Thyroid Cancer Surgical Practice Guidelines
Thyroid Cancer Surgical Practice Guidelines
The Society of Surgical Oncology surgical practice guidelines focus
on the signs and symptoms of primary cancer, timely evaluation of the symptomatic
patient, appropriate preoperative evaluation for extent of disease, and
role of the surgeon in diagnosis and treatment. Separate sections on adjuvant
therapy, follow-up programs, or management of recurrent cancer have been
intentionally omitted. Where appropriate, perioperative adjuvant combined-modality
therapy is discussed under surgical management. Each guideline is presented
in minimal outline form as a delineation of therapeutic options.
Since the development of treatment protocols was not the specific aim
of the Society, the extensive development cycle necessary to produce evidence-based
practice guidelines did not apply. We used the broad clinical experience
residing in the membership of the Society, under the direction of Alfred
M. Cohen, MD, Chief, Colorectal Service, Memorial Sloan-Kettering Cancer
Center, to produce guidelines that were not likely to result in significant
Following each guideline is a brief narrative highlighting and expanding
on selected sections of the guideline document, with a few relevant references.
The current staging system for the site and approximate 5-year survival
data are also included.
The Society does not suggest that these guidelines replace good medical
judgment. That always comes first. We do believe that the family physician,
as well as the health maintenance organization director, will appreciate
the provision of these guidelines as a reference for better patient care.
Symptoms and Signs
- Early-stage disease
- Mass in the thyroid region
- Presence of enlarged lymph node in the supraclavicular region
- Vague pain or discomfort in the thyroid region
- Advanced-stage disease
- Cervical lymphadenopathy
- Large mass in the thyroid region
- Rapidly increasing thyroid nodule
- Change in voice
- Difficulty in breathing
- Difficulty in swallowing
Evaluation of the Symptomatic Patient
- Clinical evaluation, physical examination, complete head and neck examination,
including indirect laryngoscopy
- Risk factor analysis
- Fine-needle aspiration (FNA)
- Ancillary diagnostic work-up if necessary
- Thyroid function tests
- Ultrasound, thyroid scan, and CT scan in selected patients
- Appropriate timeliness of surgical referral
- Initial work-up should include a thorough and detailed clinical examination
and evaluation of the physical findings.
- FNA should be considered the first diagnostic test.
- Evaluation of a solitary thyroid nodule
- If FNA is benign, begin levothyroxine for 3 to 6 months.
- If lesion regresses or is unchanged, follow clinically.
- If lesion increases in size, operate.
- If scan reveals a "cold" nodule, operate.
- If scan reveals a "hot" nodule, observe.
Preoperative Evaluation for Extent of Disease
- Physical examination
- Indirect laryngoscopy
- Chest x-ray
- Baseline thyroglobulin for papillary cancer and calcitonin
for medullary cancer
Role of the Surgeon in Initial Management
- Evaluation of the symptomatic patient
- Clinical examination
- Indirect laryngoscopy with fiberoptic laryngoscope if necessary
- FNA of the neck or thyroid mass
- Chest x-ray for evaluation of the airway
- Diagnostic procedures
- Surgical considerations: well-differentiated (papillary and follicular)
- Risk group analysis is very helpful.
- Extracapsular extent of disease and tumor Size (AGES)
- Presence of distant Metastasis
- Extracapsular spread of disease and tumor Size (AMES)
- Lobectomy and isthmectomy
- Subtotal thyroidectomy
- Near total thyroidectomy
- Total thyroidectomy
- Modified neck dissection in selected patients
- Surgical considerations: medullary carcinoma of the thyroid
- Total thyroidectomy with appropriate neck dissection should be performed
if nodes are clinically palpable.
- Central compartment clearance is extremely important.
- Surgical considerations: anaplastic thyroid cancer
- Diagnosis can be made based on clinical suspicion of a rapidly growing
mass, age of the patient, unusual symptoms, a rapidly growing mass in the
central compartment of the neck and fixed to the surrounding structures,
and airway problems.
- FNA will raise suspicion of anaplastic thyroid cancer.
- Confirmation of the diagnosis can be made by either open biopsy or
Tru-cut needle biopsy (core biopsy).
- Treatment should consists of the combination of chemotherapy (including
doxorubicin) and external radiation therapy.
- The role of surgery is very limited.
- Occasional patients may need a tracheostomy. (Most of these patients
will do very poorly.)
These guidelines are copyrighted by the Society of Surgical Oncology
(SSO). All rights reserved. These guidelines may not be reproduced in any
form without the express written permission of SSO. Requests for reprints
should be sent to: James R. Slawny, Executive Director, Society of Surgical
Oncology, 85 West Algonquin Road, Arlington Heights, IL 60005.
Although thyroid cancer is not of the more common tumors, it accounts
for 90 % of tumors originating in the endocrine glands. Approximately 16,000
patients with thyroid cancer are seen every year, and 1,200 patients die
from this cancer annually.
The most important risk factor for thyroid cancer is a history of radiation
to the neck. The most common indications for neck irradiation include acne
and other skin conditions and an enlarged tonsil or thymus. The incidence
of thyroid cancer is slightly higher in patients with Graves' disease and
There are four main types of thyroid cancer: papillary, follicular,
medullary, and anaplastic. The differentiated thyroid cancers (papillary
and follicular) account for less than 90% of all thyroid malignancies,
while medullary and anaplastic represent 5% to 10% and greater than 5%
of cases, respectively. Hurthle cell cancers were formerly included
in the differentiated group, but the World Health Organization has eliminated
Hurthle cell tumor as a separate category and included it as a variant
of follicular thyroid cancer.
Papillary cancer is more common in younger individuals (those in the
second and third decades of life), while anaplastic thyroid cancer is uniformly
seen in the sixth and seventh decades. Follicular cancer is more common
in endemic regions, such as Europe. The majority (approximately 80%) of
patients with medullary cancer have a sporadic form of the disease, and
the remaining 20% have familial disease.
The most common presentation is an asymptomatic mass in the thyroid
region. Occasional patients, particularly those 20 to 35 years old or those
over age 60, may present with enlarged supraclavicular lymph nodes.
Patients with advanced-stage disease may present with massive cervical
lymphadenopathy, a large, fixed mass in the thyroid region, or a change
in voice. Occasionally, the patient may exhibit difficulty in breathing
or swallowing on presentation.