Impact of timing on completion thyroidectomy for thyroid cancer
- Author: M. P. Tan, G. Agarwal, T. S. Reeve, B. H. Barraclough, L. W. Delbridge
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Carcinoma of the thyroid is a rare, but it is the most common malignancy of endocrine system. Differentiated tumours are highly treatable and usually curable. Poorly differentiated cancers are much less common, aggressive, metastasize early, and have a much poorer prognosis.
The extent of surgery in the management of differentiated thyroid cancer (DTC) is controversial. It should be noted that lack of international consensus regarding the extent of initial surgery continues. Any surgeon confronted with DTC can choose virtually any operation and find support for it in the literature. A common knee-jerk response is to schedule every patient to have total thyroidectomy, but this has no fundamental basis.
The principal reason for this controversy is the fact that the survival is so excellent in the low-risk group that no prospective trials have been conducted regarding the extent of surgery. The prognostic factors in DTC are well described. The 20-year survival rate is 98% for low-risk patients and 50% for high-risk patients. The operating surgeon should be quite familiar with risk-group analysis.
Numerous multi-factorial risk group definitions have been published that readily define both low-risk and high-risk patients with DTC. These allow rational selection of treatment that can separate the need for radical or conservative surgical procedures.
It is illogical to apply a similar surgical procedure to all thyroid cancers. Such selection follows basic surgical oncology principles in all human cancers and is necessary to make therapy logical, while minimizing penalties.
The primary surgical procedures employed in treating DTC vary from unilateral lobectomy with isthmectomy to near-total, or total thyroidectomy. In reviewing the arguments for and against total or less than total thyroidectomy, the minimal operation for solitary thyroid nodules should be lobectomy and isthmusectomy. Reports recommend a near-total thyroidectomy, which involves leaving some thyroid tissue to preserve parathyroids and the recurrent laryngeal nerve. However, if the disease and the risk-group interpretation require aggressive surgical procedure, then total thyroidectomy should be performed with an intention to leave behind no thyroid tissue.
Routine subtotal thyroidectomy should be avoided for fear of leaving microscopic tumour and for the difficulty in radioiodine ablation of the remaining thyroid tissue. Procedures such as nodulectomy should be abandoned for patients suspected of thyroid cancer.
Survival results may be similar; but the difference lies in the rates of surgical complications and local recurrence. Routine application of total thyroidectomy is likely to lead to a significant incidence of complications, which appears to be directly proportional to the extent of thyroidectomy and inversely proportional to the experience of the surgeon. In low-risk DTC, Shaha and colleageus found no statistical difference between unilateral total lobectomy and total thyroidectomy. Cady has suggested that the vast majority of low-risk DTC patients require only thyroid lobectomy without adjuvant therapy.
It is well recognized that while thyroid cancers occur in the same organ, they are uniquely different. Initial management of patients with TC can be optimized by developing a multidisciplinary team of highly specialized individuals.
Khalid Alkhouly, Security Forces Hospital, 60 Street, Riyadh 11481, Saudi Arabia email@example.com
1 Cady B, Rossi R. An expanded view of risk-group definition in differentiated thyroid carcinoma. Surgery 1988; 104: 947-953.
2 2 Hay Id, Grant Cs, Van Heerden Ja, et al. Papillary thyroid microcarcinoma: a study of 535 cases observed in a 50-year period. Surgery 1992; 112: 1139-47.
- Date: Feb 26, 2003