Thyroid nodule surgery: Difference between revisions
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==Overview== | ==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. | 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== | == Surgery== | ||
Not all thyroid nodules require a surgical intervention, in fact surgical intervention goals for a thyroid nodule include: | 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 forceps|biopsy]] | * Provision of a diagnosis after a non-diagnostic or suspicious [[Biopsy forceps|biopsy]] | ||
* Removal of the [[thyroid cancer]] | * Removal of the [[thyroid cancer]] | ||
* [[Thyroid cancer]] staging for [[Radioactive iodine uptake|radioactive ablation]] and serum [[thyroglobulin]] monitoring | * [[Thyroid cancer]] staging for [[Radioactive iodine uptake|radioactive ablation]] and serum [[thyroglobulin]] monitoring | ||
==== Thyroid surgery definition terms ==== | ==== Thyroid surgery definition terms ==== | ||
{| class="wikitable" | {| class="wikitable" | ||
!Term | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Term | ||
!Definition | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Definition | ||
|- | |- | ||
! | ! | ||
| Line 24: | Line 24: | ||
|- | |- | ||
!Near-total thyroidectomy | !Near-total thyroidectomy | ||
|Removal of all grossly visible [[thyroid]] [[Tissue (biology)|tissue]], leaving only a small amount | |Removal of all grossly visible [[thyroid]] [[Tissue (biology)|tissue]], leaving only a small amount (<1 g) of [[Tissue (biology)|tissue]] adjacent to the [[recurrent laryngeal nerve]] near the [[ligament]] of Berry | ||
|- | |- | ||
!Total thyroidectomy | !Total thyroidectomy | ||
| Line 42: | Line 42: | ||
* [[Toxic adenoma]] | * [[Toxic adenoma]] | ||
* Features suggestive of but not definitive for [[papillary thyroid cancer]] | * 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]]) | * [[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 | * Large solid nodules with suspicious [[ultrasound]] findings | ||
* If growth of the nodule (>20 percent in two dimensions on [[ultrasound]]) is detected during observation | * If growth of the nodule (>20 percent in two dimensions on [[ultrasound]]) is detected during observation | ||
* Recurrent [[symptomatic]] | * Recurrent [[symptomatic]] cysts with associated fluid accumulation | ||
** Generally [[hemithyroidectomy]] or [[percutaneous]] [[ethanol]] [[Injection (medicine)|injection]] | ** Generally [[hemithyroidectomy]] or [[percutaneous]] [[ethanol]] [[Injection (medicine)|injection]] | ||
** Decision should be made based on compressive [[symptoms]] and [[Cosmetic Surgery|cosmetic]] concerns | ** Decision should be made based on compressive [[symptoms]] and [[Cosmetic Surgery|cosmetic]] concerns | ||
=== Surgical procedure based on tumor status === | === Surgical procedure based on tumor status === | ||
{| class="wikitable" | {| class="wikitable" | ||
!Tumor criteria | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Tumor criteria | ||
!Tumor | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Tumor size | ||
!Surgical procedure | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Surgical procedure | ||
!Note | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Note | ||
|- | |- | ||
! rowspan="2" |Tumor without extrathyroidal extension and no [[lymph nodes]] | ! rowspan="2" |[[Tumor]] without extrathyroidal extension and no [[lymph nodes]] | ||
! rowspan="2" |<1 cm | ! rowspan="2" |<1 cm | ||
|Thyroid lobectomy | |[[Thyroid]] lobectomy | ||
| | | | ||
* Unilateral intrathyroidal differentiated thyroid cancer <1 cm | * Unilateral intrathyroidal differentiated [[thyroid]] [[cancer]] <1 cm | ||
|- | |- | ||
|Total [[thyroidectomy]] | |Total [[thyroidectomy]] | ||
| Line 68: | Line 68: | ||
* Imaging abnormalities suspicious of [[Thyroid cancer|malignancies]] | * Imaging abnormalities suspicious of [[Thyroid cancer|malignancies]] | ||
|- | |- | ||
! rowspan="2" |Tumor without extra thyroidal extension and no [[lymph node]] | ! rowspan="2" |[[Tumor]] without extra thyroidal extension and no [[lymph node]] | ||
! rowspan="2" |1 to 4 cm | ! rowspan="2" |1 to 4 cm | ||
|[[Thyroid]] lobectomy | |[[Thyroid]] lobectomy | ||
| Line 77: | Line 77: | ||
|Total [[thyroidectomy]] | |Total [[thyroidectomy]] | ||
|- | |- | ||
!Tumor, extrathyroidal extension, or [[metastases]] | ![[Tumor]], extrathyroidal extension, or [[metastases]] | ||
!≥4 cm | !≥4 cm | ||
| colspan="2" |Total [[thyroidectomy]] | | colspan="2" |Total [[thyroidectomy]] | ||
|- | |- | ||
!Tumor in a patient with a history of childhood head and neck radiation | ![[Tumor]] in a patient with a history of childhood head and [[neck]] [[radiation]] | ||
!Any size | !Any size | ||
