Surgical Management Of Thyroid Cancer Research Articles

Korean Thyroid Association Guidelines on the Management of Differentiated Thyroid Cancers; Part I. Initial Management of Differentiated Thyroid Cancers - Chapter 2. Surgical Management of Thyroid Cancer 2024

Korean Thyroid Association Guidelines on the Management of Differentiated Thyroid Cancers; Part I. Initial Management of Differentiated Thyroid Cancers - Chapter 2. Surgical Management of Thyroid Cancer 2024

Recent Advances in the Surgical Management of Thyroid Cancer

A growing incidence of differentiated thyroid cancer (DTC) has been reported in most developed countries, corresponding mainly to incidentally discovered small papillary thyroid carcinomas. Given the excellent prognosis of most patients with DTC, optimal therapeutic management, minimizing complications, and preserving patient quality of life are essential. Thyroid surgery has a central role in both the diagnosis, staging, and treatment of patients with DTC. Thyroid surgery should be integrated into the global and multidisciplinary management of patients with DTC. However, the optimal surgical management of DTC patients is still controversial. In this review article, we discuss the recent advances and current debates in DTC surgery, including preoperative molecular testing, risk stratification, the extent of thyroid surgery, innovative surgical tools, and new surgical approaches.

Nuances in the Surgical Management of Thyroid Cancer.

The incidence of thyroid cancer is rapidly rising, primarily due to the increased use of imaging studies and incidentalomas. In the USA, the incidence has quadrupled. The last decades have seen remarkable advances in diagnosis and surgery for thyroid cancer. We will discuss the surgical advances in this manuscript. The American Thyroid Association and many other organizations around the world have been quite instrumental in developing the guidelines for the management of thyroid cancer, which have streamlined the treatment approaches. There have also been advances made in the management of medullary and anaplastic thyroid cancer, which will be a different subject not included in this manuscript. The major surgical advances include the following: impact of molecular markers, risk group stratifications, de-escalation in surgery, nerve monitoring, and endoscopic surgery. We will discuss some of these surgical nuances in this review article.

Application of extracorporeal membrane oxygenation in surgical management of thyroid cancer invading the trachea: A report of two cases

Application of extracorporeal membrane oxygenation in surgical management of thyroid cancer invading the trachea: A report of two cases

Extent of Surgery for Low-Risk Differentiated Thyroid Cancer.

Although the incidence of thyroid cancer is increasing, survival remains unchanged. Due to concern for overtreatment, surgical management of thyroid cancer has evolved. Papillary thyroid microcarcinoma measuring 1cm or smaller are considered very low risk and can be managed with either thyroid lobectomy or active surveillance. Total thyroidectomy is no longer recommended for these cancers unless there is evidence of metastasis, local invasion, or aggressive disease. Recommendations for low-risk differentiated thyroid cancer measuring 1 cm to 4cm remain controversial. This article explores the controversies over the extent of surgery for patients with very low-risk and low-risk differentiated thyroid cancer.

Association of Insurance Expansion With Surgical Management of Thyroid Cancer

To our knowledge, thyroid cancer incidence is increasing faster than any other cancer type and is currently the fifth most common cancer among women. While this rise is likely multifactorial, there has been scarce consideration of the effect of insurance statuses on the treatment of thyroid cancer. We evaluate the association of insurance expansion with thyroid cancer treatment using the 2006 Massachusetts health reform, which serves as a unique natural experiment. We used the Agency for Healthcare Research and Quality State Inpatient Databases to identify patients with government-subsidized or self-pay insurance or private insurance who were admitted to a hospital with thyroid cancer and underwent a thyroidectomy between 2001 and 2011 in Massachusetts (n = 8534) and 3 control states (n = 48 047). Difference-in-differences models were used to evaluate an association between the 2006 Massachusetts health care reform and thyroid cancer treatment, and participants were controlled for age, sex, comorbidities, and secular trends. Change in the thyroidectomy rate for thyroid cancer treatment was the primary outcome evaluated. The Massachusetts cohort consisted of 6443 women (75.5%) and 2091 men (24.5%), of whom 6388 (79.6%) were white, 391 (4.9%) were black, 527 (6.6%) were Hispanic, 424 (5.3%) were Asian/Pacific Islander, 63 (0.8%) were Native American, and 228 (2.8%) were other. The participants from control states included 36 818 women (76.6%) and 11 229 men (23.4%), of whom 30 432 (65.5%) were white, 3818 (8.2%) were black, 6462 (13.9%) were Hispanic, 2591 (5.6%) were Asian/Pacific Islander, 211 (0.5%) were Native American, and 2947 (6.3%) were other. Before the 2006 Massachusetts insurance expansion, patients with government-subsidized or self-pay insurance had lower thyroidectomy rates for thyroid cancer in Massachusetts and the control states compared with patients with private insurance. The Massachusetts insurance expansion was associated with a 26% increased rate of undergoing a thyroidectomy (incident rate ratio, 1.26; 95% CI, 1.04-1.52; P = .02) and a 22% increased rate of neck dissection (incident rate ratio, 1.22; 95% CI, 1.07-1.37; P = .002) for treating cancer compared with control states. The 2006 Massachusetts health reform, which is a model for the Affordable Care Act, was associated with a 26% increased rate of thyroidectomy for treating thyroid cancer. Our study suggests that insurance expansion may be associated with increased access to the surgical management of thyroid cancer. Further studies need to be conducted to evaluate the effect of healthcare expansion at a national level.

