Thyroidectomy for Thyroid Cancer: The Big Picture 

What is a thyroidectomy?

Thyroidectomy is removal of the thyroid. This is also known as “thyroid surgery” or “thyroid resection”. Thyroid surgery is the mainstay of treating thyroid cancer. There are 2 main types of thyroidectomy: thyroid lobectomy (removal of half of the thyroid) and total thyroidectomy (removal of the entire thyroid). This surgery done correctly in experienced and skilled hands is crucial for curing thyroid cancer.

There are 5 Types of thyroid resection, but some are not appropriate for thyroid cancer. Let’s look at the different ways a surgeon can remove a thyroid gland.

The 5 Types of thyroidectomy for thyroid cancer.

1) Partial Thyroid Lobectomy

This operation is not performed very often because there are not many conditions which will allow this limited approach. Additionally, a benign lesion must be ideally located in the upper or lower portion of one lobe for this operation to be a choice. This is not a good operation for cancer unless the cancer was not known ahead of time.

If cancer is found in a nodule after a partial thyroid lobectomy, then almost all of these people will need at least the rest of that half of the thyroid removed with a second surgery. In some rare instances, this technique is used for a non-cancerous thyroid nodule in conjunction with a thyroid lobectomy on the other side (see #2 below) to save normal thyroid thyroid tissue. This operation is almost never done for thyroid cancer by experienced surgeons. Most likely, if you need a partial thyroid lobectomy, you actually need a complete thyroid lobectomy (#2).

2) Thyroid Lobectomy

The thyroid lobectomy (removing half of the thyroid) is typically the "smallest" operation performed on the thyroid gland for thyroid cancer. This is also performed for solitary dominant nodules, which may be cancerous, or those which are atypical or suspicious following fine needle biopsy. Thyroid lobectomy may also be appropriate for benign (non-cancerous nodules), solitary hot (overactive/toxic) or cold (solid, non-toxic) nodules, or goiters (enlarged thyroid gland) which are isolated to one lobe (not common).

Removing half of the thyroid gland is appropriate for many thyroid cancers. The surgery is brief, usually lasting no more than 30-45 minutes, and spares all parathyroid glands (calcium control glands) as well as all important nerves to the voice box (superior laryngeal nerve and its branches and recurrent laryngeal nerve and its branches). Even for larger tumors, the incision is small and cosmetically designed to be almost unnoticeable. This surgery is beneficial because half of a healthy thyroid is saved allowing for natural thyroid hormone production. Additionally, thyroid lobectomy involves less surgery since only 1 side of the neck is operated on (therefore, risks of the surgery are decreased). Thyroid lobectomy should not be performed by inexperienced surgeons. The potential risks are just too great.

3) Thyroid Lobectomy with Isthmusectomy

This simply means removal of a thyroid lobe (half of the thyroid) and the isthmus (the middle part that connects the 2 halves). This removes more thyroid tissue than a simple lobectomy, and is used when a larger margin of tissue is needed to assure that the "problem" has been removed. This isn’t really a different operation and should be considered part of number 2: the thyroid lobectomy.

This also is used to cure a larger cancer that is in the isthmus of the thyroid. Sometimes, this surgery is used to address a non-cancerous nodule in the isthmus that is growing or symptomatic in conjunction with a cancer or concerning nodule in one lobe of the thyroid. Again, this surgery has the benefits of leaving behind a normal, healthy half of the thyroid. As noted above, this also limits surgery to only 1 side of the neck.

 4) Subtotal Thyroidectomy

Just as the name implies, the subtotal thyroidectomy operation removes not quite all the thyroid. The "problem" side of the gland as well as the isthmus and the majority of the opposite lobe are taken out during this surgery. This operation is typically performed by non-expert surgeons who are afraid of damaging the recurrent laryngeal nerve (nerve to the voice box). But this often leads to increased nerve damage, not less—which is a function of the inexperience of the surgeon who is choosing this method. This also guarantees that radioactive iodine is needed after the operation, which is typically not effective given the amount of thyroid tissue that is left behind.

