With the progress of society, the emphasis on health, the development of medical security and the improvement of treatment technology, the detection rate of thyroid nodules and the number of surgeries in hospitals at all levels in China have risen significantly. The correct management of the large number of clinically detected thyroid nodules is still a pressing clinical problem to be solved.
1. Strictly grasp the indications for surgical treatment of thyroid nodules
The 1st edition of the Guidelines for the Treatment of Thyroid Nodules and Differentiated Thyroid Cancer, which was formulated by the Endocrinology Branch of the Chinese Medical Association, the Endocrine Surgery Group of the Surgery Branch of the Chinese Medical Association, the Head and Neck Tumor Specialized Committee of the Chinese Anti-Cancer Association and the Nuclear Medicine Branch of the Chinese Medical Association in 2012, clearly states that the indications for surgery of benign thyroid nodules are.
(1) The presence of local pressure symptoms associated with the nodule;
(2) Combination of hyperthyroidism and failure of medical treatment;
(3) The mass is located in the posterior sternum or mediastinum;
(4) Progressive growth of the nodule with clinical consideration of malignant tendency or combined with high risk factors for thyroid cancer. The relative indications for surgery are those who strongly request for surgery because of the appearance or the thought that it will affect their normal life. The relative indications are based on the current medical environment and the actual situation in China.
At present, the popularity and improvement of ultrasound examination of thyroid nodules in China have increased the detection rate of thyroid nodules and thyroid cancer year by year; the accuracy of ultrasound in the majority of primary hospitals is not high and fine needle aspiration cytology (FNA) is not widely used in clinical practice, which makes it impossible to effectively assess the nature of the detected nodules; economic interests and ward turnover pressure have led to the expansion of the indications for surgery. In some hospitals, thyroid surgery has become an important tool to reduce the average length of stay.
Some surgeons also perform surgery on many benign patients without surgical indications in order to practice their surgical skills (including lumpectomy and open surgery), leading to widespread over-examination and over-surgery of patients with thyroid nodules. The rate of non-essential thyroid nodule surgery is significantly higher, which not only causes unnecessary injury to patients and may lead to or aggravate hypothyroidism in patients, but also results in a waste of medical resources.
Also the number of cases of medical disputes related to it in China is on the rise year by year. Here, we emphasize the importance of preoperative evaluation of thyroid nodules and strict control of surgical indications to improve the treatment level of thyroid nodules in China.
2. How to avoid secondary surgery for benign thyroid nodules
Thyroid nodules can be single or multiple, and lesions can be confined to one side or occur in both lobes. In clinical practice, it is often found that some patients have to be operated again for residual thyroid masses several years after the first operation.
How to avoid secondary surgery depends on the choice of the initial surgical approach and the postoperative treatment. Commonly performed surgical procedures include thyroid nodule removal, partial thyroidectomy, thyroid lobectomy, thyroid lobectomy + contralateral lobectomy, subtotal thyroidectomy (complete excision of one lobe with the intrinsic perineum + isthmus + most of the contralateral lobe, leaving only up to 10% of the contralateral and dorsal thyroid tissue), and total thyroidectomy.
Clinical surgeons prefer partial thyroidectomy or partial resection of one lobe + contralateral lobe in order to avoid injury to the recurrent laryngeal nerve and parathyroid glands. However, without alternative medical treatment, nodule recurrence often occurs in the residual thyroid gland, and some require reoperation, which not only causes some pain to the patient but also increases the difficulty and complications of surgery (especially in patients with major lobectomy).
The author’s choice of surgical procedure for thyroid nodules is to perform lobectomy on one side of the lobe, and near-total or total thyroidectomy on both sides of the lesion (if both have surgical indications).
If a mass can be palpated, it will be excised, and if no mass is found (but nodules are often found on ultrasonography), it will be followed up. The above method is for the reader’s reference, and I hope it will be discussed.
3. Surgical management of retrosternal nodular goiter
A retrosternal goiter is a goiter in which more than 50% of the volume is located below the thoracic population and accounts for 1% to 15% of thyroid surgeries. Because the left side of the posterior sternum is blocked by the aortic arch and the left common carotid artery, there are more posterior sternal goiters on the right side of the clinic than on the left side, and surgery is the only effective treatment. There are three types of retrosternal nodular goiter: Type I is incomplete retrosternal goiter;
Type Ⅰ and type Ⅱ are complete goiters. Type Ⅰ and type Ⅱ are due to the combined effect of gravity of the thyroid gland, swallowing activity and negative pressure in the thoracic cavity, causing it to fall into the thoracic cavity along the anterior tracheal space, with the blood supply coming from the upper and lower thyroid arteries; type Ⅲ is rare and is a vagrant thyroid gland behind the sternum, with the blood supply mostly coming from the blood vessels in the thorax. The majority of type I and type II goiters can be removed through a cervical surgical approach, while only a few type I and type II and a small number of type III goiters have to be removed through a sternotomy approach or a combined cervicothoracic approach.
Because of the large mediastinal space in the thoracic cavity, posterior sternal goiters tend to be large in size and can easily extrude important surrounding structures such as the trachea and great vessels. Therefore, it is more difficult to remove a post-thoracic goiter through a cervical approach, and a specialist with extensive experience should perform it to reduce the occurrence of complications.
4. Application of standardized lumpectomy in the treatment of thyroid nodules
In 1997, Hiiseher et al. first reported lumpectomy-assisted thyroid lobectomy, followed by Ikeda et al. who reported fully lumpectomized thyroid surgery. The indications have expanded from benign thyroid disease to differentiated thyroid cancer in the low-risk group.