Thyroid nodule surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. 
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.
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
- Removal of the thyroid cancer
- Thyroid cancer staging for radioactive ablation and serum thyroglobulin monitoring
Thyroid surgery definition terms
|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
- Repeatedly nondiagnostic aspirations of:
- Partially cystic nodules
- Solid nodules
- If molecular testing is unavailable and repeat aspirates continue to show atypical cells
- Cytology result is diagnostic of or suspicious for papillary thyroid cancer
- Toxic adenoma
- Features suggestive of but not definitive for papillary thyroid cancer
- Cytology diagnostic of malignancy (include papillary thyroid cancer, medullary thyroid cancer, thyroid lymphoma, anaplastic thyroid cancer, and metastatic thyroid cancer)
- Large solid nodules with suspicious ultrasound findings
- If growth of the nodule (>20 percent in two dimensions on ultrasound) is detected during observation
- Recurrent symptomatic cysts with associated fluid accumulation
- Generally hemithyroidectomy or percutaneous ethanol injection
- Decision should be made based on compressive symptoms and cosmetic concerns
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|
|Tumor without extra thyroidal extension and no lymph node||1 to 4 cm||Thyroid lobectomy||Based on:
|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
to whether perform a total thyroidectomy or a unilateral lobectomy
|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:
|Thyroid lobectomy||Nondiagnostic biopsy, a biopsy suspicious for papillary cancer or suggestive of follicular neoplasm||
|Total thyroidectomy||Indicated in :
|Surgery for a biopsy diagnostic for malignancy||Near-total or total thyroidectomy if:
|Central-compartment (level VI) neck dissection||Therapeutic central-compartment (level VI) neck dissection:
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||
Pregnancy and surgical resection of tumors
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:
- A nodule with cytology indicating papillary thyroid carcinoma (PTC), discovered early in pregnancy that grows during pregnancy by 24 weeks gestation
- Patients with more advanced disease
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.