Minimally Invasive Surgery of the Thyroid Workup

  • Author: Jagdish K Dhingra, MBBS, FRCS, FRCS(Edin), MS; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Jun 7, 2011
 

Laboratory Studies

Serum thyrotropin (TSH) is recommended for a thyroid nodule larger than 10-15 mm.[2]

Serum thyroglobulin and calcitonin are additional tests that can be performed if other thyroid conditions or medullary carcinoma of the thyroid (MCT) are suspected.

A full thyroid-function panel that includes TSH levels and free T3 and T4 levels can be performed if a clinical suspicion of hypothyroidism or hyperthyroidism exists.

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Imaging Studies

Thyroid ultrasonography (US) is the initial imaging modality of choice for suspicion of one or more thyroid nodules.[2]

CT, MRI, and positron emission tomography (PET) are adjunctive imaging modalities that can be used to assess cervical lymph node involvement for staging purposes. CT scanning and MRI can also reveal invasion of adjacent structures and airway compression and gauge the extent of substernal extension for large goiters.

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Other Tests

Radionuclide scanning (thyroid scintigraphy or iodine-131 uptake scan) can be used to diagnose an autonomously functioning or “hot” nodule. Lack of uptake or “cold” nodules have a malignant risk of 5-8%.[3]

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Diagnostic Procedures

Fine-needle aspiration (FNA) is the initial diagnostic procedure of choice. FNA can be performed under palpation or with US guidance. Nondiagnostic or inadequate FNA by palpation should be repeated with US guidance.

FNA is usually performed with a 27- or 25-gauge, 1.5-inch needle placed on a syringe. Once the needle has been inserted into the nodule, gentle suction is applied to the syringe; multiple passes are made within the nodule. Suction is then released prior to removing the needle from the nodule. The procedure is repeated 2-4 times and slides are prepared. Having a cytopathologist available for slide preparation to check on the adequacy of the sample is useful.

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Histologic Findings

FNA results, which are diagnostic, are most commonly benign. The most common benign diagnosis is a colloid nodule.[3]

Follicular neoplasms on FNA are hypercellular, low in colloid, and show microfollicular arrangement. Hürthle cell carcinoma is a variant of follicular carcinoma with a prominence of Hürthle cells.

The most frequent malignant lesion on FNA is papillary thyroid carcinoma (PTC). Histology shows tumor cells arranged in sheets, papillary cell groups, and nuclear abnormalities.

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Staging

The American Joint Committee on Cancer has devised the following staging system:[9]

  • Primary tumor (T)
    • TX: The primary tumor cannot be assessed.
    • T0: No evidence of a primary tumor is found.
    • T1: The tumor is 2 cm or less in its greatest dimension (limited to the thyroid).
    • T2: The tumor is larger than 2 cm but 4 cm or smaller in its greatest dimension (limited to the thyroid).
    • T3: The tumor is larger than 4 cm in its greatest dimension (limited to the thyroid), or a tumor with minimal extrathyroid extension is found (eg, extension to the sternothyroid muscle or perithyroid soft tissues).
    • T4a: A tumor of any size extends beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve.
    • T4b: A tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels.
  • Regional lymph nodes (N)
    • NX: The regional lymph nodes cannot be assessed.
    • N0: No regional lymph node metastasis is found.
    • N1: Regional lymph node metastasis is found.
      • N1a: The metastasis has reached level VI (pretracheal, paratracheal, prelaryngeal/Delphian lymph nodes).
      • N1b: The metastasis has reached unilateral or bilateral cervical or superior mediastinal lymph nodes.
  • Distant metastasis (M)
    • MX: A distant metastasis cannot be assessed.
    • M0: No distant metastasis is found.
    • M1: A distant metastasis is found.

Papillary or follicular thyroid cancer staging is as follows:

  • Patients younger than 45 years
    • Stage I is any T, any N, and M0.
    • Stage II is any T, any N, and M1.
  • Patients aged 45 years or older
    • Stage I is T1, N0, and M0.
    • Stage II is T2, N0, and M0.
    • Stage III is one of the following:
      • T3, N0, and M0
      • T1, N1a, and M0
      • T2, N1a, and M0
      • T3, N1a, and M0
    • Stage IVA is one of the following:
      • T4a, N0, and M0
      • T4a, N1a, and M0
      • T1, N1b, and M0
      • T2, N1b, and M0
      • T3, N1b, and M0
      • T4a, N1b, and M0
    • Stage IVB is T4b, any N, and M0.
    • Stage IVC is any T, any N, and M1.
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Contributor Information and Disclosures
Author

Jagdish K Dhingra, MBBS, FRCS, FRCS(Edin), MS  Clinical Assistant Professor, Department of Otolaryngology, Tufts University School of Medicine; Partner and Director, ENT Specialists, Inc

Jagdish K Dhingra, MBBS, FRCS, FRCS(Edin), MS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, Massachusetts Medical Society, Royal College of Surgeons of Edinburgh, and Royal College of Surgeons of England

Disclosure: Nothing to disclose.

