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Total thyroidectomy versus

lobectomy in conventional
papillary thyroid
microcarcinoma: Analysis of
8,676 patients at a single
Seo Ki Kim, MD,a Inhye Park, MD,a Jung-Woo Woo, MD,b Jun Ho Lee, MD,c Jun-Ho Choe, MD, PhD,a
Jung-Han Kim, MD, PhD,a and Jee Soo Kim, MD, PhD,a Seoul and Changwon, South Korea

Background. Because there is a controversy regarding the management of papillary thyroid micro-
carcinoma, the purpose of this study was to compare lobectomy with total thyroidectomy as a primary
operative treatment for papillary thyroid microcarcinoma. Loco-regional recurrence in the contralateral
remnant lobe can be managed safely by completion thyroidectomy via the previous scar. However,
reoperation for operation bed (thyroidectomy site) or regional lymph node (central or lateral) recurrence
generally is associated with morbidity. Therefore, we analyzed overall loco-regional recurrence and loco-
regional recurrence outside of the contralateral remnant lobe separately.
Methods. We retrospectively reviewed 8,676 conventional patients with papillary thyroid micro-
carcinoma who underwent thyroidectomy.
Results. Lobectomy was performed in 3,289 (37.9%) patients, and total thyroidectomy was performed in
5,387 (62.1%) patients. Total thyroidectomy significantly decreased the risk of overall loco-regional
recurrence (adjusted hazard ratio 0.398, P < .001). However, total thyroidectomy did not significantly
decrease the risk of loco-regional recurrence outside of the contralateral remnant lobe (adjusted hazard
ratio 0.880, P = .640). Particularly in conventional papillary thyroid microcarcinoma patients with
multifocality, total thyroidectomy significantly decreased the risk of overall loco-regional recurrence
(adjusted hazard ratio 0.284, P = .002) and loco-regional recurrence outside of the contralateral
remnant lobe (adjusted hazard ratio 0.342, P = .020).
Conclusion. Although lobectomy is associated with contralateral remnant lobe recurrence, lobectomy did
not increase the risk of loco-regional recurrence outside of the contralateral remnant lobe in patients with
papillary thyroid microcarcinoma, except in those with multifocality. Because recurrence in the
contralateral remnant lobe can be managed safely by completion thyroidectomy, lobectomy may be a safe
operative option for select patients with papillary thyroid microcarcinoma without multifocality. (Surgery

From the Division of Breast and Endocrine Surgery, Department of Surgery,a Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul; Department of Surgery,b Changwon Gyeongsang
National University Hospital, Gyeongsang National University School of Medicine, Changwon; and Division
of Breast and Endocrine Surgery, Department of Surgery,c Samsung Changwon Hospital, Sungkyunkwan
University School of Medicine, Changwon, South Korea


Accepted for publication July 27, 2016.
THYROID CARCINOMA (PTC) is mainly due to early
Reprint requests: Jee Soo Kim, MD, PhD, Division of Breast and
Endocrine Surgery, Department of Surgery, Samsung Medical
detection of papillary thyroid microcarcinoma
Center, Sungkyunkwan University School of Medicine, 81 (PTMC), which is defined as a carcinoma <1 cm
Irwon-ro, Gangnam-gu, Seoul 135-710, South Korea. E-mail: in size.1 Because there is no consensus regarding
jskim0126@skku.edu. the natural history of PTMC, suggested operative
0039-6060/$ - see front matter treatment of PTMC ranges from observation alone
2016 Elsevier Inc. All rights reserved. to total thyroidectomy (TT) with radioactive iodine
http://dx.doi.org/10.1016/j.surg.2016.07.037 (RAI) ablation.2 Although the American Thyroid

