Thyroid carcinoma: the surgeon's perspective

Abstract

Surgery is often needed to diagnose thyroid cancer, but is also the initial therapeutic modality. Several current imaging techniques are important for preoperative risk stratification. By optimizing initial thyroidectomy and lymphadenectomy, accurate and appropriate imaging can help minimize operative morbidity and potentially reduce the risk of recurrent disease.

Figure 1

Coronal section of a CT scan of the chest with intravenous contrast obtained for a 72 year old woman who presented with acute shortness of breath. Her large thyroid goiter is predominantly substernal and not appreciated on physical exam. Although a thoracic surgeon was available for a possible sternotomy, her thyroid was successfully mobilized and resected through a 5cm cervical incision.

Figure 2

Transverse section of a CT scan of the neck without intravenous contrast obtained of a 49 year old woman who presented with a large cervical goiter that was noted on routine physical exam. Although she was asymptomatic, her enlarged thyroid gland was causing 65% tracheal compression and she required an awake fiberoptic intubation prior to general anesthesia for her thyroidectomy.

Figure 3

(a) A transverse neck ultrasound image of a 38 year old woman with a solitary 2.5 cm right thyroid nodule (arrow) that has a hypoechoic rim and hypervascularity. A follicular neoplasm was diagnosed after FNAB. (b) Following thyroid lobectomy, a 2 cm follicular variant papillary thyroid carcinoma (arrow) was diagnosed and she went on to receive completion thyroidectomy within 2 weeks.

Figure 4

Transverse section of a fused CT-PET scan obtained for a 29 year old woman with a history of metastatic papillary thyroid cancer initially treated with total thyroidectomy, bilateral central compartment and bilateral lateral compartment lymphadenectomies followed by radioactive iodine ablation. A rising thyroglobulin level prompted whole body I131 scan and neck ultrasound, both of which were negative. Subsequent PET scan demonstrated a single focus of FDG-avidity in the upper mediastinum. After an uneventful reoperative cervical exploration and resection of the nodule, recurrent papillary thyroid cancer was confirmed.