Continuing controversy regarding individualized surgical decision-making for patients with 1–4 cm low-risk differentiated thyroid carcinoma: A systematic review

Abstract

Implementing high-quality randomized controlled trials is difficult for patients with 1e4 cm low-risk differentiated thyroid carcinoma (DTC). Controversy exists regarding whether lobectomy (LT) or total thyroidectomy (TT) is the optimal surgical approach over the short term and long term. Inconsistent recommendations have led to confusion amongst surgeons. Consequently, the outcomes of patients may be influenced. A great deal of new literature is published monthly, and there have been numerous studies supporting both LT and TT. Surgeons must spend considerable time and energy clarifying why controversy exists and which studies should be used as references. We selected 19 recent guidelines/consensuses for surgical approach in treating of 1e4 cm DTC. This study presents various topics relevant to the present debate, including disease-specific survival (DSS), persistence/recurrence, and complications between LT and TT, in patients with 1e4 cm low-risk DTC. This review includes a discussion of the background of those recommendations with regard to various medical, cultural and geographic environments. Additionally, recent technologies and future directions for current issues in risk identification were integrated into the review to provide a reference for individualized decision-making for patients with 1e4 cm low-risk DTC. Given different national conditions, there are different points of emphasis amongst the guidelines. Consideration of surgical approach should consider the character of both surgeons and patients. We should balance the relative benefits, risks and resulting quality of life in order to perform individualized surgical decision-making, and to make reasonable decisions in employing either TT or LT.

Thyroid Carcinoma, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology

“…Decisions about the extent of thyroidectomy should be individualized and made in consultation with the patient. 29 Circumstances in which lobectomy include T3 or T4 tumor, N1b disease, M1 disease, and poorly differentiated subtypes. Family history, exposure history, and coexistent bilateral thyroid disease may also be considered when making decisions about the extent of surgery.…”

Partial Versus Total Thyroidectomy

“…Regarding thyroid surgery, everyday practice does not always align with the guidelines because of a number of factors, such as local habits, patients’ wishes, the surgeon's expertise, and the influence of the media. Even though the ATA guidelines favor lobectomy for differentiated tumors less than 4 cm in size 6 for low-risk differentiated tumors, several other societies still recommend total (or near total) thyroidectomy 20 as part of a personalized strategy based on the tumor characteristics assessed during the preoperative morphological and cytological assessment, as well as on the patient's wishes, and the surgeon's expertise, which as mentioned before is also related to their training. Traditionally Europe reacts differently from the US to these trends, and it is clear that in this nationwide study, the increase in the proportion of partial thyroidectomies is a recent trend, occurring significantly only in the last 3 years and varying according to region.…”

The active surveillance management approach for patients with low risk papillary thyroid microcarcinomas: is China ready?

“…In autopsy studies, latent, asymptomatic PTMC was present in 4%-11% of autopsy patients who died from nonthyroidal diseases 14 . A systematic review and meta-analysis pooled for over 6 decades by Furuya-Kanamori et al 14 confirmed that the average prevalence of occult differentiated thyroid carcinoma was 12.7% in autopsy studies, which examined sectioned whole thyroid glands (5,597 cases) 15 . It was therefore assumed that a certain percentage of PTMC may be resting and inert.…”