Papillary thyroid cancer surgery: Difference between revisions

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{{Papillary thyroid cancer}}
{{Papillary thyroid cancer}}
{{CMG}}; {{AE}} {{Ammu}}
{{CMG}}; {{AE}} {{Sahar}} {{Ammu}}
==Overview==
==Overview==
[[Surgery]] is the mainstay of treatment for papillary thyroid cancer.
[[Surgery]] is the mainstay of treatment for papillary thyroid cancer. [[Surgical]] [[interventions]] of papillary thyroid cancer include total [[thyroidectomy]] and [[lobectomy]]. Each of these has its [[Indications and usage|indications]].
==Surgery==
==Surgery==
Surgery remains the mainstay of treatment for papillary thyroid cancer. The Revised 2009 American Thyroid Association guidelines for papillary thyroid cancer state that the initial procedure should be near-total or total thyroidectomy. Thyroid lobectomy alone may be sufficient treatment for small (<1cm), low-risk, unifocal, intrathyroidal papillary carcinomas in the absence of prior head and neck irradiation or radiologically or clinically involved cervical nodal metastasis.<ref>{{Cite journal|url = |title = Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer.|last = Cooper|first = David|date = November 2009|journal = Thyroid|doi = |pmid = |access-date = }}</ref>
* [[Surgery]] remains the mainstay of treatment for papillary thyroid cancer.<ref name="urlNCCN Clinical Practice Guidelines in Oncology">{{cite web |url=https://www.nccn.org/professionals/physician_gls/default.aspx#site |title=NCCN Clinical Practice Guidelines in Oncology |format= |work= |accessdate=}}</ref><ref name="pmid18953806">{{cite journal |vauthors=Bilimoria KY, Zanocco K, Sturgeon C |title=Impact of surgical treatment on outcomes for papillary thyroid cancer |journal=Adv Surg |volume=42 |issue= |pages=1–12 |date=2008 |pmid=18953806 |doi= |url=}}</ref><ref name="pmid22435914">{{cite journal |vauthors=Stack BC, Ferris RL, Goldenberg D, Haymart M, Shaha A, Sheth S, Sosa JA, Tufano RP |title=American Thyroid Association consensus review and statement regarding the anatomy, terminology, and rationale for lateral neck dissection in differentiated thyroid cancer |journal=Thyroid |volume=22 |issue=5 |pages=501–8 |date=May 2012 |pmid=22435914 |doi=10.1089/thy.2011.0312 |url=}}</ref><ref name="pmid25590215">{{cite journal |vauthors=Viola D, Materazzi G, Valerio L, Molinaro E, Agate L, Faviana P, Seccia V, Sensi E, Romei C, Piaggi P, Torregrossa L, Sellari-Franceschini S, Basolo F, Vitti P, Elisei R, Miccoli P |title=Prophylactic central compartment lymph node dissection in papillary thyroid carcinoma: clinical implications derived from the first prospective randomized controlled single institution study |journal=J. Clin. Endocrinol. Metab. |volume=100 |issue=4 |pages=1316–24 |date=April 2015 |pmid=25590215 |doi=10.1210/jc.2014-3825 |url=}}</ref>
*Minimal disease (diameter up to 1.0 centimeters) - [[hemithyroidectomy]] (or unilateral lobectomy) and [[isthmectomy]] may be sufficient. There is some discussion whether this is still preferable over total thyroidectomy for this group of patients.
* [[Surgical]] [[interventions]] of papillary thyroid cancer include total [[thyroidectomy]] and [[lobectomy]]. Each of these has its [[Indications and usage|indications]].
*Gross disease (diameter over 1.0 centimeters) - total [[thyroidectomy]], and central compartment lymph node removal is the therapy of choice. Additional lateral neck nodes can be removed at the same time if an ultrasound guided FNA and thyrobulin TG cancer washing was positive on the pre-operative neck node ultrasound evaluation.
==indications==
 
