BACKGROUND
The development of cancer in the thyroid gland, a butterfly-shaped organ in the front part of the neck that produces thyroid hormone, will be diagnosed in approximately 44,000 Americans in 2024. Treatment of thyroid cancer usually requires surgery to remove part, or all, of the thyroid gland and, in general, long term survival rates after surgery are excellent for most kinds of thyroid cancer – the vast majority of people treated for thyroid cancer do not die of this disease. The traditional way of performing thyroid surgery involves making a small cut (incision) in the front part of the neck, through which the thyroid is removed (transcervical thyroid surgery). This method is known to be both safe and effective in treating thyroid cancer, but does leave a small scar on the front part of the neck where the incision to remove thyroid tissue was made.

A small fraction of people who have transcervical thyroid surgery will find scarring like this unacceptable and, as a result, will experience a long-term decrease in their overall happiness/quality of life. For this reason, techniques to remove thyroid tissue without leaving a visible scar have been developed. The newest method for this involves making cuts in the mouth and then, using fine instruments and cameras, removing part or all of the thyroid through these mouth incisions (transoral thyroid surgery). Two common versions of this technique are called transoral endoscopic thyroidectomy transvestibular approach (TOETVA) and transoral robotic thyroidectomy (TORT).

Multiple studies evaluating these ‘scarless’ techniques have shown that they are safe and effective for removing some kinds of noncancerous thyroid growths. It remains unclear, however, if transoral thyroid surgery is as good as the well-established transcervical thyroid surgery approach for treating the most common kinds of thyroid cancer, in particular with regard to making sure that all cancerous tissue is removed during surgery and that the risk of a thyroid cancer coming back after surgery is as low as possible. For this reason, the authors of the research described here sought to study the effectiveness of transoral thyroid surgery in treating the most common kinds of thyroid cancer.

THE FULL ARTICLE TITLE
Chen YH et al. Transoral endoscopic and robotic thyroidectomy for thyroid cancer: the mid-term oncological outcome. Surg Endosc 2023;37(10):7829-7838. doi: 10.1007/s00464-023-10339-9. PMID: 37605012.

SUMMARY OF THE STUDY
The authors of this work reviewed the medical records for people who chose to undergo TOETVA or TORT thyroid surgery, performed by one surgeon at their institution between July 2017 and November 2021 (4 years, 4 months), for treatment of the most common forms of thyroid cancer. Overall, 78% of these people were women, 40% of thyroid cancers removed were very small (less than 1 cm in diameter) and, on average, almost 5 neck lymph nodes were removed per patient at the time of thyroid surgery (when thyroid cancer tries to spread out of the thyroid, it will first spread to the neck lymph nodes that sit next to the thyroid.). Of the lymph nodes removed, 43.9% were found to contain thyroid cancer. Complication rates from surgery were low, with one person having a permanent injury to a nerve that helps control the voice and one person developing permanent low body calcium levels after surgery. The authors found that only one of the 122 people who underwent transoral thyroid surgery had their thyroid cancer come back during the follow-up time period of the study. Although this study did not collect information about people who underwent traditional transcervical thyroid cancer surgery with the study surgeon, the results of transoral thyroid cancer surgery identified during this study are similar to those generally reported for transcervical thyroid cancer surgery.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
This work suggests that transoral thyroid surgery, when performed by an experienced thyroid surgeon, is similarly effective to transcervical thyroid surgery for treating the most common kinds of thyroid cancer, while leaving no visible scar after surgery. Thus, transoral thyroid surgery may be an appropriate option for thyroid cancer patients wishing to avoid a neck scar after surgery. It is important to note, however, that thyroid cancers that come back following thyroid surgery may take many years to do so (many more years after surgery than this study reviews). For this reason, more studies are needed, looking at longer time-frames following transoral thyroid cancer surgery, to determine if the transoral approach for treatment of thyroid cancer is truly as good as the traditional transcervical approach.

— Jason D. Prescott, MD PhD

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