Endoscopic thyroid surgery via a breast approach: a single institution’s experiences
© Kim et al.; licensee BioMed Central Ltd. 2014
Received: 10 November 2013
Accepted: 28 July 2014
Published: 5 August 2014
Thyroid carcinoma in young women is rapidly increasing, and cosmesis plays an important role in thyroid operations. Various endoscopic thyroid surgery approaches have been performed, and their application has recently been extended. We performed endoscopic thyroid surgeries via a breast approach since 1999. Herein, we evaluate the safety of this approach and identify the outcomes for differentiated thyroid carcinoma.
A total of 452 consecutive patients with thyroid and parathyroid disease underwent endoscopic thyroidectomy via a breast approach at Uijeongbu St. Mary’s Hospital between November 1999 and December 2012. The inclusion criteria for endoscopic thyroidectomy included a benign tumour less than 4 cm in diameter, malignant thyroid nodules less than 2 cm, and no evidence of lymph node metastasis or local invasion. We analysed the clinicopathologic data and surgical factors of this approach.
The mean age of the patients was 38.4 ± 10.6 years (range 11-73 years). The mean tumour size was 2.12 ± 1.17 cm (range 0.1-4 cm). The final tumour pathologies included papillary carcinoma (n = 120), follicular carcinoma (n = 8), nodular hyperplasia (n = 266), follicular adenoma (n = 43), and Hüthle cell adenoma (n = 4). The mean postoperative hospital stay was 3.8 ± 1.3 days (range 1-17 days). Temporary and permanent hypoparathyroidism requiring calcium and vitamin D supplementation developed in 32 (7.1%) and 4 (0.9%) patients, respectively. Transient vocal cord paresis occurred in 20 (4.4%) patients.
For patients with benign and low-risk malignant thyroid disease, endoscopic thyroidectomy via a breast approach is a safe, feasible, and minimally invasive surgical method with minimal complications.
KeywordsEndoscopic thyroidectomy Thyroidectomy Thyroid carcinoma
Conventional open thyroidectomy remains the treatment of choice for benign and malignant thyroid nodules, but the surgery requires a long incision line on the neck and leaves a long scar on the lower anterior neck. This incision may lead to prominent scarring that can develop into keloid or hypertrophic scars and lead to paraesthesia or hypaesthesia .
With the development of laparoscopic and endoscopic surgery, thyroid and parathyroid surgery has recently been attempted using an endoscopic approach. Since endoscopic parathyroidectomy and thyroidectomy were first introduced by Gagner and Huscher et al. [2, 3], various endoscopic thyroid surgery approaches have been devised, including cervical, axillary, breast, and anterior chest approaches.
Endoscopic thyroidectomy was initially performed in patients with benign thyroid nodules. As surgical experience was accumulated, the application of endoscopic thyroidectomy was extended to patients with early cases of thyroid cancer.
We have previously reported on the feasibility of endoscopic thyroidectomy compared with conventional open thyroidectomy . Since 1999, we have operated on 452 patients using endoscopic thyroidectomy via a breast approach. The results of our 13-year experience are presented in this article. The purpose of this study was to evaluate the safety and surgical outcomes of endoscopic thyroidectomy and to analyse the clinicopathologic features, types of operation, operation time, and complications of this surgical approach.
A total of 452 consecutive patients with thyroid and parathyroid disease underwent endoscopic thyroidectomy via a breast approach at Uijeongbu St. Mary’s Hospital between November 1999 and December 2012. All operations were performed by a single surgeon (JSK). Written informed consent was obtained from the patients and their families. This study was reviewed and approved by the institutional review board at Uijeongbu St. Mary’s Hospital (UC13RISI0156).
Preoperative diagnoses of thyroid nodules were made by ultrasonography and ultrasonography-guided fine needle aspiration cytology (FNAC). If FNAC identified malignancy or atypical cells that were suspicious for malignancy, computed tomography was performed to identify the tumour location, invasion, and central lymph node metastasis.
The indications for endoscopic thyroidectomy were as follows: 1) benign tumour with the largest diameter less than 4 cm in size (as estimated by preoperative ultrasonography); 2) malignant thyroid nodules less than 2 cm in size; and 3) no evidence of lymph node metastasis or local invasion. Patients who had undergone neck surgery or irradiation were excluded. Additional exclusion criteria were lateral lymph node metastases, extrathyroid extension, invasion into adjacent organs, or suspicion of distant metastasis on the preoperative imaging.
We performed prophylactic ipsilateral central lymph node dissection for differentiated thyroid carcinoma. All patients with differentiated thyroid carcinoma were treated with levothyroxine to suppress thyroid-stimulating hormone, and all patients were regularly followed by ultrasonography and thyroglobulin at 6-month intervals. Differentiated thyroid carcinomas were described using tumour-node-metastasis (TNM) staging on the basis of the 7th edition of the recommendations of the American Joint Committee on Cancer (AJCC).
Clinicopathologic characteristics of 452 patients who underwent endoscopic thyroidectomy via a breast approach
Results (n = 452)
38.4 ± 10.6 (range 11-73)
2.12 ± 1.17 (range 0.1-4)
Hüthle cell adenoma
Mean postoperative hospital stay (days)
3.8 ± 1.3 (range 1-17)
Extent of surgery and mean operation time (min)
Extent of surgery
Mean operation time (min)
156.6 ± 48.0
Total thyroidectomy with CLND*
171.6 ± 38.9
120.0 ± 40.9
Near-total thyroidectomy with CLND
159.9 ± 45.5
130.7 ± 50.2
Subtotal thyroidectomy with CLND
170.3 ± 35.4
104.6 ± 35.1
Thyroid lobectomy with CLND
128.0 ± 35.2
Clinicopathologic characteristics of the patients with differentiated thyroid carcinoma (n = 128)
Tumour size (cm)
1.05 ± 0.79
Central lymph node metastasis
Retrieved central lymph nodes
6.15 ± 4.90 (range 1-26)
Metastatic central lymph nodes
3.53 ± 2.78 (range 1-16)
Mean follow-up period (months)
54.0 ± 35.7 (range 6-160)
Postoperative complications (n = 452)
Recurrent laryngeal nerve injury
In 128 patients with differentiated thyroid carcinoma, 72 patients underwent total thyroidectomy or near-total thyroidectomy. Postoperative thyroglobulin(Tg) levels were available for 60 of the 72 patients. Mean postoperative Tg level was 0.78 ng/ml. 47 of these patients (78.3%) had T4-suppressed level of Tg < 1.0 ng/ml.
In accordance with the increased utilization of ultrasonography, the worldwide incidence of thyroid nodules and carcinoma has progressively increased in recent decades . Because the incidence of thyroid carcinoma in young women is rapidly increasing, cosmesis plays an important role in thyroid operations. In addition to improving the cosmetic results, endoscopic thyroidectomy can reduce the postoperative hospital stay and postoperative pain. Thus, various endoscopic thyroid surgical approaches have been performed, including cervical , anterior chest wall , axilla [8, 9], axilla-breast [10, 11], and breast [12, 13]. While endoscopic thyroid surgery has advantages over other techniques, endoscopic thyroid surgery presents disadvantages for surgeons with limited experience. These disadvantages include a longer learning curve, longer operation time, and the potential for more severe injuries compared to the conventional procedure; however, these disadvantages can be overcome by experienced surgeons.
We have performed endoscopic thyroid surgeries via a breast approach since 1999. Compared with various endoscopic thyroid surgery techniques, such as conventional open thyroidectomy, the breast approach has the advantage of presenting a good visual field. Because a 5-mm endoscope is inserted into the right parasternal region, both thyroid lobes, the recurrent laryngeal nerves, the upper and lower parathyroid glands, and the thyroid vessels can be identified with a symmetrical view. With respect to cosmesis, patient satisfaction is high. The circumareolar wounds of the breast nipples and the 3-mm working port wound heal extremely well and are rarely visible after the procedure unless hypertrophic scars or keloids form.
