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Thyroid Cancer Surgical Practice Guidelines

Thyroid Cancer Surgical Practice Guidelines

Scope and Format of 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.

of Surgical Oncology Practice Guidelines: Thyroid Cancer

Symptoms and Signs

    Early-stage disease
  • Asymptomatic
  • 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
  1. 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 FNA shows follicular neoplastic cells, obtain a thyroid scan.
    • If scan reveals a "cold" nodule, operate.
    • If scan reveals a "hot" nodule, observe.
  • If FNA shows malignant or suspicious cells, operate.
  • 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
    • FNA
      Surgical considerations: well-differentiated (papillary and follicular)
      thyroid cancer
    • Risk group analysis is very helpful.
    1. Age
    2. Grade
    3. Extracapsular extent of disease and tumor Size (AGES)
    4. Presence of distant Metastasis
    5. Extracapsular spread of disease and tumor Size (AMES)
  • Surgical procedures
    1. Lobectomy and isthmectomy
    2. Subtotal thyroidectomy
    3. Near total thyroidectomy
    4. Total thyroidectomy
    5. 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.


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