For hurthle cell cancer of the thyroid (and basically all of the different types of other thyroid cancers), surgery, by far, is the most critical first treatment. In fact, hurthle cell cancer surgery is not only the first treatment but is commonly the only treatment that may be indicated. It is critical that a highly experienced surgeon and the right surgery is obtained the first time. Hurthle cell cancer surgery should only be done by expert surgeons. Lesions that are highly suspicious for a risk of hurthle cell cancer should be removed with a total thyroidectomy! Total thyroidectomies should only be performed by highly experienced thyroid cancer surgeons.
Thyroid surgery was one of the first ever described surgeries in medicine, but early on it wasn’t very pretty or safe. Over the past 100 years, thyroid surgery has evolved into its current state of the art by some of the most recognized names in surgical history. Today, in skilled hands, hurthle cell cancer surgery may be considered an art form in its own right.
Hurthle cell cancer surgery must be considered in several different lights when you think about the neck. Surgery of the thyroid gland itself and surgery for the surrounding soft tissues around the thyroid gland.
Hurthle cell cancer was once thought to be a type of follicular thyroid cancer, but clearly it is not. One big difference between these cancers is that hurthle cell cancer has a significant ability to spread to local lymph nodes, especially underneath the thyroid gland. Because these lymph nodes are involved in over 20% of hurthle cell cancers and the risk of complications from persistent and recurrent hurthle cell cancer are so serious, I strongly advocate for the routine removal of the lymph nodes for hurthle cell cancers and in fact for hurthle cell neoplasms (based upon fine needle aspiration).
In doing so, all the hurthle cell cancer is completely removed and even in those lesions such as hurthle cell neoplasms (where you cannot tell while you are asleep whether it is cancer or not by looking at the thyroid gland), you can easily tell if there if a hurthle cell cancer has spread to the central neck lymph nodes and then do the complete thyroidectomy if cancer is identified.
The basic concept is very simple, remove all of the hurthle cell cancer.
Hurthle Cell Cancer can be approached by three basics types of thyroid gland surgery: What are they and what is right for me?
- One is removal of about half of the thyroid gland called thyroid lobectomy.
- The other is removal of all of the thyroid gland and is called total thyroidectomy.
- The third type of thyroidectomy is called a subtotal thyroidectomy where almost all of the thyroid gland is removed
Subtotal thyroidectomy is largely a surgery for removal of thyroid goiters and is not a commonly indicated surgery. Almost all hurthle cell cancers are treated primarily withremoval of the entire thyroid gland (total thyroidectomy).
This approach must be taken in the light that the patient will not be able to monitor their thyroglobulin levels or receive radioactive iodine….both which may be totally appropriate for these diagnoses of hurthle cell cancer.
In this surgery, about half of the thyroid gland is removed. A small incision in the lower neck is required which is about an inch in length unless the thyroid mass requires a longer length to allow it to be “delivered”. All of the critical structures on the side of the removed thyroid lobe are spared including both parathyroid glands (the glands that control the calcium) and the nerves that provide movement and sensation to the voice box. Again, even in a thyroid lobectomy, I prefer to remove the lymph nodes along the side and beneath the thyroid gland and analyze them at the time of surgery while you are asleep. Don’t forget, most patients with a hurthle cell cancer do not know they have a hurthle cell cancer before their surgery. You have been likely told you have a hurthle cell neoplasm or a follicular neoplasm of the thyroid. Make sure you choose you do your work and choose the right surgeon to do the right surgery.
Editors note: A thyroid lobectomy is generally not recommended when there are nodules present in both sides of the thyroid gland (both lobes possessing nodules).
- A very effective surgical treatment for small to intermediate size (up to 2.5 cm or 1 inch) hurthle cell neoplasms.
- The lymph nodes on the side of the thyroid surgery should be removed an examined with “frozen section pathology” to determine whether there is cancer in lymph nodes
- Small cosmetic incision design
- Essentially little to no risk of hypoparathyroidism (low blood calcium)
- Outpatient surgical procedure
- Return to normal aerobic activities and daily functions in 24 hours.
- No heavy lifting for three weeks
- Remaining thyroid tissue facilitates ease in thyroid hormone regulation.
- The follicular thyroid cancer cannot be effectively monitored by measuring Thyroglobulin levels.
- Only one nerve to the voice box is even at theoretical risk of injury.
- Procedure converted to total thyroidectomy if lymph node spread found at the time of surgery.
- The hurthle cell cancer is less than 2.5 cm and there is no evidence of soft tissue extension on ultrasound or CAT scan
- This is a young woman patient!! (not in a patient above 50)
- There is no spread to lymph nodes in the central or side of the neck
- Adequate surgical therapy for:
- Hurthle cell neoplasm of uncertain malignant behavior
- Hurthle cell cancer with minimal capsular invasion
- There are no pathologic findings of angioinvasion or soft tissue invasion.
