Which of the following is not an indication for Total Thyroidectomy?
a. Total thyroidectomy is recommended for Hurthle cell neoplasms larger than 4 cm.
b. Total thyroidectomy is recommended for Papillary thyroid cancer exceeding 1 cm.
c. For patients with hyperthyroidism due to a single hot nodule, total thyroidectomy
is the best operation.
d. Total thyroidectomy is advocated in a patient of a thyroid nodule with a history of head and neck irradiation.
Answer:
c
While cancer is very uncommon with Hurthle cell neoplasms less than 2 cm in size, the rate of cancer exceeds 50% in lesions of a greater size than 4 cm. Thus, we typically recommend a total thyroidectomy for Hurthle cell neoplasms larger than 4 cm. We would also consider a total thyroidectomy in patients with contralateral nodular disease and Hashimoto’s thyroiditis if the patient was already taking thyroid hormone or patient preference.
Papillary thyroid cancer. For lesions <1 cm, either thyroid lobectomy or total thyroidectomy is acceptable. For lesions 1 cm or greater, total thyroidectomy is recommended. If abnormal lymph nodes are seen intraoperatively or by ultrasound, level 6 central lymph node dissection is indicated. In
patients with enlarged lateral lymph nodes, FNA should be performed on the lymph node and if positive a compartmentalized lymph node dissection often involving levels 2, 3, and 4 lymph nodes should be done.
Hyperthyroidism. Kocher developed subtotal thyroidectomy as the treatment for hyperthyroidism from Graves’ disease, which then became the routine form of therapy for the disease. After the advent of radioactive iodine therapy in the 1930s, surgery became less commonly performed as
the primary treatment. There are still a number of important indications for surgical treatment of hyperthyroidism such as age, sex, pregnancy, and lactation, the presence of a thyroid nodule or large goiter (Plummer’s), and patient preference. These factors may guide clinicians to offer surgery as a first-line treatment. For patients with Graves’ disease or Plummer’s disease, total thyroidectomy is the operation of choice and has largely replaced subtotal thyroidectomy, which is associated with a much high recurrence rate and similar morbidity. For patients with hyperthyroidism due to a single hot nodule, unilateral thyroid lobectomy is the best operation.
The management of a thyroid nodule that is “benign” on FNA is dependent upon the size of the nodule and if the patient has symptoms due to the nodule. Benign nodules generally do not require surgery unless they are causing compressive symptoms (airway compromise, dysphagia,
etc.). Data from multiple investigators have shown that thyroidectomy in symptomatic patients can greatly improve quality of life. Thyroidectomy should also be considered in patients with thyroid nodules and a history of head and neck irradiation because of the increased risk of developing thyroid cancer. We generally advocate a total thyroidectomy in patients with thyroid nodules and a history of head and neck irradiation, irrespective of biopsy findings.
Reference: Fischer's Mastery of surgery. 6th edition Page 469.
a. Total thyroidectomy is recommended for Hurthle cell neoplasms larger than 4 cm.
b. Total thyroidectomy is recommended for Papillary thyroid cancer exceeding 1 cm.
c. For patients with hyperthyroidism due to a single hot nodule, total thyroidectomy
is the best operation.
d. Total thyroidectomy is advocated in a patient of a thyroid nodule with a history of head and neck irradiation.
Answer:
c
While cancer is very uncommon with Hurthle cell neoplasms less than 2 cm in size, the rate of cancer exceeds 50% in lesions of a greater size than 4 cm. Thus, we typically recommend a total thyroidectomy for Hurthle cell neoplasms larger than 4 cm. We would also consider a total thyroidectomy in patients with contralateral nodular disease and Hashimoto’s thyroiditis if the patient was already taking thyroid hormone or patient preference.
Papillary thyroid cancer. For lesions <1 cm, either thyroid lobectomy or total thyroidectomy is acceptable. For lesions 1 cm or greater, total thyroidectomy is recommended. If abnormal lymph nodes are seen intraoperatively or by ultrasound, level 6 central lymph node dissection is indicated. In
patients with enlarged lateral lymph nodes, FNA should be performed on the lymph node and if positive a compartmentalized lymph node dissection often involving levels 2, 3, and 4 lymph nodes should be done.
Hyperthyroidism. Kocher developed subtotal thyroidectomy as the treatment for hyperthyroidism from Graves’ disease, which then became the routine form of therapy for the disease. After the advent of radioactive iodine therapy in the 1930s, surgery became less commonly performed as
the primary treatment. There are still a number of important indications for surgical treatment of hyperthyroidism such as age, sex, pregnancy, and lactation, the presence of a thyroid nodule or large goiter (Plummer’s), and patient preference. These factors may guide clinicians to offer surgery as a first-line treatment. For patients with Graves’ disease or Plummer’s disease, total thyroidectomy is the operation of choice and has largely replaced subtotal thyroidectomy, which is associated with a much high recurrence rate and similar morbidity. For patients with hyperthyroidism due to a single hot nodule, unilateral thyroid lobectomy is the best operation.
The management of a thyroid nodule that is “benign” on FNA is dependent upon the size of the nodule and if the patient has symptoms due to the nodule. Benign nodules generally do not require surgery unless they are causing compressive symptoms (airway compromise, dysphagia,
etc.). Data from multiple investigators have shown that thyroidectomy in symptomatic patients can greatly improve quality of life. Thyroidectomy should also be considered in patients with thyroid nodules and a history of head and neck irradiation because of the increased risk of developing thyroid cancer. We generally advocate a total thyroidectomy in patients with thyroid nodules and a history of head and neck irradiation, irrespective of biopsy findings.
Reference: Fischer's Mastery of surgery. 6th edition Page 469.
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