Modern surgery for advanced thyroid cancer: a tailored approach

Abstract

Surgical treatment of advanced thyroid malignancy can be morbid, compromising normal functions of the upper aerodigestive tract. There is a paucity of guidelines dedicated to the management of advanced disease. In fact, there is not even a uniform definition for advanced thyroid cancer currently. The presence of local invasion, bulky cervical nodes, distant metastases or recurrent disease should prompt careful preoperative evaluation and planning. Surgical strategy should evolve from multidisciplinary discussion that integrates individual disease characteristics and patient preference. Intraoperative neuromonitoring has important applications in surgery for advanced disease and should be used to guide surgical strategy and intraoperative decision-making. Recent paradigm shifts, including staged surgery and use of neoadjuvant targeted therapy hold potential for decreasing surgical morbidity and improving clinical outcomes. Modern surgical planning provides optimal treatment for each patient through a tailored approach based on exact extent and type of disease as well as incorporating appreciation of surgical complications, patient preferences and intraoperative findings.

Keywords: Advanced thyroid cancer; intraoperative neuromonitoring; neoadjuvant therapy; staged surgery; tailored approach.

Figure 1

Tailored approach to surgical management of advanced thyroid cancer: in cases with invaded nerve management, intraoperative LOS or extensive loco-regional disease. LOS, loss of signal; EMG, electromyography; RLN, recurrent laryngeal nerve.