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Appropriate Surgical Procedure for Dominant
Thyroid Nodules of the Isthmus 1 cm or Larger
Melanie Goldfarb, MD; Steven S. Rodgers, MD, PhD; John I. Lew, MD

Hypothesis: Surgeon-performed ultrasound (SUS) and plasm. Among these 12 patients, final pathologic results
fine-needle aspiration (FNA) may guide the manage- demonstrated multifocal disease (8 patients), extracap-
ment of dominant thyroid nodules of the isthmus. sular invasion (4 patients), or lymph node involvement
(7 patients). When 11 patients with a malignant domi-
Design: Retrospective review of prospectively col- nant thyroid nodule of the isthmus were compared with
lected data. an overall group of 270 other well-differentiated papil-
lary thyroid carcinomas 1 cm or larger on final patho-
Setting: Tertiary academic referral center. logic results, patients with isthmus nodules trended to-
ward having higher rates of multifocal disease (P=.08),
Patients: Of 942 patients who underwent preoperative extracapsular invasion (P=.09), and lymph node involve-
SUS and FNA, followed by thyroidectomy, between Janu- ment (P=.09).
ary 1, 2002, and April 10, 2010, a total of 28 patients had
a dominant thyroid nodule of the isthmus. Conclusions: Preoperative SUS features and FNA find-
ings in patients with dominant thyroid nodules of the isth-
Main Outcome Measures: Preoperative SUS fea- mus can accurately predict malignant or benign thyroid
tures and FNA findings and final pathologic results. disease and direct the extent of thyroidectomy. For ma-
lignant isthmus nodules, total thyroidectomy and pos-
Results: Of 28 patients (3%) who had a dominant thy- sible central node dissection are recommended owing to
roid nodule of the isthmus, 16 had benign final patho- high rates of multifocal disease and lymph node involve-
logic results, with all having at least 2 benign SUS fea- ment. For benign isthmus nodules, thyroid lobectomy
tures and 9 having 3 benign SUS features; 15 of 16 patients with isthmusectomy or isthmusectomy alone may be
had an FNA finding that was benign or indeterminate. appropriate.
Of 12 patients with malignant final pathologic results, 8
had 3 malignant SUS features, and all had an FNA find- Arch Surg. 2012;147(9):881-884. Published online May
ing that was malignant or suspicious for a malignant neo- 21, 2012. doi:10.1001/archsurg.2012.728

D
OMINANT THYROID NOD- predicting benign and malignant disease.
ules of the isthmus are a When combined with FNA findings, sur-
rare indication for surgi- geons may be able to determine the proper
cal resection. Although the extent of surgical treatment. Total thy-
overall frequency of isth- roidectomy for a benign isthmus nodule
mus nodules is uncertain, cancers arising may be unnecessary and result in hypo-
within such nodules among all malignant thyroidism, whereas isthmusectomy alone
thyroid nodules reportedly range from 1% for a malignant isthmus nodule may be in-
to 9%.1-3 Although the American Thyroid adequate for correct oncologic resection.
Association4 and the British Thyroid Asso- This study examines the role of preopera-
ciation5 have overall recommendations for tive SUS and FNA in the appropriate sur-
well-differentiated thyroid cancer, no spe- gical management of dominant thyroid
Author Affiliations: Division of Author Affil
Endocrine Surgery, Department cific guidelines exist for the management of nodules of the isthmus. Endocrine Su
of Surgery, University of Miami thyroid nodules confined to the isth- of Surgery, U
Miller School of Medicine, mus.4,5 As such, the appropriate surgical METHODS Miller Schoo
Miami, Florida. Dr Goldfarb is treatment of dominant thyroid nodules of Miami, Flori
now with the Division of the isthmus remains unclear. now with th
Breast/Soft Tissue and Clinical and pathologic data on 1356 consecu- Breast/Soft T
Current workup of a thyroid nodule of- tive patients who underwent thyroidectomy be-
Endocrine Surgery, Department Endocrine Su
of Surgery, University of
ten consists of preoperative ultrasonogra- tween January 1, 2002, and April 10, 2010, were of Surgery, U
Southern California Keck phy and fine-needle aspiration (FNA). collected prospectively in an institutional re- Southern Ca
School of Medicine, Studies6,7 have documented the efficacy of view board–approved database at the Univer- School of Me
Los Angeles. surgeon-performed ultrasound (SUS) in sity of Miami Health System, Miami, Florida. Los Angeles.