The surgical management of thyroid cancer.

Thyroid cancer has been increasing in incidence, with the number of reported cases in the US rising by 25% over the last 3 years. With growing technological advances in the field and improved contributions of diagnostics, surgical decision-making and operative planning have taken on new challenges. Herein, we review the current clinical practice recommendations and active areas of surgical controversy, reflective of the most recently published professional consensus guidelines and a systematic review of the literature.

Robotic Thyroidectomy via a Transaxillary Approach

Objective: Recently, various robotic surgical procedures have been performed, and most reports have proved that the application of robotic technology for surgery is technically feasible and safe. The feasibility and safety of robotic thyroid surgery was examined via transaxillary single port approach without gas insufflation. Method: The study included 109 consecutive patients with papillary thyroid cancer who underwent robot-assisted endoscopic thyroid surgery using a gasless transaxillary single port approach by a single surgeon (Y.W.K.) between May 2010 and August 2011 at the department of otorhinolaryngology, Yonsei University College of Medicine. Results: The console time for 50 hemithyroidectomy (HT) with ipsilateral central compartment neck dissection (CCND) was 45.67 min, and that of 59 total thyroidectomy (TT) with ipsilateral or bilateral CCND was 93.77 min. The amount of drainage was 194.07 mL, and the duration of drainage was 3.5 days. The hospital stay was 6.09 days. Mean primary tumor size was 6.58 mm. The average number of lymph nodes resected was 3.51 (range, 1-19). Temporary hypoparathyroidism encountered with 24 patients in the TT group (40.7%, 24/59). There were 5 cases of temporary recurrent laryngeal nerve injury and 12 of seromas. One case of temporary brachial plexus injury occurred due to arm positioning. Conclusion: The technique of robotic thyroid surgery using a gasless transaxillary single port approach is a feasible, safe, and effective method for selected patients with thyroid cancer. The authors suggest that application of robotic technology for endoscopic thyroid surgeries could overcome the limitations of conventional endoscopic surgeries in the surgical management of thyroid cancer.

18F‐fluorodeoxyglucose and 131I Radioguided Surgical Management of Thyroid Cancer

To describe a technique that assists in the surgical management of recurrent local regional well-differentiated thyroid cancer (WDTC). Case series with chart review. Two academic health centers from 2001 to 2009. Patients operated upon by the senior surgeon (BCS) for recurrent WDTC. Thirteen patients with recurrent WDTC were operated upon with radioguided surgical (RGS) technique to indentify recurrence for excision. Eight patients had iodine avid disease and were candidates for RGS with (131)I. The remaining 5 patients had cancer with a proven loss of iodine avidity and were, therefore, operated upon with a fluorodeoxygluocose (FDG) RGS technique. RGS is a feasible approach to identify recurrent disease in an operated field and ensure its successful excision. Although focal disease may be identified with this technique, this is not a tool for limited excisions ("berry picking").

