One topic of discussion that I have seen come up on several thyroid cancer websites lately, is the question of "Which is better? Thyroidectomy( removal of all of the thyroid gland) or lobectomy ( removal of about half of the thyroid gland)?" As with anything else, we are all individuals, and there is no one size fits all per se. I will briefly discuss the different surgeries, pros and cons, and then I will tell you what I had done and how I made my decision.
Probably one of the most important things to do at the first signs of thyroid trouble, ( nodules that are growing or " cold", rapid thyroid gland enlargement,etc) is to schedule an ultrasound led biopsy which is done by a person who has experience in doing thyroid biopsies. Sometimes, though, despite someone's best efforts, the biopsy will come back as " inconclusive". I will mention that it took three biopsies, over the course of a few years, to get one that actually showed my thyroid cancer. The last one that I had, the one that was positive for cancer, was ultrasound led ( otherwise, it would have been like sticking a needle in a haystack and expecting good results). Also, the biopsy was done by my endocrinologist. This was my FOURTH endocrinologist. Yes, it took me that long to find a doctor who not only was skilled in thyroid disorders, but one who also listened to me, as far as how I was feeling and what treatment sounded good to me. Do not hesitate to switch doctors, or get a second opinion, if you feel like your needs are not being met. This is your life, and you need to be your own best patient advocate.
Another very important thing to do, is to find a very good surgeon. A surgeon who specializes in thyroid cancer surgeries and does a LOT of them. Thyroid surgery, full or partial, is not easy. There are several things to consider, such as, your vocal cords. You may not want to be a contestant on " The Voice", but you need to be able to talk! An inexperienced surgeon can damage the vocal cords, your esophagus, nerves in the neck, and probably most importantly, the parathyroids.
Just a word about the parathyroid glands. We are ( usually) born with four parathyroid glands. Although the parathyroid glands are near to the thyroid and share the same blood supply, they do not perform the same function as the thyroid. Our thyroid gland controls our metabolism, and affects every cell and organ in our bodies. The parathyroids regulate calcium levels ( so that our nervous systems will work) but do NOT affect our metabolism. Calcium also is the primary element involved in muscle contraction. A person can function fairly well with just one parathyroid, amazingly enough. But if the surgeon accidentally removes all four parathyroid glands, then the patient has hypoparathyroidism for life. There are calcium supplements, prescription ones, that a patient can take, but acceptable calcium levels are difficult to maintain. The optimum level of calcium in our bodies should be roughly 9 to 10mg/dl. Two of my parathyroid glands were also cancerous. My surgeon had to remove them, but that still left me with two functioning parathyroid glands. I did receive IV calcium in the hospital, and had to take a prescription calcium plus an OTC one for about 6 weeks or so after the surgery. My surgeon was afraid that my parathyroid glands would not " wake up". They are pesky little things ( only about the size of a grain of rice) and do not like to be messed with.
In a total thyroidectomy, the entire thyroid gland is removed, perhaps with some lymph nodes if they look suspicious. The reasons for having a total thyroidectomy can be due to a large papillary thyroid cancer, a follicular thyroid cancer ( with or without spread), hurthle cell cancer, medullary thyroid cancer, a cancer that is unencapsulated ( appears to have spread beyond the gland, but not to distant sites), a cancer that HAS spread to the lymph nodes or other sites in the body, just to name a few reasons. A patient can also request that the surgeon remove the whole gland. This may be a good idea if it may be probable that the thyroid cancer could return in the other side. This would prevent a second surgery and may be the best option for the patient. Here is where it is important to have a good relationship with the surgeon. She/He can inform the patient of other patients' surgeries, total or partial, and relate the outcomes.
With a total thyroidectomy, the patient must be on thyroid supplement medications for life. There should be monitoring of the dose, as well as other tests, to insure that the patient is feeling well and in remission. With a total removal of the thyroid, RAI can be used. This is another weapon in the doctor's arsenal that can be used to fight thyroid cancer. I will not go into the pros and cons of RAI, but I have discussed it in earlier blogs. Again, the patient should discuss the benefits versus potential side effects of using the RAI for treatment, and make the best decision for them.
Lobectomy, or partial removal of the thyroid gland, can be performed if the thyroid cancer is small. There should be no lymph node involvement, as determined by ultrasound or CT scan. Of course, there is always the chance that the thyroid cancer can return, or be present and not detected, in the side that is not removed. This would result in another surgery. RAI is not used for treatment after surgery because it would damage the remaining part of the thyroid gland. The amount of thyroid hormone medication after surgery is either small or non-existent. A patient having a partial removal of the thyroid, can not depend on thyroglobulin levels to predict the existence of thyroid cancer. That is because the healthy cells of the thyroid gland produce the thyroglobulin, too. There is also the added benefit that the potential damage to the vocal cords as well as the parathyroid glands, is not as likely compared to a full thyroidectomy.
The decision to have a total removal or partial removal of a cancerous thyroid gland requires a good relationship between the patient , a very experienced surgeon, and a doctor familiar with thyroid disease. Every person is different as far as what type of thyroid cancer is present, the stage of disease, what other organs or lymph nodes are affected, the age of the patient, just to name a few variants. I will now recount my story. I had papillary, with follicular variant, stage three, thyroid cancer. Two of my parathyroid glands were cancerous, as I stated above, and were also removed- along with eleven lymph nodes. Both of my main tumors were unencapsulated and diffusely infilitrative. While none of my lymph nodes tested positive, the tumors had burst open and spilled into the vascular tissues around my thyroid gland. Here is the surprise: I had initially wanted to have the surgeon just remove one side of my thyroid- a lobectomy. He said no, because in his experience, this would involve a second surgery at some point. I am glad that I let him do a total thyroidectomy because I had undetected thyroid cancer in the other side.( Detected in an after surgery biopsy)
I decided to get the RAI after the surgery, as recommended by my endocrinologist and the radiologist. I had a large dose, 155 milicuries, and still continue to be monitored by my endocrinologist, and will be for life. After almost nine years of being on a dose of levothyroxine that has suppressed my TSH to essentially zero, my endocrinologist is letting my TSH rise into the low normal range. I still have office visits and ultrasound exams every six months. I do have " scan anxiety" as do many others, but I feel that it is worth a little testing anxiety to make sure that the cancer has not returned.
To wrap things up, there is no one correct answer for the question "Is it best to get a lobectomy or a total thyroidectomy?" Do your homework. Find out as much as you can from reputable books and websites about the type of thyroid cancer that you have, what factors may be affecting your treatment plan, keep copies of tests, biopsies, ultrasounds( they belong to you, after all), and find doctors that are knowledgeable and that will work with you. Again, be your own best patient advocate. I have said this many times to others, but that really is the best treatment plan that you can have.