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 Table. Characteristics of 28 Patients With Benign vs Malignant Dominant Thyroid Nodules of the Isthmus

Benign Group Malignant Group

Characteristic (n = 16) (n = 12)
Patient Demographics
Age, mean, y 52 47
Male sex, % 13 25
Nonwhite race/ethnicity, % 50 67
Surgeon-Performed Preoperative Tests
Ultrasonography features
Nodule size, mean, cm 2.7 1.8
Dominant nodule
Echogenicity Isoechoic or hyperechoic Hypoechoic
Borders Regular Irregular
Calcification No microcalcifications Microcalcifications
Total No. of features 9 Patients had all 3 features; all patients had ⱖ2 8 Patients had all 3 features
Fine-needle aspiration findings, No. of patients
Benign 10 0
Indeterminate 5 0
Suspicious 1 4
Malignant 0 8

In total, 967 patients had both SUS and FNA performed before (3%) underwent surgical treatment of a dominant thy-
thyroidectomy. A retrospective review was performed of 942 roid nodule of the isthmus 1 cm or larger by preopera-
patients with no history of thyroid cancer. tive SUS. The mean age of the 28 patients was 50 years.
Preoperative SUS was performed using high-frequency linear- The mean nodule size by preoperative SUS was 2.3 cm.
array transducers (7.5-13.0 MHz). All the ultrasonography stud-
ies were performed by surgeons certified in basic cervical ul-
On final pathologic results, 16 nodules were benign,
trasonography by the American College of Surgeons. and 12 nodules were malignant (43%). Characteristics
Prospectively collected SUS features of thyroid nodules in- of the benign and malignant groups are given in the
cluded size (height, width, and length), echogenicity (hy- Table.
poechoic, isoechoic, or hyperechoic), borders (regular or ir- Of 16 patients with benign disease on final patho-
regular), calcifications (microcalcification vs coarse or none), logic results, the indications for surgical resection were
cystic component (vs solid), shape (taller vs wider on trans- an enlarging thyroid nodule (9 patients), indeterminate
verse view), number of nodules (single vs multiple), and loca- or suspicious FNA findings (6 patients), and toxic nod-
tion (unilobar vs bilobar). ule (1 patient). Most patients (14 of 16 patients [88%])
Within this series, 28 patients underwent surgical resec-
had palpable lesions; only 1 patient with benign patho-
tion for a solitary or dominant thyroid nodule of the isthmus 1
cm or larger by preoperative SUS. Patient demographics and logic results was initially seen with obstructive symp-
preoperative SUS features and FNA findings were evaluated as toms (dysphagia and shortness of breath).
predictors of a malignant neoplasm and the appropriate sur- Of 12 patients with malignant disease on final patho-
gical procedure in these patients. logic results, the indication for surgical resection was a
All the patients underwent either thyroid lobectomy with preoperative FNA finding that was malignant or suspi-
isthmusectomy or total thyroidectomy with or without cen- cious for a malignant neoplasm. All the patients had
tral node dissection. Lateral neck dissection was performed in palpable nodules of the thyroid isthmus, with no ob-
patients when clinically evident nodal metastases were de- structive symptoms. Final pathologic results were con-
tected before surgery by physical examination or by SUS or FNA sistent with classic papillary thyroid carcinoma in 10
confirmation of metastatic disease.
patients and with follicular variant of papillary thyroid
Patients with a differentiated thyroid carcinoma 1 cm or larger
on final pathologic results were then subdivided into 2 groups carcinoma in 2 patients. Six patients (50%) had 1 or
based on the location of their primary tumor. The first group more cancerous lymph nodes in the central compart-
had a dominant thyroid nodule of the isthmus (11 patients), ment, and 1 patient had a positive lateral neck lymph
and the second group had 1 or more dominant nodules else- node. On final pathologic results, 11 of 12 patients had
where in the thyroid gland (270 patients). cancerous nodules 1 cm or larger, while 1 patient had a
Statistical analysis was performed using commercially avail- cancerous lesion measuring 0.8 cm. Among 12 patients,
able software (SPSS 18.0; IBM Co) to compare rates of multi- multifocal disease was seen in 8 patients, extracapsular
focal disease, extracapsular invasion, and lymph node involve- invasion in 4 patients, and lymph node involvement in
ment between groups. P ⬍ .05 was considered statistically 7 patients. The tumors of 11 patients with a cancerous
significant.
nodule 1 cm or larger showed one of these aggressive
features.
RESULTS Of 942 patients, 281 underwent thyroidectomy for
well-differentiated papillary thyroid carcinoma 1 cm or
Of 942 patients with no history of thyroid cancer who larger on final pathologic results. Among this group, the
underwent thyroidectomy in this series, 28 patients frequency of well-differentiated papillary thyroid carci-

