Current Innovations and Opinions in the Surgical Management of Differentiated Thyroid Carcinoma

Over the last decade, surgeons have witnessed dramatic changes in the surgical management of differentiated thyroid carcinoma (DTC). This is not only a result of the introduction of new technologies in surgery but also a result of better understanding of the disease and its behavior. DTC accounts for over 90% of all follicular-cell derived thyroid malignancies and is the commonest primary endocrine-related malignancy. In our locality, its age-adjusted incidence has doubled over the last 20-25 years with a similar trend being observed elsewhere.(Hong Kong Cancer Registry, 2011) Despite this, the cancer-specific mortality remains low with an overall 10-year survival above 90%.(Lang et al., 2007a) However, recurrent or persistent disease after seemingly curative surgery poses a problem for both clinicians and patients.(Mazzaferri et al.,2001) Since surgery remains to play a pivotal role in the overall management of DTC, the primary aim of any new changes would be to further reduce and if possible, to prevent these recurrences or persistent diseases from occurring. Examples of some of these new changes would include: 1. the adoption of new, innovative surgical approaches (i.e. endoscopic, robot-assisted and trans-oral thyroidectomy) in surgical management of DTC in order to reduce the surgical morbidity, shorten hospital stay and enhance patient satisfaction; 2 the use of several surgical adjuncts such as new alternate energy sources (Harmonic scalpel (Ethicon), Sonosurg® (Olympus) and LigaSureTM (Valleylab), intraoperative nerve monitoring (IONM) and quick intraoperative parathyroid hormone assay (IOPTH) 3. the routine adoption of prophylactic central neck dissection (pCND) in DTC during total thyroidectomy. The aims of this review were to examine and evaluate these 3 broad subjects in an evidence-based matter and see if these changes could lead to better patient outcomes when compared to the conventional open thyroidectomy with or without the help of the surgical adjunct(s).