2 Kim et al Surgery
j 2016

Association and British Thyroid Association guide- tumor size >1 cm, sub-/near-TT cases, presence of
lines recommend lobectomy alone for primary distant metastasis at the time of diagnosis, or a
operative treatment of PTMC without multifocality, follow-up duration of <6 months (residual tumor
extrathyroid extension (ETE), or regional lymph or suspicious LN detected within 6 months after
node (LN; central or lateral) metastasis,3,4 a recent initial operations, reoperation within 6 months after
survey study showed that 30% of surgeons felt the initial operation, or loss to follow-up within
need to proceed with TT for a single PTMC focus.5 6 months).
TT has several advantages, including facilitating Because there was no patient with gross ETE or
iodine-131 scan, RAI ablation, and the use of lateral LN metastasis in the lobectomy group, we
thyroglobulin as a tumor marker, in PTC patients. excluded TT group patients with gross ETE and
However, 2 recent large group studies showed that lateral LN metastasis to reduce potential selection
there were no significant difference in long-term bias. Finally, a total of 8,676 pathologically proven
rates of recurrence and death between lobectomy conventional PTMC patients were included in the
and TT.6,7 In addition, several studies have not analyses.
found any benefit of RAI ablation after TT in Surgical methods. In our institution, lobectomy
PTMC.8-10 Moreover, it is clear that the incidence or TT is the standard operative option for the
of morbidity is directly proportional to the extent treatment of PTMC patients; sub-total/near-TT is
of operation.11-14 Although many lobectomy pa- rarely performed. TT was performed according to
tients do not require lifelong thyroid hormone published guidelines.3,4 Therapeutic central neck
replacement due to a remnant functioning lobe, dissection was performed when suspicious central
lifelong thyroid hormone replacement always is LN metastasis was detected during preoperative
required after TT.15,16 Therefore, the clinical or intraoperative examination. Prophylactic cen-
benefit of TT in PTMC has been questioned. tral neck dissection was performed on clinically
The purpose of this study was to compare node-negative PTMC patients with gross ETE3,4
lobectomy and TT as a primary operative treat- or according to the surgeons personal preference
ment for PTMC. Because mortality is extremely low at the time of operation. At our institution, we only
in PTMC,17 we adopted loco-regional recurrence performed therapeutic lateral neck dissection
(LRR) as the primary end point. Because the when lateral LN metastasis was demonstrated on
contralateral remnant lobe remains intact after lo- fine needle aspiration biopsy. Lateral neck dissec-
bectomy, LRR in the contralateral remnant lobe tion, which included modified radical neck dissec-
can be managed safely by completion thyroidec- tion and selective neck dissection, was performed
tomy via the previous scar.18-20 However, reopera- as previously described in the literature.23 Open
tion for operation bed (thyroidectomy site) or (conventional low collar approach) or oncoplastic
regional LN (central or lateral) recurrence gener- (endoscopic or robotic) thyroidectomy was chosen
ally is associated with a greater risk of morbidity.21 based on patient preference after a thorough dis-
Therefore, to assess clinical risk and benefit based cussion of the pros and cons of each approach.
on the extent of thyroidectomy, we separately Histopathologic examination of operative spec-
analyzed overall LRR and LRR outside of the imens. Operative specimens were microscopically
contralateral remnant lobe. Because different examined by $2 experienced pathologists, and the
pathologic variants of PTC have different behav- following histopathologic factors were assessed:
iors and prognoses,22 we included only conven- cell type of the main lesion, primary tumor size
tional PTMC. (longest diameter of the largest lesion), multi-
focality, bilaterality, ETE (microscopic or gross),
PATIENTS AND METHODS regional LN metastasis (central or lateral), and
Patient selection. We conducted a retrospective underlying conditions of the thyroid, such as
cohort study at a single institution. Between chronic lymphocytic thyroiditis (CLT). To distin-
January 1997 and June 2015, 20,030 patients guish bilaterality from multifocality, multifocality
underwent thyroidectomy with or without neck was defined as the presence of $2 lesions of
dissection at the Thyroid Cancer Center of conventional PTMC in a single lobe, regardless of
Samsung Medical Center, a tertiary referral center the presence of bilaterality. The staging of thyroid
in Korea. A total of 11,354 patients with the following cancer was determined in accordance with the
conditions were excluded: a history of previous American Joint Committee on Cancer.24
thyroidectomy, age <18 years, non-PTC carcinoma Postoperative follow-up and management. After
(follicular/medullary/anaplastic), mixed-type PTC, the initial operation, all patients underwent reg-
pathologic variants other than conventional PTC, ular follow-up at 6- to 12-month intervals with
Surgery Kim et al 3
Volume j, Number j