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 for thyroid isthmus nodules when SUS features are com-
Dominant thyroid nodule of the isthmus bined with FNA findings (Figure).
Owing to their unique anatomical location, lym-
SUS
phatic drainage, and blood supply, nodules originating
from the thyroid isthmus have higher rates of multifo-
cal cancer and extracapsular invasion. In this series,
FNA
67% (8 of 12) of patients with thyroid cancer in the
§
isthmus had multifocal disease, which is higher than
the 48.6% reported in the literature. Furthermore, 33%
Malignant or Indeterminate Benign
suspicious
(4 of 12) of patients had extracapsular invasion, which
‡ is less than the 70% reported in the literature. Neverthe-
SUS SUS
less, as seen herein, well-differentiated thyroid carci-
noma of the isthmus had higher rates of multifocal dis-
† ease and extracapsular invasion compared with tumors
arising from dominant nodules in the right or left thy-
Suspicious Benign or Observation
features equivocal features roid lobes. In this study, the few patients with thyroid
cancer of the isthmus may have contributed to the re-
Total Thyroid lobectomy
sults not reaching statistical significance.
thyroidectomy with isthmusectomy or In addition, 6 of 12 patients (50%) in the present study
± CND isthmusectomy alone
had 1 or more metastatic lymph nodes compared with
an overall group having well-differentiated papillary thy-
Figure. Algorithm for the management of dominant thyroid nodules of the roid carcinomas.1,2 However, rates of aggressive patho-
isthmus. CND indicates central neck dissection (performed in the case of logic findings and lymph node involvement are much
preoperative or intraoperative diagnosis of a malignant neoplasm); higher in the present study than those reported in an-
FNA, surgeon-performed fine-needle aspiration. †Performed in the case of
obstructive symptoms, cosmetic concerns, or very suspicious other series,3 possibly owing to their inclusion of le-
surgeon-performed ultrasound (SUS) features. ‡In the case of follicular cells sions smaller than 1 cm.
of undetermined significance or follicular adenoma. §May consider molecular Small case series in the literature advocate isthmus-
testing.
ectomy alone for solitary isthmus nodules, detailing the
ease and low morbidity of the procedure with good long-
term outcomes, even for well-differentiated papillary thy-
noma in a dominant isthmus nodule was 3.9%. When 11
roid carcinoma.8,9 However, the present study and oth-
patients with a malignant dominant thyroid nodule of the
ers 1,2 demonstrate high rates of multifocal disease,
isthmus were compared with the overall group, patients
extracapsular invasion, and lymph node involvement, in-
with isthmus nodules trended toward having higher rates
dicating that total thyroidectomy should be strongly con-
of multifocal disease (P = .08), extracapsular invasion
sidered for any thyroid nodule of the isthmus that is sug-
(P=.09), and lymph node involvement (P = .09).
gestive of a malignant neoplasm. Conversely, for thyroid
nodules of the isthmus that are consistent with benign
COMMENT disease, if neither the tracheal space is violated nor any
dissection is attempted beyond the limits of isthmus re-
A solitary or dominant thyroid nodule of the isthmus is an section, isthmusectomy alone may be an acceptable al-
uncommon clinical entity requiring surgical evaluation. The ternative to diagnostic lobectomy in select circum-
present study reports an overall 3% (28 of 942 patients) stances when no other small nodules are identified in
frequency of dominant thyroid nodules of the isthmus either lobe by preoperative ultrasonography and when
treated by surgical resection. In addition, of all the pa- the lesion is truly midline.
tients with well-differentiated papillary thyroid carcino- In conclusion, preoperative SUS and FNA for thy-
mas 1 cm or larger on final pathologic results, 4% (11 of roid nodules of the isthmus can accurately predict ma-
281 patients) had a dominant isthmus nodule, which falls lignant or benign thyroid disease and direct the extent
within the reported range from previous series.1-3 of thyroidectomy. For malignant isthmus nodules, total
For solitary or dominant thyroid nodules of the isth- thyroidectomy and possible central node dissection are
mus, SUS may be a useful test to evaluate for nodular fea- recommended owing to high rates of multifocal disease
tures that are suggestive of a malignant neoplasm (ie, hy- and lymph node involvement. For benign isthmus nod-
poechoic, with irregular borders and microcalcifications). ules, thyroid lobectomy with isthmusectomy or isthmus-
With such information, surgeons can advise patients that ectomy alone may be appropriate.
total thyroidectomy and possible central neck dissec-
tion may be required.7 Conversely, if SUS features are Accepted for Publication: March 15, 2012.
suggestive of a benign nodule (ie, isoechoic or hyper- Published Online: May 21, 2012. doi:10.1001
echoic, with regular borders and without microcalcifi- /archsurg.2012.728
cations), thyroid lobectomy with isthmusectomy or isth- Correspondence: Melanie Goldfarb, MD, Division of
musectomy alone may be appropriate.6 For lesions of the Breast/Soft Tissue and Endocrine Surgery, Department
isthmus that do not fall into 1 of these 2 categories, FNA of Surgery, University of Southern California Keck School
is recommended. According to the present study, sur- of Medicine, 1510 San Pablo St, Ste 412K, Los Angeles,
geons can more confidently plan the extent of operation CA 90033 ([email protected]).

