The primary object of surgery is to remove all the cancer in the thyroid and any disease in the local lymph nodes or involved local structures. Prior to surgery the same testsused for simple goitres may be performed (see simple goitre section).
Guidelines have been published in 2007 in the UK for the management of thyroid cancers. These guidelines suggest that all thyroid cancers should be managed by physicians expert in thyroid cancer carewho have access to a multidisplinary team(MDT).
The Guidelines for Papillary Thyroid Cancer suggest that:
1# Patients with node negative papillary cancer of 1cm diameter or less can be adequately treated by thyroid lobectomy and subsequent thyroxine therapy for life.
2# Most other patients should be treated by total thyroidectomy especially if the tumour is greater than 1 cm, is multifocal, has spread outside the thyroid or if there is a family history or positive lymph nodes. All children with papillary thyroid cancer and a history of neck irradiation should be treated by total thyroidectomy.
3#If the diagnosis of papillary thyroid cancer is made after a thyroid lobectomy and the tumour does not fall in category 1# then a completion (contralateral) lobectomy should be performed within 8 weeks.
4# Lobectomy alone may be appropriate if the tumour is greater than 1 cm and the MDT considers it low risk.
5# Patients who are high risk with no evidence of positive lymph nodes should undergo a prophylactic central neck dissection (level VI).
6# Palpable disease in level VI nodes should be dissected. Suspicious or clinically involved lateral lymph nodes diagnosed pre-operatively or per-operatively should be treated by a selective neck dissection (levels IIa-Vb). Removal of onlyinvolved lymph nodes ("berry picking") must never be performed, because it is associated with a high risk of lymph noderecurrence. For years Mr Lynn has practicied routine removal of the thymus when performing a Level 6 dissection. Recent studies suggest that this unecessary unless there is obvious involement with cancer. A recent study presented to the BAETS in 2009 suggests that unless there is obvious tumour in the thymus that it should not be removed. Thymectomy (removal of thymus) is not associated with an increased risk of permanent hypocalcaemia and although harvesting of unexpected intra-thymic lymph nodesis not common,it is a simple procedure with virtually no morbidity and if ther is anydoubt Mr Lynn's view is thatthe thymus should be removed.
It is hoped that surgeons in the UK will follow these guidelines. In the past the results of thyroid cancer surgery in the UKwere very poor as compared to the USA or mainland Europe. This was most likely due to inadequate surgery, which the 2007 guidelines has confronted.