THYROID CANCER
Minimally Invasive Thyroidectomy

The thyroid gland, shaped like a butterfly, sits just below the skin and several thin muscle layers in the lower part of the neck (Figure 1). It's attached to the deeper neck structures (trachea and voice box) and elevates when we swallow. The thyroid gland secretes hormones that control a variety of systems all through out life including our metabolism, growth and development.

Each year about 30,000 Americans are diagnosed with thyroid cancer. It is about 2 to 4 times more common in women than in men, and is most prevalent between ages 25 and 65.

The four kinds of thyroid cancer are papillary, follicular, medullary, and anaplastic.

Papillary and follicular thyroid carcinomas are referred to as well-differentiated thyroid cancer and account for 80–90% of all thyroid cancers, with papillary being the most predominant. They tend to be relatively slow growing, thus creating an opportunity for cure. Variants include tall cell, schirrous, insular, Hurthle cell, etc. Their treatment and management are similar, despite the fact that some variants may be more aggressive. If detected early, most papillary and follicular thyroid cancers can be treated successfully, and cured. Important favorable prognostic factors include female gender, age less than 45, tumor being limited to the thyroid gland, size less than 4 cm, and absence of distant metastases
(Table 1).

Medullary thyroid carcinoma (MTC) accounts for 5-10% of all thyroid cancers. MTC is easier to treat and control if found before it spreads to other parts of the body. So prompt measures need to be taken to diagnose, prepare the patient and proceed with treatment. There are two types of medullary thyroid cancer: sporadic (80%) and familial (20%). Genetic testing (of the RET proto-oncogene) should be performed in all patients with MTC to determine whether there are genetic changes, as well as children and direct family members of patients with inherited forms of MTC. In individuals with these genetic changes, removal of the thyroid during childhood has a high probability of being curative. Keep in mind, the familial forms of MTC are often times associated with other types of tumors (MEN 2A & 2B syndromes) and hormonal abnormalities that demand investigation, and preparation before surgery (Table 2). Your physician will fully investigate all these possibilities before starting any course of treatment.

Anaplastic thyroid carcinoma is the least common and accounts for only 1–2% of all thyroid cancer. This type of cancer is very difficult to control and treat because it is an extremely aggressive type of tumor that rapidly grows and spreads.

Risk Factors

The most well known cause of thyroid cancer is radiation exposure, either through the environment (Chernobyl) or as part of treatment for a prior head and neck disorder. Other risk factors are long history of a goiter or nodules being present, and a history of thyroid tumors in the family.

Symptoms and Diagnosis

Thyroid cancer usually begins as a lump or swelling in the neck, called a nodule. Thyroid nodules are very common (12% of general population) and most are benign. All nodules, however, need to be carefully evaluated as a very high percentage of nodules are cancerous (10-15%).

The first step in assessing thyroid nodules is a blood test for thyroid hormone levels, followed by a needle biopsy (fine needle aspiration or FNA), which can be performed in the office setting (Figure 2). Ultrasound visualization and thyroid scans are adjunctive tests that can help your physician develop a treatment plan.

Treatment

Surgery – Most thyroid cancers are very treatable and carry a high cure rate, especially when discovered early. Treatment of thyroid cancer requires a close collaboration between endocrinologists and thyroid surgeons. The treatment plan by our team of doctors is always decided through this collaboration. The first and most effective step in treatment of thyroid cancer is usually surgery. Surgical treatment of thyroid masses includes removal of a portion (hemi-thyroidectomy) or the entire thyroid gland (total thyroidectomy).

The newest advances in the field of surgery (endoscopes and endoscopic instruments) allow for minimally invasive thyroidectomy(Endoscopic Assisted Thyroidectomy, E.A.T.™) (as small as 2.5 cm or close to an inch, Figure 3), rather than the standard technique using a large incision and greater tissue trauma. This is a revolutionary way of surgically treating the thyroid.  Our surgeons are able to completely remove the thyroid through this much smaller incision and combine that with a plastic surgery closure of the skin, making the scar barely visible.  The success rate and complication rate for this procedure is equivalent to conventional treatment, and in the hands of experts surgeon even better.  The recovery from this type of surgery is relatively quick and requires very little care.  In fact patients who have a hemithyroidectomy can go home the same day, several hours after surgery.  If you have any more questions about the surgery please don't hesitate to contact our surgeons.

At the Center our philosophy is to individualize the treatment of thyroid cancer. This customized treatment is designed based on your individual condition, pathology, risk category and your endocrinologist’s input. Papillary and Follicular Carcinoma: In the high risk category patients (Table 1), total thyroidectomy is advocated for all patients. While the low and intermediate risk category patients have the option of either undergoing a hemi-thyroidectomy or a total thyroidectomy; the choice of surgical approach is very much individualized to the patient’s circumstances. Despite the extent of surgery and preservation of part of the thyroid gland (as in a hemi-thyroidectomy) all patients are placed on post-operative thyroid hormone replacement pills to suppress the remaining thyroid tissue and prevent any further activity in the thyroid gland. Fortunately, if you must have your thyroid removed because of tumor, cancer, or improper function, everything your gland used to do can be replaced with a small tablet of thyroid hormone.

