What are the surgical options for thyroidectomy?

The thyroid gland is located in the neck just in front of the trachea, and consists of left and right thyroid lobes connected by a central isthmus lobe, and in some cases a cone lobe that extends upward. The overall shape is like a butterfly, and the “coat” of the butterfly is the envelope of the thyroid gland.

Four major surgical options for thyroid cancer

Surgery is preferred for the treatment of thyroid cancer. There are many different surgical approaches, with the main difference being the extent of resection. The table below provides a summary of these.

Surgical Modalities	Extent of resection	Applications
Unilateral thyroidectomy	The affected glandular lobe and its envelope + isthmus + conus lobe. For thyroid cancer, this is the most “minor” surgery, less invasive, but with the possibility of recurrence in the contralateral lobe or neck	Usually the tumor is no larger than 1 cm, solitary, confined to the gland, no lymph node metastasis, and the patient has no high risk factors for recurrence (e.g., history of head and neck radiation, family history of thyroid cancer, etc.).
Subtotal thyroidectomy	Affected gland lobe and envelope + isthmus + contralateral part of the gland lobe. Bilateral subtotal thyroidectomy is a major excision of both thyroid lobes with partial residual on both sides	Usually indicated for surgical treatment of unilateral early malignant lesions, contralateral benign lesions.
Proximal total thyroidectomy	Excision of almost all thyroid tissue, with up to approximately 1 gram of residual normal tissue on each side, helps protect the parathyroid glands and the recurrent laryngeal nerve.	Usually for patients who need to have as much thyroid tissue removed as possible but absolutely need to preserve function such as the parathyroid glands or the recurrent laryngeal nerve
Total thyroidectomy	Complete removal of all thyroid tissue	Follicular carcinoma is prone to vascular invasion and distant metastasis, and is most often treated by total thyroidectomy, facilitating postoperative treatment with radioactive iodine and follow-up. Medullary carcinoma of the thyroid. Because of its poor prognosis and susceptibility to metastasis and recurrence, total thyroidectomy is often recommended.

Compared with Europe and the United States, the extent of resection is relatively more conservative in China for primary lesions, and unilateral resection is usually done for microscopic, early differentiated thyroid cancer. In contrast, Europe and the United States tend to favor a greater extent of resection, usually with total or near-total resection. For example, the US 2015 guidelines state that total or near-total resection is done for differentiated thyroid cancer that is greater than 4 cm in diameter, significantly invades outside the gland, or has clear lymph node metastases or distant metastases.

For lymph node management, we are more aggressive and generally perform ipsilateral central zone lymph node dissection regardless of preoperative examination or intraoperative suspicion of lymph node metastasis, whereas abroad, central zone lymph node dissection is currently performed only in patients who are preoperatively considered to have possible lymph node metastasis, or who are locally advanced.