When contraindications are absent, endoscopic thyroidectomy has recently been applied for benign thyroid tumours. However, safety guidelines for endoscopic thyroidectomy for thyroid cancer have not been published. Thyroid cancer was initially considered to be a contraindication for endoscopic thyroidectomy . However, because differentiated thyroid cancers exhibit good prognoses, endoscopic thyroidectomies for low-risk thyroid cancer are increasingly being performed. With the advent of new surgical skills and the accumulation of a surgeon’s experiences, the indications for endoscopic thyroidectomy are being extended. Currently, the indications for endoscopic thyroidectomy are as follows: patients younger than 45 years old; well-differentiated thyroid cancer of less than 2 cm in diameter; no definite evidence of local invasion or central lymph node metastasis; no adhesion or fixation of enlarged lymph nodes around the neck compartment; and patients who are interested in endoscopic thyroid surgery . We also performed endoscopic thyroidectomy for malignant thyroid carcinoma with the above-mentioned indications.
In 90 out of the 128 patients who underwent endoscopic thyroidectomy for thyroid carcinoma, ipsilateral or bilateral central lymph node dissections were performed with no risk of complications. In our study, the mean number of retrieved lymph nodes was 6.15 ± 4.90 in the central compartment. In patients with thyroid carcinoma, central lymph node dissection is feasible using our surgical technique.
The rates of transient and permanent hypoparathyroidism after conventional open thyroidectomy range from 0.3% to 49% and 0% to 14.3%, respectively, and the rate of unintentional recurrent laryngeal nerve injury ranges from 0% to 5.7% [16–18].
The results of this study were similar. Transient and permanent hypoparathyroidism were observed in 7.1% and 0.9% of patients, respectively. Transient and permanent recurrent laryngeal nerve injuries were observed in 4.4% and 0% of patients, respectively. Compared with conventional open thyroidectomy, our surgical technique does not differ with respect to the incidences of hypoparathyroidism and recurrent laryngeal nerve injury.
There were no life-threatening operative complications after the endoscopic thyroidectomies. While there were cases of immediate postoperative bleeding (2 cases) and wound infection (3 cases), these complications were corrected without difficulty. Tracheal injury, oesophageal injury, flap injury, and subcutaneous emphysema were not observed.
In this study, 2 out of 128 patients developed recurrent thyroid carcinoma after endoscopic thyroidectomy. One patient underwent endoscopic total thyroidectomy with central lymph node dissection. Tumour histology revealed papillary carcinoma. The tumour size was 2.2 cm, and extrathyroidal extension was not observed, but central lymph node metastasis was observed. The patient was treated with radioactive iodine therapy. After 28 months, the follow-up imaging study revealed metastases to the central and right lateral lymph nodes. FNAC was performed in the right lateral lymph node, which supported the diagnosis of papillary carcinoma. Therefore, we performed a modified radical neck dissection. Another patient underwent endoscopic lobectomy in September 2000. Tumour histology revealed papillary microcarcinoma. The tumour was 0.5 cm in size. The patient was treated with levothyroxine for serum thyrotropin (TSH) suppression. After 132 months, a newly developed lesion was observed in the contralateral thyroid lobe. We performed open completion thyroidectomy with central lymph node dissection. To date, no mortality has been reported in these patients. Thus, endoscopic thyroidectomy for thyroid carcinoma is safe, especially in cases of low-risk differentiated thyroid carcinoma.
Endoscopic thyroidectomy via a breast approach is a safe, feasible, and minimally invasive surgical method for benign and low-risk malignant thyroid disease. This approach provides good operative results and has a low complication rate. For selected thyroid disease patients who worry about neck scars, endoscopic thyroidectomy via a breast approach is an effective surgical option.
Fine needle aspiration cytology
American Joint Committee on Cancer.
There is no financial support.
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