A central compartment neck dissection (or removal of midline neck lymph nodes) is also performed in high risk patients and in those patients that have enlarged lymph nodes in this area; this is done to remove any cancer cells hiding in the lymph nodes (Figure 4). If patients also have enlarged lymph nodes in the remaining neck areas, then they will also undergo a modified neck dissection removing the lymph nodes in the lateral aspect of the neck.

Medullary Thyroid Cancer: MTC is a more aggressive tumor and all patients despite the size of the tumor undergo a total thyroidectomy and a central compartment neck dissection. A modified neck dissection of the lateral compartment is reserved for patients with large lymph nodes in that area.

Anaplastic Carcinoma: Surgical treatment for anaplastic carcinoma remains total thyroidectomy but despite an aggressive surgical approach the outcome is generally fatal.

One of the major risks of thyroid surgery is injury to the nerve controlling the vocal cord which would lead to hoarseness (recurrent laryngeal nerve, Figure 5); to minimize the risk to this nerve even more we use a special nerve monitoring device (EMG) that alerts us during surgery when we are in close proximity of the nerve (Figure 6). The risk of permanent injury to the nerve is less than 1%. The other major risk is injury to the parathyroid glands, which also occurs less than 1%. These glands control the calcium balance in our body, and injury to these glands would cause low blood calcium levels. Careful surgical dissection in experienced hands minimizes this risk. To minimize scarring, we have developed a two-team approach of working with facial plastic surgeons to ensure the best possible aesthetic outcome. Furthermore, we use the state-of-the-art video-assisted endoscopic thyroidectomy which allows removal of the gland through a small incision.

Radioactive Iodine (RAI) - Surgery for well differentiated thyroid cancer (papillary or Follicular) is often followed by radiation therapy with radioactive iodine. Again, you and all your physicians working hand in hand decide this course of treatment.  Iodine is preferentially absorbed by the thyroid gland, so radioactive iodine specifically targets thyroid tissue (both normal and cancerous thyroid tissue) that may remain after surgery. Radioactive iodine is used to treat only microscopic levels of thyroid cells; it cannot be used as a primary modality instead of surgery because the doses would be toxic. The patients with well-differentiated thyroid cancer undergo RAI treatment 4-6 weeks after surgery. Your endocrinologist carefully plans this out.

External Beam Radiation - Indications for external beam radiation for thyroid cancer is the following:

Follow up - After treatment for thyroid cancer, most patients live normal lives. However, we continue to monitor patients very closely and follow their progress frequently along with their primary physician and endocrinologists. Routine blood tests such as thyroglobulin levels (either under thyroid hormone withdrawal or with Thyrogen stimulation) are done for all patients with a total thyroidectomy. All patients are followed with routine ultrasound and Thyroid scanning. PET scan also plays a role when other tests do not render a clear answer.

Goiter

A goiter is a non-cancerous enlargement of the thyroid (Figure 7). It is usually quite recognizable as a swelling of the lower neck area. A goiter can sometimes grow so large that it puts pressure on the trachea (wind-pipe) and esophagus (swallowing tube). As a result, patients complain of coughing, a feeling of tightness in the throat, and difficulty breathing and swallowing. Iodine deficiency is one cause of goiter, but is now uncommon in America as iodine is quite plentiful in our diets. Rather, a more common cause is an excess of thyroid stimulating hormone (TSH). This hormone is released from the brain (pituitary gland) and regulates the thyroid gland function and hormone production; the blood thyroid hormone levels (T3 & T4) are detected by the brain which it uses to regulate the function and hormone production of the thyroid itself (Figure 8). When TSH is in excess, the thyroid can become overactive, resulting in goiter.

Smaller goiters can be treated with thyroid hormone therapy in the form of a pill. Once TSH is regulated in this way, the goiter may start to shrink. However, some goiters will not respond to hormone therapy and continue to grow, ultimately causing symptoms such as difficulty swallowing and shortness of breath. Sometimes the goiter grows to be so large that it extends downwards into the chest cavity toward the lungs. Once the patient is symptomatic a partial or complete thyroidectomy (surgical removal of the thyroid) is required to prevent further progression. The same precautions are taken as mentioned previously for thyroid tumor surgery.

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Hospital Course
Patients that have a hemi-thyroidectomy (removal of only half of the gland) may be discharged home on the same day.

Patients who are having a total thyroidectomy: