Controversies in the Surgical Management of Newly Diagnosed and Recurrent/Residual Thyroid Cancer

Background: Thyroid surgery is the mainstay of treatment for thyroid cancer, but there are options for the surgical approach. There is a general agreement that the goal of thyroid cancer surgery is to remove evident disease, minimize treatment and disease-related morbidity, minimize the risk of recurrence and metastatic spread, and facilitate long-term follow-up. Within these parameters, however, there are a number of controversies regarding the extent of surgery. Summary: To minimize the risk of recurrence and to optimize the treatment of patients with thyroid cancer, a total thyroidectomy should be performed as the initial operation if the preoperative diagnosis is consistent with thyroid cancer. Macroscopic lymph node involvement does impact recurrence and may influence survival. Therefore, a preoperative ultrasound evaluation of the neck is essential before operative intervention. If pathologic nodes are identified in either the central or lateral neck they should be removed at the initial operation. The role of prophylactic central neck dissection remains controversial, and the risks of this procedure may outweigh the benefits. Therefore, we do not recommend the routine performance of a central neck dissection. Similar to the recent American Thyroid Association guidelines, we agree that their may be a subset of high-risk patients who may benefit from a prophylactic central neck dissection, but that population has yet to be defined. The extent of lateral dissection that is required is also debated as levels 1 and 5 lymph node involvement is uncommon with thyroid cancer. Recurrent disease can be challenging to remove, but several adjuncts are available to maximize the safety and efficacy of reoperation, making it the best option for patients with localized recurrences. Conclusions: Total thyroidectomy and neck dissection are very safe procedures when performed by experienced surgeons and can play an essential role in the management of patients with thyroid cancer.