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Review Thyroid Disorders Ensuring Quality in Thyroid Cancer Surgery Maria F Bates, Kristin L Long, and Rebecca S Sippel Department of Surgery, University of Wisconsin, Madison, Wisconsin, US T hyroid cancer incidence is increasing worldwide. Though long-term survival rates are excellent, recurrence remains a significant problem, which highlights potential areas of needed improvement, including the surgical care of these patients. This review paper identifies tools and markers that can be used to improve surgical quality in thyroid cancer. Preoperative surgical planning starts with an adequate ultrasound evaluation of the cervical lymph node basins. Postoperatively, thyroglobulin and radioactive iodine uptake scans can track adequacy of resection. In addition, lymph node yield and lymph node ratios serve as indirect markers for assessing the quality of lymph node dissections. Current research also suggests that high-volume surgeons have improved oncological outcomes. Surgeons can use these tools and information to follow and potentially improve the care provided to patients. Keywords Thyroid cancer, surgical quality, ultrasound, thyroglobulin, nodal dissection Disclosure: Maria F Bates, Kristin L Long, and Rebecca S Sippel have nothing to declare in relation to this article. No funding was received in the publication of this article. This study involves a review of the literature and did not involve any studies with human or animal subjects performed by any of the authors. Authorship: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit. Received: February 21, 2017 Accepted: April 24, 2017 Citation: US Endocrinology, 2017;13(1):22–6 Corresponding Author: Maria F Bates, Department of Surgery, 600 Highland Avenue, K4/739 CSC, Madison, WI 53792, US. E: batesm@surgery.wisc.edu Thyroid carcinoma is one of the most common solid tumors worldwide. The incidence of thyroid cancer is increasing, with an estimated 57,000 newly diagnosed cases in the US in 2017. Approximately three-quarters of these patients are female, with the majority being between 20 and 34 years of age. Though five-year survival rates are greater than 98% overall, the disease still inflicts significant morbidity on those affected. 1 At present, surgery represents the mainstay for treatment and the only option for a definitive cure. Performing the appropriate operation for thyroid carcinoma is the first step towards achieving optimal outcomes. Current quality markers in thyroid surgery are predominately based on morbidity from often transient complications, such as temporary hypoparathyroidism or recurrent laryngeal nerve palsy. In order to improve the surgical care of patients with thyroid cancer, it is important that we focus not just on safety, but also on oncologic outcomes. Given the time delay to disease recurrence, surgeons are often not aware that disease recurrence has been identified or that the recurrence may have been due to inadequate initial surgical management. In a recent retrospective view of our institutional data, we collected all patients that underwent re-operative surgery for differentiated thyroid cancer. We found that the majority of patients had abnormal radiographic and/or elevated thyroglobulin (Tg) levels at their 6 month postoperative follow up from their initial surgery. Only three patients out of 92 actually had a negative ultrasound and undetectable Tg within 1 year, defining them as truly recurrent disease. By this definition, the remaining patients really just underwent a re-operation for persistent disease, which suggests a need for improved surgical quality. In order to improve the quality of thyroid cancer surgery, we need to identify short-term markers that can be used to give feedback to surgeons to allow them to improve their surgical care. In this review, we focus on the importance on quality surgery for thyroid cancer, specifically on the initial pre-operative evaluation, surgeon volume and outcomes, adequacy of surgical resection, and nodal disease. It is our hope that surgeons who perform surgery for thyroid cancer will use this information not only to track their own clinical outcomes but also to use these tools to re-evaluate the quality of care given to their patients. Quality surgery starts with a good pre-operative evaluation In order to achieve curative surgery as well as optimizing the effects of postoperative treatment and facilitate follow-up, surgeons must eradicate all the disease from the neck at the initial operation. Pre-operative radiographic imaging is the first step towards optimizing these outcomes. The neck ultrasound has emerged as the recommended first-line imaging modality to evaluate, not only disease within the thyroid gland, but also any potential spread to the central or lateral nodal basins in the neck. The most recent American Thyroid Association (ATA) guidelines recommend a formal pre-operative neck ultrasound evaluation of nodal disease prior to undergoing any thyroid surgery. 2,3 This is further supported by Kocharyan and colleagues who demonstrated that lymph node disease identified on pre-operative ultrasound accurately corresponds to postoperative lymph node pathology. 4 22 TOUCH ME D ICA L ME D IA