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Total thyroidectomy can be overtreatment in cN1a papillary thyroid carcinoma patients whose tumor is smaller than 1 cm

  • Kyorim Back
    Affiliations
    Division of Endocrine Surgery, Department of Surgery, Chung-Ang University Hospital, Chung-Ang University School of Medicine, Seoul, South Korea
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  • Jiyeon Lee
    Affiliations
    Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, South Korea
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  • Jun-Ho Choe
    Affiliations
    Division of Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, South Korea
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  • Jung-Han Kim
    Affiliations
    Division of Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, South Korea
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  • Young Lyun Oh
    Affiliations
    Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, South Korea
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  • Jee Soo Kim
    Correspondence
    Corresponding author. Division of Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University, School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
    Affiliations
    Division of Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, South Korea
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      Highlights

      • The 2015 ATA guidelines recommend total thyroidectomy with CND in patients with cN1a, regardless of tumor size.
      • This study demonstrated that more than two-third of PTMC patients with cN1a were actually lobectomy candidates.
      • Total thyroidectomy as the first surgical option for cN1a, especially in PTMC patients, should be reconsidered.
      • Intra-operative frozen exam will help select PTMC patients who are able to undergo lobectomy.

      Abstract

      Background

      The 2015 American Thyroid Association (ATA) guidelines recommend pursuing total thyroidectomy with therapeutic central lymph-node dissection (CND) in patients with clinically apparent nodal disease (cN1a), regardless of tumor size. The aim of this study was to investigate whether total thyroidectomy is necessary for thyroid papillary microcarcinoma (PTMC) patients with preoperative unilateral cN1a.

      Methods

      This study included 295 papillary thyroid microcarcinoma patients who underwent total thyroidectomy with bilateral CND from January 2012 to June 2015.

      Results

      The median follow-up time was 42.5 months. Locoregional recurrence (LRR) was observed in only two (0.9%) patients. Among 70 cN1a patients, only 19 (27.1%) were at intermediate risk for disease recurrence and required total thyroidectomy per the ATA guidelines. Lobectomy can be considered as a treatment option for the remaining patients (72.9%).

      Conclusions

      Our study showed that more than two-thirds of PTMC patients with clinical nodal disease who underwent total thyroidectomy and CND were actually lobectomy candidates. Total thyroidectomy as the first surgical option for cN1a, especially in PTMC patients, should be reconsidered.

