Papillary Thyroid Cancer Surgery in Ankara, Turkey

Papillary thyroid cancer surgery is the main and most effective step in the treatment of this common type of thyroid cancer. This surgical intervention is the safe removal from the body of the thyroid tissue containing the cancerous nodule or nodules. In today’s modern surgical approach, the extent of the operation is no longer the same for every patient; it is determined entirely according to the status of the disease and the patient’s individual needs. Successful papillary thyroid cancer treatment is based on a delicate balance that requires experience—clearing cancerous tissue while preserving important functions such as voice quality and calcium balance.

You can contact Prof. Dr. Ebru Soy, one of the doctors performing Papillary Thyroid Cancer Surgery in Ankara, to get information about Papillary Thyroid Cancer Surgery prices, the process, and the hospital where Papillary Thyroid Cancer Surgery is performed.

What Is Papillary Thyroid Cancer?

Papillary thyroid cancer is the most common type of thyroid cancer and is generally indolent. It tends to progress slowly and responds well to treatment when diagnosed at an early stage. It can spread to lymph nodes in the neck, but distant metastasis is rare. Diagnosis is usually made with ultrasound-guided fine-needle aspiration biopsy. Treatment may include surgery, radioactive iodine, and hormone-suppressive therapy.

Which risk factors affect the decision for surgery?

From the moment papillary thyroid cancer is diagnosed, the first and most important step is to determine the “risk” of this cancer. This is a classification that helps us understand how “aggressive” or “indolent” the cancer is. All key decisions—such as which type of surgery will be performed and whether additional “RAI therapy” will be needed after surgery—are made according to this risk assessment.

International guidelines such as those of the American Thyroid Association (ATA) are used in this classification. Patients are generally placed into one of three main groups: Low Risk, Intermediate Risk, and High Risk.

Risk assessment considers the following:

• The patient’s age
• Tumor size (millimetric or centimetric)
• Whether the cancer has extended beyond the thyroid (capsular violation)
• Spread to neck lymph nodes (metastasis)
• The pathological subtype of the cancer (for example, “tall cell”)
• Vascular invasion

Age has a special place among these factors. Especially in patients under 55 years of age, even if the disease has spread to lymph nodes, the response to treatment is generally excellent and survival rates are close to 98–100%. Being over 55 is considered one of the factors that increases risk to some extent.

The treatment plan is shaped entirely according to this risk group. Providing an unnecessarily extensive (radical) treatment to a low-risk patient exposes the patient to unnecessary complication risks. Providing insufficient treatment to a high-risk patient, on the other hand, may lead to cancer recurrence (relapse). The goal of modern surgery is to establish this balance perfectly.

Why is surgeon experience so important in thyroid surgery?

This is perhaps the most critical point in thyroid surgery. The answer is clear and definite: Yes, it is extremely important.

The thyroid gland is located at a very delicate “junction” in the neck. Immediately behind it are the nerves that go to our vocal cords (recurrent laryngeal nerve) and four parathyroid glands—usually about the size of a grain of rice—that regulate the body’s calcium balance:

There are two main goals in thyroid surgery:

• To completely remove the cancerous tissue.
• To absolutely avoid damage to these delicate structures (the vocal nerve and the calcium glands).

The success of the operation is measured not only by clearing cancerous tissue, but also by avoiding harm to these delicate structures. Scientific studies have repeatedly proven that “high-volume” surgeons (specialists who typically perform more than 25 to 50 thyroid surgeries per year) achieve these operations with much lower complication rates (less hoarseness, less low calcium).

An experienced surgeon can more easily recognize a vocal nerve that runs in an atypical location (anatomical variation) and can better preserve the fine vessels supplying the parathyroid glands. Especially in complex situations such as advanced-stage cancers that have spread to lymph nodes, the ability to clear cancerous tissue while avoiding injury to healthy structures is directly related to the surgeon’s experience.

Therefore, particularly in complex or high-risk thyroid cancer cases, referring patients to specialized, high-volume surgeons or centers is one of the most important safety recommendations in modern medicine.

Can very small (micro) thyroid cancers be followed without surgery?

Yes, in some very specific situations, this is possible. This is called “Active Surveillance.”

