Optimal Extent of Surgery for Papillary Thyroid Carcinoma

ABSTRACT

The goal of thyroid cancer surgery is the complete removal of the cancer, verification that patients receive appropriate treatment through accurate staging after surgery, minimization of local recurrence, and improvement of survival rate. However, maintaining the patient’s functional outcome and quality of life by minimizing postoperative complications as well as having good oncological outcomes is also important. To determine the optimal surgical extent, appropriate diagnosis and evaluation should be made on age, gender, tumor size, multiplicity, extrathyroidal extension, lymph node/distant metastasis, and biologic aggressiveness. In the low-risk group, lobectomy is required, and experienced high-volume surgeons may consider ipsilateral prophylactic central lymph node dissection because of the acceptable risk of hypoparathyroidism. In the intermediate-risk group, personalized decision-making should be determined according to the patient’s preferences and characteristics while also considering the pros and cons of lobectomy or total thyroidectomy. For the patient with high-risk factors, total thyroidectomy is considered. However, if a total thyroidectomy is not absolutely necessary and complications are expected, lobectomy could be a second option. If the patient has central lymph node metastasis, a therapeutic central lymph node dissection must be performed, and in the case of high-risk groups (T3/4 and N1b), ipsilateral prophylactic node dissection should be considered, and the contralateral parathyroid gland should be preserved. In the high-risk group (especially with massive ipsilateral lymph node metastasis or gross extrathyroidal involvement), the surgeon may consider bilateral central lymph node dissection if the ipsilateral parathyroid gland and the recurrent laryngeal nerve are well preserved, because of the risk of contralateral lymph node metastasis.