- The hurthle cell cancer patient understands their thyroid cancer and accepts that the blood test for the blood marker for hurthle cell cancer called thyroglobulin, will not be useful in their monitoring of their cancer since this protein is also produced by the remaining normal thyroid cells in the remaining thyroid tissue
- The hurthle cell cancer patient understands that radioactive iodine will not be used for the treatment of their cancer
- The hurthle cell cancer patient does not desire or accept radioactive iodine as a treatment option for their cancer.
In this surgery, the entire thyroid gland is removed. A small incision in the lower neck is required which is about an inch in length unless the thyroid mass requires a longer length to allow it to be “delivered”. The length of a total thyroidectomy incision is no longer than an incision for a thyroid lobectomy. Realize that most hurthle cell cancers are 4 cm or greater and therefore the respective incision must be long enough to accommodate the largest dimension of the hurthle cell cancer or thyroid itself. All of the critical structures on both sides of the thyroid are maintained including all four parathyroid glands and all four nerves that provide movement (recurrent laryngeal nerves) and sensation to the voice box (superior laryngeal nerves). The lymph nodes along the side and beneath the hurthle cell cancer/neoplasm are also removed during this surgery to make sure that they are not cancerous as well.
- The hurthle cell cancer is more than 2.5 centimeters or 1 inches
- The hurthle cell cancer appears to have extended outside of the surface of the thyroid gland (called its capsule)
- The hurthle cell cancer has spread to the lymph nodes underneath the thyroid gland (called central compartment lymph nodes [also called Level VI or VII lymph nodes] of the neck) or the lateral neck. This is commonly found!!!!!!
- The hurthle cell cancer has spread to distant sites outside of the neck (most commonly the lungs, bones, or liver)
- The hurthle cell cancer patient with a small thyroid cancer, does not accept the potential of another surgery to remove the remainder of the thyroid gland if a new thyroid cancer should develop within the remaining thyroid tissue.
- The hurthle cell cancer patient desires the ability to monitor blood levels of thyroglobulin for their cancer surveillance
Extended or Complicated Thyroidectomy
Hurthle cell cancer can sometimes be more aggressive locally when it presents. Imaging prior to surgery such as ultrasound or CT may detect these aggressive hurthle cell cancers. In some instances, imaging may not adequately predict this invasive component of the hurthle cell cancer. Let me tell you that these hurthle cell cancers are not “the good cancers” and the first surgery must be the right surgery and the only surgery!!. In these cases, an expert surgeon that recognizes those “more aggressive” intraoperative findings such as growth or extension of the cancer outside of the thyroid gland or invasion of the cancer into adjacent structures such as the nerve to the voice box (recurrent laryngeal nerve), breathing tube (trachea), voice box, or esophagus-must adapt the surgery to adequately address the complete removal of the cancer. Unfortunately, occasional thyroid surgeons are commonly unprepared to perform the appropriate surgery and a subsequent surgery for persistent disease will be required.
Hurthle Cell Cancer Surgery for Central Compartment Lymph Nodes (the lymph nodes beneath and surrounding the thyroid gland, breathing tube (trachea) and swallowing tube (esophagus)
The removal of the lymph nodes of the central neck should be performed initially when the thyroid gland is removed in the treatment of hurthle cell cancer on the side of the cancer or hurthle cell neoplasm. It may be necessary following the initial surgery if the hurthle cell cancer recurs or persists. The central compartment lymph node surgery spares all critical structures including the nerves to the voice box and all parathyroid glands not directly involved by cancer. Central compartment dissection extends from the carotid arteries on both sides of the neck, below to the blood vessels of the upper chest, and above to where the blood vessel of the upper portion of the thyroid gland begins off of the carotid artery (called the superior thyroid artery).
In hurthle cell cancer when it is recurrent or persistent, these surgeries are complex, difficult, and complicated with the risk of further recurrence. These surgeries should only be undertaken by the most skilled of thyroid cancer surgeons. Recurrent or persistent hurthle cell cancer is commonly not confined within lymph nodes and be found sometimes in just deposits in the area of prior surgery (not even within lymph nodes). The central compartment neck dissection is more commonly seen as a method of three dimensionally “getting around the cancer” more often than just removing the lymph nodes themselves.
- In hurthle cell cancer, the central compartment lymph nodes are at risk of containing cancer in at least 20% of patients. That risk increases with the size of the hurthle cell cancer. Even prior to surgery, most central compartment lymph nodes can be well examined with high quality ultrasound to determine if they are cancerous. Enlarged or abnormal lymph nodes seen on ultrasound next to the thyroid gland before surgery should be examined. These abnormal lymph nodes undergo fine needle aspiration (FNA) examination to determine whether cancer is present. In this way, an expert ultrasound can tell the difference between a hurthle cell neoplasm and a hurthle cell cancer even before you go to surgery.
- Some lymph nodes which lay immediately underneath the thyroid gland cannot be seen until the time of surgery and required a skilled surgeon to identify them and can then be confirmed during the surgery by a process called frozen section pathology.
