Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Advances in surgical therapy for thyroid cancer

Nature Reviews Endocrinology volume 7, pages 581–588 (2011)Cite this article

Subjects

A Correction to this article was published on 06 December 2011

This article has been updated

Abstract

Thyroid cancer is the most common malignancy of the endocrine system and its incidence has dramatically increased over the past three decades. Well-differentiated thyroid cancers (DTCs) are the main focus of this article, as they represent >90% of thyroid malignancies. This Review provides an overview of the controversies surrounding the optimal choice of surgery and extent of resection for patients with low-risk DTC or with papillary thyroid microcarcinoma, and the role of prophylactic central lymph node dissection. This Review also outlines the current surgical management of DTC and presents updated results for these techniques, along with important advances and current dilemmas in surgical approaches to treatment of these cancers. For example, endoscopic and robotic thyroidectomy are the two most recent innovations to present technical and other challenges to the endocrine surgeon; in addition, the risks as well as the advantages of same-day thyroid surgery, which has gained some acceptance, are detailed. Arguments for and against each approach are presented, along with supporting evidence. The authors' personal opinions are also provided for each topic.

Key Points

  • Thyroid cancer is the most common malignancy of the endocrine system and its incidence is increasing

  • The optimal therapy for papillary thyroid microcarcinoma is currently unclear, and is a controversial issue; suggested management strategies range from regular observation to total thyroidectomy

  • Prophylactic central lymph node dissection might identify high rates of lymph node involvement without providing long-term benefits; therefore, its routine use is currently unwarranted

  • Same-day thyroid surgery is gaining acceptance and can be safely performed in the majority of patients as long as an appropriate support system is present

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Incision and dissection plane for transaxillary thyroidectomy.

Similar content being viewed by others

Change history

  • 06 December 2011

    At the end of the second paragraph of the section 'Papillary thyroid microcarcinoma', it should read “In one study, tumor growth of 2 mm was detected in 30% of patients who underwent observation alone. More than one-third (56 of 162) of all patients assigned to observation underwent surgery after 19–56 months of observation, although for 47 of them this decision was not necessarily related to tumor progression. Lymph-node metastases were suspected by ultrasonography at the beginning of the study or during follow-up in 12.3% of all patients who underwent observation.” The error has been corrected for the HTML and PDF versions of the article.

References

  1. Jemal, A. et al. Cancer statistics, 2007. CA Cancer J. Clin. 57, 43–66 (2007).

    PubMed  Google Scholar 

  2. National Cancer Institute at the NIH. Cancer.gov [online], (2011).

  3. Zarebczan, B. & Chen, H. Multi-targeted approach in the treatment of thyroid cancer. Minerva Chir. 65, 59–69 (2010).

    CAS  PubMed  PubMed Central  Google Scholar 

  4. Ito, Y. et al. Preoperative ultrasonographic examination for lymph node metastasis: usefulness when designing lymph node dissection for papillary microcarcinoma of the thyroid. World J. Surg. 28, 498–501 (2004).

    Article  Google Scholar 

  5. Suliburk, J. & Delbridge, L. Surgical management of well-differentiated thyroid cancer: state of the art. Surg. Clin. North Am. 89, 1171–1191 (2009).

    Article  Google Scholar 

  6. Cooper, D. S. et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 19, 1167–1214 (2009).

    Article  Google Scholar 

  7. Bilimoria, K. Y. et al. Extent of surgery affects survival for papillary thyroid cancer. Ann. Surg. 246, 375–381 (2007).

    Article  Google Scholar 

  8. Hay, I. D., Bergstralh, E. J., Goellner, J. R., Ebersold, J. R. & Grant, C. S. Predicting outcome in papillary thyroid carcinoma: development of a reliable prognostic scoring system in a cohort of 1,779 patients surgically treated at one institution during 1940 through 1989. Surgery 114, 1050–1057 (1993).

    CAS  PubMed  Google Scholar 

  9. Hay, I. D. et al. Papillary thyroid carcinoma managed at the Mayo Clinic during six decades (1940–1999): temporal trends in initial therapy and long-term outcome in 2,444 consecutively treated patients. World J. Surg. 26, 879–885 (2002).

    Article  Google Scholar 

  10. Rubino, C. et al. Second primary malignancies in thyroid cancer patients. Br. J. Cancer 89, 1638–1644 (2003).

    Article  CAS  Google Scholar 

  11. The American Association of Endocrine Surgeons Patient Education Site. The American Association of Endocrine Surgeons [online], (2011).

