Endorcrine Head & Neck Surgery

Stanford Head & Neck Center

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Thyroid Cancer & Treatments

What is Thyroid Cancer?

Thyroid cancer is one of the most common forms of cancer, representing 3.6% of all new cancer cases each year (almost 63,000 cases according to the National Cancer Institute 2014 statistics). It occurs in 5-10 percent of thyroid nodules and has increased in prevalence over the last 30 years. Thyroid cancer occurs more commonly in woman than in men and can occur at any age. Risk factors for thyroid cancer include radiation exposure to the head, neck, or chest and a family history of thyroid cancer. However, it may occur in people without any known risk factors. Most thyroid cancer can be cured with appropriate treatment. The five-year survival rate of people with thyroid cancer is about 98%. The incidence rates of thyroid cancer in both women and men have been increasing in recent years, and Stanford researchers are working to figure out why.

There are several types of thyroid cancer and a spectrum of aggressiveness. The four main forms of thyroid cancer are:

Papillary thyroid carcinoma, the most common and least aggressive type of thyroid cancer, usually grows slowly but often spreads to lymph nodes.  Papillary thyroid cancer affects more women than men, and accounts for more than 80% of all thyroid cancers. These cancers can be successfully cured with appropriate treatment and are rarely fatal.

Follicular carcinoma is the second most common type of thyroid cancer, accounting for about 10% of thyroid cancer cases.  This type of thyroid cancer can spread through the bloodstream to other parts of the body, and is more aggressive than papillary carcinoma, though the prognosis (outlook) is still usually very good.

Medullary thyroid cancer accounts for less than 5% of thyroid cancer, and sometimes has a genetic predisposition as part of familial medullary thyroid cancer or multiple endocrine neoplasia syndrome. This type of cancer is unrelated to the above cancers, and produces excessive amounts of calcitonin, a hormone also produced by unique cells in the thyroid gland itself. Medullary thyroid cancer can be aggressive and tends to spread to lymph nodes as well as through the bloodstream to other parts of the body. Because medullary cancer can run in families in up to 20% of cases, screening blood tests for genetic abnormalities may be conducted.

Anaplastic thyroid carcinoma is a rare but extremely aggressive form of cancer. This rapidly-progressive cancer usually results in a large growth in the neck. It has often spread to other parts of the body by the time it is detected, and is very hard to treat effectively.

Other rare types of thyroid cancer include Hurthle cell carcinoma (a rare subtype of follicular carcinoma), thyroid lymphoma, as well as cancers that spread from other parts of the body to the thyroid gland.

With thyroid cancer, there are generally no symptoms other than a painless lump in the neck area. This lump may represent a thyroid nodule or an enlarged lymph node that contains thyroid cancer. Some thyroid nodules with cancer cannot be felt on exam and are detected by radiologic studies done for other purposes (ultrasound, CT scan, MRI scan, PET/CT scan). Cancerous thyroid nodules can sometimes compress or invade surrounding structures, such as the windpipe (trachea), throat (pharynx or esophagus), or nerves that control the vocal cords. Such invasion can lead to changes in the voice, problems with swallowing, cough, shortness of breath, or pain.

Diagnosis

The diagnosis of thyroid cancer is usually made by fine needle biopsy, performed without or with ultrasound guidance. Ultrasound-guided fine needle biopsy is the most precise and common approach. When the presence of thyroid cancer is confirmed, further evaluation is made with radiographic studies that include high-resolution ultrasound of the thyroid and entire neck, if not done already, and sometimes CT or MRI scanning of the neck and upper chest area.

Treatment for Thyroid Cancer

The prognosis for thyroid cancer is generally favorable, with surgery to remove part or all of the thyroid gland and any involved lymph node usually recommended. The extent of surgery necessary will depend on a number of factors, including the size and location of the malignant nodule(s), the type of cancer, and the presence of affected lymph nodes.

For small tumors with no evidence of lymph node involvement, your surgeon may be able to preserve ½ of the thyroid gland. For larger tumors, or those that have grown or spread outside the thyroid gland, a total thyroidectomy will likely be performed. The considerations given to each approach will be reviewed with you during your visit.  

It is quite common for thyroid cancer to spread, or metastasize, to lymph nodes in the neck. The presence of lymph node metastasis increases the risk of thyroid cancer persistence or recurrence. The spread of tumors cells occurs in a predictable pattern that begins in the central neck and progresses to the lymph nodes of the lateral neck compartments and the upper central chest. Detection of lymph node metastasis is important in guiding surgical management. Physical examination and complete neck ultrasound are the main methods by which lymph node metastasis is detected, although sometimes CT, MRI, and PET/CT scans are complementary or necessary. Inspection and even biopsy of the lymph nodes during surgery also allows for detection of metastasis that can be removed during a neck dissection. Neck dissection refers to the systematic removal of lymph nodes within specific compartments of the neck, where the lymph nodes have been shown to contain or are at high risk of harboring cancer.

