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SURGICAL APPROACH TO THYROID NODULES Non-irradiated Patients Any nodule suspected of being a carcinoma should be completely removed, along with surrounding tissue; this means that a total lobectomy (or lobectomy with isthmectomy) is the initial operation of choice in most patients (see Fig. 11). A frozen section should be obtained intraoperatively. If a colloid nodule is diagnosed, the operation is terminated. If a follicular neoplasm is diagnosed, treatment is more controversial. Differentiating follicular adenoma from follicular carcinoma, or a benign Hürthle cell tumor from Hürthle cell carcinoma, using frozen section is usually very difficult. These diagnoses require careful assessment of capsular and vascular invasion, which are often difficult to evaluate on frozen section. To aid in the diagnosis, enlarged lymph nodes of the central compartment are often sampled, and a biopsy of the jugular nodes is also performed. If the result is negative, two options are available: First, performing a lobectomy on the side of the nodule with the understanding that a second operation might be necessary to complete the thyroidectomy if a carcinoma is ultimately diagnosed. This choice is prefered by most patients and is the recommended guideline of the American Thyroid Association. 25a However, some patients do not want the possibility of a second operation if a cancer is later diagnosed. In such cases, a resection of most of the thyroid on the contralateral side is performed. We treat most patients who have benign neoplasms with thyroxine replacement anyway, even if only one lobe has been removed. Furthermore, a second operation is eliminated if the lesion is later diagnosed as malignant. If appropriate, the remaining small thyroid remnant can be ablated with radioiodine therapy. We discuss these options with the patient preoperatively. Irradiated Patients Patients who received low-dose or high-dose external irradiation or were exposed to excessive ionizing radiation are at risk of developing single or multiple nodules of the thyroid, both benign and malignant. There is a greater chance of malignancy than in the non-irradiated gland. For single nodules, FNA analysis is performed and the decision as to whether or not to operate is determined by the result of the cytology. Multiple nodules in such a patient present more of a diagnostic problem. When an operation is performed in a patient with a radiation history and a suspicious nodule, we are more inclined to perform a near-total or total thyroidectomy rather than a lobectomy. This procedure removes all nodules and also all potentially damaged thyroid tissue. SURGICAL APPROACH TO THYROID CANCER PAPILLARY CARCINOMA Approximately 37,000 new cases of thyroid cancer are diagnosed in the United States each year. Approximately 80-85% of them are papillary carcinomas. The surgical treatment of papillary
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