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* Recurrent symptomatic cystic fluid accumulation
* Recurrent symptomatic cystic fluid accumulation
** Generally [[hemithyroidectomy]] or percutaneous ethanol injection (PEI)
** Generally [[hemithyroidectomy]] or percutaneous ethanol injection (PEI)
** Decision should be made based on compressive symptoms and cosmetic concerns
** Decision should be made based on compressive [[symptoms]] and [[Cosmetic Surgery|cosmetic]] concerns
Surgery in these cases may be required for further evaluation.
 
=== Surgical procedure based on tumor status ===
=== Surgical procedure based on tumor status ===
{| class="wikitable"
{| class="wikitable"
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==== Pregnancy and surgical resection of tumors ====
==== Pregnancy and surgical resection of tumors ====
Pregnant patients that are diagnosed with nodules as differentiated thyroid carcinoma (DTC) 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.<ref name="pmid9284711">{{cite journal |vauthors=Moosa M, Mazzaferri EL |title=Outcome of differentiated thyroid cancer diagnosed in pregnant women |journal=J. Clin. Endocrinol. Metab. |volume=82 |issue=9 |pages=2862–6 |year=1997 |pmid=9284711 |doi=10.1210/jcem.82.9.4247 |url=}}</ref>
[[Pregnancy|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.<ref name="pmid9284711">{{cite journal |vauthors=Moosa M, Mazzaferri EL |title=Outcome of differentiated thyroid cancer diagnosed in pregnant women |journal=J. Clin. Endocrinol. Metab. |volume=82 |issue=9 |pages=2862–6 |year=1997 |pmid=9284711 |doi=10.1210/jcem.82.9.4247 |url=}}</ref>


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 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


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{| class="wikitable"
{| class="wikitable"
!
!
!
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|-
|-
!
!
|Surgical options to address the primary tumor should be limited to
Duren M, Yavuz N, Bukey Y, Ozyegin MA, Gundogdu S, Ac¸bay 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 iodinedeficient region. World J Surg 24:1290–1294
|
|
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|
* Surgical options to address the primary tumor should be limited to
11038196
|-
|-
!nondiagnostic biopsy, a biopsy suspicious for papillary cancer or suggestive of ‘‘follicular neoplasm’’
! rowspan="2" |Nondiagnostic biopsy, a biopsy suspicious for [[Papillary thyroid cancer|papillary cancer]] or suggestive of [[Follicular thyroid cancer|follicular neoplasm]]
|For patients with an isolated indeterminate solitary nodule who prefer a more limited surgical procedure, thyroid lobectomy is the recommended initial surgical approach
|[[Lobectomy|Thyroid lobectomy]]
total thyroidectomy is indicated in patients with indeterminate nodules who have large tumors (>4 cm), when marked atypia is seen on biopsy, when the biopsy reading is ‘‘suspicious for papillary carcinoma,’’ in patients with a family history of thyroid carcinoma, and in patients with a history of radiation exposure
 
Patients with indeterminate nodules who have bilateral nodular disease, or those who prefer to undergo bilateral thyroidectomy to avoid the possibility of requiring a future surgery on the contralateral lobe, should also undergo total or near-total thyroidectomy
|
|
|
* For patients with an isolated indeterminate solitary nodule who prefer a more limited surgical procedure
* Recommended as initial surgical approach
|-
|[[Thyroidectomy|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 of the thyroid|papillary carcinoma]]’’
* In patients with a family history of [[Thyroid cancer|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
! colspan="2" |Surgery for a biopsy diagnostic for [[malignancy]]
|Neartotal or total thyroidectomy is recommended 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, or the patient has first-degree family history of DTC. 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
|Near-total or total [[thyroidectomy]] if:
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 26:879–885. 123.
* 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
12016468 


Lin JD, Chao TC, Huang MJ, Weng HF, Tzen KY 1998 Use of radioactive iodine for thyroid remnant ablation in welldifferentiated thyroid carcinoma to replace thyroid reoperation. Am J Clin Oncol 21:77–81
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 89:1638–1644
14583762 
|
|
|-
|-
!central-compartment (level VI) neck dissection
! colspan="2" |Central-compartment (level VI) neck dissection
|
|Therapeutic 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.
** 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):
* 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)
** 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:
* Near-total or total thyroidectomy without prophylactic central neck dissection:
* Consider in small (T1 or T2), noninvasive, clinically node-negative PTCs and most follicular cancer
** Consider in small (T1 or T2), noninvasive, clinically node-negative PTCs and most follicular cancer
|
|
|-
|-
!lateral neck compartmental lymph node dissection  
! colspan="2" |Lateral neck compartmental lymph node dissection  
|For patients with biopsyproven metastatic lateral cervical lymphadenopathy. Recommendation rating
|
|
|-
!Completion thyroidectomy
|should be offered to those patients for whom a near-total or total thyroidectomy would have been recommended had the diagnosis been available before the initial surgery. This includes all patients with thyroid cancer except those with small (<1 cm), unifocal, intrathyroidal, node-negative, low-risk tumors
|
|
|-
!
|
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* For patients with biopsy proven metastatic lateral cervical lymphadenopathy
|-
|-
!Tumors invade the upper aerodigestive tract
! colspan="2" |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 or laryngopharyngoesophagectomy
|
|
|
* 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
|}
|}
Increased extent of primary surgery may improve survival for high-risk patients and low-risk patients
Increased extent of primary surgery may improve survival for high-risk patients and low-risk patients

Revision as of 16:50, 29 October 2017


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Surgery

Not all thyroid nodules require a surgical intervention, in fact surgical intervention goals for a thyroid nodule include:

Diagnostic and curative surgical interventions

Indications:

Surgical procedure based on tumor status

Tumor criteria Tumor siza Surgical procedure Note
Tumor without extrathyroidal extension and no lymph nodes <1 cm thyroid lobectomy unilateral intrathyroidal differentiated thyroid cancer <1 cm
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 isthmusectomy
Multifocal papillary microcarcinoma (more than five foci) Total thyroidectomy
Indeterminate or suspicious thyroid nodules unilateral lobectomy and

isthmusectomy

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

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

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.[1]

Exception should be made in these cases, which the surgery should be done during the pregnancy:

Table

summary recommendation:

For patients with thyroid cancer >1 cm, the initial surgical procedure should be a near-total or total thyroidectomy unless there are contraindications to this surgery. Thyroid lobectomy alone may be sufficient treatment for small (<1 cm), low-risk, unifocal, intrathyroidal papillary carcinomas in the absence of prior head and neck irradiation or radiologically or clinically involved cervical nodal metastases

  • Surgical options to address the primary tumor should be limited to

11038196

Nondiagnostic biopsy, a biopsy suspicious for papillary cancer or suggestive of follicular neoplasm Thyroid lobectomy
  • 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

12016468 

9499265

14583762 

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 PTCs 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

Increased extent of primary surgery may improve survival for high-risk patients and low-risk patients

[2][3][4]

Therapeutic comprehensive compartmental lateral and=or central neck dissection, sparing uninvolved vital structures, should be performed for patients with persistent or recurrent disease confined to the neck.

Limited compartmental lateral and=or central compartmental neck dissection may be a reasonable alternative to more extensive comprehensive dissection for patients with recurrent disease within compartments having undergone prior comprehensive dissection and=or external beam radiotherapy [5] [6][7]

For tumors that invade the upper aerodigestive tract, surgery combined with additional therapy such as 131I and=or external beam radiation is generally advised

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(in table too) [8]

References

  1. ↑ 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.
  2. ↑ 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.
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ 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.

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