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1. 고분화 갑상선암 치료, Well-differentiated thyroid cancer
https://blog.naver.com/sjloveu2/220817675994
2. 갑상선암, 림프절 절제, Thyroid cancer, LN dissection
https://blog.naver.com/sjloveu2/221178078631
1. Goldman-Cecil Internal Medicine 26th edition
Treatment of differentiated thyroid cancer entails surgery, selectively followed by radioiodine ablation of remnant thyroid tissue. Total or near-total thyroidectomy with or without selective central compartment lymph node resection is often the appropriate initial surgical procedure. However, lobectomy may be considered for patients with tumors smaller than 4 cm confined to one lobe of the thyroid gland and without other negative prognostic indicators such as cervical node involvement or extrathyroidal extension. Thyroid surgery can be complicated by hypoparathyroidism or recurrent laryngeal nerve injury, which causes hoarseness if it is unilateral and airway obstruction if it is bilateral. Traditionally, the rationale for bilateral surgery is the frequent presence of bilateral disease in papillary thyroid cancer, and the lower risk of recurrence after bilateral gland removal in some but not all studies. In addition, there may be greater accuracy in detecting residual disease after the eradication of all remaining normal thyroid tissue. Recent guidelines have suggested that the selection of initial surgery (thyroidectomy versus lobectomy) can be considered on a case by case basis, considering the suspected extent of disease on the basis of thyroid ultrasonography and preoperative cervical node mapping, and the likelihood that radioactive iodine treatment may be pursued. Use of postoperative cervical ultrasonography and following the trend in thyroglobulin concentration provides sensitive tools for surveillance in those patients who have not had a total thyroidectomy or received radioiodine therapy.
2. Harrison's Principles of Internal Medicine, 20e
All well-differentiated thyroid cancers >1cm (T1b or larger) should be surgically excised although active surveillance may be an option for small intrathyroidal micropapillary thyroid cancers (T1a) without metastases. In addition to removing the primary lesion, surgery allows accurate histologic diagnosis and staging. Because there is no compelling evidence that bilateral thyroid surgery improves survival, the initial surgical procedure may be either a unilateral (lobectomy) or bilateral (near total thyroidectomy) procedure for patients with intrathyroidal cancers >1 cm and <4 cm (T1b and T2 tumors) in the absence of metastatic disease. For patients at high risk for recurrence, bilateral surgery allows administration of radioiodine for remnant ablation and potential treatment of iodine-avid metastases, if indicated, as well as for monitoring of serum Tg levels. Therefore, near-total thyroidectomy is appropriate for tumors >4 cm or in the presence of metastases or clinical evidence of extrathyroidal invasion. In addition, for patients found to have a high risk tumor after lobectomy based upon aggressive pathology features (e.g., vascular invasion or a less differentiated subtype), completion surgery should be performed. Surgical complication rates are acceptably low if the surgeon is highly experienced in the procedure. Preoperative sonography should be performed in all patients to assess the central and lateral cervical lymph node compartments for suspicious adenopathy, which if present, should undergo FNA and be removed, as indicated, at surgery.
3. UpToDate 2020.02.23
1. We suggest preoperative ultrasound evaluation of the central and lateral neck lymph nodes for all patients with malignant cytological findings on the fine-needle aspiration (FNA) and additional imaging in patients with locally advanced disease.
2. The primary therapy for differentiated (papillary and follicular) thyroid cancer is surgery. Surgical options include total/near-total thyroidectomy or unilateral lobectomy with isthmusectomy. The operative approach depends upon the extent of the disease (eg, primary tumor size and the presence of extrathyroidal extension or lymph node metastases), the patient's age, and the presence of comorbid conditions. Subtotal thyroidectomy is an inadequate procedure for patients with thyroid cancer.
3. For patients with papillary or follicular cancer with a primary tumor >4 cm in diameter, extrathyroidal extension of tumor, or metastases to lymph nodes or distant sites, we recommend total thyroidectomy
3. For patients with 1 to 4 cm intrathyroidal tumors, either thyroid lobectomy or total thyroidectomy can be performed depending on the preference of the patient and the treatment team. We usually reserve thyroid lobectomy for tumors less than 3 cm confined to the thyroid without evidence of aggressive histologies or vascular invasion. Total thyroidectomy is preferred for tumors greater than 3 cm or if there are ultrasonographic findings in the contralateral lobe or in cervical lymph nodes that would make follow-up difficult.
However, it is recognized that if an experienced thyroid surgeon is unavailable and the patient cannot be referred elsewhere, a near-total thyroidectomy or a lobectomy may be preferable to a more complete operation complicated by bilateral nerve damage.
4. For patients with intrathyroidal unilateral differentiated thyroid cancer <1 cm, we suggest a thyroid lobectomy and isthmusectomy rather than total thyroidectomy (Grade 2B). The 30-year survival rate for this subgroup of patients approaches 100 percent. If there are clear indications to remove the contralateral lobe (eg, microcalcifications or small [3 to 4 mm] nodules with suspicious characteristics in the contralateral lobe, previous history of head and neck radiation, strong family history of thyroid cancer, or imaging abnormalities that will make follow-up difficult), total thyroidectomy is preferred.
5. For patients with thyroid cancer with clinical evidence (on exam or ultrasound) of central or lateral node metastases, we recommend therapeutic regional lymph node dissection (Grade 1B). For patients with large primary tumors (>4 cm), high-risk features for recurrence (extrathyroidal invasion), or if the information will contribute to the planning of further therapy, we suggest prophylactic central compartment lymph node dissection (Grade 2C). Prophylactic central lymph node dissection is not necessary for small, noninvasive papillary and most follicular cancers.
6. Because of the high risk of hypocalcemia after thyroidectomy, serum calcium concentration should be measured the evening and first morning after thyroidectomy. Treatment of postoperative hypocalcemia should be tailored to the severity and expected duration of parathyroid deficiency (table 1).
Lymph node levels of the neck
Level I, submental (IA) and submandibular (IB); level II, upper internal jugular nodes; level III, middle jugular nodes; level IV, low jugular nodes; level V, posterior triangle nodes; level VI, central compartment; level VII, superior mediastinal nodes.
Lymphadenectomy for thyroid cancer
The extent of lymphadenectomy is based on the type of thyroid malignancy and the risk for lymph node metastasis.
