Making wise decisions for completion thyroidectomies

Abstract

<p>Unilateral differentiated thyroid cancer (DTC) <4 cm can be treated with thyroid lobectomy or total thyroidectomy (TT), depending on the presence of high-risk features. Information about some of these features, such as micrometastasis in lymph nodes or microscopic extrathyroidal extension (ETE), are usually incidental findings that only become available after histological assessment from the first surgery. If such features or risk factors are present, physicians face the dilemma of suggesting completion thyroidectomy or not. There is often considerable room for clinical judgement in these cases, even though thyroid cancer guidelines generally say that completion thyroidectomy should be offered as if the information were available before the initial surgery. <p>In this issue of <i>Gland Surgery</i>, Choi and coworkers (1) provide data that may help clinicians making their wise decisions when faced with this situation. The authors looked at patients whose American Thyroid Association (ATA) risk classification was upstaged from low to intermediate after incidental findings of lymph node micrometastasis or microscopic ETE. The authors present data from 2,830 patients treated for assumed low risk DTC with lobectomy and prophylactic ipsilateral central compartment neck dissection (CCND). Patients with lymph node metastasis >2 mm or gross ETE of the cancer were treated with TT and not included in the study. Thus, patient selection included only “the better part” of intermediate risk patients. The presence of micrometastasis or microscopic ETE, two features that according to ATA guidelines (2) would add to the argument for completion thyroidectomy, did not change the treatment strategy at the author’s clinic. This allowed the unique opportunity for the authors to compare long-term oncological outcomes for patients with micrometastasis in the central lymph nodes or microscopic ETE, to those who had not, without further surgical or radioiodine treatment.