Surgical approaches in thyroid cancer and lymph-node metastases

Thyroid cancer collectively encompasses a variety of tumors of disparate morphology and biology. With the exception of radio-iodine therapy for iodine-concentrating well-differentiated thyroid cancers, surgery is the foremost and generally sole effective treatment. Because the growth patterns of these tumors vary tremendously, there is a need to tailor the extent of dissection to the respective tumor entity, especially for less aggressive tumors. No international consensus exists about what precisely constitutes a ‘low-risk’ or ‘high-risk’ tumor. Established indications for less-than-total thyroidectomy include small (≤1 cm), unifocal, and non-metastatic papillary thyroid carcinomas (PTC), and minimally invasive follicular thyroid carcinomas (FTC; invasion of the tumor capsule only). Whether occult multifocal PTC and minimally invasive FTC with histopathological evidence of vascular invasion also fall into the ‘low-risk’ category remains unclear. For node-positive thyroid cancers, compartment-oriented microdissection is the gold standard of care, whereas the concept of prophylactic lymph-node dissection continues to arouse controversy. Most experts agree that routine lymph-node dissection is unnecessary for low-risk well-differentiated thyroid cancer (DTC). Because occult lymph-node metastases are frequent in high-risk PTC and medullary thyroid carcinoma, compartment-oriented microdissection helps prevent reoperations for ‘recurrences’ arising from residual nodes, sparing patients the excess morbidity from reoperations in the neck. Because of the looming epidemic of early forms of thyroid cancer, an international consensus is needed regarding (1) the definition of low- versus high-risk tumors; (2) classification of neck nodes; and (3) lymph-node dissection terminology.