This option applies to Papillary Thyroid Microcarcinoma (PTMC), meaning tumors that are 1 cm or smaller. Long-term scientific studies have shown that such very small cancers that meet specific criteria often behave “indolently,” especially in older patients.

During follow-up in patients under active surveillance, it has been observed that in the vast majority of patients (over 90%), the tumor either does not grow at all or grows only insignificantly. When surgery is performed in the small number of patients (around 3–5%) in whom growth is observed or lymph node spread develops, cancer control is still achieved with near-100% success. No cancer-related deaths have been observed in this process.

However, active surveillance is not suitable for every cancer smaller than 1 cm. Certain conditions are required:

• The tumor must be smaller than 1 cm
• The cancer must not have extended beyond the thyroid capsule
• There must be no suspicion of lymph node spread
• The tumor must not be very close to critical structures such as the vocal nerve or the windpipe
• The patient must be able to tolerate this follow-up psychologically
• The patient must accept regular ultrasound follow-ups

Active surveillance can be an excellent option especially for elderly patients who have additional health problems or a high surgical risk. In younger patients, surgery is generally preferred because they have a much longer life expectancy ahead and the chance of tumor growth (even if low) is somewhat higher. This decision should be made through a “shared decision-making” process in which all details are discussed between the patient and the physician.

Is removal of only half of the thyroid (Lobectomy) sufficient for thyroid cancer?

This is the biggest and most important revolution in thyroid surgery in recent years. In the past, when papillary thyroid cancer was diagnosed, the standard approach was to remove the entire thyroid (Total Thyroidectomy), no matter how small the tumor was. However, this approach has fundamentally changed.

Current scientific data and guidelines clearly show that in the treatment of low- and intermediate-risk papillary thyroid cancers (generally smaller than 4 cm, confined to the thyroid, and without lymph node spread), removing only the lobe containing the cancer (half of the thyroid) (Thyroid Lobectomy) is sufficient.

Large scientific studies involving thousands of patients have proven that in this risk group, there is no difference between lobectomy (removal of half) and total thyroidectomy (removal of all) in terms of cancer recurrence risk (relapse) or patient survival (overall survival). In other words, in terms of cancer control, lobectomy is as effective as total thyroidectomy.

The main difference appears in surgical risks and the patient’s quality of life.

The advantages of lobectomy (partial surgery) compared to total thyroidectomy (complete removal) are clear:

• Much lower risk of complications
• Nearly zero risk of permanent low calcium (hypoparathyroidism)
• Lower risk of permanent hoarseness
• 70–80% of patients do not have to use lifelong thyroid medication (Levothyroxine)

The remaining healthy thyroid lobe continues to produce the hormone the body needs. For these reasons, in papillary thyroid cancers smaller than 4 cm with no obvious spread and no aggressive features, the preferred standard surgical method is now Lobectomy.

In which situations is removal of the entire thyroid (Total Thyroidectomy) mandatory?

Despite the increasing popularity of lobectomy (partial surgery), removal of the entire thyroid gland (Total Thyroidectomy – TT) remains the “gold standard” and a mandatory treatment method in certain situations. While lobectomy is an option, TT is a necessity for these patients.

Total thyroidectomy is mandatory in the following situations:

• If the tumor is larger than 4 cm (T3)
• If the cancer has clearly extended beyond the thyroid (T4)
• If lymph node spread (metastasis) has been detected preoperatively (cN1)
• If there is spread to distant organs (lungs, bone) (M1)
• If postoperative “RAI therapy” will be required
• If aggressive pathological subtypes are identified
• If there is cancer or a suspicious nodule in both thyroid lobes

In summary, TT is now a more radical surgical option applied mainly to high-risk, advanced-stage patients or those who will require RAI therapy. The reason for performing TT is generally to prepare the ground for postoperative RAI therapy and to facilitate follow-up with blood tests (Thyroglobulin).

If it is known that the cancer has spread to lymph nodes (cN1), what kind of surgery is performed?

If preoperative ultrasound or fine-needle biopsy has proven that the cancer has spread (metastasized) to lymph nodes in the neck (this is called cN1), the treatment plan changes. In this situation, removing only the thyroid gland is not sufficient.

