Search

Objective To analyze all the most recent guidelines/consensus as well as papers regarding the relationship between size of tumor, type of surgery, and prognosis, and to try to produce a critical synthesis for real practice. Background Differentiated thyroid cancer (DTC) is characterized by a wide range of biological behavior. The type of intervention can range from lobectomy (LT) to total thyroidectomy (TT), with tumor size being a point of discussion in choosing the treatment. Methods We carried out a search on PubMed, EMBASE, and Cochrane Library, looking at all the guidelines and consensus regarding DTC, as well as examining original articles, inserting as our research keys "total thyroidectomy vs. lobectomy in differentiated thyroid cancer" and "hemithyroidectomy in thyroid cancer". The guidelines and consensus published over the last 5 years were 6 in total: ATA Guidelines, Italian Consensus of Six Italian Societies, United Kingdom National Multidisciplinary Guidelines, ESMO Clinical Practice Guidelines, a Practical Guidance of a Multidisciplinary Panel of Experts, and The Revised Clinical Practise Guidelines on the Management of Thyroid Tumours by the Japanese Association of Endocrine Surgeons. There were 13 papers cited in the guidelines, and we found another 5 original articles, all of which were retrospective studies. Conclusions The type of initial surgical intervention must of course consider tumor size, but must also take into account all the risk factors, which is paramount in deciding the type of treatment. LT can have some advantages, and can represent an option that can be offered to patients. However, even in the absence of any special risk factors, a review of the literature suggests to us that patients should be informed that LT for tumors of a size between 2 and 4 cm can be associated with an increased risk of LR as well as with a possible reduced OS.

Although robot-assisted transaxillary thyroidectomy (RATT) has become a widely used treatment modality for thyroid disease in the Far East, the procedure remains under discussion in Western World (1,2). Different body mass index, anthropometric characteristics, size of tumours, goitre and ethical considerations, combined with elevated cost of the procedure and the need of training, hinder the diffusion of this approach in US and Europe (1,3). To date, RATT, although excellent results in terms of feasibility, oncological safety and patient’s compliance are described, plays a niche role in selected patients with appropriate pathology in high-volume centers (1,4).

Post-thyroidectomy neck hematoma represents a major concern for surgeons because it can result in severe and even life-threatening complications. In fact, postoperative hemorrhage may result in airway compression and respiratory distress, and therefore, effective hemostasis is an important goal in thyroid surgery. Postoperative hematoma occurs at a rate of approximately 0.1% to 1.1%. Almost all cases occur in the first 6 h after surgery and can be the result of several surgeon or patient factors. For many years the clamp-and-tie technique has been the most common way to divide the main vascular pedicles of the thyroid gland. Alternatively, bipolar electrocautery has been used for only very small vessels. Other hemostatic systems have been introduced and proved to be potentially very useful in neck surgery and, in particular, for thyroid surgery. This new class of instruments is generally known as “energy devices” because they use different forms of energy, such as advanced bipolar (LigaSureTM Small Jaw Medtronic, Covidien product, Mineapolis, MN, USA) and ultrasound (Harmonic Focus; Ethicon, Johnson and Johnson, Cincinnati, OH, USA), and hybrid devices that join these two technologies (Thunderbeat by Olympus, Japan). Although they all generate a significant elevation of temperature in the tissues, as in any form of energy, the temperatures reached by these instruments are never as high as the standard monopolar electrocautery. For small bleeding very close to critical structures, where energy devices are too dangerous to be used and clamp and tie is not possible, several studies have assessed the use of adjunctive hemostatic agents. In conclusion, all energy devices have been shown to significantly decrease operative times without increasing costs or complications. Adjunctive hemostatic agents have shown equivalent differences when added to standard methods from a clinically significant perspective.

Metastases to lymph nodes of the superior mediastinum have been found in up to 10% of patients with thyroid carcinoma. The treatment of mediastinal lymph node metastases in thyroid cancer is still far from being standardized. However, in selected cases, especially in case of radioiodine ablation and radiation therapy failure, a surgical resection may improve the patients’ survival in addition to the symptomatic benefits. We report our experience in four consecutive patients who underwent extended mediastinal surgery for large lymph node metastases from thyroid cancer during the last year. All patients were pre-operatory evaluated by a multidisciplinary team involving endocrinologist, anaesthesiologist and surgeons. Surgery was carried out in all cases in two steps, firstly through a cervicotomy in order to remove the eventual local recurrence and ensure a radical neck dissection bilaterally and then by sternotomy, in order to dissect all the lymphadenopathies from the mediastinal structures. Two patients (50%) had an extended vascular infiltration and the extracorporeal circulation (ECC) and, at least, one vascular graft, were needed. No intraoperative or perioperative mortality occurred in this series. Two patients (50%) presented a sternal dehiscence that required a second surgery and a prolonged postoperative hospital stay. In all cases the surgery was radical, and the histological report revealed a macroscopic complete resection and, up to date, no recurrences were found. When feasible, surgery is more effective than systemic therapy in the treatment of thyroid cancer recurrences, especially for medullary thyroid cancer in which radioiodine therapy is ineffective and should always be evaluated in case of vascular infiltration or symptomatic patients. Moreover, due to diversity and complexity of the cervical and mediastinal structures that may be involved, a multidisciplinary medical team should always be guaranteed during the surgery.

Papillary thyroid carcinoma (PTC) is an often indolent disease implying a long survival and in most of the cases an excellent prognosis, but there is still a limited percentage of cases where, in spite of their pre-operative conventional staging, these tumors could better be treated through a more selective surgical approach. Small PTC in fact are generally considered as “low risk” tumors but using simply a TNM classification might lead to a limited surgery such as unilateral hemithyroidectomy, in particular according to the most recent guidelines of the American Thyroid Association. On the other hand though, an absence of the mutation could allow simplifying the follow-up of these patients, for example avoiding unnecessary radioactivated iodine therapy after surgery or even limiting to a unilateral thyroidectomy the operative procedure for these cases. Molecular testing has a peculiar interest for surgeons in two different ways: (I) with respect to diagnosis, in order to reduce the number of indeterminate citologies; (II) with respect to prognosis after both cytology and histology, in order to improve risk stratification and help the surgeon in developing a tailored surgical therapy. The aim of this review is the second issue: how to implement the concept of a tailored surgery according to molecular analysis in differentiated thyroid carcinomas (DTC).