This technique is done by surgeons who are not experts in thyroid surgery. When this surgery is performed, the correct surgery almost always would have been a total thyroidectomy (see #5 below) to cure the patient. The concern with leaving behind a significant portion of thyroid tissue is that not all of the cancer was removed with an adequate amount of normal surrounding thyroid tissue. This will lead to the cancer growing back or recurring. Again, if you have a subtotal thyroidectomy, you almost certainly would do better with a total thyroidectomy (#5).

5) Total Thyroidectomy

This operation is designed to remove all of the thyroid gland. This is the operation of choice for most thyroid cancers which are not small and non-aggressive in young patients. Some surgeons, particularly those who are inexperienced and not up to date on current guidelines, prefer complete removal of thyroid tissue for all the different types of thyroid cancer even when removal of half the thyroid (thyroid lobectomy) would be enough. This surgery is not long, usually lasting no more than 60 minutes, and spares all four parathyroid glands and all the nerves to the voice box (both superior laryngeal nerves and their branches and recurrent laryngeal nerves and their branches). Even for larger tumors, the incision is usually small and always cosmetically designed to be almost unnoticeable.

This is also the operation of choice for thyroid cancers that are present in both halves of the thyroid. Total thyroidectomy is also done for patients who have cancer on one side of the gland with surgical disease in the other half of the thyroid (large nodule, nodule that is suspicious for thyroid cancer, goiter or enlarged thyroid, etc.).  Additionally, if there is enough spread of thyroid cancer to lymph nodes in the neck, you will also need the entire thyroid gland removed to cure the cancer. Similar to a thyroid lobectomy, total removal of the thyroid gland should not be performed by inexperienced surgeons due to the risks of thyroid surgery (calcium- control glands and nerves to the voice box).

Thyroidectomy for thyroid cancer:

Thyroid surgery for thyroid cancer is frequently not different than surgery for non-cancerous disease. As mentioned above, many cancerous thyroid nodules can be treated by removal of half the thyroid along with the lymph nodes that are located behind and around the thyroid. Numerous studies have shown that up to 30% of thyroid cancers have spread to lymph nodes at the time of diagnosis and surgery. Expert evaluation and complete removal of all cancer with the first surgery are extremely important to avoid complications and leaving cancer behind.

In other instances, total removal of the thyroid is needed to treat cancers that are large, located in both halves of the thyroid, or when cancer has spread to lymph nodes in the neck. Again, removal of the lymph nodes behind and around the thyroid in the middle of the neck at a minimum is important to ensure the cancer is completely cured. Complete thyroid removal is even riskier than thyroid surgery for half the thyroid. This is because both sides of the neck are worked on, exposing all 4 parathyroid glands as well as all the nerves to the voice box to potential damage. Thus, total thyroid removal should only be done by high-volume, experienced surgeons at busy centers such as ours. For more information about thyroid cancer surgery and our new, state of the art hospital, visit www.thyroidcancer.com and Hospital for Endocrine Surgery.

How is thyroidectomy for thyroid cancer performed?

Thyroidectomy for thyroid cancer is typically done in 3 ways: via a standard incision (larger incision/cut), a minimally-invasive approach (small incision), or a robotic- assisted method. The approach depends on numerous factors. Experience and expertise of the surgeon, size of the thyroid gland and the cancer, location of the cancer, amount of thyroid cancer present, and the presence of cancer that has spread outside of the thyroid gland all influence how the thyroid surgery is performed.

The standard approach involves a large incision in the neck that is readily visible and undesirable in appearance. Inexperienced thyroid surgeons use this method for almost all of their cases. Many times, the incision is not oriented and placed in a favorable fashion for the optimal cosmetic outcome! Sometimes the size of the thyroid cancer or the thyroid gland along with spread to other areas of the neck requires that the incision is larger. Still, an experienced surgeon will carefully choose the location of the incision and pay a great deal of attention to an excellent cosmetic closure to ensure the incision is hard to see after complete healing.

Is minimally invasive thyroidectomy appropriate for thyroid cancer?

Minimally-invasive thyroid surgery is done by expert thyroid surgeons for most of their operations. This technique involves using a small incision in the neck that is well-designed and hidden to allow for the best cosmetic outcome. We cannot stress how important planning and designing the incision pre-operatively is in achieving a great cosmetic outcome. Only high-volume, experienced thyroid surgeons are skilled at this method.