  12. Kikuchi, S. et al. Complication of thyroidectomy in patients with radiation-induced thyroid neoplasms. Arch. Surg. 139, 1185–1188 (2004).

    Article  Google Scholar 

  13. Sturniolo, G. et al. The recurrent laryngeal nerve related to thyroid surgery. Am. J. Surg. 177, 485–488 (1999).

    Article  CAS  Google Scholar 

  14. Youngwirth, L., Benavidez, J., Sippel, R. & Chen, H. Parathyroid hormone deficiency after total thyroidectomy: incidence and time. J. Surg. Res. 163, 69–71 (2010).

    Article  CAS  Google Scholar 

  15. Leyre, P. et al. Does the risk of compressive hematoma after thyroidectomy authorize 1-day surgery? Langenbecks Arch. Surg. 393, 733–737 (2008).

    Article  Google Scholar 

  16. Shaha, A. R., Shah, J. P. & Loree, T. R. Differentiated thyroid cancer presenting initially with distant metastasis. Am. J. Surg. 174, 474–476 (1997).

    Article  CAS  Google Scholar 

  17. Sanders, L. E. & Cady, B. Differentiated thyroid cancer: reexamination of risk groups and outcome of treatment. Arch. Surg. 133, 419–425 (1998).

    Article  CAS  Google Scholar 

  18. Barney, B. M., Hitchcock, Y. J., Sharma, P., Shrieve, D. C. & Tward, J. D. Overall and cause-specific survival for patients undergoing lobectomy, near-total, or total thyroidectomy for differentiated thyroid cancer. Head Neck 33, 645–649 (2011).

    Article  Google Scholar 

  19. Pitt, S. C., Sippel, R. S. & Chen, H. Contralateral papillary thyroid cancer: does size matter? Am. J. Surg. 197, 342–347 (2009).

    Article  Google Scholar 

  20. Mazeh, H. et al. Multifocality in well-differentiated thyroid carcinomas calls for total thyroidectomy. Am. J. Surg. 201, 770–775 (2011).

    Article  Google Scholar 

  21. Mazzaferri, E. L. What is the optimal initial treatment of low-risk papillary thyroid cancer (and why is it controversial)? Oncology (Williston Park) 23, 579–588 (2009).

    Google Scholar 

  22. Mendelsohn, A. H., Elashoff, D. A., Abemayor, E. & St. John, M. A. Surgery for papillary thyroid carcinoma: is lobectomy enough? Arch. Otolaryngol. Head Neck Surg. 136, 1055–1061 (2010).

    Article  Google Scholar 

  23. Iyer, N. G. & Shaha, A. R. Management of thyroid nodules and surgery for differentiated thyroid cancer. Clin. Oncol. (R. Coll. Radiol.) 22, 405–412 (2010).

    Article  CAS  Google Scholar 

  24. Cross, S., Wei, J. P., Kim, S. & Brams, D. M. Selective surgery and adjuvant therapy based on risk classifications of well-differentiated thyroid cancer. J. Surg. Oncol. 94, 678–682 (2006).

    Article  CAS  Google Scholar 

  25. Shah, J. P. et al. Prognostic factors in differentiated carcinoma of the thyroid gland. Am. J. Surg. 164, 658–661 (1992).

    Article  CAS  Google Scholar 

  26. Dean, D. S. & Hay, I. D. Prognostic indicators in differentiated thyroid carcinoma. Cancer Control 7, 229–239 (2000).

    Article  CAS  Google Scholar 

  27. Pasieka, J. L. et al. Addition of nuclear DNA content to the AMES risk-group classification for papillary thyroid cancer. Surgery 112, 1154–1159 (1992).

    CAS  PubMed  Google Scholar 

  28. Hedinger, C., Wiliams, E. D. & Sobin, L. H. in International Histological Classification of Tumors 1–18 (WHO, Geneva, 1988).

    Google Scholar 

  29. Davies, L., Ouellette, M., Hunter, M. & Welch, H. G. The increasing incidence of small thyroid cancers: where are the cases coming from? Laryngoscope 120, 2446–2451 (2010).