      Keywords

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      References

        • Ito Y.
        • Miyauchi A.
        • Oda H.
        Low-risk papillary microcarcinoma of the thyroid: a review of active surveillance trials.
        Eur J Surg Oncol. 2018; 44: 307-315
        • Brito J.P.
        • Ito Y.
        • Miyauchi A.
        • Tuttle R.M.
        A clinical framework to facilitate risk stratification when considering an active surveillance alternative to immediate biopsy and surgery in papillary microcarcinoma.
        Thyroid. 2016; 26: 144-149
        • Sugitani I.
        • Fujimoto Y.
        • Yamada K.
        Association between serum thyrotropin concentration and growth of asymptomatic papillary thyroid microcarcinoma.
        World J Surg. 2014; 38: 673-678
        • Ito Y.
        • Miyauchi A.
        • Inoue H.
        • et al.
        An observational trial for papillary thyroid microcarcinoma in Japanese patients.
        World J Surg. 2010; 34: 28-35
        • Fukuoka O.
        • Sugitani I.
        • Ebina A.
        • et al.
        Natural history of asymptomatic papillary thyroid microcarcinoma: time-dependent changes in calcification and vascularity during active surveillance.
        World J Surg. 2016; 40: 529-537
        • Sugitani I.
        • Toda K.
        • Yamada K.
        • et al.
        Three distinctly different kinds of papillary thyroid microcarcinoma should be recognized: our treatment strategies and outcomes.
        World J Surg. 2010; 34: 1222-1231
        • Ito Y.
        • Tomoda C.
        • Uruno T.
        • et al.
        Papillary microcarcinoma of the thyroid: how should it be treated?.
        World J Surg. 2004; 28: 1115-1121
        • Ito Y.
        • Miyauchi A.
        • Kihara M.
        • et al.
        Patient age is significantly related to the progression of papillary microcarcinoma of the thyroid under observation.
        Thyroid. 2014; 24: 27-34
        • Haser G.C.
        • Tuttle R.M.
        • Su H.K.
        • et al.
        Active surveillance for papillary thyroid microcarcinoma: new challenges and opportunities for the health care System.
        Endocr Pract. 2016; 22: 602-611
        • Ito Y.
        • Uruno T.
        • Nakano K.
        • et al.
        An observation trial without surgical treatment in patients with papillary microcarcinoma of the thyroid.
        Thyroid. 2003; 13: 381-387
        • Haugen B.R.
        • Alexander E.K.
        • Bible K.C.
        • et al.
        American thyroid association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American thyroid association guidelines task force on thyroid nodules and differentiated thyroid cancer.
        Thyroid. 2015; 26 (2016): 1-133
        • Kandil E.
        • Krishnan B.
        • Noureldine S.I.
        • et al.
        Hemithyroidectomy: a meta-analysis of postoperative need for hormone replacement and complications.
        ORL J Otorhinolaryngol Relat Spec. 2013; 75: 6-17
        • Stoll S.J.
        • Pitt S.C.
        • Liu J.
        • et al.
        Thyroid hormone replacement after thyroid lobectomy.
        Surgery. 2009; 146 (; discussion 558-560): 554-558
        • Hauch A.
        • Al-Qurayshi Z.
        • Randolph G.
        • Kandil E.
        Total thyroidectomy is associated with increased risk of complications for low- and high-volume surgeons.
        Ann Surg Oncol. 2014; 21: 3844-3852
        • Son Y.I.
        • Jeong H.S.
        • Baek C.H.
        • et al.
        Extent of prophylactic lymph node dissection in the central neck area of the patients with papillary thyroid carcinoma: comparison of limited versus comprehensive lymph node dissection in a 2-year safety study.
        Ann Surg Oncol. 2008; 15: 2020-2026
        • Mazzaferri E.L.
        • Doherty G.M.
        • Steward D.L.
        The pros and cons of prophylactic central compartment lymph node dissection for papillary thyroid carcinoma.
        Thyroid. 2009; 19: 683-689
        • Bergamaschi R.
        • Becouarn G.
        • Ronceray J.
        • Arnaud J.P.
        Morbidity of thyroid surgery.
        Am J Surg. 1998; 176: 71-75
        • Tuttle R.M.
        • Haugen B.
        • Perrier N.D.
        Updated American Joint committee on cancer/tumor-node-metastasis staging System for differentiated and anaplastic thyroid cancer (eighth edition): what changed and why?.
        Thyroid. 2017; 27: 751-756
        • Vaisman F.
        • Shaha A.
        • Fish S.
        • Michael Tuttle R.
        Initial therapy with either thyroid lobectomy or total thyroidectomy without radioactive iodine remnant ablation is associated with very low rates of structural disease recurrence in properly selected patients with differentiated thyroid cancer.
        Clin Endocrinol. 2011; 75: 112-119
        • Nixon I.J.