Prospects of Robotic Thyroidectomy Using a Gasless, Transaxillary Approach for the Management of Thyroid Carcinoma

Robotic surgical systems are among the most innovative surgical developments and have radically promoted the use of minimally invasive techniques. Robotic technologies using different approaches have also been applied to thyroid surgery. Recently, the authors described a novel robotic surgical method for thyroid surgery based on a gasless, transaxillary approach (TAA), and have since serially reported on its technical feasibility and safety. Here, the authors report their experience of a consecutive series of 1000 cases treated using robotic thyroidectomy, and demonstrate its use for the surgical management of thyroid cancer. From October 2007 to November 2009, 1000 patients with thyroid cancer underwent robot-assisted endoscopic thyroid surgery using a gasless TAA. All patients were selected using predetermined inclusion criteria after considering surgical risk, and all procedures were completed successfully using the da Vinci S or Si surgical system (Intuitive Surgical, Sunnyvale, CA). Patient's clinicopathologic characteristics, operation types, operation times, numbers of retrieved lymph nodes (LNs), postoperative hospital stays, complications, and short-term follow-up results were analyzed. Mean patient age was 39.1 ± 9.6 years and the male-to-female ratio was 1:12.6 (73:927). Six hundred twenty-seven patients underwent less than total and 373 patients underwent bilateral total thyroidectomy. Ipsilateral central compartment node dissection was conducted in all 1000 cases and additional lateral neck node dissection was conducted in 36 of the 1000 patients. Mean operation time was 136.7 ± 44.4 minutes and mean postoperative hospital stay was 3.0 ± 0.45 days. No serious postoperative complication occurred, except 3 cases of recurrent laryngeal nerve injury, and 1 case of Horner syndrome. Mean tumor size was 0.79 ± 0.6 cm and papillary thyroid microcarcinoma was in 752 cases (75.5%). The mean number of retrieved central LNs per patient was 4.62 ± 3.14. Central neck LN metastasis occurred in 361(36.1%) and lateral neck LN metastasis in 36 cases (3.6%). According to tumor nodes metastasis staging, 847 patients (84.7%) were of stage I, 144 patients (14.4%) were of stage III, and 9 patients (0.9%) were of stage IVA. The authors conclude that robotic thyroidectomy using a gasless TAA is a feasible, safe, and promising surgical alternative for selected patients with low-risk thyroid cancer, and recommend that the inclusion criteria of this technique be gradually extended to advanced thyroid cancer given suitable operator experience and future developments in robotic systems and instrumentation.

The role of fine‐needle aspiration cytology in the surgical management of thyroid cancer

Diagnosis of thyroid malignancy relies on clinical assessment, imaging and fine-needle aspiration cytology 'FNAC' of thyroid nodules. The purpose of this study was to evaluate how effective synoptically reported FNAC is in clinical practice in diagnosing thyroid cancer. We also examined the effectiveness of using preoperative FNAC results to plan the type of operation for treating thyroid cancer. A retrospective case series of all patients undergoing thyroid surgery from 1993 to 2008 was analysed. All data were collected prospectively and recorded in a dedicated endocrine surgery database. Data analysed included age, sex, preoperative FNAC result, type of surgery, final histology and complications. Cytology was reported based on a five-tiered classification system. There were 1373 patients in total and 125 patients with a final diagnosis of thyroid cancer. Female to male ratio was 3:1. Cytology reported as 'malignant' was confirmed as thyroid cancer in 100% of the cases. Of the patients, 47% with 'suspicious' cytology report and 14% with 'follicular/indeterminate' cytology report had a final diagnosis of cancer. Thyroid cancer subtypes were 90 patients with papillary thyroid cancer 'PTC', 24 with follicular 'FTC', eight with medullary 'MTC' and two with anaplastic cancer. Cytology was suggestive of cancer in 89% of the patients with PTC >10 mm, 75% with FTC and 88% with MTC. Transient hypocalcaemia was the commonest complication occurring in 7.2%. There were no cases of permanent hypoparathyroidism. Recurrent laryngeal nerve neuropraxia occurred in 2.4% with a permanent palsy occurring in 0.8%. There were three cancer-related deaths. Preoperative synoptically reported FNAC is effective when used in diagnosing and planning surgery for thyroid cancer.