- If hurthle cell cancer is determined to be present in central compartment lymph nodes at any time in a patient’s lifetime, an expert surgeon who does this surgery routinely is needed to remove the lymph nodes in the central compartment, on both sides) and spare the nerves to the voice box and the critical glands that control calcium (parathyroid glands).
- In larger hurthle cell cancers (and hurthle cell neoplasms!!!!) which are greater than one inch or have grown outside of the capsule of the thyroid, removal of the lymph nodes of the central compartment on the side of the cancer should be done routinely since:
- The nerve to the voice box (recurrent laryngeal nerve) has already, by necessity from the thyroid surgery itself, been significantly identified along most of its course and another surgery on the same side would be more difficult because of scarring and this subsequent surgery would put the nerve to the voice box at high risk for injury.
- The risk of microscopic lymph node metastasis is over 20%. The removal of these local lymph nodes with hurthle cell cancer also allows surgery to “get around” the cancer.
Hurthle Cell Cancer Surgery For Spread of Cancer to Lymph Nodes Along The Side Of The Neck (anterolateral neck)
- Just the presence of enlarged lymph nodes does not mean hurthle cell cancer has spread and does not require additional surgery
- A procedure called an anterolateral neck dissection (or modified neck dissection), in untreated patients, should only be performed in instances of ultrasound with fine needle aspiration confirmed hurthle cell cancer spread to lymph nodes in the side of the neck
- The hurthle cell cancer anterolateral neck dissection is not the same neck dissection as for other cancers that occur in the neck. All thyroid cancers spread to particular areas of the neck called levels. Removing just some of the lymph nodes has been called “cherry picking” and is the wrong surgery! A thyroid cancer expert surgeon trained and experienced to perform modified neck dissections specifically for thyroid cancer is needed to prevent recurrent or persistent disease.
- The anterolateral neck dissection, in skilled hands, spares all critical nerves, muscles, and blood vessels which are not directly involved with cancer (very rarely are critical structures involved by hurthle cell cancers). It is an approximately 40 minute surgery that removes lymph nodes and fatty tissue. (see a thyroid cancer modified neck dissection)
- In rare circumstances, hurthle cell cancers may show extensive growth into the the soft tissues of the neck. In such circumstances, a special surgery that can “get around” the hurthle cell cancer can be safely performed to remove all of the cancer.
Hurthle Cell Cancer Surgery in Sites Other Than The Neck
Hurthle cell cancer surgery is uncommonly proposed as a treatment approach when disease has spread to distant sites. Although surgery is not commonly proposed for distant spread of hurthle cell cancer, consideration for surgery for distant disease is based upon the expert thyroid cancer team evaluation and considers the following issues:
- Where is the hurthle cell cancer distant disease located?
- What are the risks and benefits of surgery?
- Are there other sites of distant spread?
- What hurthle cell cancer treatments have already been used?
- What were the outcomes of other treatments for the hurthle cell cancer?
- How fast is the hurthle cell cancer growing?
- What are the patient’s treatment desires?
- What are the other treatment options?
- What is the hurthle cell cancer pathologic type (what do the cells look like under the microscope?
- What are the hurthle cell cancer genetic mutations found?
Hurthle Cell Cancer/ or Hurthle Cell Neoplasm Robotic Surgery
Robotic surgery for the thyroid was developed largely in South Korea and brought to the United States several years ago as a “tool” in thyroid surgery. Its proposed benefits were to be the following:
- Absent or less noticeable neck incisions
- Improved visualization
- Less Surgeon Fatigue
Although we have been trained and performed robotic thyroid surgery, the following is the reality of robotic thyroid surgery:
- Incisions are tremendously longer but just not located on the front of the neck
- In hurthle cell cancer, it is a one sided surgery approach to a frequently required two-sided surgery!
- The instruments used to perform the surgery are not as refined or delicate as the instruments used to perform the minimally invasive neck surgeries. (think of all the delicate structures that we have shown you here)
- Multiple surgeons are required
- The surgeon has no ability to “feel” in the neck. The fingers are the surgeon’s third eye. Subtle changes in feel, hardness or extension of cancer can be totally unappreciated.
- It is not minimally invasive by any measure. It is maximally invasive but just at a distance from where the surgery is focusing.
- It is a much longer surgical procedure by any measure (the set up of the robot is longer than the average thyroid lobectomy).
- It is an inferior surgical approach to manage hurthle cell cancer or a hurthle cell neoplasm
- Unanticipated findings during surgery may not be able to be adequately addressed robotically.
- It may be an acceptable surgical approach for clearly known benign thyroid surgery.
Most importantly, the ability to perform a surgery well, is not an indication for a surgery!!! Robotic thyroid surgery is an inferior surgical approach in managing hurthle cell cancer, any other type of thyroid cancer, or any thyroid lesion at risk of being a potential thyroid cancer, especially a hurthle cell neoplasm.