        • Ganly I.
        • Patel S.G.
        • et al.
        Thyroid lobectomy for treatment of well differentiated intrathyroid malignancy.
        Surgery. 2012; 151: 571-579
        • Nickel B.
        • Tan T.
        • Cvejic E.
        • et al.
        Health-related quality of life after diagnosis and treatment of differentiated thyroid cancer and association with type of surgical treatment.
        JAMA Otolaryngol Head Neck Surg. 2019; 145: 231-238
        • Edge S.B.
        • Compton C.C.
        The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM.
        Ann Surg Oncol. 2010; 17: 1471-1474
        • Hay I.D.
        • Hutchinson M.E.
        • Gonzalez-Losada T.
        • et al.
        Papillary thyroid microcarcinoma: a study of 900 cases observed in a 60-year period.
        Surgery. 2008; 144 (; discussion 987-988): 980-987
        • So Y.K.
        • Son Y.I.
        • Hong S.D.
        • et al.
        Subclinical lymph node metastasis in papillary thyroid microcarcinoma: a study of 551 resections.
        Surgery. 2010; 148: 526-531
        • Zhao Q.
        • Ming J.
        • Liu C.
        • et al.
        Multifocality and total tumor diameter predict central neck lymph node metastases in papillary thyroid microcarcinoma.
        Ann Surg Oncol. 2013; 20: 746-752
        • Lim Y.C.
        • Choi E.C.
        • Yoon Y.H.
        • et al.
        Central lymph node metastases in unilateral papillary thyroid microcarcinoma.
        Br J Surg. 2009; 96: 253-257
        • Podnos Y.D.
        • Smith D.
        • Wagman L.D.
        • Ellenhorn J.D.
        The implication of lymph node metastasis on survival in patients with well-differentiated thyroid cancer.
        Am Surg. 2005; 71: 731-734
        • Leboulleux S.
        • Rubino C.
        • Baudin E.
        • et al.
        Prognostic factors for persistent or recurrent disease of papillary thyroid carcinoma with neck lymph node metastases and/or tumor extension beyond the thyroid capsule at initial diagnosis.
        J Clin Endocrinol Metab. 2005; 90: 5723-5729
        • Lundgren C.I.
        • Hall P.
        • Dickman P.W.
        • Zedenius J.
        Clinically significant prognostic factors for differentiated thyroid carcinoma: a population-based, nested case-control study.
        Cancer. 2006; 106: 524-531
        • Pisanu A.
        • Reccia I.
        • Nardello O.
        • Uccheddu A.
        Risk factors for nodal metastasis and recurrence among patients with papillary thyroid microcarcinoma: differences in clinical relevance between nonincidental and incidental tumors.
        World J Surg. 2009; 33: 460-468
        • Ross D.S.
        • Litofsky D.
        • Ain K.B.
        • et al.
        Recurrence after treatment of micropapillary thyroid cancer.
        Thyroid. 2009; 19: 1043-1048
        • Wada N.
        • Duh Q.Y.
        • Sugino K.
        • et al.
        Lymph node metastasis from 259 papillary thyroid microcarcinomas: frequency, pattern of occurrence and recurrence, and optimal strategy for neck dissection.
        Ann Surg. 2003; 237: 399-407
        • Ito Y.
        • Tomoda C.
        • Uruno T.
        • et al.
        Preoperative ultrasonographic examination for lymph node metastasis: usefulness when designing lymph node dissection for papillary microcarcinoma of the thyroid.
        World J Surg. 2004; 28: 498-501
        • Trosman S.J.
        • Bhargavan R.
        • Prendes B.L.
        • Burkey B.B.
        • Scharpf J.
        The contemporary utility of intraoperative frozen sections in thyroid surgery.
        Am J Otolaryngol. 2017 Sep-Oct; 38 (Epub 2017 Jul 5. PMID: 28697907): 614-617https://doi.org/10.1016/j.amjoto.2017.07.003
        • Marshall R.
        • Alexander D.
        • Fleming J.
        • Grayson J.
        • Peters G.
        • Buczek E.
        Utility of intraoperative frozen sections of thyroid tissue in the age of molecular testing.
        Clin Otolaryngol. 2021 Apr 2; (Epub ahead of print. PMID: 33811452)https://doi.org/10.1111/coa.13766
        • Lim Y.S.
        • Choi S.W.
        • Lee Y.S.
        • et al.
        Frozen biopsy of central compartment in papillary thyroid cancer: quantitative nodal analysis.
        Head Neck. 2013; 35: 1319-1322
        • Raffaelli M.
        • De Crea C.
        • Sessa L.
        • et al.
        Can intraoperative frozen section influence the extension of central neck dissection in cN0 papillary thyroid carcinoma?.
        Langenbeck's Arch Surg. 2013; 398: 383-388
        • Raffaelli M.
        • De Crea C.
        • Sessa L.
        • et al.
        Ipsilateral central neck dissection plus frozen section examination versus prophylactic bilateral central neck dissection in cN0 papillary thyroid carcinoma.
        Ann Surg Oncol. 2015; 22: 2302-2308