Comparison of Lobectomy vs Total Thyroidectomy for Intermediate-Risk Papillary Thyroid Carcinoma With Lymph Node Metastasis

Abstract

ImportanceSurgical treatment of patients with papillary thyroid cancer (PTC) by either lobectomy or total thyroidectomy (TT) has long been a topic of debate, especially for patients with intermediate-risk PTC.ObjectiveTo compare recurrence-free survival (RFS) for patients with PTC and lymph node metastasis after lobectomy vs TT.Design, Setting, and ParticipantsThis retrospective cohort study included a review of patients with PTC treated from January 1, 2000, to December 31, 2017. Propensity score matching (PSM) was performed between patients treated with lobectomy and TT. This study involved a single institute in a cancer referral center. Enrolled were adult patients (aged 18-75 years) with unilateral PTC and ipsilateral clinical lateral neck metastasis (cN1b). Patients with the following characteristics were excluded: a lymph node yield less than 20, primary tumor size greater than 4 cm, gross extrathyroidal extension, metastatic lymph node size greater than 3 cm, and distant metastasis. Data analysis was performed from April 1 to April 30, 2022.ExposuresLobectomy and TT.Main Outcomes and MeasuresThe primary outcome was the association between extent of surgery and RFS, assessed using Cox proportional hazards regression models.ResultsA total of 946 patients with PTC (mean [SD] age, 37.0 [12.1] years, 630 female individuals [66.6%]) were analyzed. Lobectomy (624 [66.0%]) was negatively correlated with the frequencies of older age (≥65 years, 17 [2.7%]), female sex (393 [63.0%]), multifocality (132 [21.2%]), minor extrathyroidal extension (259 [41.5%]), number of metastatic lymph nodes (median [range], 9 [6-14] nodes), and radioactive iodine ablation (0). After PSM with treatment period and potential prognostic factors (age, sex, primary tumor size, multifocality, minor extrathyroidal extension, number of lymph node metastases and lymph node ratio), 265 pairs of patients were available for analysis. After a median (range) follow-up of 60 (9-150) months in the lobectomy group and 58 (8-161) months in the TT group, 21 (7.9%) and 17 (6.4%) structural recurrences were identified in the lobectomy and TT groups, respectively. Lobectomy was not associated with significantly compromised 5-year RFS rate (lobectomy, 92.3% vs TT, 93.7%; adjusted hazard ratio, 1.10; 95% CI, 0.58-2.11; P = .77). Power analysis indicated that the test had 90% power to detect a more than 4.9% RFS difference. No significant difference in RFS was observed between patients treated with TT and radioactive iodine ablation (n = 75) and their counterparts (adjusted hazard ratio, 0.59; 95% CI, 0.14-2.41; P = .46).Conclusions and RelevanceResults of this cohort study suggest that patients with PTC and lymph node metastasis had a similar RFS after lobectomy vs those who had TT. If radioactive iodine ablation is not going to be performed, lobectomy may be an effective alternative option.

Is Lobectomy as Effective as Total Thyroidectomy in Treating Patients With Intermediate-Risk Papillary Thyroid Carcinoma With Lateral Lymph Node Metastasis?

“…ing the extent of surgery but few have addressed lateral neck involvement. The report by Xu et al 3 is the largest cohort to date. This study challenges the current guidelines and surgical practices.…”

“…In a single-center, retrospective cohort analysis spanning 17 years, Xu et al 3 compared 265 propensity matched pairs of patients (lobectomy vs total thyroidectomy) and found equivalent rates of recurrence-free survival after a 5-year surveillance period (92.3% vs 93.7%). 3 Comparable oncologic outcomes and disease-free survival have been reported regarding tumor size, 4 thyroid hormone suppression therapy, 5 and multifocality when compar-…”

“…Comparable oncologic outcomes and disease-free survival have been reported regarding tumor size, thyroid hormone suppression therapy, and multifocality when comparing the extent of surgery but few have addressed lateral neck involvement. The report by Xu et al is the largest cohort to date. This study challenges the current guidelines and surgical practices.…”

“…Is lobectomy an acceptable alternative to total thyroidectomy for patients with intermediate-risk papillary thyroid cancer with lateral neck node metastasis (cN1b)? In a single-center, retrospective cohort analysis spanning 17 years, Xu et al compared 265 propensity matched pairs of patients (lobectomy vs total thyroidectomy) and found equivalent rates of recurrence-free survival after a 5-year surveillance period (92.3% vs 93.7%) …”

“…During this long study period, significant changes were made to the American Thyroid Association guidelines in 2009 and in 2017. These changes may have influenced the authors’ practice and patient selection. In addition, the study is limited by not having preoperative and postoperative molecular genetic testing that has significantly changed surgical practice in the US by improving risk stratification and guiding the extent of resection …”