The Pros and Cons of Prophylactic Central Compartment Lymph Node Dissection for Papillary Thyroid Carcinoma

A well-established feature of papillary thyroid carcinoma (PTC) is it propensity to metastasize to cervical lymph nodes in the central and lateral compartments. Currently, there is no nonor minimally invasive method that is completely reliable for detecting all of the metastases that are present. Therefore, some have advocated prophylactic cervical lymph node dissection as part of the operative procedure for PTC. There is no unanimity, however, on the efficacy and safety of prophylactic cervical lymph node dissection for this tumor. At the recent National Thyroid Cancer Workshop II,* two distinguished surgeons, Dr. Gerard M. Doherty from the University of Michigan and Dr. David L. Steward at the University of Cincinnati, were invited to debate the pros and cons of prophylactic cervical lymph node dissection. More specifically, Dr. Doherty was asked to take the positive view and Dr. Steward the contrary view concerning prophylactic central compartment (Level VI) dissection (CLND). By definition, this is a total compartment dissection that is performed when there is no preoperative or intraoperative evidence of cervical lymph-node metastases. Each participant was asked to marshal the case for one side and not necessarily reflect their personal views. To help them prepare, they were given the following hypothetical case to consider. A 22-year-old woman is referred by her endocrinologist for surgical management of an asymptomatic 2-cm PTC diagnosed 1 week before. There is no family history of thyroid cancer, and she has had no exposure to radiation. Her thyroidstimulating hormone (TSH) level is 1.7 (IU=mL. Repeat neck ultrasonography reveals a single 2-cm right lobe thyroid nodule with a hazy border and no lateral or central neck lymph-node abnormalities. The question posed to the debaters is: What are the pros and cons of prophylactic level VI lymph-node dissection for this patient? After the workshop, these surgeons, who are recognized authorities on the surgical management of thyroid cancer, were asked to prepare written commentary based on their presentations. What follows are two concise, carefully articulated, literature-based reviews that support each side of the debate.

Robot-assisted endoscopic surgery for thyroid cancer: experience with the first 100 patients

Various robotic surgical procedures have been performed in recent years, and most reports have proved that the application of robotic technology for surgery is technically feasible and safe. This study aimed to introduce the authors' technique of robot-assisted endoscopic thyroid surgery and to demonstrate its applicability in the surgical management of thyroid cancer. From 4 October 2007 through 14 March 2008, 100 patients with papillary thyroid cancer underwent robot-assisted endoscopic thyroid surgery using a gasless transaxillary approach. This novel robotic surgical approach allowed adequate endoscopic access for thyroid surgeries. All the procedures were completed successfully using the da Vinci S surgical robot system. Four robotic arms were used with this system: a 12-mm telescope and three 8-mm instruments. The three-dimensional magnified visualization obtained by the dual-channel endoscope and the tremor-free instruments controlled by the robotic systems allowed surgeons to perform sharp and precise endoscopic dissections. Ipsilateral central compartment node dissection was used for 84 less-than-total and 16 total thyroidectomies. The mean operation time was 136.5 min (range, 79-267 min). The actual time for thyroidectomy with lymphadenectomy (console time) was 60 min (range, 25-157 min). The average number of lymph nodes resected was 5.3 (range, 1-28). No serious complications occurred. Most of the patients could return home within 3 days after surgery. The technique of robot-assisted endoscopic thyroid surgery using a gasless transaxillary approach is a feasible, safe, and effective method for selected patients with thyroid cancer. The authors suggest that application of robotic technology for endoscopic thyroid surgeries could overcome the limitations of conventional endoscopic surgeries in the surgical management of thyroid cancer.

Surgical management of thyroid cancer

Thyroid cancer is the most common endocrine neoplasm; however, it only accounts for less than 1% of all human malignances. Thyroid cancers are divided into well differentiated and non-well differentiated cancers, according to their histology and behavior. The surgical management options of well-differentiated thyroid cancer include total or near-total thyroidectomy, subtotal thyroidectomy and lobectomy plus isthmusectomy. The extent of surgery for thyroid cancer continues to be an area of controversy. Complications associated with thyroid surgery are directly proportional to the extent of thyroidectomy and inversely proportional to the experience of the operating surgeon. They occur less frequently with good surgical technique and better understanding of surgical anatomy, and include wound healing and infections (seroma, hematoma and wound infection), nerve injury, hypoparathyroidism, hypothyroidism, postoperative hemorrhage and respiratory obstruction.

The surgical management of thyroid cancer.

The surgical management of thyroid cancer.

