 588: 46–50
 
For tumors that invade the upper aerodigestive tract, surgery combined with additional therapy such as 131I and=or external beam radiation is generally advised
 
techniques ranging from shaving tumor off the trachea or esophagus for superficial invasion, to more aggressive techniques when the trachea is more deeply invaded (e.g., direct intraluminal invasion) including tracheal resection and anastomosis(in table too)
 
Ge JH, Zhao RL, Hu JL, Zhou WA 2004 Surgical treatment of advanced thyroid carcinoma with aero-digestive invasion. Zhonghua Er Bi Yan Hou Ke Za Zhi 39:237–240. 330.
 
Avenia N, Ragusa M, Monacelli M, Calzolari F, Daddi N, Di Carlo L, Semeraro A, Puma F 2004 Locally advanced thyroid cancer: therapeutic options. Chir Ital 56:501–508


==References==
==References==

Latest revision as of 18:36, 1 November 2017


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Surigical management of thyroid nodule is performed in case of non-diagnostic or suspicious biopsy, for removal of primary thyroid cancer or for thyroid cancer staging for radioactive ablation and serum thyroglobulin monitoring.

Surgery

Not all thyroid nodules require a surgical intervention, in fact surgical intervention goals for a thyroid nodule include:

Thyroid surgery definition terms

Term Definition

Hemithyroidectomy

Unilateral lobectomy, removing only half of the thyroid
Isthmusectomy Excising only the thyroid isthmus
Near-total thyroidectomy Removal of all grossly visible thyroid tissue, leaving only a small amount (<1 g) of tissue adjacent to the recurrent laryngeal nerve near the ligament of Berry
Total thyroidectomy Removal of all grossly visible thyroid tissue
Subtotal thyroidectomy Leaving >1 g of tissue with the posterior capsule on the uninvolved side, is an inappropriate operation for thyroid cancer

Diagnostic and curative surgical interventions

Indications:

Surgical procedure based on tumor status

Tumor criteria Tumor size Surgical procedure Note
Tumor without extrathyroidal extension and no lymph nodes <1 cm Thyroid lobectomy
Total thyroidectomy
Tumor without extra thyroidal extension and no lymph node 1 to 4 cm Thyroid lobectomy Based on:
  • Patient preference
  • Evidence of metastasis on imaging
Total thyroidectomy
Tumor, extrathyroidal extension, or metastases ≥4 cm Total thyroidectomy
Tumor in a patient with a history of childhood head and neck radiation Any size Total thyroidectomy
Multifocal papillary microcarcinoma (fewer than five foci) Unilateral lobectomy and isthmectomy
Multifocal papillary microcarcinoma (more than five foci) Total thyroidectomy
Indeterminate or suspicious thyroid nodules unilateral lobectomy and

isthmectomy

  • Decision should be made based on the imaging suspicious

to whether perform a total thyroidectomy or a unilateral lobectomy

Total thyroidectomy
Indeterminate thyroid nodules and DTC Total thyroidectomy

Summary of surgical recommendations in thyroid nodules:

The best surgical options regarding thyroid nodules diagnosis are summarized in the table below:[1][2][3][4][5][6][7][8][9][10][11]

Surgical procedure Comment
Thyroid lobectomy Nondiagnostic biopsy, a biopsy suspicious for papillary cancer or suggestive of follicular neoplasm
  • For patients with an isolated indeterminate solitary nodule who prefer a more limited surgical procedure
  • Recommended as initial surgical approach
Total thyroidectomy Indicated in :
Surgery for a biopsy diagnostic for malignancy Near-total or total thyroidectomy if:
  • The primary thyroid carcinoma is >1 cm (156)
  • There are contralateral thyroid nodules present or regional or distant metastases are present
  • The patient has a personal history of radiation therapy to the head and neck
  • The patient has first-degree family history of differentiated thyroid carcinoma
  • Older age (>45 years) may also be a criterion for recommending near-total or total thyroidectomy even with tumors <1–1.5 cm, because of higher recurrence rates in this age group
Central-compartment (level VI) neck dissection Therapeutic central-compartment (level VI) neck dissection:
  • For patients with clinically involved central or lateral neck lymph nodes should accompany total thyroidectomy to provide clearance of disease from the central neck

Prophylactic central-compartment neck dissection (ipsilateral or bilateral):

Near-total or total thyroidectomy without prophylactic central neck dissection:

Lateral neck compartmental lymph node dissection
Tumors invade the upper aerodigestive tract Techniques ranging from shaving tumor off the trachea or esophagus for superficial invasion, to more aggressive techniques when the trachea is more deeply invaded (e.g., direct intraluminal invasion) including:
Comprehensive compartmental lateral and/or central neck dissection
  • Should be performed for patients with persistent or recurrent disease confined to the neck
  • Sparing uninvolved vital structures

Pregnancy and surgical resection of tumors[12]

Pregnant patients that are diagnosed with nodules as differentiated thyroid carcinoma by FNA, can utilize a delayed surgery, with the surgery scheduled for after the delivery. Researches have shown that delayed surgery will not decrease their response to therapy and their survival rate.

