Elective neck surgery and management after diagnostic lobectomy
THE CONTEXT
When thyroid cancer has no preoperatively detected nodal disease, elective neck surgery is controversial. Management after diagnostic lobectomy also depends on renewed risk assessment.
Elective lateral neck dissection
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Elective lateral neck dissection has been abandoned because it carries significant morbidity.
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Although occult metastases are frequent in papillary thyroid carcinoma, few progress to clinically meaningful disease.
Elective central neck dissection
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Central neck dissection has lower morbidity than lateral dissection, and the central compartment is already opened during thyroidectomy.
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Salvage surgery in the central neck carries a high risk to the RLN and parathyroid glands; this helped make elective central dissection popular.
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Recognition of morbidity from routine central dissection and the lack of evidence that more aggressive surgery improves outcomes have led to a move away from performing it in all patients.
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Patients at highest risk of occult central neck metastases, such as those with extrathyroid extension, are considered most likely to benefit.
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Elective central neck dissection is not routinely recommended in low-risk patients.
Cancer diagnosed after lobectomy
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Risk assessment is critical when thyroid cancer is diagnosed after a diagnostic lobectomy.
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For low-risk patients, further surgery is unlikely to be beneficial, and active surveillance should be considered.
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An approach pioneered in Japan has been adopted in several centres for papillary thyroid carcinomas smaller than 1 cm; only 30% develop tumour growth requiring intervention.
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Larger tumours and younger patients are at higher risk. Radioactive iodine may be recommended, in which case completion thyroidectomy may be required.
Multidisciplinary decisions
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All thyroid cancer cases should be discussed in a multidisciplinary setting because decision making is complex.
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The involved groups include surgeons, endocrinologists, radiologists, cytologists, pathologists and nuclear medicine physicians.