The lymph nodes to which the cancer has spread must also be completely removed in the same operation together with the cancerous thyroid gland. This is called “Therapeutic (Treatment) Neck Dissection.”

Lymph nodes in the neck are evaluated as different “regions.” The “Central Compartment” (Level VI) around the thyroid (beside the windpipe) and the “Lateral Compartment” (Levels II–V) on the side of the neck (around the carotid artery) are distinguished.

If the spread is only in the central region, Total Thyroidectomy + Therapeutic Central Neck Dissection is performed.

If the spread is in the lateral neck lymph nodes (cN1b), Total Thyroidectomy + Therapeutic Lateral Neck Dissection (and usually Central Dissection) is performed.

These lymph node clearance operations (neck dissections) are much more complex, longer, and higher-risk procedures than a simple thyroid operation. In addition to protecting the vocal nerve and parathyroid glands, they also require preservation of other important nerves that enable shoulder movement or assist tongue movement. Such advanced-stage surgeries must be performed by experienced, high-volume surgeons in this field.

Should “prophylactic” (pCND) clearance be performed even if no cancer is seen in lymph nodes?

This is one of the most controversial topics in thyroid surgery. The situation is as follows: There is no suspicious appearance in lymph nodes on the patient’s ultrasound or examination (this is called cN0). However, we know that papillary cancer can cause small, “hidden” (occult) metastases that do not appear on imaging.

The question is: “Even if nothing is seen, when removing the entire thyroid, should we also clear the central (Level VI) lymph nodes ‘just in case,’ meaning prophylactically?” (This is called pCND).

This procedure has both benefits and harms. The benefit is to detect hidden metastases to more accurately determine the patient’s risk (staging) and to clarify the decision for RAI therapy. The harm is that it significantly increases the risk of surgical complications. In patients who undergo pCND, the risk of temporary low calcium (parathyroid injury) is higher than in those who undergo thyroidectomy alone.

Current guidelines, considering this risk-benefit balance, recommend NOT performing “ROUTINE pCND.” In other words, not every patient receives prophylactic lymph node clearance.

pCND should be considered ONLY in SELECTED, HIGH-RISK patients. These are generally patients with large tumors (T3) or tumors that have extended beyond the thyroid (T4). Because the likelihood of “hidden” metastasis is much higher in these patients, and detecting this metastasis will directly change the treatment plan (RAI therapy). In low-risk (T1, T2) patients, pCND is not recommended because its complication risk is far greater than its potential benefit.

How is protection of the vocal cord nerves (IONM) ensured during surgery?

The nerves that enable vocal cord movement (Recurrent Laryngeal Nerve – RLN) run immediately behind the thyroid gland, closely adherent to it. One of the most important goals in thyroid surgery is to protect this nerve 100%. Unilateral injury can lead to permanent hoarseness, and bilateral injury (very rarely) can cause breathing difficulty.

The “gold standard” for protecting this nerve is for the surgeon to identify the nerve at the very beginning of the operation and protect it by seeing it throughout its entire course and performing meticulous dissection (separating it from surrounding tissue). Experience plays a key role here.

However, in today’s modern surgery, there is another very important technology that supports this visual protection: Intraoperative Nerve Monitoring (IONM) or a “Nerve Monitor.”

This system is a device that measures vocal nerve function in real time during surgery. A special “probe” (a pen-like tip) in the surgeon’s hand delivers mild electrical stimuli to the nerve. If the structure is a nerve, the device provides an audible and visual alert. This greatly facilitates locating the nerve (especially in difficult surgeries or re-operations).

More importantly, if tension or loss of function begins in the nerve while the surgeon is working nearby (before more permanent damage occurs), the device’s signal weakens or disappears. This functions as an early warning system for the surgeon, meaning “CAUTION, the nerve is under stress!” This technology maximizes safety, especially in difficult cases where the cancer is adherent to the nerve or in total thyroidectomy procedures where both sides of the thyroid are removed.

Why is preserving the calcium glands (Parathyroids) so important?

