A sentinel node biopsy is a short operation that removes and tests the first one to three lymph nodes in the armpit, the nodes that drain the breast and are the likeliest place for cancer cells to land first. To find them, the surgeon injects a tracer near the tumour or around the nipple, such as a radioactive tracer, blue dye or a magnetic agent. If those nodes are clear, a full armpit clearance is usually not needed, and even when one or two carry cancer, many patients can still avoid it. This blog explains how the test works and how the decision is made.

According to Prof. Dr. Sandeep Nayak, Surgical Oncologist in Bengaluru at MACS Clinic, many patients assume breast cancer surgery always means removing all the armpit nodes, and the fear of a swollen arm is what worries them most. Sentinel node biopsy was developed to spare many of them this. The first nodes are tested, and the result guides whether anything more is needed.

• What it is. The sentinel nodes are the “gatekeepers”, the first nodes that fluid from the tumour reaches. If cancer has begun to spread, it shows up there first. The breast cancer treatment page explains where this test fits in the overall plan.
• The tracer. A radioactive tracer, blue dye, a fluorescent dye (indocyanine green) or a magnetic tracer is injected near the tumour or around the nipple. Many surgeons use two together, which lowers the chance of missing a node.
• The operation. A small cut in the armpit, usually 2 to 3 cm, and one to three nodes are removed. It is normally done at the same sitting as the breast surgery, under anaesthesia.
• The result. A pathologist examines the nodes under the microscope. Sometimes a quick result is available during surgery, and the final report follows in a few days.
• Side effects. Blue dye can turn the urine green and the skin around the injection site bluish for a few days, and allergic reactions are rare. Some patients have numbness, tightness or a small fluid collection (seroma) in the armpit.
• Accuracy. There is a small chance, reported at roughly 5 to 10 percent, that the sentinel nodes look clear while cancer sits elsewhere in the armpit.

• Clear nodes. If the sentinel nodes are free of cancer, no further surgery on the armpit is usually needed.
• One or two positive nodes. The ACOSOG Z0011 trial studied early breast cancer (T1 or T2 tumours) treated with lumpectomy and whole-breast radiotherapy. Patients with one or two positive sentinel nodes who skipped clearance did as well as those who had it, with five-year disease-free survival of about 84 percent against 82 percent.
• Fewer complications. In the same trial, wound infection, seroma and numbness affected about 25 percent after sentinel biopsy alone, against 70 percent after clearance. Arm swelling at one year was reported by 2 percent and 13 percent of patients respectively.
• When clearance is still advised. Three or more positive nodes, nodes already proven to contain cancer on a pre-operative needle biopsy, some mastectomy patients who will not receive radiotherapy, and cancer that remains in the nodes after chemotherapy. In some of these cases, radiotherapy to the armpit can replace surgery.
• Sometimes even the biopsy is skipped. The SOUND and INSEMA trials support omitting sentinel node biopsy in carefully selected women with small, low-risk, hormone-positive cancers and a normal armpit ultrasound. It does not apply to everyone.
• A team decision. A tumour board reviews each case. The blog on choosing a cancer hospital explains what a tumour board is and what to ask.

Four things decide it.

The nodes before surgery. An armpit ultrasound, and a needle biopsy of any suspicious node, show whether cancer is already known to be there.

The tumour and the surgery planned. Lumpectomy with radiotherapy is the setting in which Z0011 applies. A mastectomy without radiotherapy may need a different approach.

The number and size of positive nodes. One or two nodes with limited deposits can often be left alone. Three or more, or nodes that have grown through their capsule, more often need further treatment.

Chemotherapy before surgery. If chemotherapy comes first, sentinel biopsy is done afterwards, usually with two tracers and at least three nodes removed. Clearance is advised if cancer is still found. The full range of cancer operations is on the services page, and more topics are on the Dr. Nayak blogs page.

Key Takeaways

• A sentinel node biopsy removes and tests the first one to three armpit nodes to see whether breast cancer has spread.
• Clear nodes usually mean no further armpit surgery.
• With one or two positive nodes, many early breast cancer patients treated with lumpectomy and radiotherapy can avoid full clearance.
• Clearance carries more complications, including a higher risk of arm swelling.
• Whether you can skip it depends on the nodes, the tumour, the surgery planned and any chemotherapy.

