First let’s discuss what each of these surgeries are and then discuss their indication. Below are anatomic diagrams of the neck showing all the relevant structures. In the section following I will show the details of surgeries.

Total Thyroidectomy

Total thyroidectomy involves the removal of the entire thyroid gland through a very small incision (3 cm, or just over an inch). All of the normal surrounding tissue and organs, including the voice box nerves (recurrent & superior laryngeal nerves), the parathyroids, breathing tube, swallowing tube and blood vessels are seen and carefully preserved so that they function normally. In most instances, this surgery is done with an overnight stay. By the following morning the patient may go home. There is no drain and the incision is closed with absorbable sutures under the skin.

The lymph nodes around the the thyroid (central compartment) and further away to the side (lateral compartment) are evaluated before surgery via ultrasound and during surgery. If any abnormality is seen then the lymph nodes below and next to the thyroid then a central compartment neck dissection is also performed. This means all the lymph nodes next to and below the thyroid is removed going from the breathing tube in the middle to the carotid artery to the side, back to the muscle in front of the spine, all the way down to the upper chest; while the whole time recurrent laryngeal RLN is visualized and protected. All of this is done through the same small incision.

Before surgery, at the CENTER Dr. Larian performs an ultrasound himself to look at all the lymph nodes; if any of the lateral compartment lymph nodes appear suspicious then he will perform a needle biopsy to see if there is the spread of cancer to the nodes. If that is the case then in addition to a total thyroidectomy, he will recommend doing both a central & lateral node dissection. This does involve making a longer incision to access the nodes to the side.

Total Thyroidectomy Important Facts

• Total thyroidectomy is a very effective treatment for almost all types, and stages of thyroid cancer.
• Small well hidden cosmetic incision
• In some cases it can be done on an outpatient basis
• As all four parathyroid glands areas are exposed, there is a risk of low parathyroid function. This risk is directly related to the experience of surgeon.
• The voice box nerves are identified on both sides, and to minimize the risk of injury nerve monitoring breathing tubes are used that alert the surgeon when there is any activity close to the nerve. This increases the safety of the surgery.
• Since all of thyroid is removed, there should be no gland to produce thyroid hormones & thryoglobulin
  • All patients will need to start thyroid hormone pills after surgery
  • Thyroglobulin levels can be used to monitor if the cancer has come back
• Return to essentially normal activities and daily functions within a week
• No heavy lifting or exercise for three weeks

Thyroid Lobectomy vs. Total Thyroidectomy Recurrence & Cure Rates

In the past, all people who thyroid cancer were recommended to have a total thyroidectomy. Then researchers looked back at the results and found that 10 year survivals were not significantly different; 97.5% for total thyroidectomy and 98.4% for Lobectomy. There was a small difference in the recurrence rate of thyroid cancer, 9.8% for a lobectomy vs. 7.7% for total thyroidectomy, but that did not seem to impact the ultimate survival rate for the cancer. This means that even though the patients that had a thyroid lobectomy had the tumor come back 2% more then the ones who had a total thyroidectomy, this increased recurrence did not translate into a higher mortality. Or in other words, recurrences can be treated in most cases effectively.

But fortunately there is enough data available to compare size and stage of tumors see the impact on survival for lobectomy vs total thyroidectomy. The data clearly shows that the survival statistics for thyroid cancers that were less then 4cm was significantly better then those that were larger. Therefore all tumors larger then 4cm should be treated with a total thyroidectomy. Other factors that decrease survival probability is extension outside of thyroid, and involvement of multiple lymph nodes. So a lobectomy is most appropriate for a tumor less then 4 cm, that is limited to the thyroid and does not involve lymph nodes.

Radioactive Iodine Treatment (RAI)

Iodine is used by normal thyroid cells to make thyroid hormone. On the surface of thyroid cells there is a channel (called the iodine symporter) that allows iodine to get inside. Both papillary and follicular thyroid cancer cells contain this symporter and therefore concentrate iodine inside of them. Once a person undergoes a total thyroidectomy, if a microscopic amount of thyroid cancer cells is still present, getting radioactive iodine would lead to the radioactive iodine concentrating inside the the cancer cells and leading to their demise. This cannot be done if the person still has half of their thyroid because then the radioactive iodine would mostly concentrate in that remaining half of thyroid gland rather then the small amount of cancer cells. So to be able to use RAI a total thyroidectomy must be done. Approximately 15-20% of the thyroid cancers will require RAI treatment, the rest can be cured with surgery alone.