What is the role of surgery in the treatment of well-differentiated thyroid cancer?

Updated: May 14, 2020
  • Author: Pramod K Sharma, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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The extent of surgical therapy for well-differentiated neoplasms is controversial. Primary treatment for papillary and follicular carcinoma is surgical excision whenever possible. Total thyroidectomy has been the mainstay for treating well-differentiated thyroid carcinoma. In this procedure, all apparent thyroid tissue is surgically removed. Major complications in this procedure are recurrent laryngeal nerve injury and hypoparathyroidism from inadvertent damage or removal of the parathyroid glands. Complications associated with total thyroidectomy are discussed in the Technique of Thyroidectomy section below.

After total thyroidectomy, patients undergo radioiodine scanning to detect regional or distant metastatic disease (see Postoperative radioiodine scanning and ablation below), followed by radioablation of any residual disease found.

Over the years, modifications to total thyroidectomy have been proposed in an effort to reduce recurrent laryngeal nerve injury and hypoparathyroidism associated with total thyroidectomy. Subtotal thyroidectomy has been proffered as an alternative to total thyroidectomy. With subtotal thyroidectomy, a small portion of gross thyroid tissue opposite the side of malignancy is left in place to minimize the risk of injuring the recurrent laryngeal nerve and of inadvertently removing the parathyroid glands on that side. Patients usually receive postoperative radioiodine treatment in an attempt to ablate the remaining thyroid tissue.

With improved stratification of patients into prognostic groups (see Prognostic factors below), some surgeons have proposed thyroid lobectomy with isthmectomy alone as definitive treatment for patients at low risk for recurrent or metastatic disease. This approach remains to be substantiated as a feasible alternative to total thyroidectomy.

Using the Surveillance, Epidemiology, and End Results (SEER) database, one study compared the overall survival (OS) and cause-specific survival (CSS) of 23,605 subjects with papillary or follicular thyroid cancer treated with local excision, lobectomy, near-total thyroidectomy, or total thyroidectomy. The 10-year OS and CSS results concluded that total thyroidectomy resulted in improved survival over other techniques; poorer outcomes were associated with age, stage T3/T4 disease, positive nodes, and tumor size. [15]

According to a 2009 study by Asari et al, of 207 patients with follicular thyroid carcinoma, the 127 patients with minimum growth had no lymph node metastases. The authors state that thyroidectomy is still recommended for all patients with follicular thyroid carcinoma, although patients with widely invasive disease may need more aggressive surgical treatment. Patients with minimal disease invasion have an excellent prognosis with limited need for nodal surgery. [16]

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