- Ansart F, de Ponthaud C, Buffet C, et al. One- or two-step total thyroidectomy for cancer indications: a 20-year retrospective study from a referral center. Ann Surg Oncol 2024;32:2329-2334; doi: 10.1245/s10434-024-16707-6. PMID: 39739263.
- Background:
- Current guidelines for the management of differentiated thyroid cancer (DTC) recommend consideration of thyroid lobectomy unless there are clear indications to remove the contralateral lobe
- Lobectomy carries fewer risks, including no risk of postoperative hypoparathyroidism, no risk of bilateral recurrent laryngeal nerve (RLN) injury, and lower risk of requiring thyroid hormone supplementation postoperatively
- However, up to 20% of patients who undergo lobectomy have unfavorable characteristics on final pathology
- Patients with high-risk DTC, such as extrathyroidal extension, multiple positive lymph nodes, or multifocal lesions, may require completion thyroidectomy
- The risks of one-stage versus two-stage total thyroidectomy have not been studied thoroughly
- This study aimed to compare the postoperative morbidity of patients with thyroid cancer who underwent total thyroidectomy in one stage versus two stages
- Methods:
- This retrospective study conducted at a high-volume endocrine surgery center included adult patients who underwent total thyroidectomy for DTC
- Patients either underwent total thyroidectomy in one stage (TT1) or in two stages—thyroid lobectomy followed by completion thyroidectomy (TT2)
- The primary outcome was postoperative morbidity within 30 days after surgery, which included hematoma requiring reoperation, wound infection or swelling, temporary or permanent RLN injury resulting in vocal cord immobility, and hypocalcemia
- Transient hypocalcemia was defined as a postoperative serum calcium level lower than 8 mg/dl within the first 6 months, while permanent hypocalcemia was defined as PTH <15 pg/ml or the need for oral calcium supplementation after 6 months
- For patients in the TT2 group, postoperative complications were quantified as the sum of those observed after each procedure
- Results:
- The study cohort consisted of 5693 patients, 5009 in the TT1 group and 684 in the TT2 group
- The majority of patients in both groups were female, though the rate was higher in the TT1 group than the TT2 group (79% vs. 69.3%, P<0.001)
- TT1 patients were significantly older (mean [±SD], 49.9±14.7 years) than TT2 patients (45.4±4.5 years, P<0.001)
- Patients with papillary thyroid cancer primarily underwent TT1 (92.1%), whereas those with follicular or oncocytic cancers underwent TT1 and TT2 equally (P<0.001)
- There was no difference in lymph node dissection rates between TT1 and TT2; however, on average, there were more nodes removed (18.1±13.4 vs. 12.2±9.5, P<0.001) and more positive results (29.8% vs. 14.3%, P<0.001) in TT1 patients than TT2
- Tumors in TT2 patients were significantly larger (14.4±13.8 mm vs. 28.2±18.4 mm, P<0.001) but there was no difference in tumor stage
- TT2 patients had significantly lower rates of all surgical complications (11.7% vs. 22.6% for TT1), transient hypocalcemia (3.2% vs. 14.5%), and permanent hypocalcemia (1.3% vs. 3.1%) (P<0.01 for all)
- There were no differences in the rate of hematoma, RLN injury, or wound infection between the two groups
- After propensity-score matching, TT1 patients experienced higher rates than TT2 patients for overall surgical complications (22% vs. 11.7%), transient hypocalcemia (14.1% vs. 3.2%)(P<0.01 for both), and permanent hypocalcemia (2.9% vs. 1.3%, P = 0.024) and there were no differences in the rates of RLN injury, hematoma, or infection
- Conclusions:
- Patients undergoing one-stage total thyroidectomy for thyroid cancer experienced higher rates of postoperative hypocalcemia and overall complications as compared with patients undergoing a two-stage operation
- However, there were no differences in the rates of RLN injury, hematoma, or infection between the two treatment groups
- Two-stage total thyroidectomy for thyroid cancer may be performed safely, with similar complication rates to those for one-stage surgery
- This retrospective study demonstrates the safety of thyroid lobectomy followed by completion thyroidectomy as necessitated by pathology results, supporting the trend toward less aggressive surgical management of small DTCs
- These results are concordant with both a retrospective study of over 70,000 patients in a national database, which found that completion thyroidectomies are associated with lower rates of complications, and a single-center study that reported that completion thyroidectomy was less likely to result in hypocalcemia and poses no additional risk of RLN injury, hematoma, or permanent hypoparathyroidism
- Thyroid lobectomy also avoids the potential need for lifelong thyroid hormone replacement, and there is no difference in overall prognosis for DTCs < 4 cm in size
- With higher complication rates identified in the TT1 group in the present study, there is further evidence that initial management of DTC < 4 cm with thyroid lobectomy may be preferred despite the potential need for completion thyroidectomy
- Applying these results to practice, there is significant evidence to support offering lobectomy to patients with DTC < 4 cm, with the knowledge that it is both therapeutic and diagnostic but also that this approach may necessitate a completion thyroidectomy
- Although there are some instances where upfront total thyroidectomy may be desired, initial lobectomy offers a less invasive option with lower complication rates even if completion thyroidectomy is needed
- Encouragingly, complication rates are low for both total and two-stage thyroidectomy, supporting either surgical approach based on patient or treatment team preference
- For patients with lower-risk thyroid cancers, lobectomy is a safe initial management choice given the favorable outcomes of two-stage thyroidectomy
- References:
- Haugen BR, Sawka AM, Alexander EK, et al. American Thyroid Association guidelines on the management of thyroid nodules and differentiated thyroid cancer task force review and recommendation on the proposed renaming of encapsulated follicular variant papillary thyroid carcinoma without invasion to noninvasive follicular thyroid neoplasm with papillary-like nuclear features. Thyroid 2017;27:481–483; Crossref. PubMed.
- Ansart F, de Ponthaud C, Buffet C, et al. One- or two-step total thyroidectomy for cancer indications: a 20-year retrospective study from a referral center. Ann Surg Oncol 2024;32:2329-2334; Crossref. PubMed.
- Brauer PR, Reddy CA, Burkey BB, et al. A national comparison of postoperative outcomes in completion thyroidectomy and total thyroidectomy. Otolaryngol. Head Neck Surg 2021;164(3):566-573; Crossref. PubMed.
- Dedhia PH, Stoeckl EM, McDow AD, et al. Outcomes after completion thyroidectomy versus total thyroidectomy for differentiated thyroid cancer: a single-center experience. J Surg Oncol 2020;122(4):660-664; Crossref.PubMed.
- Barney BM, Hitchcock YJ, Sharma P, et al. Overall and cause-specific survival for patients undergoing lobectomy, near-total, or total thyroidectomy for differentiated thyroid cancer. Head Neck 2011;33(5):645-649; Crossref.PubMed.
- Mendelsohn AH, Elashoff DA, Abemayor E, et al. Surgery for papillary thyroid carcinoma: is lobectomy enough? Arch Otolaryngol Head Neck Surg 2010;136(11):1055; Crossref. PubMed
Rodrigo Arrangoiz MS, MD, FACS, FSSO 