Coauthor(s)

Tejas Raval, MD  Resident Physician, Department of Otolaryngology, Tufts-New England Medical Center

Tejas Raval, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Benoit J Gosselin, MD, FRCSC  Associate Professor of Surgery, Dartmouth Medical School; Director, Comprehensive Head and Neck Oncology Program, Norris Cotton Cancer Center; Staff Otolaryngologist, Division of Otolaryngology-Head and Neck Surgery, Dartmouth-Hitchcock Medical Center

Benoit J Gosselin, MD, FRCSC is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, American Medical Association, American Rhinologic Society, Canadian Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, College of Physicians and Surgeons of Ontario, New Hampshire Medical Society, North American Skull Base Society, and Ontario Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Karen Hall Calhoun, MD  William E Davis Professor and Chair, Department of Otolaryngology-Head and Neck Surgery, University of Missouri-Columbia School of Medicine

Karen Hall Calhoun, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Medical Association, American Rhinologic Society, Association for Research in Otolaryngology, Society of University Otolaryngologists-Head and Neck Surgeons, Southern Medical Association, Texas Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Christopher L Slack, MD  Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

References

  1. Terris DJ, Bonnett A, Gourin CG, Chin E. Minimally invasive thyroidectomy using the Sofferman technique. Laryngoscope. Jun 2005;115(6):1104-8. [Medline].

  2. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, et al. Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. Feb 2006;16(2):109-42. [Medline].

  3. American Association of Clinical Endocrinologists and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. Endocr Pract. Jan-Feb 2006;12(1):63-102. [Medline].

  4. Jemal A, Murray T, Ward E, Samuels A, Tiwari RC, Ghafoor A, et al. Cancer statistics, 2005. CA Cancer J Clin. Jan-Feb 2005;55(1):10-30. [Medline].

  5. Frates MC, Benson CB, Charboneau JW, Cibas ES, Clark OH, Coleman BG, et al. Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology. Dec 2005;237(3):794-800. [Medline].

  6. Lombardi CP, Raffaelli M, Princi P, Lulli P, Rossi ED, Fadda G, et al. Safety of video-assisted thyroidectomy versus conventional surgery. Head Neck. Jan 2005;27(1):58-64. [Medline].

  7. Lombardi CP, Raffaelli M, Princi P, De Crea C, Bellantone R. Video-assisted thyroidectomy: report on the experience of a single center in more than four hundred cases. World J Surg. May 2006;30(5):794-800; discussion 801. [Medline].

  8. Ruggieri M, Straniero A, Genderini M, D'Armiento M, Fumarola A, Trimboli P, et al. The size criteria in minimally invasive video-assisted thyroidectomy. BMC Surg. Jan 25 2007;7:2. [Medline].

  9. American Joint Committee on Cancer. AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer; 2002:77-87. [Full Text].

  10. Lee S, Ryu HR, Park JH, et al. Excellence in robotic thyroid surgery: a comparative study of robot-assisted versus conventional endoscopic thyroidectomy in papillary thyroid microcarcinoma patients. Ann Surg. Jun 2011;253(6):1060-6. [Medline].

  11. [Best Evidence] Hong JY, Kim WO, Chung WY, Yun JS, Kil HK. Paracetamol reduces postoperative pain and rescue analgesic demand after robot-assisted endoscopic thyroidectomy by the transaxillary approach. World J Surg. Mar 2010;34(3):521-6. [Medline]. [Full Text].

  12. Dionigi G, Boni L, Rovera F, Rausei S, Dionigi R. Wound morbidity in mini-invasive thyroidectomy. Surg Endosc. Jan 2011;25(1):62-7. [Medline].

  13. Miccoli P, Berti P, Raffaelli M, Materazzi G, Baldacci S, Rossi G. Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: a prospective randomized study. Surgery. Dec 2001;130(6):1039-43. [Medline].

 
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Miccoli instrument set designed for MIVAT.
Endoscope and harmonic scalpel.
Patient position. Note the limited neck extension as compared with conventional thyroidectomy.
Incision location.
MIVAT incision length.
Video-assisted dissection of the right superior pole.
Identification of the recurrent laryngeal nerve during video-assisted right thyroid lobectomy. A parathyroid gland is also identified.
Surgical scar at 2 weeks.
Surgical scar at 6 weeks.
Minimally invasive thyroidectomy; identification of the recurrent laryngeal nerve.
Minimally invasive thyroidectomy closure.
Minimally invasive thyroidectomy; division of isthmus and delivery.
Minimally invasive thyroidectomy; incision and exposure.
Minimally invasive thyroidectomy; initial dissection.
Minimally invasive thyroidectomy; superior pole release.
 
 
 
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