Treatment for papillary and follicular cancer may include:

 

Surgery
This is done to remove part or all of the thyroid (called a thyroidectomy) and sometimes nearby lymph nodes.

Thyroid Hormone Therapy
This is done to suppress the pituitary gland from secreting more thyroid-stimulating hormone, which may stimulate a recurrence of papillary cancer.

Administration of radioactive iodine
This is done to destroy any remaining thyroid tissue.

Treatment for medullary thyroid cancer may include:

 

Surgery
This is done to remove the thyroid gland (thyroidectomy) and sometimes nearby lymph nodes. Additional surgery or other treatments may be necessary if the cancer has spread.

Radiaton Therapy

  • Targeted therapy drugs, such as vandetanib 

Treatment for anaplastic thyroid cancer is rarely curative, but may include:

Surgery
This is done to remove the thyroid gland (thyroidectomy) if the cancer has not spread extensively, although this is rare. Surgery may also protect the airway.

  • Chemotherapy
    For example, anti-cancer drugs

Radiaton Therapy

Surgical Treatment for Thyroid Cancer

Thyroid cancer presents certain unique challenges at surgery. It has traditionally been associated with higher rates of complication, including recurrent laryngeal nerve injury, as compared with surgery for benign thyroid conditions. With expertise in head and neck surgical techniques and extensive knowledge of the anatomy of the recurrent laryngeal nerve, parathyroid glands, and surrounding lymph nodes, surgeons in the Endocrine Head and Neck Surgery/ Thyroid and Parathyroid Surgery Program at Stanford are well prepared for these challenging cases. Our extensive experience and use of laryngeal nerve monitoring has allowed us to perform these complex procedures with a low risk of complications. Close pre- and postoperative communication and collaboration with the patient’s medical endocrinologist allows for coordinated care. They are joined in this multidisciplinary effort to treat thyroid malignancy by collaborators from the departments of radiology, oncology, radiation oncology, pathology and cytopathology, speech and swallowing therapy and laryngology.

For known thyroid cancer, typically the surgery involves removing the entire thyroid gland and sometimes also removing the lymph nodes. Because of the extent of surgery, it can take anywhere from about 2 hours for routine cases to 4 hours for more complex cases, with an overnight hospital stay needed. Any pain after the surgery is limited and usually alleviated with prescription and over-the-counter mild pain medication. Patients can generally speak, eat and breathe normally right after surgery.

Following surgery, the physician will review the pathologists report and make further recommendations in conjunction with the medical endocrinologist. This may include treatment with radioactive iodine therapy under the direction of the endocrinologist. This is a limited therapy with minimal side effects. Standard external beam radiation therapy and chemotherapy are rarely needed and generally only in cases of more aggressive cancers. Although the prognosis for most thyroid cancers is extremely favorable, long-term follow up is needed with thyroid cancer with both your surgeon and your endocrinologist. 

Thyroid Surgery

As with any surgical procedure, there are risks involved. There is a risk of bleeding, but this is very low. The average blood loss is less than an ounce. The risk of infection is so low that antibiotics are not routinely used. There is also a very low risk of injury to important nerves in the neck, called laryngeal nerves. These nerves control the muscles of the vocal cords. Injury to these nerves could affect your voice. The parathyroid glands are located near the thyroid gland and may be injured during thyroid surgery. This can result in a drop in blood calcium levels. There is also a small risk associated with anesthesia. However, the relative risk of complications is very low and is usually outweighed by the potential benefits of having the surgery. Your surgeon will go over this information with you and answer any questions you might have.

 

Before Surgery

If you take aspirin or nonsteroidal anti-inflammatory agents (such as ibuprofen), you should stop taking these one week before surgery. If you take prescription blood thinners (anticoagulants such as Coumadin or Plavix) please discuss the discontinuation plan and possible “bridging” plan for anticoagulation with your prescribing doctor as well as your surgeon. The night before surgery, do not have anything to eat or drink after midnight. Get a good night’s sleep.

 

What will Happen in Surgery?

You will be given general anesthesia to put you to sleep. You are positioned with special pillows under your neck to tilt your head back. An incision is made at the base of your neck and is about two to three inches long. Using magnifying lenses, the surgeon locates the thyroid gland and associated structures and all or part of the thyroid is removed. In some cases additional surgery will involve removal of lymph nodes and other structures. The incision is stitched closed and is then covered with a small dressing. The operation generally lasts from two to three hours. If neck dissection (lymph node removal) is required, additional itme will be needed. After surgery, you will go to the recovery room where you will be monitored closely and cared for as you recover from the anesthesia.

