Papillary thyroid cancer surgery
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Papillary thyroid cancer Microchapters |
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Differentiating Papillary thyroid cancer from other Diseases |
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Papillary thyroid cancer surgery On the Web |
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American Roentgen Ray Society Images of Papillary thyroid cancer surgery |
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Risk calculators and risk factors for Papillary thyroid cancer surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ammu Susheela, M.D. [2]
Overview
Surgery is the mainstay of treatment for papillary thyroid cancer.
Surgery
- Surgery remains the mainstay of treatment for papillary thyroid cancer.
- Surgery is usually reserved for patients with either:
Contraindications
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.[1]
- 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.
- 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.
Arguments for total thyroidectomy are:[2]
- Reduced risk of recurrence, if central compartment nodes are removed at the original surgery.
- 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.
- 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).
- Ease of detection of metastatic disease by thyroid and neck node ultrasound.
- Post-operative complications at high-volume thyroid surgery centers with experienced surgeons are comparable to that of hemithyroidectomy.
Arguments for hemithyroidectomy:
- Most patients have low-risk cancer with excellent prognosis, with similar survival outcomes in low-risk patients who undergo total thyroidectomy versus hemithyroidectomy.
- 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 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.
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.[3]
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.
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.[4]
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.[5] 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.
Stages I and II Papillary Thyroid Cancer
- Treatment of stage I and II papillary and follicular thyroid cancer may include the following:
- Total or near-total thyroidectomy, with or without radioactive iodine therapy.
- Lobectomy and removal of lymph nodes that contain cancer, followed by hormone therapy. Radioactive iodine therapy may be given following surgery
Stage III Papillary Thyroid Cancer
- 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.
Stage IV Papillary Thyroid Cancer
- 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.
References
- ↑ Cooper, David (November 2009). "Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer". Thyroid.
- ↑ Udelsman, Robert (July 2005). "Is total thyroidectomy the best possible surgical management for well-differentiated thyroid cancer?". The Lancet Oncology.
- ↑ "Treatment". Retrieved 2010-07-15.
- ↑ "Papillary Thyroid Carcinoma". Retrieved 2010-07-15.[dead link]
- ↑ Adam, Mohamed (January 2015). "Impact of extent of surgery on survival for papillary thyroid cancer patients younger than 45 years". J Clin Endocrinol Metab.