For follicular thyroid cancer (and basically all of the different types of other thyroid cancers), surgery, by far, is the most critical first treatment. In fact, follicular 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 correct thyroid surgery is obtained in the first operation. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surgery 1998 September 228 (3) 320. For follicular thyroid cancer (and basically all of the different types of other thyroid cancers), surgery, by far, is the most critical first treatment. In fact, follicular 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.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, follicular thyroid cancer surgery may be considered an art form in its own right.
Follicular 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 surrounding soft tissues around the thyroid gland. Because lymph nodes are so rarely involved with follicular thyroid cancer, routine removal of lymph nodes is not considered with follicular lesions or follicular thyroid cancer. 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 follicular thyroid cancers are treated primarily with removal of the entire thyroid gland (total thyroidectomy).
Editors note: For the more favorable pathologic types of follicular thyroid cancer such as follicular thyroid neoplasm or uncertain malignant potential and follicular thyroid cancer with minimal ( a small focus of capsule invasion), a thyroid lobectomy is adequate treatment. It 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 follicular thyroid 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 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).
- A very effective surgical treatment for small to intermediate size (up to 2.5 cm or 1 inch) follicular thyroid cancers
- 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.
- The follicular thyroid cancer is less than 2.5 cm and there is no evidence of soft tissue extension on ultrasound or CAT scan
- Adequate surgical therapy for:
- Follicular neoplasm of uncertain malignant behavior
- Follicular thyroid cancer with minimal capsular invasion
- There are no pathologic findings of angioinvasion or extensive soft tissue invasion.
- The patient desires an easy method to maintain their thyroid hormone blood levels following surgery. (Some patients are concerned about their ability to adequately control their hormone levels and sense of well being when they are totally dependent upon taking thyroid hormone pills)
- The follicular thyroid cancer patient understands their thyroid cancer and accepts that the blood test for the blood marker for follicular thyroid 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 follicular thyroid cancer patient understands that radioactive iodine will not be used for the treatment of their cancer
- The follicular thyroid 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 many follicular thyroid cancers are 4 cm or greater and therefore the respective incision must be long enough to accommodate the largest dimension of the follicular thyroid 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 thyroid gland are also examined during this surgery to make sure that they are not cancerous as well.
- The follicular thyroid cancer is more than 2.5 centimeters or 1 inches
- The follicular thyroid cancer appears to have extended outside of the surface of the thyroid gland (called its capsule)
- The follicular 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) or the lateral neck. This is very rarely found!
- The follicular thyroid cancer has spread to distant sites outside of the neck (most commonly the lungs, bones, or liver)
- The follicular 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.
- The follicular thyroid cancer patient desires the ability to monitor blood levels of thyroglobulin for their cancer surveillance
Extended or Complicated Thyroidectomy
Follicular thyroid cancer may sometimes be more aggressive locally when it presents. Imaging prior to surgery such as ultrasound or CT may detect these aggressive cancer but sometimes imaging may not adequately predict this invasive component of the follicular thyroid cancer. Let me tell you that these follicular thyroid 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.
Follicular 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 follicular thyroid cancer or following the initial surgery in the much less common circumstances when follicular 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 follicular thyroid cancer, the central compartment neck dissection is more commonly seen as a method of three dimensionally "getting around the cancer" more often than removing the lymph nodes themselves. This is because the incidenc of lymph node spread of follicular thyroid cancer is much less common than that of papillary thyroid cancers (the most common type of differentiated thyroid cancer)
- In follicular thyroid cancer, the central compartment lymph nodes are at risk of containing cancer in around 15% of patients. That risk increases with the size of the follicular 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. 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. 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 follicular 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 follicular 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:
- 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 around 15%. The removal of these local lymph nodes with follicular thyroid cancer also allows surgery to “get around” the cancer.
Follicular 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 follicular 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 follicular thyroid 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 follicular thyroid cancers). It is an approximately 40 minute surgery that removes lymph nodes and fatty tissue.
- In rare circumstances, follicular thyroid cancers may show extensive growth into the blood vessels draining the thyroid gland and neck. In such circumstances, those blood vessels can be safely removed without any harm to the patient.
Follicular Thyroid Cancer Surgery in Sites Other Than The Neck
Follicular 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 follicular 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 follicular thyroid cancer distant disease located?
- What are the risks and benefits of surgery?
- Are there other sites of distant spread?
- What follicular thyroid cancer treatments have already been used?
- What were the outcomes of other treatments for the follicular thyroid cancer?
- How fast is the follicular thyroid cancer growing?
- What are the patient's treatment desires?
- What are the other treatment options?
- What is the follicular thyroid cancer pathologic type (what do the cells look like under the microscope?
- What are the follicular thyroid cancer genetic mutations found?
Follicular 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
- 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 follicular 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 well, is not an indication for a surgery!!! Robotic thyroid surgery is an inferior surgical approach in managing follicular thyroid cancer, any other type of thyroid cancer, or any thyroid lesion at risk of being a potential thyroid cancer.