    Article  Google Scholar 

  30. Hughes, D. T., Haymart, M. R., Miller, B. S., Gauger, P. G. & Doherty, G. M. The most commonly occurring papillary thyroid cancer in the United States is now a microcarcinoma in a patient older than 45 years. Thyroid 21, 231–236 (2011).

    Article  Google Scholar 

  31. Hay, I. D. et al. Papillary thyroid microcarcinoma: a study of 900 cases observed in a 60-year period. Surgery 144, 980–987 (2008).

    Article  Google Scholar 

  32. Chow, S. M. et al. Papillary microcarcinoma of the thyroid—prognostic significance of lymph node metastasis and multifocality. Cancer 98, 31–40 (2003).

    Article  Google Scholar 

  33. Giordano, D., Gradoni, P., Oretti, G., Molina, E. & Ferri, T. Treatment and prognostic factors of papillary thyroid microcarcinoma. Clin. Otolaryngol. 35, 118–124 (2010).

    Article  CAS  Google Scholar 

  34. Ito, Y. et al. An observation trial without surgical treatment in patients with papillary microcarcinoma of the thyroid. Thyroid 13, 381–387 (2003).

    Article  Google Scholar 

  35. Mercante, G. et al. Prognostic factors affecting neck lymph node recurrence and distant metastasis in papillary microcarcinoma of the thyroid: results of a study in 445 patients. Thyroid 19, 707–716 (2009).

    Article  CAS  Google Scholar 

  36. Ito, Y. & Miyauchi, A. Appropriate treatment for asymptomatic papillary microcarcinoma of the thyroid. Expert Opin. Pharmacother. 8, 3205–3215 (2007).

    Article  CAS  Google Scholar 

  37. Ito, Y. et al. Clinical significance of metastasis to the central compartment from papillary microcarcinoma of the thyroid. World J. Surg. 30, 91–99 (2006).

    Article  Google Scholar 

  38. Roti, E. et al. Clinical and histological characteristics of papillary thyroid microcarcinoma: results of a retrospective study in 243 patients. J. Clin. Endocrinol. Metab. 91, 2171–2178 (2006).

    Article  CAS  Google Scholar 

  39. Arora, N. et al. Identification of borderline thyroid tumors by gene expression array analysis. Cancer 115, 5421–5431 (2009).

    Article  CAS  Google Scholar 

  40. Dunki-Jacobs, E., Grannan, K., McDonough, S. & Engel, A. M. Clinically unsuspected papillary microcarcinomas of the thyroid: a common finding with favorable biology? Am. J. Surg. doi: 10.1016/j.amjsurg.2010.12.008.

  41. Pellegriti, G. et al. Clinical behavior and outcome of papillary thyroid cancers smaller than 1.5 cm in diameter: study of 299 cases. J. Clin. Endocrinol. Metab. 89, 3713–3720 (2004).

    Article  CAS  Google Scholar 

  42. Yu, X. M., Wan, Y., Sippel, R. S. & Chen, H. Should all papillary thyroid microcarcinomas be aggressively treated? An analysis of 18,445 cases. Ann. Surg. doi: 10.1097/SLA.0b013e318230036d.

  43. Roh, J. L., Kim, J. M. & Park, C. I. Central lymph node metastasis of unilateral papillary thyroid carcinoma: patterns and factors predictive of nodal metastasis, morbidity, and recurrence. Ann. Surg. Oncol. 18, 2245–2250 (2011).

    Article  Google Scholar 

  44. Fritze, D. & Doherty, G. M. Surgical management of cervical lymph nodes in differentiated thyroid cancer. Otolaryngol. Clin. North Am. 43, 285–300 (2010).

    Article  Google Scholar 

  45. Bardet, S. et al. Macroscopic lymph-node involvement and neck dissection predict lymph-node recurrence in papillary thyroid carcinoma. Eur. J. Endocrinol. 158, 551–560 (2008).

    Article  CAS  Google Scholar 

  46. Mazzaferri, E. L., Doherty, G. M. & Steward, D. L. The pros and cons of prophylactic central compartment lymph node dissection for papillary thyroid carcinoma. Thyroid 19, 683–689 (2009).

    Article  Google Scholar 

  47. Sywak, M. et al. Routine ipsilateral level VI lymphadenectomy reduces postoperative thyroglobulin levels in papillary thyroid cancer. Surgery 140, 1000–1005 (2006).

