Thyroid nodule surgery
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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
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:
|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):
|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
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