In our bodies, there are typically 4 parathyroid glands, about the size of a lentil or grain of rice, usually attached to the four corners of the thyroid gland (two upper, two lower). These tiny glands have no functional relation to the thyroid; their only role is to secrete parathyroid hormone (PTH) and maintain blood calcium levels in a delicate balance.

During total thyroidectomy (removal of the entire thyroid), these glands must be carefully separated from the thyroid and their blood supply (perfusion) must be preserved. If all four glands are damaged or their blood supply is compromised, “Hypoparathyroidism” (low calcium) develops after surgery.

Low calcium (hypoparathyroidism) causes the following symptoms:

• Numbness around the hands and lips
• Tingling
• Painful muscle cramps
• Severe muscle spasms (tetany)

This condition may be “temporary” and can resolve with calcium supplementation over a few weeks. However, if it becomes “permanent,” it is one of the most serious complications of thyroid surgery. Permanent hypoparathyroidism requires the patient to take handfuls of calcium and active vitamin D pills every day for the rest of their life. Dose adjustment is difficult; if the dose is insufficient, cramps occur; if the dose is excessive, the risk of kidney stones or kidney failure increases. This significantly impairs the patient’s quality of life.

Which advanced technologies (NIRAF/ICG) are used to protect the parathyroid glands?

In the traditional method, preserving the parathyroid glands depends entirely on the surgeon’s visual assessment (with the naked eye). An experienced surgeon distinguishes the parathyroid gland from surrounding fat tissue or a lymph node by its color (usually brownish-yellow). However, this can be very difficult, especially in a bleeding field or when the gland’s color changes, and it depends on the surgeon’s experience (it is subjective).

In modern endocrine surgery, two revolutionary technologies are used that replace this subjective assessment and base parathyroid preservation on objective data:

• Near-Infrared Autofluorescence (NIRAF) – Autofluorescence Imaging:

This technology is based on the fact that parathyroid glands have a “natural glow.” During surgery, a special camera system delivers an invisible, harmless “near-infrared” (NIR) light to the surgical field. Under this special light, parathyroid glands “glow” in a bright white or greenish color, unlike all other surrounding tissues. This provides the surgeon with a “parathyroid finder.” Even glands embedded in fat tissue that are impossible to see with the naked eye can be identified within seconds with this camera.

• Indocyanine Green (ICG) Fluorescence Imaging – ICG Angiography:

Finding the gland with NIRAF is the first step. The second and more important step is determining whether the gland is “alive,” meaning whether its blood supply (perfusion) is sufficient after the thyroid is separated. This is where ICG angiography comes in. A special green dye called Indocyanine Green (ICG) is injected intravenously. Using the same camera (in a different mode), the surgical field is observed. Parathyroid glands with good perfusion are seen to rapidly fill with the dye and glow in a bright green color (angiography). If a parathyroid gland does not glow sufficiently, this indicates that its blood supply is impaired (ischemia).

If impaired perfusion of a gland is objectively detected with ICG, that gland is not left in place. The surgeon removes it, divides it into very small pieces on the operating table, and “plants” it into a neck muscle (Autotransplantation). These implanted pieces gradually begin secreting hormone again in their new location. These technologies represent the most up-to-date and safest approach to minimizing the risk of permanent low calcium.

What is robotic or “scarless” thyroid surgery?

Traditional (open) thyroid surgery is performed through a horizontal incision of about 4–6 cm on the front of the neck. Although this is an extremely safe and effective method, it leaves a permanent scar on the neck.

Minimally Invasive and Robotic Thyroidectomy (RT) are techniques developed to avoid this scar and to perform the operation through small incisions made in less visible parts of the body.

The incisions (scars) are made in hidden locations instead of the neck:

• Armpit
• Inside the mouth (transoral)
• Around the nipple

In these techniques, a high-resolution camera and very fine, delicate surgical instruments are used. Especially in robotic surgery, the surgeon sits at a console and performs the operation using robotic arms capable of movements much more precise than the human hand, under a 3D image magnified 10–15 times.

