Extent of Surgery for Papillary Thyroid Cancer

Main debate centres around management for T2 (1-4cm) tumors with no evidence of metastases

Aggressive surgical therapy (Hay/Mayo Clinic):
- microscopic disease present in both lobes regardless of whether macroscopic disease evident bilaterally
- disease is aggressive in certain subpopulations: older men, pts with large tumors, tumors that have invaded adjacent structures

Hay et al, WJS 2002:
- retrospective review from 1940's to present time.
- trend in 1940's to perform lobectomy yielded higher cause-specific mortality and tumor-recurrence (14% vs. 2%) as compared to 1950's and beyond where total thyroidectomy was favoured.
- addition of radioiodine remnant ablation in past few decades has not made a difference in mortality or recurrence.
Conclusion: near-total thyroidectomy and conservative nodal excision favoured management for papillary thyroid ca

Conservative surgical therapy:
- likelihood pt will develop clinically evident disease after lobectomy is only 5%
- recurrent disease can be managed by completion thyroidectomy
- majority of thyroid carcinomas grow slowly, few patients die from disease
- complications of total thyroidectomy (higher in inexperienced surgeon's hands)

Central compartment LN:

- involved in 50-80% of cases

Current NCCN guidelines recommends (2001):
- Total thyroidectomy
- if LN involved: bilateral central compartment LN dissection +/- lateral modified radical LN dissection
- ?do new guidelines advocated routine central compartment LN dissection that most people are doing?