References

1. Cleveland Clinic. Sentinel Node Biopsy. https://my.clevelandclinic.org/health/diagnostics/9192-sentinel-node-biopsy Explains what a sentinel node biopsy is, how the tracer is used and what to expect.
2. Journal of Clinical Oncology (2007). Surgical complications associated with sentinel lymph node dissection plus axillary dissection compared with sentinel node dissection alone in ACOSOG Z0011. https://pubmed.ncbi.nlm.nih.gov/17485711/ Compares infection, seroma, numbness and arm swelling with and without clearance.

Disclaimer: This blog is for informational and educational purposes only and is not a substitute for professional medical advice or diagnosis.

Often it can. If the cancer is small, lies in only one lobe and hasn’t spread to the neck nodes, removing just that lobe, a partial thyroidectomy, may be all that is needed. What the surgeon decides rests on the cancer type, the tumour’s size and exact position, and the histopathology report that comes back after the operation. Some cancers, though, need the whole gland out from day one. This blog explains which is which, what each option means for tablets and follow-up, and how the decision is made.

According to Prof. Dr. Sandeep Nayak, Surgical Oncologist in Bengaluru at MACS Clinic, patients commonly arrive assuming a cancer diagnosis means the entire gland has to be removed. Often that isn’t the case, and the news is a real relief. The first decision comes from the needle biopsy and the scans, but the report on the removed tissue can alter it afterwards. The plan is therefore best discussed in full before the operation.

• Small, low-risk papillary cancer. It’s the commonest thyroid cancer. The American Thyroid Association’s 2015 guidelines say lobectomy alone is acceptable when the tumour is 4 cm or smaller, sits within the thyroid and hasn’t reached the lymph nodes. The thyroid cancer treatment page describes the types and how each is treated.
• Very small tumours. For papillary cancers under 1 cm, lobectomy is the usual operation, and some very low-risk ones are simply watched.
• Low-risk follicular cancer. A minimally invasive follicular cancer can sometimes be managed the same way.
• A healthy other lobe. There should be no suspicious nodules in the opposite lobe, no family history of thyroid cancer and no earlier radiation to the head or neck.
• Outcomes in selected patients. In pooled data on low-to-intermediate-risk papillary cancer, around 96% of patients were free of recurrence five years after lobectomy. After total thyroidectomy it was 95%.
• Sometimes a second operation follows. Now and then the report on the removed lobe shows higher-risk features, and the other lobe has to be taken out later. How often depends on the study: about 1 in 10 in some, nearer 1 in 3 in others.

• Tablets. A fair number of patients get by on the lobe left behind. Others become hypothyroid, meaning the thyroid is underactive, and need levothyroxine.
• Radioactive iodine. It is usually not needed after a lobectomy. It is used mainly after the whole gland has been removed, in cancers that need it.
• Monitoring. Serum thyroglobulin is the blood marker doctors track after thyroid cancer surgery. It becomes harder to read when thyroid tissue is still there. So the checks lean on neck ultrasound and TSH instead.
• Fewer surgical risks. A lobectomy carries a lower chance of low calcium from parathyroid injury, and of injury to the voice nerves on both sides.
• Scarless options. Robotic and open surgery both allow lobectomy, and the approach does not change how much is removed. The robotic cancer surgery page describes them.
• Completion thyroidectomy. If the report shows higher-risk features, a second operation can take out the other lobe.

Four things decide it.

The type of cancer. Papillary and follicular cancers (the differentiated types) give some room for choice. Medullary and anaplastic cancers generally call for total thyroidectomy, and medullary cancer also needs clearance of the central neck nodes.

The size and spread. A tumour over 4 cm, one growing through the thyroid capsule, or one with spread to nodes or distant organs usually calls for total thyroidectomy, with neck dissection in many cases. The head and neck cancer treatment page explains when the nodes are treated.

The other lobe and the history. Nodules in the other lobe, thyroid cancer running in the family, radiation to the neck in the past or an inherited syndrome all point towards taking the whole gland.

The final pathology and your preference. Aggressive features on the report can change the plan, and the patient’s views on tablets and follow-up matter too.