Table I. Clinicopathologic characteristics of 8,676 conventional PTMC patients according to the extent of
Total LT TT
No. (%) No. (%) No. (%) P value
Total 8,676 (100.0) 3,289 (37.9) 5,387 (62.1) NA
Female 7,057 (81.3) 2,578 (78.4) 4,479 (83.1)
Male 1,619 (18.7) 711 (21.6) 908 (16.9) <.001
Age (y)
Mean SD 47.2 10.5 45.5 10.5 48.3 10.4 <.001
#45 3,747 (43.2) 1,639 (49.8) 2,108 (39.1)
>45 4,929 (56.8) 1,650 (50.2) 3,279 (60.9) <.001
BRAF mutation*
Negative 575 (17.1) 326 (17.9) 249 (16.2)
Positive 2,790 (82.9) 1,498 (82.1) 1,292 (83.8) .188
Operative approach
Open 7,391 (85.2) 2,468 (75.0) 4,923 (91.4)
Oncoplasticy 1,285 (14.8) 821 (25.0) 464 (8.6) <.001
Central neck dissection
Absent 2,290 (26.4) 1,222 (37.2) 1,068 (19.8)
Present 6,386 (73.6) 2,067 (62.8) 4,319 (80.2) <.001
Tumor size (cm)
Mean SD 0.6 0.2 0.5 0.2 0.6 0.2 <.001
#0.5 3,818 (44.0) 1,759 (53.5) 2,059 (38.2)
>0.5 4,858 (56.0) 1,530 (46.5) 3,328 (61.8) <.001
Absent 6,958 (80.2) 2,903 (88.3) 4,055 (75.3)
Present 1,718 (19.8) 386 (11.7) 1,332 (24.7) <.001
Absent 7,269 (83.8) 3,289 (100.0) 3,980 (73.9)
Present 1,407 (16.2) 0 (0.0) 1,407 (26.1) NA
Absent 4,953 (57.1) 2,257 (68.6) 2,696 (50.0)
Microscopic 3,723 (42.9) 1,032 (31.4) 2,691 (50.0) <.001
Absent 6,454 (74.4) 2,548 (77.5) 3,906 (72.5)
Present 2,222 (25.6) 741 (22.5) 1,481 (27.5) <.001
Central LN metastasis
Absent 6,351 (73.2) 2,836 (86.2) 3,515 (65.2)
Present 2,325 (26.8) 453 (13.8) 1,872 (34.8) <.001
RAI ablation
Mean SD (mCi)z NA 0.0 0.0 56.5 65.0 <.001
Absent 4,813 (55.5) 3,289 (100.0) 1,524 (28.3)
Present 3,863 (44.5) 0 (0.0) 3,863 (71.7) <.001
*BRAF mutation analysis was started in 2008 and was performed in 3,365 conventional PTMC patients.
yEndoscopic or robotic thyroidectomy.
zCounted by the end of follow-up.
LT, Lobectomy; NA, not available.

clinical evaluations including physical examina- aggressive features as recommended by estab-

tions, ultrasonography, computed tomography, lished guidelines,3,4 the final decision was based
iodine-131 scans, and serum thyroglobulin. After on physician or patient preference. LRR was
TT, levothyroxine was administered based on defined as newly detected tumor or metastatic
weight in kilograms to suppress thyroid stimu- LN >6 months after the initial operation as
lating hormone levels of <0.5 mU/L. Although confirmed by fine needle aspiration biopsy and/
RAI ablation generally was proposed for or histopathology.
4 Kim et al Surgery
j 2016

