Workup of well-differentiated thyroid carcinoma

Well-differentiated thyroid carcinoma (WDTC) includes three main entities: papillary thyroid carcinoma (PTC), follicular thyroid carcinoma (FTC), and Hurthle cell carcinoma (HCC). A thorough knowledge of the natural history and presentation of these carcinomas is vital to the thyroid surgeon.

This review details the preoperative workup of patients having or suspected to have WDTC. We review the history, physical examination, laboratory, and radiographic evaluations that optimally prepare the surgeon to determine the ideal surgical thyroid and neck treatment for patients with WDTC.

A fiberoptic evaluation of the larynx is integral to the physical examination, and a laryngeal assessment is performed for all patients who will undergo thyroid surgery. It must be noted that vocal cord paralysis can be subtle and does not always present with clear dysphagia or voice change. Ultrasound and FNA are the primary tools of preoperative assessment. Given that patients with preoperative FNA positive for papillary cancer are expected to have clinically significant nodal disease in one third of cases, radiographic evaluation must be appropriately aggressive. The combination of US and CT allows assessment of the central and lateral neck nodes and the thyroid's relationship to central neck viscera.

The overriding principle in the surgical treatment of WDTC is that the surgeon recognizes and encompasses all gross disease in the thyroid and neck nodes at first surgery. The extent of thyroidectomy is tailored not only to the patient's risk group and gross operative findings but also to the progress of the specific surgery in terms of parathyroid and recurrent laryngeal nerve preservation.