Key Takeaways

• A small, low-risk cancer in one lobe can often be treated with a partial thyroidectomy.
• Large tumours, spread to the nodes, and medullary or anaplastic cancers usually need the whole gland removed.
• In well-chosen patients, lobectomy and total thyroidectomy have similar recurrence and survival.
• A minority of patients need a second operation when the final report shows higher-risk features.
• The plan should be settled before surgery, with the surgeon going through the scans and biopsy.

References

1. American Thyroid Association. Clinical Thyroidology for the Public: Lobectomy for low-risk papillary thyroid cancer and the 2015 guidelines. https://www.thyroid.org/?p=40788 Explains when removing one lobe may be adequate for low-risk papillary thyroid cancer.
2. Journal of Surgical Research (2019). Lobectomy Compared to Total Thyroidectomy for Low-Risk Papillary Thyroid Cancer: A Systematic Review. https://pubmed.ncbi.nlm.nih.gov/31103828/ Compares survival, recurrence and the need for a second operation after lobectomy.

Disclaimer: This article is for general information and is not a substitute for medical advice. Please consult a qualified specialist for diagnosis and treatment.

No, not all thyroid nodules need a biopsy or surgery. Most turn out to be harmless, and many never need more than a repeat ultrasound. A thyroid biopsy comes into the picture when the scan looks worrying or the nodule is on the larger side. Surgery is a smaller group still: cancer, results that stay unclear, a lump pressing on the windpipe, or a nodule making too much hormone.

According to Prof. Dr. Sandeep Nayak, Surgical Oncologist in Bengaluru at MACS Clinic, “Almost everyone who walks in with a thyroid nodule is afraid it’s cancer. Mostly it isn’t. In the first visit I try to separate the few that need action from the many we can safely keep an eye on,” he says.

About 5 to 10 out of every 100 nodules turn out to be cancer, so we don’t biopsy every lump. We start with a blood test for TSH and an ultrasound of the neck, and go from there.

A low TSH usually points to an overactive nodule. These “hot” ones are rarely cancer, so a thyroid scan tends to come next, not a needle.

The ultrasound tells us more. Irregular edges, a very dark solid look, tiny calcium specks, or a nodule that is taller than it is wide all make us cautious. A cyst full of fluid usually doesn’t.

Size matters as well. Roughly speaking, a suspicious-looking nodule of around 1 to 1.5 cm or more gets sampled. A smaller one can still be sampled if it looks bad enough.

The test is called fine needle aspiration cytology, or FNAC. It takes 10 to 20 minutes. With ultrasound guiding a thin needle, the doctor draws out a few cells, and you go home the same day. The lab then reports the result on the Bethesda scale. A benign result means we watch. An unclear one may mean a repeat biopsy or molecular testing. A suspicious or cancerous result means we start planning surgery.

Surgery makes sense in a handful of situations:

• The biopsy shows cancer, or strongly suggests it
• The result stays unclear and the risk is still worth worrying about
• A big nodule or goitre makes swallowing hard or the neck feels tight
• The nodule is making too much thyroid hormone and other treatment isn’t suitable
• It keeps growing, or it bothers you cosmetically

How much we remove depends on the diagnosis. Sometimes it’s one lobe, sometimes the whole gland. In selected patients, robotic thyroid surgery lets us avoid a scar on the neck. You can see the options on our thyroid cancer treatment page.

If the biopsy is benign, or the nodule is low risk and under the size cut-off, we simply repeat the ultrasound, usually after 12 to 24 months. That is still a plan, just a quieter one.

It comes down to the ultrasound, the size, the biopsy result and your hormone levels. Your history counts too. Radiation to the neck in the past, thyroid cancer in the family, a nodule that has grown fast, or a change in your voice all make us less willing to wait.

The heart is part of this as well. Thyroid hormone controls how fast the heart beats, and too much of it can cause palpitations or atrial fibrillation. That is why doctors check thyroid function when they assess heart failure. If you are under a cardiologist, bring those reports along, as they help us decide whether a thyroid procedure is safe and when to schedule it.

Key Takeaways

• More than nine in ten thyroid nodules are benign.
• Ultrasound pattern and size decide who gets a thyroid biopsy.
• A hot nodule usually gets a scan first, not a biopsy.
• Surgery is for cancer, unclear results, pressure symptoms or a nodule making extra hormone.
• A benign nodule is followed with repeat ultrasound.
• If you have a heart condition as well, show your thyroid and heart reports together.

