Thyroid Cancer Surgery / Thyroid Nodules

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What is thyroid cancer?

Thyroid cancer occurs in the cells of the thyroid — a butterfly-shaped gland located at the base of your neck, just below your Adam's apple. Your thyroid produces hormones that regulate your heart rate, blood pressure, body temperature and weight. Several types of thyroid cancer exist. Some grow very slowly and others can be very aggressive. Most cases of thyroid cancer can be cured with treatment. Thyroid cancer rates seem to be increasing. Some doctors think this is because new technology is allowing them to find small thyroid cancers that may not have been found in the past.

Symptoms

Thyroid cancer typically doesn't cause any signs or symptoms early in the disease. As thyroid cancer grows, it may cause:

• A lump (nodule) that can be felt through the skin on your neck
• Changes to your voice, including increasing hoarseness
• Difficulty swallowing
• Pain in your neck and throat
• Swollen lymph nodes in your neck

Causes

Thyroid cancer occurs when cells in your thyroid undergo genetic changes (mutations). The mutations allow the cells to grow and multiply rapidly. The cells also lose the ability to die, as normal cells would. The accumulating abnormal thyroid cells form a tumor. The abnormal cells can invade nearby tissue and can spread (metastasize) to other parts of the body.

Factors that may increase the risk of thyroid cancer include:

• Female sex. Thyroid cancer occurs more often in women than in men.
• Exposure to high levels of radiation. Radiation therapy treatments to the head and neck increase the risk of thyroid cancer.
• Certain inherited genetic syndromes. Genetic syndromes that increase the risk of thyroid cancer include familial medullary thyroid cancer, multiple endocrine neoplasia, Cowden's syndrome and familial adenomatous polyposis.

Types of thyroid cancer

• Papillary thyroid cancer. The most common form of thyroid cancer, papillary thyroid cancer arises from follicular cells, which produce and store thyroid hormones. Papillary thyroid cancer can occur at any age, but most often it affects people ages 30 to 50. Doctors sometimes refer to papillary thyroid cancer and follicular thyroid cancer together as differentiated thyroid cancer.
• Follicular thyroid cancer. Follicular thyroid cancer also arises from the follicular cells of the thyroid. It usually affects people older than age 50.
• Anaplastic thyroid cancer. Anaplastic thyroid cancer is a rare type of thyroid cancer that begins in the follicular cells. It grows rapidly and is very difficult to treat. Anaplastic thyroid cancer typically occurs in adults age 60 and older.
• Medullary thyroid cancer. Medullary thyroid cancer begins in thyroid cells called C cells, which produce the hormone calcitonin. Elevated levels of calcitonin in the blood can indicate medullary thyroid cancer at a very early stage. Certain genetic syndromes increase the risk of medullary thyroid cancer, although this genetic link is uncommon.
• Other rare types. Other very rare types of cancer that start in the thyroid include thyroid lymphoma, which begins in the immune system cells of the thyroid, and thyroid sarcoma, which begins in the connective tissue cells of the thyroid.

Diagnosis

• Physical exam. Your doctor will examine your neck to feel for physical changes in your thyroid, such as thyroid nodules. He or she may also ask about your risk factors, such as past exposure to radiation and a family history of thyroid tumors.
• Blood tests. Blood tests help determine if the thyroid gland is functioning normally.
• Ultrasound imaging. Ultrasound uses high-frequency sound waves to create pictures of body structures. To create an image of the thyroid, the ultrasound transducer is placed on your lower neck. The appearance of your thyroid on the ultrasound helps your doctor determine whether a thyroid nodule is likely to be noncancerous (benign) or whether there's a risk that it might be cancerous.
• Removing a sample of thyroid tissue. During a fine-needle aspiration biopsy, your doctor inserts a long, thin needle through your skin and into the thyroid nodule. Ultrasound imaging is typically used to precisely guide the needle into the nodule. Your doctor uses the needle to remove samples of suspicious thyroid tissue.
• Other imaging tests. You may have one or more imaging tests to help your doctor determine whether your cancer has spread beyond the thyroid. Imaging tests may include CT, MRI and nuclear imaging tests that use a radioactive form of iodine.
• Genetic testing. Some people with medullary thyroid cancer may have genetic changes that can be associated with other endocrine cancers. Your family history may prompt your doctor to recommend genetic testing to look for genes that increase your risk of cancer.

