**4. Risk classification of DTC**

The risk classification helps to predict the risk of local recurrence and developing metastases and the mortality in patients with DTC. It uses multiple staging systems which are based on a combination of the size of the primary tumor, specific histology, extrathyroidal spread of the tumor and the age at diagnosis.

The staging system most often used for thyroid cancer is the **TNM** (**Table 2**) system, which is based on three key pieces of information:


The most common risk classification is based on the tumor node metastasis (TNM) classification:


**TX:** Primary tumor cannot be evaluated

**T0:** There is no evidence of primary tumor

**T1:** Tumor limited to the thyroid, whose maximum dimension does not exceed 2 cm

**T1a:** Tumor limited to the thyroid, whose greatest dimension does not exceed 1 cm

**T1b:** Tumor limited to the thyroid gland with dimension >1 cm, but lower than 2 cm in greatest dimension

Based on the risk of structural disease recurrence, the American Thyroid Association defines

T2 N0/NX M0

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T2 N1 M0 T3a/T3b any N M0

• high-risk group: gross extrathyroidal extension, incomplete tumor resection, distant metas-

• intermediate-risk group: aggressive histology, minor extrathyroidal extension, vascular

The American Joint Committee on Cancer (AJCC) uses the combination of TNM classification

Total complete thyroidectomy is the procedure that can be defined as an extracapsular thy-

The tool kit consists of a scalpel, Pean forceps (1–2 pieces), anatomical and surgical forceps,

A 5–6 cm Kocher incision is performed in a flexion fold at 2–2.5 cm of the sternal notch. The skin, the subcutaneous cellular tissue and the platysma muscle are cut, after which a superior

scissors, Farabeuf or Kocher spacers, monopolar cautery and LigaSure™ small jaw.

• low-risk group: intrathyroidal DTC, ≤5 lymph nodes micrometastases (<0.2 cm)

and an age of more than 55 years at diagnosis as risk factor (**Table 3**).

roidectomy in which we remove the entire gland without remnant tissue.

in their current guideline the next classification [16]:

*Age at diagnosis <55 years*

*Age at diagnosis ≥55 years*

Stage I: any T any N M0 Stage II: any T any N M1

Stage I: T1 N0/NX M0

Stage II: T1 N1 M0

Stage III: T4a any N M0 Stage IVA: T4b any N M0 Stage IVB: any T any N M1

invasion, or >5 involved lymph nodes (0.2–3 cm);

tases, or lymph node >3 cm;

**Table 3.** Stage grouping according to AJCC.

**5. Surgery without ligatures**

**5.1. Surgical instruments**

**5.2. Incision**

**T2:** Tumor >2 cm but ≤4 cm in greatest dimension limited to the thyroid

**T3:** Tumor limited to the thyroid or with minimal extrathyroidal extension, with dimension <4 cm

**T3a:** Tumor dimension >4 cm but is limited to the thyroid

**T3b:** Minimal extrathyroidal extension invading the strap muscles (sternohyoid, sternothyroid, thyrohyoid or omohyoid muscles) from a tumor of any size

**T4:** Includes extrathyroidal extension into neck major structures

**T4a:** Tumor of any size with extrathyroidal extension invading subcutaneous soft tissues, larynx, trachea, esophagus or recurrent laryngeal nerve

**T4b:** Tumor of any size with extrathyroidal extension invading prevertebral fascia or encasing carotid artery or mediastinal vessels

**NX:** Regional lymph nodes cannot be evaluated

**N0:** There is no evidence of regional lymph node metastasis

**N1:** Metastasis to regional nodes

**N1a:** Unilateral or bilateral disease involving level VI or VII lymph nodes metastasis (pretracheal, paratracheal, prelaryngeal / Delphian or upper mediastinal)

**N1b:** Unilateral, bilateral or contralateral lymph nodes metastasis (levels I, II, III, IV or V) or retropharyngeal lymph nodes