Exception should be made in these cases, which the surgery should be done during the pregnancy:

References

  1. ↑ Duren M, Yavuz N, Bukey Y, Ozyegin MA, Gundogdu S, Açbay O, Hatemi H, Uslu I, Onsel C, Aksoy F, Oz F, Unal G, Duren E (2000). "Impact of initial surgical treatment on survival of patients with differentiated thyroid cancer: experience of an endocrine surgery center in an iodine-deficient region". World J Surg. 24 (11): 1290–4. PMID 11038196.
  2. ↑ Hay ID, Thompson GB, Grant CS, Bergstralh EJ, Dvorak CE, Gorman CA, Maurer MS, McIver B, Mullan BP, Oberg AL, Powell CC, van Heerden JA, Goellner JR (2002). "Papillary thyroid carcinoma managed at the Mayo Clinic during six decades (1940-1999): temporal trends in initial therapy and long-term outcome in 2444 consecutively treated patients". World J Surg. 26 (8): 879–85. doi:10.1007/s00268-002-6612-1. PMID 12016468.
  3. ↑ Lin JD, Chao TC, Huang MJ, Weng HF, Tzen KY (1998). "Use of radioactive iodine for thyroid remnant ablation in well-differentiated thyroid carcinoma to replace thyroid reoperation". Am. J. Clin. Oncol. 21 (1): 77–81. PMID 9499265.
  4. ↑ Rubino C, de Vathaire F, Dottorini ME, Hall P, Schvartz C, Couette JE, Dondon MG, Abbas MT, Langlois C, Schlumberger M (2003). "Second primary malignancies in thyroid cancer patients". Br. J. Cancer. 89 (9): 1638–44. doi:10.1038/sj.bjc.6601319. PMC 2394426. PMID 14583762.
  5. ↑ Mazzaferri EL, Jhiang SM (1995). "Differentiated thyroid cancer long-term impact of initial therapy". Trans. Am. Clin. Climatol. Assoc. 106: 151–68, discussion 168–70. PMC 2376543. PMID 7483170.
  6. ↑ DeGroot LJ, Kaplan EL, McCormick M, Straus FH (1990). "Natural history, treatment, and course of papillary thyroid carcinoma". J. Clin. Endocrinol. Metab. 71 (2): 414–24. doi:10.1210/jcem-71-2-414. PMID 2380337.
  7. ↑ Samaan NA, Schultz PN, Hickey RC, Goepfert H, Haynie TP, Johnston DA, Ordonez NG (1992). "The results of various modalities of treatment of well differentiated thyroid carcinomas: a retrospective review of 1599 patients". J. Clin. Endocrinol. Metab. 75 (3): 714–20. doi:10.1210/jcem.75.3.1517360. PMID 1517360.
  8. ↑ Durante C, Haddy N, Baudin E, Leboulleux S, Hartl D, Travagli JP, Caillou B, Ricard M, Lumbroso JD, De Vathaire F, Schlumberger M (2006). "Long-term outcome of 444 patients with distant metastases from papillary and follicular thyroid carcinoma: benefits and limits of radioiodine therapy". J. Clin. Endocrinol. Metab. 91 (8): 2892–9. doi:10.1210/jc.2005-2838. PMID 16684830.
  9. ↑ Moon WJ, Jung SL, Lee JH, Na DG, Baek JH, Lee YH, Kim J, Kim HS, Byun JS, Lee DH (2008). "Benign and malignant thyroid nodules: US differentiation--multicenter retrospective study". Radiology. 247 (3): 762–70. doi:10.1148/radiol.2473070944. PMID 18403624.
  10. ↑ Marchesi M, Biffoni M, Biancari F, Berni A, Campana FP (2003). "Predictors of outcome for patients with differentiated and aggressive thyroid carcinoma". Eur J Surg Suppl (588): 46–50. PMID 15200043.
  11. ↑ Ge JH, Zhao RL, Hu JL, Zhou WA (2004). "[Surgical treatment of advanced thyroid carcinoma with aero-digestive invasion]". Zhonghua Er Bi Yan Hou Ke Za Zhi (in Chinese). 39 (4): 237–40. PMID 15283286.
  12. ↑ Moosa M, Mazzaferri EL (1997). "Outcome of differentiated thyroid cancer diagnosed in pregnant women". J. Clin. Endocrinol. Metab. 82 (9): 2862–6. doi:10.1210/jcem.82.9.4247. PMID 9284711.

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