 

After Surgery

The evening after surgery you will be able to eat dinner. You may have a sore throat. Pain medicine will be available but may not be necessary. You will have a dressing on your neck  which should be removed the day after surgery.  The head of your bed will be raised to help minimize swelling. You may have an intravenous line to give you fluids until you are eating and drinking at a normal rate. You may have routine blood tests. 

 

The Incision

Usually, you may shower the day after surgery. If a drain was present, you may shower 24 hours after the drain is removed. Try to keep the neck area as dry as possible and pat dry after showering. Your stitches will be removed in the office about a week after surgery. Infection is extremely rare. If you notice any redness or drainage from the incision contact your surgeon. After the stitches are removed, the most important thing you can do to improve the appearance of your scar is to protect it with sunscreen that has a sun protection factor (SPF) of 30 for an entire year. During the year your scar may become raised or red, but will almost always fade into a thin line which will be less noticeable.

Transoral (scarless) Thyroidectomy

Why Scarless Thyroidectomy?

Traditional thyroid surgery is performed through an incision in the neck that leaves a visible scar. Recent improvements in technology and instrumentation have allowed for the removal of the thyroid gland through small incisions inside in the lower lip. This is the only thyroidectomy procedure that leaves no external scar – no one will know you had thyroid surgery! This minimally invasive approach is an ideal option for patients with tendencies for keloid or unsightly scarring, or who would rather not bear a constant reminder of their surgery.

1. The transoral endoscopic vestibular approach to thyroidectomy allows for removal of part or all of the thyroid gland through 3 small incisions inside the lower lip.

2. The instruments are passed through these incisions and tunneled underneath the skin to the neck.

3. High definition cameras provide sharp and magnified images that permit the surgeon to work with the utmost precision and protect vital structures.

When surgery is finished, you awake with dissolvable stitches and no scar on the neck.

Am I a Candidate?

Patients needing thyroid or parathyroid surgery may be eligible for a scarless approach. Ideal candidates usually have one of the following:

  • Small thyroid cancers (<2cm) with no spread to lymph nodes
  • Benign or indeterminate thyroid nodules
  • An overactive parathyroid gland causing hyperparathyroidism
  • Select patients with Graves’ disease or goiter
     

We want you to have the best possible outcome, and are very thoughtful in offering this approach to our patients. We evaluate each person thoroughly and will discuss candidacy with you during your appointment.

 

What to Expect After Surgery

The 3 small incisions inside the mouth are closed with dissolvable stitches that do not need to be removed. Typically, patients are allowed to go home either the same day, or the day after surgery. You will be provided with a dressing to wear under the chin and instructions on neck exercises to prevent stiffness. Swelling and bruising of the lower lip and chin are common and usually resolve within 7-10 days. Soft foods are recommended for the first 2 days, then you may resume your normal diet. It is important to keep your mouth clean between meals.

Neck Dissection


Neck dissection refers to the systematic removal of lymph nodes within specific compartments of the neck, when the lymph nodes are at high risk for harboring cancer. It is quite common for thyroid cancer to spread, or metastasize, to lymph nodes in the neck. The presence of lymph node metastasis increases the risk of thyroid cancer persistence or recurrence. The spread of tumors cells occurs in a predictable pattern that begins in the central neck and progresses to the lymph nodes of the lateral neck compartments and the upper central chest. Detection of lymph node metastasis is important in guiding surgical management. Physical examination and complete neck ultrasound are the main methods by which lymph node metastasis is detected, although sometimes CT, MRI, and PET/CT scans are complementary or necessary. Inspection and even biopsy of the lymph nodes during surgery also allows for detection of metastasis that can be incorporated into the surgical plan.

Central neck dissection (also known as level 6 neck dissection) is recommended for patients with central compartment lymph node metastasis detected either preoperatively or intraoperatively (during surgery.) A central neck dissection includes removal of the lymph nodes in the region surrounding the thyroid gland, the central compartment (“level 6” of the neck). The recurrent laryngeal nerves and parathyroid glands are located within the central compartment, and are preserved when possible. Parathyroid autotransplantation (reimplantation) is performed if the glands are disconnected from their blood supply during dissection. A central neck dissection is usually performed through the same incision as the thyroidectomy.

Lateral neck dissection (also known as selective neck dissection, modified radical neck dissection, dissection of levels 2-5 or any subset of levels) is recommended for patients whose cancer has spread to the lymph nodes in the lateral compartments of the neck, beyond the immediate thyroid compartment.

Complete removal of lymph node clusters (“compartment-oriented lymph node dissection”) is recommended for its higher cure rates compared to “node plucking” or individual lymph node removal. Node plucking is a common reason for patients requiring later revision surgery.

Neck Levels or Compartments

Lymph Nodes of the Central Compartment

Lymph Nodes in the Neck