Can robot-assisted thyroidectomy be used for thyroid cancer? 

Robotic-assisted thyroidectomy, or scarless thyroid surgery, is the newest, most innovative technique. Some people who need thyroid cancer surgery are candidates for scarless thyroidectomy. This involves removing the thyroid without leaving a scar in the neck. The scars are small and located inside the mouth (transoral) or in other hidden locations (in the armpit and around the nipple). The goals of these scarless thyroid surgery techniques are to provide same successful outcome as the traditional surgery while providing highest cosmetic satisfaction and confidentiality benefits for the patients. Please visit Scarless Thyroid Surgery to learn more.

Recovery from thyroidectomy for thyroid cancer:

Recovery from thyroid cancer removal is not long or painful for almost all of our patients. Almost everyone is walking, talking, eating/drinking the same day as their thyroidectomy. If you have your entire thyroid removed or a larger thyroid surgery involving lymph node removal, you will stay in the hospital overnight for observation and leave the following morning. All other patients are discharged the same day as their surgery (outpatient thyroid surgery).

Most patients only need ice and over the counter medications (Ibuprofen/Advil/Aleve along with Tylenol) for pain control. You can shower the next day resume normal aerobic exercise 48 hours after surgery. No wound care is needed since the incision is covered with superglue and the stitches are underneath the skin and dissolve on their own over time. The vast majority of our patients are fully recovered for the most part in 3-5 days and back at work within 1 week. Importantly, patients need to follow up with their endocrinologist or primary doctor in 4-6 weeks after thyroid surgery to check their thyroid levels to ensure thyroid medication or a change in thyroid medication dosage is not needed. Your thyroid surgeon should be available any time during your recovery for questions or issues related to the surgery or recovery process.

Thyroidectomy for thyroid cancer: Questions I should ask my surgeon:

Unfortunately, almost 90% of these operations are performed by surgeons that perform 10 or less thyroid surgery operations per year! This is a truly scary statistic. The critical nerves of the voice box that control sensation and movement of the vocal cords must be identified and preserved in every thyroid operation. In addition, the parathyroid glands that control calcium in the body, must also be identified and spared. Almost all surgeons performing thyroid operations in the United States do less than 2 per month. The literature deems a “high-volume surgeon” to be one who performs 50 or more thyroid surgeries in a year. Our surgeons perform over 500-600 operations each year! Learn how to become our patient here.

The American Thyroid Association states that thyroid surgery should only be performed by board-certified surgeons who did extra training in thyroid surgery (i.e. a fellowship) if possible. Volume and experience in thyroid surgery are critical to nearly eliminating major complications (1% chance or less of permanent damage to the nerves to the voice box and calcium control glands). Here are some key questions to ask your thyroid surgeon when choosing who will do your thyroidectomy:

• Are they board certified?
• Did they complete extra, dedicated training (fellowship) in thyroid surgery?
• How many thyroid operations they perform each year and is their complication rate?
• What percentage of their practice is thyroid surgery/thyroid cancer surgery?
• Who assists or works with them during the operation? (At our center, 2 high-experienced thyroid surgeons are involved in every case!)
• How much experience with thyroidectomy and caring for patients with thyroid cancer does their team have? (Expertise of the team that is assisting in your care before, throughout, and during your recovery after thyroid surgery. This importance of this aspect of your thyroidectomy experience cannot be underestimated.)

For more help choosing the best thyroid cancer surgeon, visit: How to find the best thyroid surgeon                  

Summary of thyroidectomy for thyroid cancer:

Thyroid surgery for thyroid cancer is the mainstay of treatment and cure. There are different types of thyroid surgery performed for thyroid cancer. Additionally, there are different ways to perform thyroid removal for cancer. The training, qualifications, and experience of your thyroid surgeon and their team are crucial for achieving excellent outcomes and almost eliminating complications.

Additional Resources

• Become our patient at www.thyroidcancer.com/become-a-patient
• More about the The Clayman Thyroid Center at www.thyroidcancer.com
• More about the Hospital for Endocrine Surgery
• Scarless Thyroid Surgery