| Abstract: |
Although thyroid surgery is generally standardized, a variety of difficult problems are noted in thyroid surgery including substernal goiter, locally aggressive thyroid cancer invading surrounding tissues, and recurrent thyroid tumors. Patients with large substernal goiter with tracheal deviation or compression are generally advised to undergo surgical intervention to avoid future airway problems. The majority of the substernal goiters can be easily resected through the neck while approximately 1% to 2% will require a sternal split. The most important prognostic factor in thyroid cancer is extrathyroidal invasion into surrounding structures. This requires appropriate surgical intervention with removal of all gross tumor. If the tumor invades the trachea, appropriate tracheal resection may be necessary, which requires a complete evaluation of the larynx and trachea with imaging studies. A high incidence of local recurrence exists in patients initially presenting with extrathyroidal extension of thyroid cancer. In elderly individuals this may represent poorly differentiated thyroid cancer. Adjuvant therapy including radioactive iodine and external radiation therapy in select patients may be necessary. Management of recurrent thyroid cancer continues to be a difficult problem due to the location of the tumor, especially in the tracheoesophageal groove. Complete resection of the tumor with preservation of at least one recurrent laryngeal nerve is crucial to avoid tracheostomy. The patients at high-risk for local recurrence require close follow-up with appropriate imaging studies such as computed tomography scan and/or ultrasound with fine-needle aspiration biopsy. Difficult thyroid continues to be a surgical challenge that requires collaboration among endocrinologist, surgeon, diagnostic radiologist, and nuclear physicians. |