    Article  Google Scholar 

  48. Pereira, J. A. et al. Nodal yield, morbidity, and recurrence after central neck dissection for papillary thyroid carcinoma. Surgery 138, 1095–1100 (2005).

    Article  Google Scholar 

  49. Bozec, A. et al. Clinical impact of cervical lymph node involvement and central neck dissection in patients with papillary thyroid carcinoma: a retrospective analysis of 368 cases. Eur. Arch. Otorhinolaryngol. 268, 1205–1212 (2011).

    Article  Google Scholar 

  50. So, Y. K., Seo, M. Y. & Son, Y. I. Prophylactic central lymph node dissection for clinically node-negative papillary thyroid microcarcinoma: Influence on serum thyroglobulin level, recurrence rate, and postoperative complications. Surgery doi: 10.1016/j.surg.2011.02.004.

  51. Rosenbaum, M. A. & McHenry, C. R. Central neck dissection for papillary thyroid cancer. Arch. Otolaryngol. Head Neck Surg. 135, 1092–1097 (2009).

    Article  Google Scholar 

  52. Ito, Y. et al. Risk factors for recurrence to the lymph node in papillary thyroid carcinoma patients without preoperatively detectable lateral node metastasis: validity of prophylactic modified radical neck dissection. World J. Surg. 31, 2085–2091 (2007).

    Article  Google Scholar 

  53. White, M. L., Gauger, P. G. & Doherty, G. M. Central lymph node dissection in differentiated thyroid cancer. World J. Surg. 31, 895–904 (2007).

    Article  Google Scholar 

  54. Eichhorn, W. et al. Prognostic factors determining long-term survival in well-differentiated thyroid cancer: an analysis of four hundred eighty-four patients undergoing therapy and aftercare at the same institution. Thyroid 13, 949–958 (2003).

    Article  Google Scholar 

  55. Xing, M. Prognostic utility of BRAF mutation in papillary thyroid cancer. Mol. Cell Endocrinol. 321, 86–93 (2010).

    Article  CAS  Google Scholar 

  56. Nikiforov, Y. E. Molecular diagnostics of thyroid tumors. Arch. Pathol. Lab. Med. 135, 569–577 (2011).

    CAS  PubMed  Google Scholar 

  57. Melck, A. L., Yip, L. & Carty, S. E. The utility of BRAF testing in the management of papillary thyroid cancer. Oncologist 15, 1285–1293 (2010).

    Article  Google Scholar 

  58. Scheumann, G. F., Gimm, O., Wegener, G., Hundeshagen, H. & Dralle, H. Prognostic significance and surgical management of locoregional lymph node metastases in papillary thyroid cancer. World J. Surg. 18, 559–567 (1994).

    Article  CAS  Google Scholar 

  59. Pacini, F. et al. European consensus for the management of patients with differentiated thyroid carcinoma of the follicular epithelium. Eur. J. Endocrinol. 154, 787–803 (2006).

    Article  CAS  Google Scholar 

  60. Burkey, S. H. et al. Reexploration for symptomatic hematomas after cervical exploration. Surgery 130, 914–920 (2001).

    Article  CAS  Google Scholar 

  61. Steckler, R. M. Outpatient thyroidectomy: a feasibility study. Am. J. Surg. 152, 417–419 (1986).

    Article  CAS  Google Scholar 

  62. Inabnet, W. B., Shifrin, A., Ahmed, L. & Sinha, P. Safety of same day discharge in patients undergoing sutureless thyroidectomy: a comparison of local and general anesthesia. Thyroid 18, 57–61 (2008).

    Article  Google Scholar 

  63. Tuggle, C. T., Roman, S., Udelsman, R. & Sosa, J. A. Same-day thyroidectomy: a review of practice patterns and outcomes for 1,168 procedures in New York State. Ann. Surg. Oncol. 18, 1035–1040 (2011).

    Article  Google Scholar 

  64. Snyder, S. K. et al. Outpatient thyroidectomy is safe and reasonable: experience with more than 1,000 planned outpatient procedures. J. Am. Coll. Surg. 210, 575–582 (2010).

    Article  Google Scholar 

  65. Sitges-Serra, A. et al. Outcome of protracted hypoparathyroidism after total thyroidectomy. Br. J. Surg. 97, 1687–1695 (2010).

