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:

• 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

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:

• 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	Unilateral intrathyroidal differentiated thyroid cancer <1 cm
		Total thyroidectomy	Evidence of thyroid cancer in the contralateral lobe Previous history of head and neck radiation Family history of thyroid cancer Imaging abnormalities suspicious of malignancies
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:

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 : Patients with indeterminate nodules who have large tumors (>4 cm) Patients with marked atypia is seen on biopsy Patients with a biopsy reading ‘‘suspicious for papillary carcinoma’’ In patients with a family history of thyroid carcinoma In patients with a history of radiation exposure Patients with indeterminate nodules who had bilateral nodular disease Patients who prefer to undergo bilateral thyroidectomy to avoid the possibility of requiring a future surgery on the contralateral lobe
	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): Consider in patients with papillary thyroid carcinoma with clinically uninvolved central neck lymph nodes, especially for advanced primary tumors (T3 or T4) Near-total or total thyroidectomy without prophylactic central neck dissection: Consider in small (T1 or T2), noninvasive, clinically node-negative papillary thyroid cancers and most follicular cancer
Lateral neck compartmental lymph node dissection		For patients with biopsy proven metastatic lateral cervical lymphadenopathy
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: Tracheal resection and anastomosis Laryngopharyngoesophagectomy
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

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