Total Thyroidectomy vs Thyroid Lobectomy in Differentiated Thryoid Cancer (DTC)

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Overview:
    • The evolution from routinely performing total thyroidectomy (TT) to more selective use of thyroid lobectomy (TL) in DTC:
      • Reflects growing evidence that low- and select intermediate-risk patients can achieve equivalent oncologic outcomes with less morbidity
  • Key Historical and Modern Data:
    • Historical Basis for Total Thyroidectomy:
      • Mazzaferri & Young (1981, Am J Med):
        • Retrospective analysis:
          • Patients who underwent TT had better recurrence-free survival and lower disease-specific mortality
        • Study limitations:
          • Included many patients with advanced disease and used pre-ATA classification systems
        • Reference:
          • Mazzaferri EL, Young RL. Am J Med. 1981;70(3):511–518.
      • Shift Toward Risk-Adapted, Less Extensive Surgery:
        • Bilimoria et al. (2007, Ann Surg) – NCDB Study:
          • 52,000 PTC patients:
            • TT associated with better survival in tumors > 1 cm
          • Limitations:
            • Retrospective, confounded by extent of disease
          • Reference:
            • Bilimoria KY, et al. Ann Surg. 2007;246(3):471–479
        • Adam et al. (2014, J Clin Oncol) – NCDB Analysis:
          • 61,775 patients with 1 to 4 cm tumors:
            • No overall survival benefit for TT over TL
          • Supported shift toward more conservative surgery in low-risk DTC
          • Reference:
            • Adam MA, et al. J Clin Oncol. 2014;32(23):2000–2005.
        • Nixon et al. (2012, Ann Surg) – MSKCC Experience:
          • 889 patients with PTC < 4 cm, no extrathyroidal extension or lymph node metastasis:
            • No difference in recurrence or survival between TL and TT
          • Reference:
            • Nixon IJ, et al. Ann Surg. 2012;256(3):518–520
        • Prospective Trials and Systematic Reviews:
          • Japanese Prospective Data – Sugitani et al:
            • Prospective follow-up of TL in low-risk PTC (≤ 4 cm):
              • Low recurrence and excellent survival
            • Reference:
              • Sugitani I, et al. World J Surg. 2010;34(6):1215–1221.
          • Jeon et al. (2017, J Clin Endocrinol Metab):
            • Matched cohort study, 3,444 patients with 1 to 2 cm tumors:
              • No difference in recurrence-free survival or disease-specific survival
            • Reference:
              • Jeon MJ, et al. J Clin Endocrinol Metab. 2017;102(6):1965–1972
          • Sanabria et al. (2020, Cochrane Review):
            • Meta-analysis:
              • No survival benefit of TT over TL in tumors ≤ 4 cm without ETE or lymph node metastasis
              • Higher complication rates with TT
            • Reference:
              • Sanabria A, et al. Cochrane Database Syst Rev. 2020;12:CD012703
        • Complication Rates:
          • TT carries a higher risk of permanent hypoparathyroidism and recurrent laryngeal nerve injury:
            • 30% to 40% transient and 1% to 3% permanent hypoparathyroidism
            • Higher reoperation risk for contralateral disease post-TL, but lower surgical morbidity initially
        • ATA 2015 Guidelines (Current as of 2025):
          • Recommendations:
            • Tumors < 1 cm (T1a): 
              • Active surveillance or TL
            • Tumors 1cm to 4 cm (T1b to T2):
              • No aggressive features (ETE, nodal metastases, poor histology, vascular invasion): 
                • TL is sufficient
            • If aggressive features present or bilateral disease suspected: 
              • TT recommended.
            • > 4 cm tumors, bilateral disease, gross ETE, clinical N1, distant mets:
              • TT preferred
            • Reference:
              • Haugen BR, et al. Thyroid. 2016;26(1):1–133
  • Emerging Data / Future Directions:
    • Upcoming 2025 ATA Guidelines may further support TL in more intermediate-risk patients, especially with molecular profiling and personalized risk stratification
    • Role of genomics and molecular markers (e.g., BRAF, TERT, RAS) in guiding extent of surgery is under investigation
  • Conclusions:
    • Thyroid lobectomy is oncologically safe in selected patients with low-risk DTC (unifocal, ≤ 4 cm, cN0, no ETE or aggressive histology)
    • Total thyroidectomy remains necessary for high-risk features, RAI candidates, or bilateral disease
    • The trend is toward individualized, risk-adapted surgical strategies balancing recurrence risk with surgical morbidity
  • References:
    • Mazzaferri EL, Young RL. Am J Med. 1981;70(3):511–518.
    • Bilimoria KY, et al. Ann Surg. 2007;246(3):471–479.
    • Adam MA, et al. J Clin Oncol. 2014;32(23):2000–2005.
    • Nixon IJ, et al. Ann Surg. 2012;256(3):518–520.
    • Sugitani I, et al. World J Surg. 2010;34(6):1215–1221.
    • Jeon MJ, et al. J Clin Endocrinol Metab. 2017;102(6):1965–1972.
    • Sanabria A, et al. Cochrane Database Syst Rev. 2020;12:CD012703.
    • Haugen BR, et al. Thyroid. 2016;26(1):1–133.
Unknown's avatar

Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

Leave a comment