Surgical Management Of Thyroid Cancer

To present an overview of surgical management of differentiated thyroid cancer. Evaluation of the thyroid nodule, assessment of indications for surgical treatment, analysis of the extent of surgical excision, and recommendations for lymph node dissection are addressed. In a patient with a thyroid nodule, certain historical information (such as prior irradiation to the head and neck or a family history of thyroid carcinoma) and physical findings (for example, a nonfunctioning, solitary thyroid nodule) increase the likelihood of a thyroid malignant lesion. Some indications for surgical intervention are a diagnosis of cancer on fine-needle aspiration biopsy, the presence of a cold nodule, or the presence of a large thyroid lesion, especially one that causes symptoms such as hoarseness or dysphagia. Although the extent of surgical excision is controversial, the presence of metastatic lesions, extrathyroidal extension, and multicentricity all are indications for total thyroidectomy. Grossly enlarged lymph nodes should be surgically excised. Probe-guided surgical resection is a promising advance in the management of persistent or recurrent thyroid carcinoma. Most patients with differentiated thyroid cancer have an excellent prognosis. Appropriate management is the key to minimizing morbidity and recurrences.

Thyroid cancer surgery.

The surgical management of thyroid cancer is complex, controversial, and categorized by divergent opinions based upon retrospective, self-fulfilling data. This chapter will review the role of the surgeon in the evaluation of thyroid nodules and the management of malignant thyroid disease. Patients who ultimately prove to have thyroid cancer generally present with 1) a thyroid nodule with or without preoperative cytologic evidence of malignancy, 2) a rapidly enlarging neck mass with or without symptoms and signs associated with local invasion, or 3) a positive history of familial thyroid cancer with or without a positive calcitonin stimulation test, or more likely, a positive RET protooncogene screening examination for medullary carcinoma of the thyroid. The initial surgical evaluation is focused on evaluating risk factors. A history of head or neck irradiation in childhood or a familial history of medullary carcinoma of the thyroid significantly impact surgical management. The physical examination needs to focus on evidence of local invasion, fixation to surrounding structures, recurrent laryngeal nerve involvement, regional nodal metastases, and systemic disease. In addition, it is the surgeon’s obligation to screen for nonthyroidal disease that could impact perioperative management. This includes a history of bleeding disorders, cardiac, pulmonary, hepatic or renal disease, a potentially difficult airway, as well as potential endocrinopathies including thyrotoxicosis, Addisonian crisis and pheochromocytoma. It is also important to perform a laryngeal examination in every surgical candidate to evaluate recurrent laryngeal nerve integrity by the demonstration of vocal cord function. Surgery is an important, but not the only essential component in the management of patients with thyroid cancer. It is a requisite that each surgeon who manages these patients has an integrated plan that operates in concert with cytopathologists, endocrinologists, and radiation oncologists. The sensitivity and specificity of fine needle aspiration (FNA) varies between institutions and even among individual cytopathologists. Since FNA is the single most important preoperative diagnostic procedure for the majority of patients with dominant thyroid nodules, every thyroid surgeon must be able to evaluate the reliability and accuracy of the FNA findings upon which critical clinical decisions are based.

Surgical management of thyroid cancer invading the airway.

Locally advanced thyroid cancer invading the tracheal cartilage represents a difficult treatment dilemma during thyroidectomy. A retrospective chart review was performed to determine the results of laryngotracheal resection or tracheal cartilage shave with adjuvant radiotherapy in patients with locally advanced thyroid cancer invading the upper airway. Of 597 patients undergoing thyroidectomy for thyroid cancer, 40 were found to have laryngotracheal invasion. Thirty-five patients with superficial invasion underwent cartilage shave procedures with adjuvant radiotherapy; five with full-thickness invasion underwent radical resection, including tracheal sleeve resection (n = 3) or total laryngectomy (n = 2). Histologic subtypes included papillary (n = 32), follicular (n = 2), Hurthle cell (n = 1), medullary (n = 3), and anaplastic (n = 2). Of the cartilage shave group, 25 are currently alive with no evidence of disease at a mean follow-up of 81 months (range 1-290). Six developed isolated local/regional recurrence and were managed with total laryngectomy (n = 1), tracheal resection (n = 1), cervical lymphadenectomy (n = 1), or repeat radiotherapy (n = 3). All six patients remain free of disease at a mean follow-up of 5 years. Of those who underwent initial laryngotracheal resection, four remain free of disease at a mean follow-up of 5 years. The rates of 10-year disease-free survival and overall survival for all patients were 47.9% (95% confidence interval [CI] 24.8, 71.0) and 83.9% (95% CI 70.3, 97.5), respectively. These data suggest that adequate management of thyroid cancer with laryngotracheal invasion can be achieved with a more conservative surgical approach and adjuvant radiotherapy, reserving more radical resections for extensive primary lesions or locally recurrent disease.

On the surgical management of thyroid cancer.

On the surgical management of thyroid cancer.