The main advantage is cosmetic—there is no scar on the neck. In addition, the magnified and 3D image provided by the robotic camera allows millimetric structures such as the vocal nerve and parathyroid glands to be seen much more clearly. Some studies have shown that thanks to this superior visualization, complications such as temporary hoarseness and temporary low calcium may occur less frequently compared to open surgery. When applied to selected patients (tumors that are not very large and cases without extensive spread) by experienced surgeons, these techniques offer excellent cosmetic outcomes without compromising cancer control.

Who needs “RAI Therapy” after surgery?

This is one of the most frequently asked questions after thyroid cancer surgery. “RAI therapy” (Radioactive Iodine – RAI) is given by having the patient swallow a capsule containing radioactive iodine. This radioactive iodine destroys (“ablates”) any remaining normal thyroid tissue or microscopic cancer cells by effectively “burning” them away.

However, RAI is NOT REQUIRED for every patient with papillary thyroid cancer. The current approach is to give RAI therapy only to patients who truly need it (and it can only be given if the entire thyroid has been removed).

The current approach is as follows:

• Low-Risk Patients: It is NOT REQUIRED for almost any of them. Surgery is sufficient.
• High-Risk Patients: It is DEFINITELY recommended.
• Intermediate-Risk Patients: It is a “gray zone.” The decision is individualized (age, pathology details).

“High-risk” patients are generally those whose cancer has clearly extended beyond the thyroid, who have extensive lymph node spread in the neck, who have distant organ metastasis (lungs, bone), or who have an aggressive subtype. In these patients, RAI is required to reduce recurrence risk and to facilitate follow-up.

I had only a lobectomy, but what if the pathology turns out worse?

This is an important question in lobectomy (partial thyroidectomy) planning. In a patient taken to surgery assuming low risk (for example, a 2 cm nodule), the final postoperative pathology report can sometimes be surprising. For example, the report may unexpectedly identify “extensive vascular invasion” or an “aggressive subtype.”

In this situation, the patient moves from the “low-risk” group to the “intermediate/high-risk” group, and RAI therapy may be needed according to this new status. However, the patient still has a healthy thyroid lobe and cannot receive RAI.

In the old approach, the only option for these patients was a second surgery (Completion Thyroidectomy) to remove the remaining thyroid lobe. However, these second surgeries are technically much more difficult due to adhesions from the first operation and carry a much higher risk in terms of vocal nerve/parathyroid complications.

In the modern approach, there is a non-surgical, much lower-risk option for these patients: “Radioisotopic Lobectomy” (Radioablation). In this method, the patient is given a high dose of Radioactive Iodine (RAI). This high dose “burns” (ablates) the remaining healthy thyroid lobe as well. Thus, the patient avoids a risky second surgery, and since the remaining lobe is eliminated, standard RAI therapy or scanning can be performed later if needed (if there is still suspicion of cancer). The existence of this “radioisotopic completion” option is an important “safety net” that allows surgeons to choose lobectomy more confidently in low/intermediate-risk patients.

What can ultimately be said about outcomes in papillary thyroid cancer treatment?

Expert surgical management of papillary thyroid cancer has ended the era of “the same operation for everyone” and instead embraced the philosophy of “the right operation for the right patient.” Treatment is individualized according to cancer risk.

In summary, the foundations of the modern approach are:

• Less surgery in low risk (Lobectomy)
• Complete surgery in high risk (Total Thyroidectomy)
• Choosing a “high-volume” surgeon to reduce complication risk
• Using a nerve monitor (IONM) to protect the vocal nerve
• Using special imaging (NIRAF/ICG) to protect the calcium glands
• Offering “scarless” (robotic) surgery for cosmetic concerns

The goal is to completely remove the cancer (oncologic safety) while preserving the patient’s voice quality, calcium balance, and hormonal functions (functional safety), thereby maximizing long-term quality of life.

Frequently Asked Questions

How Long Does Papillary Thyroid Cancer Surgery Take?

Papillary thyroid cancer surgery usually takes between 1.5 and 3 hours. The duration depends on whether the entire thyroid or only one lobe will be removed (total vs lobectomy), whether lymph node dissection is needed, and the patient’s anatomy.

Which Doctor Should You See for Papillary Thyroid Cancer?

When papillary thyroid cancer is diagnosed, you should first consult an endocrine surgery specialist or a general surgery specialist.