For papillary thyroid cancer (and all of the different types (variants) of papillary thyroid cancers that exist within this group), surgery, by far, is the most common first treatment. In fact, papillary thyroid 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. Papillary thyroid cancer surgery should only be done by expert surgeons. By choosing the right surgeon and surgery, you are cured. The wrong choice may lead to repeated surgeries, complications, and even worse!
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, papillary thyroid cancer surgery may be considered an art form in its own right.
Papillary thyroid 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 lymph nodes of the neck. The basic concept is however very simple, remove all of the cancer.
- 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
(Editors note: Subtotal thyroidectomy is largely a surgery for removal of thyroid goiters and is not a commonly indicated surgery. Almost all papillary thyroid cancers are treated primarily with removal of either the entire thyroid gland (total thyroidectomy) or half of the thyroid gland (thyroid lobectomy).
Thyroid Lobectomy. 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 maintained including both parathyroid glands (the glands that control the calcium) and the nerves that provide movement and sensation to the voice box. The lymph nodes along the side and beneath the thyroid gland are also examined during this surgery to make sure that they are not cancerous as well. 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).
- 1. A very effective surgical treatment for small to intermediate size ( up to 4 cm or 1.75 inch) papillary thyroid cancers
- 2. Small cosmetic incision design
- 3. Essentially little to no risk of hypoparathyroidism (low blood calcium)
- 4. Outpatient surgical procedure
- 5. Return to normal aerobic activities and daily functions in 24 hours
- 6. No heavy lifting for three weeks
- 7. Remaining thyroid tissue facilitates ease in thyroid hormone regulation
- 8. The papillary thyroid cancer cannot be effectively monitored by measuring Thyroglobulin levels
- 9. Only one nerve to the voice box is even at theoretical risk of injury
Total Thyroidectomy. 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. 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 thyroid gland are also examined during this surgery to make sure that they are not cancerous as well.
- The papillary thyroid cancer is large (more than 4 centimeters or 1.75 inches
- The papillary thyroid cancer appears to have extended outside of the surface of the thyroid gland (called its capsule)
- The papillary thyroid 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)
- The papillary thyroid cancer has spread to lymph nodes along the side of the neck (called lateral neck lymph nodes)
- The papillary thyroid cancer has spread to distant sites outside of the neck (most commonly the lungs, bones, or liver)
- The papillary thyroid 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.
Papillary Thyroid 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 can be performed initially when the thyroid gland is removed in the treatment of papillary thyroid cancer or following the initial surgery in the less common circumstances when papillary thyroid 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 papillary thyroid cancer, the central compartment lymph nodes are at risk of containing cancer in up to 50% of patients. That risk increases with the size of the papillary thyroid cancer. Even prior to surgery, most central compartment lymph nodes can be well examined with high quality ultrasound to determine if they are cancerous. Here, the arrow points to an abnormal lymph node seen on ultrasound next to the thyroid gland before surgery. Abnormal lymph nodes undergo fine needle aspiration (FNA) examination to determine whether cancer is present. 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 papillary thyroid 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 papillary thyroid cancers 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:
- 1. 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.
- 2. The risk of microscopic lymph node metastasis is approximately 50%.
Extended or Complicated Thyroidectomy
Papillary thyroid cancer may sometimes be more aggressive than ultrasound or CT imaging suggested prior to undergoing 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.
Papillary Thyroid 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 papillary thyroid 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 papillary thyroid cancer spread to lymph nodes in the side of the neck
- The papillary thyroid cancer anterolateral neck dissection is not the same neck dissection as for other cancers that occur in the neck. Papillary thyroid cancer spreads 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 papillary thyroid 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 papillary thyroid cancers). It is an approximately 40 minute surgery that removes lymph nodes and fatty tissue.
Papillary Thyroid Cancer Surgery in Sites Other Than The Neck
Papillary thyroid 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 papillary thyroid cancer, consideration for surgery for distant disease is based upon the expert thyroid cancer team evaluation and considers the following issues:
- Where is the papillary thyroid cancer distant disease located?
- What are the risks and benefits of surgery?
- Are there other sites of distant spread?
- What papillary thyroid cancer treatments have already been used?
- What were the outcomes of other treatments for the papillary thyroid cancer?
- How fast is the papillary thyroid cancer growing?
- What are the patient's treatment desires?
- What are the other treatment options?
- What is the papillary thyroid cancer pathologic type (what do the cells look like under the microscope?
- What are the papillary thyroid cancer genetic mutations found?
Papillary Thyroid Cancer 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 papillary thyroid 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 papillary thyroid cancer
- 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 is not an indication for a surgery!!! Robotic thyroid surgery is an inferior surgical approach in managing papillary thyroid cancer, any other type of thyroid cancer, or any thyroid lesion at risk of being a potential thyroid cancer.