Table II. Recurrence sites in 139 conventional in the lobectomy group and 89 (1.7%) in the TT
PTMC patients with LRR group. LRR outside of the contralateral remnant
LT TT lobe in the lobectomy group was observed in 21
No. (%) No. (%) patients (0.6%).
Recurrence sites in the lobectomy group
Contralateral lobe 29 (58.0) 0 (0.0)
included the contralateral remnant lobe in 29
Operation bed 1 (2.0) 4 (4.5)
patients (58.0%), regional LN (central or lateral)
(thyroidectomy site)
Regional LN 10 (20.0) 18 (20.2) in 20 patients (40.0%), and the operation bed
(central neck) (thyroidectomy site) in 1 patient (2.0%). Recur-
Regional LN 10 (20.0) 67 (75.3) rent sites in the TT group included regional LN
(lateral neck) (central or lateral) in 85 patients (95. 5%) and the
LT, Lobectomy.
operation bed (thyroidectomy site) in 4 patients
(4.5%). In terms of overall LRR, recurrence-free
survival in the lobectomy group was 98.1% at
Statistical analysis. Statistical analyses were per- 5 years, 91.8% at 10 years, and 90.6% at 15 years,
formed using SPSS software (version 22.0; IBM while recurrence-free survival in the TT group was
Corp, Armonk, NY). Continuous variables are 98.5% at 5 years, 97.5% at 10 years, and 97.0% at
presented as mean standard deviation (SD), 15 years (Fig, A).
and categorical variables are presented as the With regard to LRR outside of the contralateral
number and percentage of cases; v2 test and remnant lobe, recurrence-free survival in the
linear-by-linear association were used for categori- lobectomy group was 99.2% at 5 years, 96.7% at
cal variables, and the Student t test for continuous 10 years, and 95.5% at 15 years, while recurrence-
variables. The Kaplan-Meier method was adopted free survival in the TT group was 98.5% at 5 years,
to analyze time-dependent variables. The adjusted 97.5% at 10 years, and 97.0% at 15 years (Fig, B).
hazard ratio (HR) and 95% confidence interval After adjustment for clinicopathologic characteris-
(CI) for LRR were calculated using Cox regression tics in the Cox proportional hazard model
models. To verify the prognostic impact of RAI (Table III), TT significantly decreased the risk of
ablation on TT, additional subgroup analysis was overall LRR in conventional PTMC patients
performed. (adjusted HR 0.398, P < .001). However, TT did
not significantly decrease the risk of LRR outside
RESULTS of the contralateral remnant lobe in conventional
Clinicopathologic characteristics of 8,676 con- PTMC patients (adjusted HR 0.880, P = .640).
ventional PTMC patients according to the extent On further subgroup analysis (Table IV), TT did
of thyroidectomy. Of the 8,676 conventional not significantly decrease the risk of LRR outside
PTMC patients, 3,289 (37.9%) underwent lobec- of the contralateral remnant lobe in patients with
tomy and 5,387 (62.1%) underwent TT (Table I). BRAF mutation positivity (adjusted HR 1.038,
Age >45 years (P < .001), central neck dissection P = .939), tumor size >0.5 cm (adjusted HR
(P < .001), tumor size >0.5 cm (P < .001), multifo- 0.799, P = .505), microscopic ETE (adjusted HR
cality (P < .001), microscopic ETE (P < .001), CLT 0.724, P = .360), or central LN metastasis (adjusted
(P < .001), and central LN metastasis (P < .001) HR .946, P = .895). In conventional PTMC patients
were significantly more frequent in the TT group with multifocality, TT significantly decreased the
than the lobectomy group. However, male sex risk of overall LRR (adjusted HR 0.284, P = .002)
(P < .001) and oncoplastic thyroidectomy and LRR outside of the contralateral remnant
(P < .001) were significantly less frequent in the lobe (adjusted HR 0.342, P = .020).
TT group than the lobectomy group. BRAF positiv- We also verified the prognostic impact of RAI
ity was not significantly associated with the extent ablation on TT. We compared conventional PTMC
of thyroidectomy (P = .188). patients who underwent lobectomy without RAI
Prognostic impact of the extent of thyroidec- ablation (n = 3,289), TT without RAI ablation
tomy on LRR in 8,676 conventional PTMC pa- (n = 1,524), and TT with RAI ablation
tients. The mean follow-up time was 64.6 months (n = 3,863). Regardless of RAI ablation, TT signifi-
(range, 6.0230.9 months). Because cause-specific cantly decreased the risk of overall LRR compared
death was only noted in 9 (0.1%) of the 8,676 with lobectomy: TT without RAI (adjusted HR
conventional PTMC patients, survival analysis was 0.228, P = .001) and TT with RAI (adjusted HR
not performed. As shown in Table II, overall LRR 0.443, P < .001). However, TT did not significantly
was observed in 139 patients (1.6%): 50 (1.6%) decrease the risk of LRR outside of the
Surgery Kim et al 5
Volume j, Number j

Fig. Recurrence-free survival for conventional papillary thyroid microcarcinoma according to the extent of thyroidec-
tomy. (A) loco-regional recurrence (overall); (B) loco-regional recurrence (outside of contralateral remnant lobe). LT,
Lobectomy; TT, total thyroidectomy.