**M0:** No distant metastasis

**M1:** Distant metastasis

**Table 2.** TNM classification, 8th edition [15].


**Table 3.** Stage grouping according to AJCC.

• T = the size of the tumor

98 Cancer Survivorship

**TX:** Primary tumor cannot be evaluated **T0:** There is no evidence of primary tumor

• N = the spread to the nearby lymph nodes • M = the spread to distant sites (metastasis)

• very low-risk group: pT1a, cN0/pN0, cM02; • low-risk group: pT1b, pT2, cN0/pN0, cM0; • high-risk group: pT3, pT4, each N1, all M1.

**T1:** Tumor limited to the thyroid, whose maximum dimension does not exceed 2 cm **T1a:** Tumor limited to the thyroid, whose greatest dimension does not exceed 1 cm

**T2:** Tumor >2 cm but ≤4 cm in greatest dimension limited to the thyroid

**T3a:** Tumor dimension >4 cm but is limited to the thyroid

**T4:** Includes extrathyroidal extension into neck major structures

omohyoid muscles) from a tumor of any size

esophagus or recurrent laryngeal nerve

**NX:** Regional lymph nodes cannot be evaluated

prelaryngeal / Delphian or upper mediastinal)

**Table 2.** TNM classification, 8th edition [15].

**N0:** There is no evidence of regional lymph node metastasis

mediastinal vessels

lymph nodes

**M0:** No distant metastasis **M1:** Distant metastasis

**N1:** Metastasis to regional nodes

The most common risk classification is based on the tumor node metastasis (TNM) classification:

**T1b:** Tumor limited to the thyroid gland with dimension >1 cm, but lower than 2 cm in greatest dimension

**T3b:** Minimal extrathyroidal extension invading the strap muscles (sternohyoid, sternothyroid, thyrohyoid or

**T4a:** Tumor of any size with extrathyroidal extension invading subcutaneous soft tissues, larynx, trachea,

**T4b:** Tumor of any size with extrathyroidal extension invading prevertebral fascia or encasing carotid artery or

**N1a:** Unilateral or bilateral disease involving level VI or VII lymph nodes metastasis (pretracheal, paratracheal,

**N1b:** Unilateral, bilateral or contralateral lymph nodes metastasis (levels I, II, III, IV or V) or retropharyngeal

**T3:** Tumor limited to the thyroid or with minimal extrathyroidal extension, with dimension <4 cm

Based on the risk of structural disease recurrence, the American Thyroid Association defines in their current guideline the next classification [16]:


The American Joint Committee on Cancer (AJCC) uses the combination of TNM classification and an age of more than 55 years at diagnosis as risk factor (**Table 3**).

## **5. Surgery without ligatures**

Total complete thyroidectomy is the procedure that can be defined as an extracapsular thyroidectomy in which we remove the entire gland without remnant tissue.

#### **5.1. Surgical instruments**

The tool kit consists of a scalpel, Pean forceps (1–2 pieces), anatomical and surgical forceps, scissors, Farabeuf or Kocher spacers, monopolar cautery and LigaSure™ small jaw.

#### **5.2. Incision**

A 5–6 cm Kocher incision is performed in a flexion fold at 2–2.5 cm of the sternal notch. The skin, the subcutaneous cellular tissue and the platysma muscle are cut, after which a superior and a lower flap is made by dissection using LigaSure™ or electrocautery. The upper flap is suspended, exposing the white line (**Figures 1**–**3**).

#### **5.3. How we do it**

Penetration into the cleavage space by cutting the medial raf and releasing the anterior face of the anterior thyroide lobe. The thyroid lobe is mobilized with a thread (**Figure 4**).The dissection is continued laterally by sealing the middle thyroid vein with the LigaSure™ small

**Figure 1.** Kocher incision.

**Figure 2.** Preparing the upper and lower flap.

jaw, then continuing cranially to the upper thyroid at the same time as the thyroid lobe

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Upper pole dissection with LigaSure*™ Small Jaw*, sealing the upper thyroid vascular pedicle

The sealing of the lower branches of the lower thyroid pedicle is the essential time of this intervention, with the preservation of parathyroids, secondary branches of the inferior artery and the recurrent nerve. Dissection proceeds to the median line, sectioning Berry's ligaments.

dislocates (**Figure 5**).