* Total [[thyroidectomy]] is usually reserved for [[patients]] with either:<ref name="urlNCCN Clinical Practice Guidelines in Oncology">{{cite web |url=https://www.nccn.org/professionals/physician_gls/default.aspx#site |title=NCCN Clinical Practice Guidelines in Oncology |format= |work= |accessdate=}}</ref><ref name="pmid18953806">{{cite journal |vauthors=Bilimoria KY, Zanocco K, Sturgeon C |title=Impact of surgical treatment on outcomes for papillary thyroid cancer |journal=Adv Surg |volume=42 |issue= |pages=1–12 |date=2008 |pmid=18953806 |doi= |url=}}</ref><ref name="pmid22435914">{{cite journal |vauthors=Stack BC, Ferris RL, Goldenberg D, Haymart M, Shaha A, Sheth S, Sosa JA, Tufano RP |title=American Thyroid Association consensus review and statement regarding the anatomy, terminology, and rationale for lateral neck dissection in differentiated thyroid cancer |journal=Thyroid |volume=22 |issue=5 |pages=501–8 |date=May 2012 |pmid=22435914 |doi=10.1089/thy.2011.0312 |url=}}</ref><ref name="pmid25590215">{{cite journal |vauthors=Viola D, Materazzi G, Valerio L, Molinaro E, Agate L, Faviana P, Seccia V, Sensi E, Romei C, Piaggi P, Torregrossa L, Sellari-Franceschini S, Basolo F, Vitti P, Elisei R, Miccoli P |title=Prophylactic central compartment lymph node dissection in papillary thyroid carcinoma: clinical implications derived from the first prospective randomized controlled single institution study |journal=J. Clin. Endocrinol. Metab. |volume=100 |issue=4 |pages=1316–24 |date=April 2015 |pmid=25590215 |doi=10.1210/jc.2014-3825 |url=}}</ref>
Arguments for total thyroidectomy are:<ref>{{Cite journal|url = |title = Is total thyroidectomy the best possible surgical management for well-differentiated thyroid cancer?|last = Udelsman|first = Robert|date = July 2005|journal = The Lancet Oncology|doi = |pmid = |access-date = }}</ref>
** Known distant [[metastasis]]
*Reduced risk of recurrence, if central compartment nodes are removed at the original surgery.
** Extra-thyroidal extension
*30-85% of papillary carcinoma is multifocal disease. Hemithyroidectomy may leave disease in the other lobe. However, multifocal disease in the remnant lobe may not necessarily become clinically significant or serve as detriment to patient survival.
** [[Tumor]]> 4 cm in diameter
*Ease of monitoring with thyroglobulin (sensitivity for picking up recurrence is increased in presence of total thyroidectomy, and ablation of remnant normal thyroid by low dose [[radioiodine]] 131 after following a low iodine diet (LID).
** Cervical [[lymph node]] [[metastasis]]
*Ease of detection of metastatic disease by thyroid and neck node ultrasound.
** Poorly differentiated [[tumor]]
*Post-operative complications at high-volume thyroid surgery centers with experienced surgeons are comparable to that of hemithyroidectomy.
** In case of [[bilateral]] nodularity
Arguments for hemithyroidectomy:
** Prior [[radiation]] exposure
* Most patients have low-risk cancer with excellent prognosis, with similar survival outcomes in low-risk patients who undergo total thyroidectomy versus hemithyroidectomy.
* Total [[thyroidectomy]] or [[lobectomy]] is [[Indications and usage|indicated]] if all of these criteria are present:
* Less likelihood of patient requiring lifelong thyroid hormone replacement after surgery. Papillary tumors tend to be more aggressive in patients over age 45. In such cases it might be required to perform a more extensive resection including portions of the [[Vertebrate trachea|trachea]]. Also, the [[sternocleidomastoid muscle]], [[jugular vein]], and accessory nerve are to be removed if such procedure allows apparently complete tumor resection. If a significant amount of residual tumor is left in the [[neck]], external radiotherapy has been indicated and has proven useful especially in those cases when residual tumor does not take up radioiodine.
** No prior [[radiation]] exposure
 
** No distant [[metastasis]]
After surgical thyroid removal, the patient waits around 4–6 weeks to then have radioiodine therapy. This therapy is intended to both detect and destroy any [[metastasis]] and residual tissue in the thyroid. The treatment may be repeated 6–12 months after initial treatment of metastatic disease where [[disease]] recurs or has not fully responded.<ref>{{cite web|url=http://emedicine.medscape.com/article/282276-treatment| title=Treatment|date=|accessdate= 2010-07-15}}</ref>
** No cervical [[lymph node]] [[metastasis]]
 
** No extra-thyroidal extension
Patients are administered hormone replacement [[levothyroxine]] for life after surgery, especially after total thyroidectomy. [[Chemotherapy]] with [[cisplatin]] or [[doxorubicin]] has proven limited efficacy, however, it could be helpful for patients with [[bone metastases]] to improve their [[quality of life]]. Patients are also prescribed levothyroxine and radioiodine after surgery. Levothyroxine influences growth and maturation of tissues and it is involved in normal growth, [[metabolism]], and development. In case of metastases, patients are prescribed antineoplastic agents which inhibit [[cell growth]] and proliferation and help in palliating symptoms in progressive disease.
** [[Tumor]]≤ 4 cm
 
* [[Lobectomy]] is considered curative if all of the following are present:
After successful treatment, 35 percent of the patients may experience recurrence within a 40-year span. Also, patients may experience a high incidence of nodule metastasis, with 35 percent cases of cervical node metastases. Approximately 20 percent of patients will develop multiple tumors within the thyroid gland.<ref>{{cite web|url=http://www.bcm.edu/oto/grand/12_04_03.htm| title=Papillary Thyroid Carcinoma|date=|accessdate= 2010-07-15}} {{Dead link|date=October 2010|bot=H3llBot}}</ref>
** Negative resection margins
 
