Thyroid nodule surgery

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

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 Tg monitoring

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 PTC
• Toxic adenoma
• Features suggestive of but not definitive for papillary thyroid cancer
• Cytology diagnostic of malignancy (include papillary cancer, medullary thyroid cancer, thyroid lymphoma, anaplastic cancer, and metastatic thyroid cancer)
• Larg solid nodules with sonographically suspicious features
• If growth of the nodule (>20 percent in two dimensions on ultrasound) is detected during observation
• Recurrent symptomatic cystic fluid accumulation
  • Generally hemithyroidectomy or percutaneous ethanol injection (PEI)
  • Decision should be made based on compressive symptoms and cosmetic concerns

Surgery in these cases may be required for further evaluation.

Surgical procedure based on tumor status

	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	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 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 lobectomu
		Total thyroidectomy

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. 9284711

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
• Patients with more advanced disease

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

indeterminate thyroid nodules and DTC	Surgical options to address the primary tumor should be limited to hemithyroidectomy with or without isthmusectomy, 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), and 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 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
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, thyroid lobectomy is the recommended initial surgical approach 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
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 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. 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 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
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 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
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

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

Mazzaferri EL, Young RL 1981 Papillary thyroid carcinoma: a 10 year follow-up report of the impact of therapy in 576 patients. Am J Med 70:511–518. 159.

DeGroot LJ, Kaplan EL, McCormick M, Straus FH 1990 Natural history, treatment, and course of papillary thyroid carcinoma. J Clin Endocrinol Metab 71:414–424. 160.

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 75:714–720

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

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 92:450–455

Noguchi S, Yamashita H, Murakami N, Nakayama I, Toda M, Kawamoto H 1996 Small carcinomas of the thyroid. A long-term follow-up of 867 patients. Arch Surg 131: 187–191. 328.

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

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)

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 39:237–240. 330.

Avenia N, Ragusa M, Monacelli M, Calzolari F, Daddi N, Di Carlo L, Semeraro A, Puma F 2004 Locally advanced thyroid cancer: therapeutic options. Chir Ital 56:501–508