    Article  CAS  Google Scholar 

  66. Sippel, R. S., Ozgul, O., Hartig, G. K., Mack, E. A. & Chen, H. Risks and consequences of incidental parathyroidectomy during thyroid resection. ANZ J. Surg. 77, 33–36 (2007).

    Article  Google Scholar 

  67. Brunaud, L. et al. Incision length for standard thyroidectomy and parathyroidectomy: when is it minimally invasive? Arch. Surg. 138, 1140–1143 (2003).

    Article  Google Scholar 

  68. Huscher, C. S., Chiodini, S., Napolitano, C. & Recher, A. Endoscopic right thyroid lobectomy. Surg. Endosc. 11, 877 (1997).

    Article  CAS  Google Scholar 

  69. Miccoli, P., Berti, P., Conte, M., Bendinelli, C. & Marcocci, C. Minimally invasive surgery for thyroid small nodules: preliminary report. J. Endocrinol. Invest. 22, 849–851 (1999).

    Article  CAS  Google Scholar 

  70. Terris, D. J., Angelos, P., Steward, D. L. & Simental, A. A. Minimally invasive video-assisted thyroidectomy: a multi-institutional North American experience. Arch. Otolaryngol. Head Neck Surg. 134, 81–84 (2008).

    Article  Google Scholar 

  71. Miccoli, P. et al. Surgical treatment of low- and intermediate-risk papillary thyroid cancer with minimally invasive video-assisted thyroidectomy. J. Clin. Endocrinol. Metab. 94, 1618–1622 (2009).

    Article  CAS  Google Scholar 

  72. Wilhelm, T. & Metzig, A. Endoscopic minimally invasive thyroidectomy (eMIT): a prospective proof-of-concept study in humans. World J. Surg. 35, 543–551 (2011).

    Article  Google Scholar 

  73. Kang, S. W. et al. Robot-assisted endoscopic surgery for thyroid cancer: experience with the first 100 patients. Surg. Endosc. 23, 2399–2406 (2009).

    Article  Google Scholar 

  74. Henry, J. F. Minimally invasive thyroid and parathyroid surgery is not a question of length of the incision. Langenbecks Arch. Surg. 393, 621–626 (2008).

    Article  Google Scholar 

  75. Ryu, H. R. et al. Feasibility and safety of a new robotic thyroidectomy through a gasless, transaxillary single-incision approach. J. Am. Coll. Surg. 211, e13–e19 (2010).

    Article  Google Scholar 

  76. Berber, E. et al. Robotic transaxillary thyroidectomy: report of 2 cases and description of the technique. Surg. Laparosc. Endosc. Percutan. Tech. 20, e60–e63 (2010).

    Article  Google Scholar 

  77. Landry, C. S., Grubbs, E. G. & Perrier, N. D. Bilateral robotic-assisted transaxillary surgery. Arch. Surg. 145, 717–720 (2010).

    Article  Google Scholar 

  78. Kuppersmith, R. B. & Holsinger, F. C. Robotic thyroid surgery: An initial experience with North American patients. Laryngoscope 121, 521–526 (2011).

    Article  Google Scholar 

  79. Perrier, N. D. et al. Robotic thyroidectomy: a framework for new technology assessment and safe implementation. Thyroid 20, 1327–1332 (2010).

    Article  Google Scholar 

  80. Dhiman, S. V. & Inabnet, W. B. Minimally invasive surgery for thyroid diseases and thyroid cancer. J. Surg. Oncol. 97, 665–668 (2008).

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Section of Endocrine Surgery, University of Wisconsin, K3/705 Clinical Science Center, 600 Highland Avenue, Madison, 53792, WI, USA

    Haggi Mazeh & Herbert Chen

Authors
  1. Haggi Mazeh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Herbert Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

H. Mazeh researched the data for the article. Both authors wrote the article, and provided substantial contributions to discussions of the content, as well as to review and/or editing of the manuscript before submission.

Corresponding author

Correspondence to Haggi Mazeh.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Mazeh, H., Chen, H. Advances in surgical therapy for thyroid cancer. Nat Rev Endocrinol 7, 581–588 (2011). https://doi.org/10.1038/nrendo.2011.140

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrendo.2011.140

This article is cited by

Search

Advanced search

Quick links

Nature Briefing: Cancer

Sign up for the Nature Briefing: Cancer newsletter — what matters in cancer research, free to your inbox weekly.

Get what matters in cancer research, free to your inbox weekly. Sign up for Nature Briefing: Cancer