References

1. National Cancer Institute (NCI). Thyroid Cancer Treatment. https://www.cancer.gov/types/thyroid/patient/thyroid-treatment-pdq Explains thyroid nodule evaluation, ultrasound, fine-needle aspiration biopsy and surgical treatment options.
2. National Cancer Institute (NCI). Thyroid Cancer Screening. https://www.cancer.gov/types/thyroid/hp/thryoid-screening-pdq Discusses the evaluation of suspicious thyroid nodules, biopsy findings and the risks of unnecessary investigations.

Disclaimer: The information shared in this content is for educational purposes only and not for promotional use. It is not a substitute for consultation with a qualified doctor.

Tongue cancer surgery can often be done without a visible neck scar, depending on the stage of the cancer and on whether the lymph nodes in the neck need treatment. The tumour itself is removed through the mouth, so the question usually comes down to the neck. Where the nodes do need to be dealt with, some approaches avoid a cut across the neck, though not every patient is suited to them. This article explains how tongue cancer treatment is planned and when a neck scar can be avoided. It is one part of oral cancer treatment.

According to Prof. Dr. Sandeep Nayak, Surgical Oncologist in Bengaluru at MACS Clinic, “When patients hear tongue cancer surgery, they often picture a large cut on the neck. The tumour is usually taken out through the mouth, so that part leaves no mark outside. The neck is a separate question. Whether the lymph nodes need to be removed depends on the stage and on how deep the tumour has grown, and that decides whether a neck incision is needed at all.”

The scar doesn’t come from the tongue. It comes from the neck.

• The tongue tumour is removed through the mouth, along with a rim of healthy tissue around it. How much tongue comes out depends on the size and position of the cancer. Whether the margins are truly clear matters afterwards, and our blog on cancer recurring despite clear margins explains why.
• A cancer at the back of the tongue, near the base, can sometimes be reached with a robot passing instruments through the mouth.
• The scar usually comes from a neck dissection, an operation to remove the lymph nodes where tongue cancer tends to spread first. Done the traditional way, it needs a long incision across the side of the neck.
• If a good part of the tongue is removed, it may be rebuilt using tissue from elsewhere in the body.

Two people with a similar-looking ulcer can need quite different plans. Our page on head and neck cancer covers the wider picture, and these are the main factors.

• Stage and size. How big the tumour is, and whether the nodes are involved, set the starting point.
• Depth of invasion. It predicts the chance of hidden spread to the nodes, and it is often the deciding detail for the neck.
• Location. A tumour on the side of the tongue and one at the base are reached and treated differently.
• Scans. MRI, CT or PET scans help show whether any nodes look involved.
• General health. Fitness for anaesthesia and for a longer operation affects what is safe.

It depends on whether the neck needs surgery at all, and then on how it is done.

• Sometimes the neck can be left alone. For a small, shallow tumour with no sign of spread on examination and scans, doctors may watch the neck closely, or take a sentinel lymph node biopsy to check whether cancer has reached the nodes. Not every centre offers the biopsy, and the right choice varies.
• Depth matters. A tumour that has gone deeper than about four millimetres is more likely to have sent cells to the nodes, so a neck dissection is usually advised. Centres use slightly different cut-offs, and this is a general guide and not a rule.
• A cut on the neck can’t always be avoided. Large or bulky nodes, nodes fixed to nearby structures, or earlier neck surgery or radiation usually call for conventional open neck dissection, which remains a safe and standard operation.
• Age on its own is not a barrier. Robotic surgery isn’t limited by age, as our blog on the age limit for robotic surgery explains.
• What the report shows after surgery. Radiation, and sometimes chemotherapy, may follow if the pathology shows higher-risk features.

Tobacco is the biggest preventable risk factor.

Key Takeaways

• The tongue tumour is usually removed through the mouth, so it doesn’t leave a neck scar.
• A neck scar comes from neck dissection, and some early tumours may not need one.
• When the nodes do need removing, robotic routes such as RIA-MIND can avoid a cut on the neck for suitable patients.
• Large tumours, bulky nodes and earlier treatment often need open surgery, so the plan depends on the stage.

For more information, visit our clinic.

References

1. Macmillan Cancer Support – Surgery for Head and Neck Cancer

Read reference

2. Cancer Research UK – Types of Surgery for Mouth Cancer

Read reference

Disclaimer: This blog is for informational and educational purposes only and is not a substitute for professional medical advice or diagnosis.

