Surgical Approaches to Thyroid Cancer
Thyroid cancer, a complex disease affecting the thyroid gland, often requires surgical intervention as a primary treatment option. Surgical approaches play a central role in the management of most forms of thyroid cancer, aiming to remove the tumor while preserving thyroid function and minimizing potential complications. In this blog post, we will explore the various surgical approaches commonly employed in the treatment of thyroid cancer, highlighting their benefits, considerations, and potential outcomes.
Total thyroidectomy is a surgical procedure where the entire thyroid gland is removed. It is often recommended for specific types of thyroid cancer, such as papillary and follicular carcinomas, especially when the tumor is large, invasive, or has spread to the lymph nodes. Total thyroidectomy aims to eliminate the source of the cancer. This helps to reduce the risk of the cancer spreading or recurring in the future. However, total thyroidectomy results in the complete loss of thyroid function, as the thyroid gland produces hormones essential for regulating metabolism. After the procedure, individuals will require lifelong thyroid hormone replacement therapy to maintain normal hormone levels. This involves taking synthetic thyroid hormones in the form of medication to make up for the missing thyroid function.
Lobectomy is a surgical procedure that involves removing only one lobe of the thyroid gland, along with the isthmus that connects the two lobes. It is often considered for smaller, localized thyroid cancers that are confined to one lobe. To be eligible for lobectomy, the cancer must meet specific criteria, including:
- Tumor size: The cancer should be relatively small in size and limited to one lobe of the thyroid gland. If the tumor is larger or has spread to both lobes, total thyroidectomy may be recommended instead. It must be possible to remove the entire tumor with the procedure.
- Absence of lymph node involvement: Lobectomy is typically considered when the cancer has not spread to the nearby lymph nodes. If lymph node involvement is present, additional treatment or a more extensive surgery may be necessary.
- Favorable histological features: The characteristics of the cancer cells, as determined by microscopic examination, should indicate favorable features that suggest a lower risk of aggressive behavior or recurrence.
Compared to total thyroidectomy, where the entire thyroid gland is removed, lobectomy offers the advantage of preserving a portion of the thyroid gland. After a lobectomy, the remaining lobe can still produce enough thyroid hormones to maintain normal function in many cases. This means that in most cases, individuals who undergo lobectomy may not require lifelong hormone replacement therapy. However, regular monitoring of hormone levels will be necessary to ensure optimal thyroid function. In some cases, individuals may still need hormone replacement therapy, but the dosage required may be lower than with total thyroidectomy.
Completion thyroidectomy is a surgical procedure performed when the initial surgery, which involved removing only one lobe of the thyroid gland (lobectomy), reveals the presence of additional cancerous cells or aggressive features.
After a lobectomy, the removed thyroid tissue is examined under a microscope to determine the extent of cancer and its characteristics. In some cases, the examination, known as the final pathology report, may reveal high-risk factors that were not initially detected. These factors can include:
- Larger tumor size: The examination may show that the tumor is larger than initially thought, indicating a higher risk of cancer spread or recurrence.
- Extensive lymph node involvement: If the cancer has spread to nearby lymph nodes, it suggests a higher risk of the cancer spreading further throughout the body.
- Adverse histological features: The microscopic analysis of the tumor cells may reveal unfavorable characteristics associated with more aggressive behavior and a higher chance of recurrence.
When these high-risk factors are identified in the final pathology report, completion thyroidectomy is often recommended. This procedure involves removing the remaining thyroid tissue to ensure comprehensive treatment and reduce the risk of cancer recurrence.
By removing the entire thyroid gland through completion thyroidectomy, all remaining cancer cells or potentially aggressive cells are eliminated. This reduces the risk of the cancer coming back or spreading further. After completion thyroidectomy, individuals will require lifelong hormone replacement therapy since the entire thyroid gland is removed.
Central Neck Dissection
When thyroid cancer spreads to the lymph nodes in the central compartment of the neck, a surgical procedure called central neck dissection may be recommended.
During a central neck dissection, lymph nodes located near the thyroid gland are removed. The purpose of this procedure is to eliminate any cancer cells that may have migrated from the primary tumor and are present in the lymph nodes. By removing these affected lymph nodes, the goal is to reduce the risk of the cancer spreading further.
The decision to perform a central neck dissection is based on several factors, including the size and characteristics of the primary tumor, as well as the presence of cancerous cells in the central compartment lymph nodes. If imaging tests or a biopsy indicate lymph node involvement, a central neck dissection may be recommended to ensure thorough removal of the cancer cells.
Some surgeons will routinely perform a central neck dissection for thyroid cancer, even if there is no evidence of lymph node involvement. By removing the lymph nodes in the central compartment, even if they appear normal, the surgeon can eliminate any microscopic cancer cells that may be present. This proactive approach aims to reduce the risk of future recurrence or spread of the cancer.
Lateral Neck Dissection
When thyroid cancer spreads to the lymph nodes in the sides of the neck, a surgical procedure called lateral neck dissection may be recommended. Lateral neck dissection involves removing the lymph nodes in the lateral neck compartments that have been affected by thyroid cancer. This procedure is typically recommended for cases of aggressive or advanced thyroid cancer, where the cancer has spread beyond the thyroid gland.
By removing the cancerous lymph nodes in the lateral neck compartments, the surgeon aims to control the spread of the disease. This can help prevent further growth of the cancer and reduce the risk of it spreading to other areas. Removing all lymph nodes containing cancer will also help facilitate delivery of targeted therapies such as radioactive iodine, reducing the risk of recurrence.
Minimally Invasive Techniques
In recent years, doctors have been using less invasive techniques for thyroid surgery, such as endoscopic or robotic-assisted procedures. These methods involve making smaller incisions and using special tools and advanced imaging technology to make the surgery more precise and minimize scarring. Minimally invasive techniques have become popular because they offer benefits like less scarring, quicker recovery, and higher patient satisfaction.
It’s important to know that not everyone can have these minimally invasive procedures. A qualified surgeon will evaluate your case and determine if you’re a candidate for this type of surgery. They will consider factors like the size and location of the tumor, as well as your overall health.
Surgical approaches remain a cornerstone in the management of thyroid cancer, enabling accurate staging, tumor removal, and improved patient outcomes. Whether it’s a total thyroidectomy, lobectomy, neck dissection, or a minimally invasive procedure, each surgical approach is carefully tailored to the individual’s specific diagnosis, tumor characteristics, and stage of disease. The choice of procedure is a collaborative decision made by the patient and their healthcare team, considering factors such as tumor size, location, spread to lymph nodes, and the overall goal of treatment.
Recently, molecular tests such as Thyroid GuidePx® have become available. These molecular tests are designed to help doctors to tailor the surgical approach according to how likely the cancer will recur. In general, cancers with a high risk of recurrence are treated with more aggressive surgical procedures. Low-risk cancers with a favourable biology can be treated with more conservative procedures. Thyroid GuidePx® is molecular test for papillary thyroid cancer, the most common type of thyroid cancer.