| colspan="2" |Total [[thyroidectomy]] | | colspan="2" |Total [[thyroidectomy]] | ||
|- | |- | ||
! colspan="2" |Multifocal papillary microcarcinoma (fewer than five foci) | ! colspan="2" |Multifocal [[Papillary carcinoma of the thyroid|papillary microcarcinoma]] (fewer than five foci) | ||
| colspan="2" |Unilateral lobectomy and isthmectomy | | colspan="2" |Unilateral lobectomy and isthmectomy | ||
|- | |- | ||
! colspan="2" |Multifocal papillary microcarcinoma (more than five foci) | ! colspan="2" |Multifocal [[Papillary carcinoma of the thyroid|papillary microcarcinoma]] (more than five foci) | ||
| colspan="2" |Total [[thyroidectomy]] | | colspan="2" |Total [[thyroidectomy]] | ||
|- | |- | ||
| Line 108: | Line 108: | ||
{| class="wikitable" | {| class="wikitable" | ||
! colspan="2" |Surgical procedure | ! colspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Surgical procedure | ||
!Comment | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Comment | ||
|- | |- | ||
![[Lobectomy|'''Thyroid lobectomy''']] | ![[Lobectomy|'''Thyroid lobectomy''']] | ||
| Line 122: | Line 122: | ||
* Patients with marked [[atypia]] is seen on [[biopsy]] | * Patients with marked [[atypia]] is seen on [[biopsy]] | ||
* Patients with a [[biopsy]] reading ‘‘suspicious for [[Papillary carcinoma of the thyroid|papillary carcinoma]]’’ | * Patients with a [[biopsy]] reading ‘‘suspicious for [[Papillary carcinoma of the thyroid|papillary carcinoma]]’’ | ||
* In patients with a family history of [[Thyroid cancer|thyroid carcinoma]] | * In patients with a [[family history]] of [[Thyroid cancer|thyroid carcinoma]] | ||
* In patients with a history of [[radiation]] exposure | * In patients with a history of [[radiation]] exposure | ||
* Patients with indeterminate nodules who had bilateral nodular disease | * 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 | * 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]]''' | !'''Surgery for a biopsy diagnostic for [[malignancy]]''' | ||
| Line 132: | Line 132: | ||
* There are contralateral thyroid nodules present or regional or distant [[metastases]] are present | * 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 a personal history of [[radiation therapy]] to the head and neck | ||
* The patient has first-degree family history of differentiated thyroid carcinoma | * The patient has first-degree family history of differentiated [[Thyroid Cancer|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 | * 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 | ||
|- | |- | ||
! colspan="2" |'''Central-compartment (level VI) neck dissection''' | ! colspan="2" |'''Central-compartment (level VI) neck dissection''' | ||
| Line 140: | Line 140: | ||
Prophylactic central-compartment neck [[dissection]] (ipsilateral or bilateral): | Prophylactic central-compartment neck [[dissection]] (ipsilateral or bilateral): | ||
* Consider in patients with [[Papillary thyroid cancer|papillary thyroid carcinoma]] with clinically uninvolved central neck [[lymph nodes]], especially for advanced primary tumors (T3 or T4) | * Consider in patients with [[Papillary thyroid cancer|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: | Near-total or total [[thyroidectomy]] without [[Prophylaxis|prophylactic]] central neck dissection: | ||
* Consider in small (T1 or T2), noninvasive, clinically node-negative [[Papillary thyroid cancer|papillary thyroid cancers]] and most [[Follicular cancer of the thyroid|follicular cancer]] | * Consider in small (T1 or T2), noninvasive, clinically node-negative [[Papillary thyroid cancer|papillary thyroid cancers]] and most [[Follicular cancer of the thyroid|follicular cancer]] | ||
|- | |- | ||
| Line 162: | Line 162: | ||
Exception should be made in these cases, which the surgery should be done during the [[pregnancy]]: | 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 | * 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 | * Patients with more advanced disease | ||
Latest revision as of 18:36, 1 November 2017
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Risk calculators and risk factors for Thyroid nodule surgery |
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 | |
| Total thyroidectomy |
| ||
| Tumor without extra thyroidal extension and no lymph node | 1 to 4 cm | Thyroid lobectomy | Based on:
|
| 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 |
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 |
|
| 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):
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 |
| |
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:
- 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
References
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.