**Figure 6.** Sealing the upper thyroid pedicle.

**Figure 4.** Traction of the thyroid lobe using thread.

**Figure 5.** Lateral dissection with the sealing of the medial vein.

(**Figure 6**).

**Figure 3.** Suspending the upper flap.

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**Figure 4.** Traction of the thyroid lobe using thread.

and a lower flap is made by dissection using LigaSure™ or electrocautery. The upper flap is

Penetration into the cleavage space by cutting the medial raf and releasing the anterior face of the anterior thyroide lobe. The thyroid lobe is mobilized with a thread (**Figure 4**).The dissection is continued laterally by sealing the middle thyroid vein with the LigaSure™ small

suspended, exposing the white line (**Figures 1**–**3**).

**5.3. How we do it**

100 Cancer Survivorship

**Figure 1.** Kocher incision.

**Figure 3.** Suspending the upper flap.

**Figure 2.** Preparing the upper and lower flap.

**Figure 5.** Lateral dissection with the sealing of the medial vein.

**Figure 6.** Sealing the upper thyroid pedicle.

jaw, then continuing cranially to the upper thyroid at the same time as the thyroid lobe dislocates (**Figure 5**).

Upper pole dissection with LigaSure*™ Small Jaw*, sealing the upper thyroid vascular pedicle (**Figure 6**).

The sealing of the lower branches of the lower thyroid pedicle is the essential time of this intervention, with the preservation of parathyroids, secondary branches of the inferior artery and the recurrent nerve. Dissection proceeds to the median line, sectioning Berry's ligaments.

All patients have been prior diagnosed by fine needle aspiration (FNA) biopsy showing

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All patients had preoperative and postoperative endocrinological consultations, and all the

Surgery consisted of performing total thyroidectomy and double drainage of the thyroid

The two groups included in this study had similar demographics (age, sex) and the thyroid

In the evaluation of the operative time measured from the moment of the skin incision to wound closure, we have found that statistical data followed a Gaussian distribution and it could be interpreted by Student's t-test. The mean operative time in group 1 was 73.81 ± 16.96 min, which is significantly less than the operative time in the second group

To appreciate the length of hospital stay, we applied the nonparametric Mann-Whitney test, since the two groups did not have a Gaussian distribution pattern, because of the value of 17 days in group 1 and of 19 days in group 2. For group 1, the mean hospitalization time was of 4 days (range: 2–17 days), and for group 2, it was also 4 days (range: 3–19 days) (**Table 6**). We have not found statistically significant differences relating to these parameters of the

**Group 1 Group 2**

female patients had gynecological examination prior to the surgery.

patients in the two groups, regardless of the statistic method applied.

Mean age 54 52 Sex ratio F:M 45:5 43:7

Minimum 45 65 Mean 73.81 106.19 Maximum 120 200 Median 72.5 100 Standard deviation 16.96 31.66

Extracapsular thyroidectomy was performed in all patients.

either papillary or follicular cancer.

pathology also being the same (**Table 4**).

(conventional) 106.19 ± 31.66 min (**Table 5**).

**Table 4.** Patient's demographic characteristics.

**Table 5.** Distribution of patients depending to the operative time.

**6.2. Results**

compartment.

**Figure 7.** Monobloc resection of the thyroid gland.

Lobectomy ends with the separation of the isthmus, being an optional time, or we can achieve a monobloc resection of the gland (**Figure 7**).

Control of the hemostasis, drainage of the thyroid cavity, intradermal resorbable suture.
