- The 2015 ATA guidelines:
- Now accept a minimalistic surgical approach (thyroid lobectomy without neck dissection):
- To treat intrathyroidal papillary thyroid carcinomas < 4 cm in properly selected patients
- Careful peri-diagnosis, preoperative, and intraoperative risk stratification:
- Are the keys to successful use of thyroid lobectomy:
- Without having to perform an unacceptable rate of early-completion thyroidectomies
- Are the keys to successful use of thyroid lobectomy:
- Now accept a minimalistic surgical approach (thyroid lobectomy without neck dissection):
- Patients classified as being ideal for lobectomy:
- Would have papillary microcarcinomas:
- That appeared to be confined to the thyroid in the setting of an otherwise normal thyroid ultrasound and clinical N0 neck
- Would have papillary microcarcinomas:
- We classify patients as appropriate for lobectomy:
- If the tumor is 1 to 4 cm in maximum dimension, if the contralateral lobe is normal, or if there are other abnormalities on the ultrasound, such as thyroiditis or benign-appearing nodules (again, in the setting of the clinical N0 neck)
- Patients with extrathyroidal extension, clinical N1 disease, or distant metastasis:
- Would be considered inappropriate for thyroid lobectomy as initial therapy
- In addition to the relevance of peri-diagnostic and preoperative risk stratification with respect to the selection of thyroid lobectomy as initial therapy:
- It is important to recognize that there are intraoperative findings that should alter that recommendation and lead to an immediate total thyroidectomy:
- We encourage patients to find a surgeon who they trust and to empower the surgeon to make a final decision in the operating room regarding the extent of initial surgery that should be performed, which can vary from lobectomy to total thyroidectomy, with or without neck dissection
- However, even with appropriate preoperative and intraoperative risk stratification:
- As many as 6% to 20% of patients will have unexpected findings on the final pathology report:
- That may lead to a completion thyroidectomy and usually, radioactive iodine
- An additional 5% to 10% may require completion thyroidectomy:
- At some later point during follow-up for diagnostic or therapeutic purposes
- At some later point during follow-up for diagnostic or therapeutic purposes
- The rate of early-completion thyroidectomy, performed following review of the initial pathology report, will vary, depending on how aggressive each management team is with regard to the use of radioactive iodine for either remnant ablation or adjuvant treatment
- If minor factors, such as minor extrathyroidal extension, very small-volume lymph node metastasis, or small tumors with aggressive histologic features usually lead to radioactive iodine therapy, then the completion thyroidectomy rate may be as high as 20%
- In our hands, the completion thyroidectomy rate is much lower, as we have a much more restricted use of radioactive iodine:
- The most common reason for completion thyroidectomy in our hands is unanticipated, extensive vascular invasion documented on the pathology report that obviously could not be visualized preoperatively or intraoperatively
- As many as 6% to 20% of patients will have unexpected findings on the final pathology report:
- It is important to recognize that there are intraoperative findings that should alter that recommendation and lead to an immediate total thyroidectomy:
- Thus, patients need to understand that the final determination of whether a thyroid lobectomy is the appropriate initial therapy can only be achieved by:
- The integration of preoperative, intraoperative, and postoperative risk stratification
- Patients who are uncomfortable with this approach will often choose a total thyroidectomy as initial therapy
- Patients motivated to keep part of the thyroid will often accept that uncertainty, recognizing that the final decision regarding the completeness of initial therapy cannot be completely known until several weeks after the surgery is completed when more complete risk stratification can be accomplished
- References:
- Tuttle RM, Zhang L, Shaha A. A clinical framework to facilitate selection of patients with differentiated thyroid cancer for active surveillance or less aggressive initial surgical management. Expert Rev Endocrinol Metab. 2018;13(2):77–85.
- Carty SE, Doherty GM, Inabnet WB III, Pasieka JL, Randolph GW, Shaha AR, Terris DJ, Tufano RP, Tuttle RM; Surgical Affairs Committee Of The American Thyroid Association. American Thyroid Association statement on the essential elements of interdisciplinary communication of perioperative information for patients undergoing thyroid cancer surgery. Thyroid. 2012;22(4):395–399.
Rodrigo Arrangoiz MS, MD, FACS, FSSO 