How To Treat Thyroid Cancer with Surgery

Surgery is usually the initial and most important initial thyroid cancer treatment and subsequent thyroid cancer management is done by your endocrinologist. This type of surgery is best performed by an endocrine surgeon or ear-nose-throat doctor trained in head and neck surgery. There is generally a very good chance for complete remission if the tumor is removed before it has spread outside the thyroid gland. Even if the tumor has spread to lymph nodes in the neck, these nodes can be removed. Patients are admitted to the hospital on the day of surgery but usually spend only one night in the hospital after the operation. However, patients traveling to Houston from out of town should plan to stay at least five days after surgery. During an outpatient visit before surgery, patients are instructed about taking regular medications and when to stop eating and drinking before surgery. Patients will also meet with a member of the anesthesia team and complete necessary blood tests before surgery.

Thyroid surgery is performed under general anesthesia. The type of surgery performed depends on the type of tumor and what is known about it ahead of time from the ultrasound and FNA biopsy. The surgeon will discuss details of the surgery with the patient and family beforehand.

Common types of thyroid and neck surgery are described below.

Lobectomy

Only one lobe of the thyroid gland is removed. This surgery is usually done when the tumor is only in one part of the thyroid gland and the doctor suspects that the tumor is likely to be benign. If cancer is found in this initial procedure, it is standard of care to remove the rest of the thyroid gland in a second procedure called completion thyroidectomy.

Total Thyroidectomy

This is procedure of choice for if thyroid cancer is suspected based on FNA biopsy prior to surgery. The entire thyroid gland is removed. Even if the biopsy is benign, a patient may have this surgery if he or she has "compressive symptoms". Compressive symptoms are caused by large thyroid masses which cause local damage to nearby organs. Compressive symptoms can include hoarseness, difficulty swallowing, and shortness of breath. Patients who have had their entire thyroid gland removed live normal lives. It is only necessary to take one thyroid hormone pill each day and have occasional blood tests to check the level of thyroid hormone.

Lymph Node Dissection

Regional lymph node metastases are present at the time of diagnosis of thyroid cancer in some patients. Your doctors may recommend removal of lymph nodes in the center or sides of the neck that are known or suspected to contain metastatic cancer.

Possible Complications of Thyroid Surgery

You will need to discuss the complications in detail with your surgery team and anesthesiologist. Some of the complications include:

• Infection and bleeding

• Difficulty swallowing while the neck is healing

• Hoarseness if the nerves that control the vocal cords are injured. These nerves are located just behind the thyroid gland. Injury to nerves occurs in one to three out of 100 operations (a 1 percent to 3 percent risk). Hoarseness normally improves with time, but sometimes it can be permanent.

• Difficulty with hoarseness if the recurrent laryngeal nerves are injured or must be removed because of thyroid tumor involvement.

• Injury to the parathyroid glands. If all the parathyroid glands are injured, which occurs in 1 percent to 3 percent of operations, the level of calcium in the blood may be too low. This is called hypocalcemia and can be treated with calcium supplements and vitamin D pills that may be needed only for a short time after surgery, but occasionally for a longer period of time or permanently.

After Surgery

Some patients will have a small drain tube placed near the incision to collect fluid that drains after thyroid surgery. This drain is usually removed before the patient leaves the hospital, but sometimes it is removed during a follow-up visit. Patients will often return to the hospital for a checkup one to two weeks after surgery. The incision will fade as it heals. However, exposure to the sun will make the scar more visible, so it is important to cover the scar with sunscreen when outdoors.

Patients with certain types of differentiated thyroid cancer (papillary, follicular or Hurthle cell carcinoma) may have a thyroid scan and function test four to six weeks after surgery to see if there is any thyroid tissue left in the neck. Depending on the age and stage of the thyroid cancer, treatment with radioactive iodine may be recommended to destroy this tissue and reduce the chance that cancer will return. Traditional intravenous chemotherapy is not used for these types of thyroid cancers. Thyroid "suppression therapy" is the most important long term "chemotherapy" to prevent recurrence. Endocrinologists are usually the type of physicians who manage thyroid cancers over the life of the patient.

Medullary thyroid cancer and anaplastic thyroid cancer do not respond to radioactive iodine treatment. Patients with either of these cancer types may be candidates for radiation therapy or therapies in these rare situtations.

Follow-up care is very important for patients with thyroid cancer. Your endocrinologist will discuss with you a schedule for regular checkups. Checkups include physical examination, X-rays and other radiologic tests (e.g., ultrasound of the neck).

Periodic blood tests will be done to measure thyroglobulin levels and ensure proper levels and proper suppression of TSH levels in patients with papillary, follicular or Hurthle cell cancers. Similarly, blood tests will be done to check the levels of calcitonin for signs of cancer recurrence in patients with medullary thyroid cancer.

Side Effects After Surgery

Although it is rare, a malignant thyroid tumor may sometimes involve the vocal cords that control the voice and critical nerves in the neck, called recurrent laryngeal nerves, which control the ability to speak and swallow. Surgery to remove thyroid cancer and/or postoperative thyroid cancer treatment may cause paralysis of the vocal cords(s) or require removal of the recurrent laryngeal nerve(s). Fortunately, new approaches in speech rehabilitation and surgery can improve voice and swallowing function. Some of these treatments include surgery to reposition paralyzed vocal cords closer together, vocal cord injections, speech and swallowing interventions and rehabilitation.