THE CONTEXT
Surgery balances removal of macroscopic disease, reduction of recurrence and minimization of morbidity. Risk assessment guides the extent of surgery and use of radioactive iodine.
Treatment aims and evidence
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For most patients, outcomes are excellent irrespective of the extent of surgery.
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Low numbers of recurrences and deaths make prospective trials difficult, and few such trials exist.
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The surgical aims are to remove macroscopic disease, reduce recurrence and minimize surgical morbidity.
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Radioactive iodine is rarely indicated in low-risk cases but is used almost universally in high-risk patients.
Extent of thyroid surgery
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High-risk patients with nodal or distant metastases undergo total thyroidectomy to eradicate thyroid disease and prepare for radioactive iodine.
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Low-risk patients with a single focus confined to the thyroid can be offered thyroid lobectomy.
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Lobectomy protects the contralateral RLN and parathyroid glands and is considered appropriate unless high-risk disease features are present.
Established neck metastases
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Metastatic neck disease requires therapeutic compartment-orientated neck dissection.
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The central or lateral compartment is treated according to the site of involvement.