The role of surgery in the current management of differentiated thyroid cancer

In the last decades, a surprising increased incidence of differentiated thyroid cancer (DTC), along with a precocious diagnosis of "small'' tumors and microcarcinomas have been observed. In these cases, better oncological outcomes are expected, and a "tailored'' and "less aggressive'' multimodal therapeutic protocol should be considered, avoiding an unfavorable even if minimal morbidity following an "overtreatment.'' In order to better define the most suitable surgical approach, its benefits and risks, we discuss the role of surgery in the current management of DTCs in the light of data appeared in the literature. Even if lymph node metastases are commonly observed, and in up to 90 % of DTC cases micrometastases are reported, the impact of lymphatic involvement on long-term survival is still argument of intensive research, and indications and extension of lymph node dissection (LD) are still under debate. In particular, endocrine and neck surgeons are still divided between proponents and opponents of routine central LD (RCLD). Considering the available evidence, there is agreement about total thyroidectomy, therapeutic LD in clinically node-positive DTC patients, and RCLD in "high risk'' cases. Nevertheless, indications to the best surgical treatment of clinically node-negative "low risk'' patients are still subject of research. Considering on the one hand, the recent trend toward routine central lymphadenectomy, avoiding radioactive treatment, and on the other hand, the satisfactory results obtained reserving prophylactic LD to "high risk'' patients, we think that further prospective randomized trials are needed to evaluate the best choice between the different surgical approaches.