Thyroid nodule surgery

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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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