** No contralateral [[lesion]]
There is ongoing discussion regarding the best management regarding the optimal surgical procedure for papillary thyroid cancer.Recent studies have examined a more conservative approach to surgery and have demonstrated that hemithyroidectomy may be acceptable for patients with low-risk papillary thyroid cancer with tumor size 1cm to 4cm with no presence of invasion to tissues surrounding the thyroid or metastasis. Studies examining large databases of patients with papillary thyroid cancer have concluded that there is no survival advantage for patients with stage I papillary thyroid cancer size 1-4cm receiving total thyroidectomy versus hemithyroidectomy.<ref>{{Cite journal|url = |title = Impact of extent of surgery on survival for papillary thyroid cancer patients younger than 45 years|last = Adam|first = Mohamed|date = January 2015|journal = J Clin Endocrinol Metab|doi = |pmid = |access-date = }}</ref> In light of this data, choosing the optimal course of surgical and medical management of papillary thyroid cancer should involve shared decision making from patient, endocrinologists, and surgeons.
** No suspicious [[lymph nodes]]
====Stages I and II Papillary Thyroid Cancer====
** Small [[tumors]] (< 1 cm) found incidentally on the final [[pathology]] sections
* Treatment of stage I and II papillary and follicular thyroid cancer may include the following:
* [[Lobectomy]] plus isthmusectomy is recommended for [[patients]] who are not willing to take [[thyroxine]] replacement therapy for the rest of their lives.
:* Total or near-total thyroidectomy, with or without radioactive iodine therapy.
* Total [[thyroidectomy]] should be performed after [[lobectomy]] plus [[isthmusectomy]] if either of these criteria is present:
:* Lobectomy and removal of lymph nodes that contain cancer, followed by hormone therapy. Radioactive iodine therapy may be given following surgery
** Large [[tumor]] (> 4 cm)
====Stage III Papillary Thyroid Cancer====
** Positive resection margins
* Treatment of stage III papillary and follicular thyroid cancer is usually total thyroidectomy. Cancer that has spread outside the thyroid, as well as any lymph nodes that have cancer in them, will also be removed.Radioactive iodine therapy or external radiation therapy may be given after surgery.
** Gross extra-thyroidal extension
====Stage IV Papillary Thyroid Cancer====
**[[Macroscopic]] multi-focal [[disease]]
* Treatment of stage IV papillary and follicular thyroid cancer that has spread only to the lymph nodes can often be cured. When cancer has spread to other places in the body, such as the lungs and bone, treatment usually does not cure the cancer, but can relieve symptoms and improve the quality of life. Treatment may include the following:
**[[Vascular]] invasion
:* For tumors that take up iodine
**[[Macroscopic]] nodal [[metastasis]]
:* Radioactive iodine therapy.
:* For tumors that do not take up iodine
:* Hormone therapy.
:* Targeted therapy with a tyrosine kinase inhibitor (sorafenib).
:* Surgery to remove cancer from areas where it has spread.
:* External-beam radiation therapy
:* A clinical trial of chemotherapy.
:* A clinical trial of a targeted therapy.
 
===Stem Cell Transplant===
 
==Indications==
 
==Contraindications==


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
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Latest revision as of 23:34, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2] Ammu Susheela, M.D. [3]

Overview

Surgery is the mainstay of treatment for papillary thyroid cancer. Surgical interventions of papillary thyroid cancer include total thyroidectomy and lobectomy. Each of these has its indications.

Surgery

indications

References

  1. ↑ 1.0 1.1 "NCCN Clinical Practice Guidelines in Oncology".
  2. ↑ 2.0 2.1 Bilimoria KY, Zanocco K, Sturgeon C (2008). "Impact of surgical treatment on outcomes for papillary thyroid cancer". Adv Surg. 42: 1–12. PMID 18953806.
  3. ↑ 3.0 3.1 Stack BC, Ferris RL, Goldenberg D, Haymart M, Shaha A, Sheth S, Sosa JA, Tufano RP (May 2012). "American Thyroid Association consensus review and statement regarding the anatomy, terminology, and rationale for lateral neck dissection in differentiated thyroid cancer". Thyroid. 22 (5): 501–8. doi:10.1089/thy.2011.0312. PMID 22435914.
  4. ↑ 4.0 4.1 Viola D, Materazzi G, Valerio L, Molinaro E, Agate L, Faviana P, Seccia V, Sensi E, Romei C, Piaggi P, Torregrossa L, Sellari-Franceschini S, Basolo F, Vitti P, Elisei R, Miccoli P (April 2015). "Prophylactic central compartment lymph node dissection in papillary thyroid carcinoma: clinical implications derived from the first prospective randomized controlled single institution study". J. Clin. Endocrinol. Metab. 100 (4): 1316–24. doi:10.1210/jc.2014-3825. PMID 25590215.

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