Treatment

Treatment may not be needed right away

In some people, the cancer might never grow and never require treatment. In others, growth may eventually be detected and treatment can be initiated. Most people with thyroid cancer undergo surgery to remove the thyroid. Which operation your doctor might recommend depends on the type of thyroid cancer, the size of the cancer, whether the cancer has spread beyond the thyroid and the results of an ultrasound exam of the entire thyroid gland.

Operations used to treat thyroid cancer include:

• Removing all or most of the thyroid (thyroidectomy). An operation to remove the thyroid gland might involve removing all of the thyroid tissue (total thyroidectomy) or most of the thyroid tissue (near-total thyroidectomy). The surgeon often leaves small rims of thyroid tissue around the parathyroid glands to reduce the risk of damage to the parathyroid glands, which help regulate the calcium levels in your blood.
• Removing a portion of the thyroid (thyroid lobectomy). During a thyroid lobectomy, the surgeon removes half of the thyroid. It might be recommended if you have a slow-growing thyroid cancer in one part of the thyroid and no suspicious nodules in other areas of the thyroid.
• Removing lymph nodes in the neck (lymph node dissection). When removing your thyroid, the surgeon may also remove nearby lymph nodes in the neck. These can be tested for signs of cancer.

Risks Involved in Open surgery

Thyroid surgery carries a risk of bleeding and infection. Damage to your parathyroid glands also can occur during surgery, which can lead to low calcium levels in your body. There's also a risk that the nerves connected to your vocal cords might not work normally after surgery, which can cause vocal cord paralysis, hoarseness, voice changes or difficulty breathing. Treatment can improve or reverse nerve problems.

Robotic thyroidectomy—a minimally invasive surgical technique to remove all or part of the thyroid—was developed by doctors in South Korea. It can also be called robot-assisted thyroid surgery, or robot-assisted endoscopic surgery. Robotic thyroidectomy would be the next step in thyroid surgery, especially for those who don't want a neck scar. Before its development, there were two main options for thyroid surgery: conventional open surgery or endoscopic surgery. Conventional open surgery involves a scar on the neck; endoscopic techniques might or might not involve a neck scar. Robot-assisted surgery has been done on other parts of the body; it's been used to do prostatectomies and hysterectomies, for example. However, robotic thyroidectomy is the first time robot-assisted surgery has been done in the head and neck.

How It Works

Robotic thyroidectomy eliminates the neck scar by accessing the thyroid gland through an incision under the arm. This is called an axillary approach. That incision is 5-7cm long, but it's hidden—not front and center, like neck scars from open or even most endoscopic thyroidectomies. There's another very small incision—5mm—in the chest. Robotic thyroidectomy is done using the daVinci Surgical System, a system that's been used in many other robot-assisted surgeries with much success. The daVinci system has:

• Four robotic hands: These are called EndoWrist instruments, and they do work just like hands. They can grab things, twist, and turn—and they're incredibly small. The robotic hands allow the surgeon to make very precise movements.
• 3D camera: This is a high-definition camera that gives the surgeon a 3D image of the thyroid. He or she can zoom in and get an even more detailed look; the camera includes magnification of 10x.
• Console: The surgeon sits at the console, where he or she controls the four robotic hands and sees images from the 3D camera. The four robotic hands and the 3D camera are inserted through the incisions. The surgeon can then accurately remove part or all of the thyroid, depending on what the patient needs. As a reassurance, the daVinci robot is completely under the control of the surgeon. The robotic hands cannot move on their own; they must be told what to do by the surgeon. The daVinci Surgery System also cannot be programmed; the surgeon must be there giving input and making decisions during the surgery.

Advantages of Robotic Thyroidectomy

• No incision in the neck- In open surgery, you're looking at the thyroid from the top down, so it's a little difficult to see the deeper structures, such as the recurrent laryngeal nerve. The 3D camera gives you a magnified view in robotic thyroidectomy and enables you look at the thyroid directly."
• Better identification of critical structures: Due to the magnified 3D view, it is easier to identify critical structures, such as the recurrent laryngeal nerve (the nerve that goes to your voice box) and parathyroid glands.
• Better dexterity in certain areas: The robotic instruments give the surgeon a 6º freedom of motion, which enables manipulation of certain portions of the thyroid more easily.

Disadvantages of Robotic Thyroidectomy

• Robotic thyroidectomy right now is that it can't be used on every patient.

Who can have Robotic Thyroidectomy?

• Are not overweight
• Have a smaller thyroid gland (4cm at the largest)
• Have smaller nodules (2cm at the largest)
• Have nodules on just one side of the thyroid gland 

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