Follicular Thyroid Cancer Surgery Basics: From Minimally Invasive Surgery to Comprehensive (Appropriate) Surgery.

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.

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.

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).

• 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.

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. 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.

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 and transoral thyroid surgery has been developed and continues to evolve as a mechanism of performing thyroid surgery with less noticeable or truly no visible incisions. Our Thyroid Program offers the world leaders in both approaches of transoral and robotic thyroid surgery. Its benefits can include the following:

• Absent or less noticeable neck incisions
• Improved visualization
• Less Surgeon Fatigue

These approaches may be the appropriate thyroid surgery for appropriately selected patients.

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