5. Extent of surgery - AAES guidelines

EXTENT OF INITIAL THYROIDECTOMY

The surgical decision as to the extent of thyroid surgery is driven by multiple factors including indications for surgery (either local compression, risk of cancer or thyrotoxicosis), presence of unilateral or bilateral pathology, family history, surgical risk and patient preferences. The guidelines note three approaches:

Summary of Table 11 - Clinical factors that favour initial total thyroidectomy versus lobectomy

TOTAL THYROIDECTOMY  FAVOURED:

This includes high risk papillary cancer where radioiodine ablation may be required or where invasion or metastasis is already present. For benign nodular disease the presence of significant bilateral nodules, history of radiation exposure, or strong family history are indications. Graves' disease is best treated by total thyroidectomy.

CONTROVERSIAL - TOTAL VS LOBECTOMY

Lower risk cancer such as single nodules < 4cm in size, or benign nodules where the patient is already on thyroxine.

LOBECTOMY FAVOURED

Low risk papillary thyroid cancer confined to one lobe can be treated safely with lobectomy, diagnostic thyroidectomy for  Bethesda 3 or 4 fine needle biopsies, or unilobar benign goitre. 

COMMENT

Patient preference is now one of the major factors in determining the extent of thyroid surgery. Apart from patients with advanced cancer requiring radioiodine therapy, there is usually a choice between having all the thyroid removed as a total thyroidectomy, half removed as a hemithyroidectomy, or just having the nodule removed. Mostly it is a balance between  a preference for avoiding post-operative thyroxine therapy and minimising the risks of surgery, versus avoidance of long term surveillance and possible further surgery in the future.