After a total thyroidectomy, replacement tablets are needed permanently because nothing is left to make thyroid hormones. However, when only one lobe is removed, the remaining lobe often works well enough, and many patients never need tablets. The need for medication depends on the extent of surgery and the function of the remaining thyroid.

According to Prof. Dr. Sandeep Nayak, Surgical Oncologist in Bengaluru at MACS Clinic, patients tend to dread the word “lifelong” and imagine a heavy burden. In practice it usually means one small tablet each morning and a blood test now and then. It helps to ask this before the operation, when the extent of surgery is still being decided, so nothing comes as a surprise afterwards.

• Total thyroidectomy. With the whole gland gone, levothyroxine is always needed, and it continues for life. If the operation is for cancer, the thyroid cancer treatment page shows how the extent of surgery is chosen.
• Hemithyroidectomy (lobectomy). One lobe stays behind. Reported figures differ between studies, from about 15 to 50 percent, with around one in three on tablets a few years later. The rest keep normal thyroid function.
• Who is more likely to need them. A high TSH before surgery, Hashimoto’s thyroiditis (autoimmune thyroid inflammation), a cancer diagnosis on the pathology report and a small remaining lobe all raise the chance.
• Completion thyroidectomy. Sometimes cancer is found only after a lobectomy, and the other lobe has to be taken out too. That patient then falls into the total thyroidectomy group and needs tablets permanently.
• Starting early isn’t always forever. A few patients are put on tablets soon after a lobectomy and are later able to stop, once blood tests show the remaining lobe is coping.
• Tablets are not a failure. They just stand in for the hormone the gland would have made.

• The daily routine. A single levothyroxine tablet, taken with water on an empty stomach, around half an hour to an hour before breakfast. Leave a gap of some hours from calcium and iron supplements.
• The dose. It starts from body weight and is then fine-tuned by TSH blood tests, which are repeated about 6 to 8 weeks after any change. Once things settle, a yearly or twice-yearly check is usual. Please don’t alter the dose on your own.
• Energy and weight. When the dose is right, most people return to their usual routine. Tiredness, weight gain or feeling cold early on often mean the dose needs adjusting.
• Calcium. A total thyroidectomy can bruise the tiny parathyroid glands beside the thyroid, which brings calcium down for a while. Tingling around the lips or in the fingertips is the usual clue, so mention it, as it normally settles.
• Scarless surgery. Robotic or scarless operations move the incision away from the neck but don’t change how much thyroid comes out, so the answer on tablets stays the same. The robotic cancer surgery page describes the approaches.
• Pregnancy. Many women need a higher dose during pregnancy, so tell the doctor as soon as you know.

Four things decide it.

How much thyroid is removed. The whole gland means tablets for life. One lobe means tablets only in some patients.

The reason for surgery. In cancer, the surgeon may want a slightly higher dose to keep TSH lower in higher-risk cases. With a benign nodule, a healthy remaining lobe is often enough.

Thyroid function before surgery. If TSH is high or thyroid antibodies are raised, the remaining lobe is more likely to struggle.

Blood tests afterwards. TSH checks guide whether tablets are started, changed or stopped. The full range of neck and thyroid operations is on the services page, and more topics are on the Dr. Nayak blogs page.

Key Takeaways

• Tablets are needed for life after a total thyroidectomy, with no exceptions.
• When one lobe is removed, roughly one in three patients need tablets, and many don’t.
• A high pre-operative TSH, thyroiditis or a cancer diagnosis makes tablets more likely.
• One tablet daily on an empty stomach, with the dose guided by TSH tests.
• Once the dose is right, most people carry on with normal life.

References

1. American Thyroid Association. Clinical Thyroidology for the Public: Quality of life after lobectomy versus total thyroidectomy (November 2022). https://www.thyroid.org/patient-thyroid-information/ct-for-patients/november-2022/vol-15-issue-11-p-11-12/
   2.Frontiers/PMC. Levothyroxine treatment after hemithyroidectomy for differentiated thyroid cancer, 3-year follow-up of Danish patients. https://pmc.ncbi.nlm.nih.gov/articles/PMC12558410
   

Disclaimer: This blog is for informational and educational purposes only and is not a substitute for professional medical advice or diagnosis.