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 Author Contributions: Study concept and design: Gold- 2. Sugenoya A, Shingu K, Kobayashi S, et al. Surgical strategies for differentiated
carcinoma of the thyroid isthmus. Head Neck. 1993;15(2):158-160.
farb, Rodgers, and Lew. Acquisition of data: Goldfarb. 3. Nixon IJ, Palmer FL, Whitcher MM, et al. Thyroid isthmusectomy for well-
Analysis and interpretation of data: Goldfarb and Lew. differentiated thyroid cancer. Ann Surg Oncol. 2011;18(3):767-770.
Drafting of the manuscript: Goldfarb and Lew. Critical re- 4. Cooper DS, Doherty GM, Haugen BR, et al; American Thyroid Association (ATA) Guide-
vision of the manuscript for important intellectual content: lines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer. Revised Ameri-
Rodgers and Lew. Statistical analysis: Goldfarb. Study su- can Thyroid Association management guidelines for patients with thyroid nodules
and differentiated thyroid cancer. Thyroid. 2009;19(11):1167-1214.
pervision: Rodgers and Lew. 5. Watkinson JC; British Thyroid Association. The British Thyroid Association guide-
Financial Disclosure: None reported. lines for the management of thyroid cancer in adults. Nucl Med Commun. 2004;
Previous Presentation: This paper was presented at the 25(9):897-900.
83rd Annual Meeting of the Pacific Coast Surgical As- 6. Goldfarb M, Gondek S, Irvin GL III, Lew JI. Normocalcemic parathormone eleva-
tion after successful parathyroidectomy: long-term analysis of parathormone varia-
sociation; February 18, 2012; Napa Valley, California; and tions over 10 years. Surgery. 2011;150(6):1076-1084.
is published after peer review and revision. 7. Jabiev AA, Ikeda MH, Reis IM, Solorzano CC, Lew JI. Surgeon-performed ultra-
sound can predict differentiated thyroid cancer in patients with solitary thyroid
nodules. Ann Surg Oncol. 2009;16(11):3140-3145.
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1. Lee YS, Jeong JJ, Nam KH, Chung WY, Chang HS, Park CS. Papillary carcinoma 9. Maser C, Donovan P, Udelsman R. Thyroid isthmusectomy: a rarely used but simple,
located in the thyroid isthmus. World J Surg. 2010;34(1):36-39. safe, and efficacious operation. J Am Coll Surg. 2007;204(3):512-514.

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