Table III. Cox proportional hazards model for LRR in conventional PTMC patients
LRR (outside of contralateral remnant
LRR (overall) lobe)
Adjusted HR (95% CI) P value Adjusted HR (95% CI) P value
LT (reference) NA NA NA NA
TT 0.398 (0.2650.599) <.001 0.880 (0.5141.504) .640
Male sex 0.855 (0.5431.347) .500 1.101 (0.6851.769) .692
Age (per 10-y increment) 0.962 (0.8211.127) .630 1.047 (0.8781.249) .606
Operative approach
Open (reference) NA NA NA NA
Oncoplastic* 1.049 (0.6171.785) .860 1.230 (0.6422.356) .532
Central neck dissection 0.516 (0.3400.784) .002 0.440 (0.2690.721) .001
Tumor size (per 0.1-cm 4.513 (1.94910.446) <.001 4.314 (1.64711.298) .003
Multifocality 1.655 (1.1372.408) .009 1.720 (1.1502.572) .008
Microscopic ETE 1.430 (1.0512.093) .048 1.796 (1.1842.724) .006
CLT 0.875 (0.5751.329) .530 0.803 (0.4941.305) .376
Central LN metastasis 3.568 (2.3955.317) <.001 4.669 (2.9567.375) <.001
*Endoscopic or robotic thyroidectomy.
CI, Confidence interval; LT, lobectomy; NA, not available.

contralateral remnant lobe either with (adjusted metastasis were associated with an increased likeli-
HR 0.545, P = .850) or without RAI (adjusted hood of TT (Table I). This reflects the fact that TT
HR = 0.597, P = .275). was preferred in patients with aggressive features.3
Because we generally performed TT in PTC pa-
DISCUSSION tients with gross ETE, there was no patient with
In this study, age >45 years, open thyroidec- gross ETE in the lobectomy group. Therefore, we
tomy, central neck dissection, tumor size >0.5 cm, excluded all patients with gross ETE and lateral
multifocality, microscopic ETE, and central LN LN metastasis from the TT group in order to
6 Kim et al Surgery
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Table IV. Subgroup analysis of Cox proportional hazards model for LRR according to the various
conditions in conventional PTMC patients who underwent TT compared with those who underwent LT
LRR (outside of contralateral remnant
LRR (overall) lobe)
Adjusted HR (95% CI) P value Adjusted HR (95% CI) P value
Male sex 0.670 (0.2471.816) .432 0.800 (0.2812.275) .675
Age (y)
#45 0.307 (0.1710.551) <.001 0.797 (0.3581.774) .578
>45 0.520 (0.2910.927) .027 0.944 (0.4591.940) .874
BRAF (+)* 0.492 (0.2351.033) .061 1.038 (0.3962.725) .939
Tumor size >0.5 cm 0.379 (0.2280.631) <.001 0.799 (0.4141.545) .505
Multifocality (+) 0.284 (0.1260.642) .002 0.342 (0.1380.847) .020
Microscopic ETE (+) 0.492 (0.2700.897) .021 0.724 (0.3631.445) .360
Central LN metastasis (+) 0.732 (0.3471.544) .412 0.946 (0.4142.163) .895
LT/RAI () (reference) NA NA NA NA
TT/RAI () 0.228 (0.0960.540) .001 0.597 (0.2361.509) .275
TT/RAI (+) 0.443 (0.2890.679) <.001 0.948 (0.5451.648) .850
*BRAF mutation analysis was started in 2008 and 2,790 conventional PTMC patients showed BRAF mutation positivity.
CI, Confidence interval; LT, lobectomy; NA, not available.

reduce selection bias. TT was significantly more LRR occurred in regional LN (central or lateral).
frequent in patients with CLT. Pseudonodules are As shown in Table III, with the exception of the
occasionally difficult to distinguish from true nod- extent of thyroidectomy (lobectomy or TT), inde-
ules in coexisting CLT, and reactive LN enlarge- pendent predictors for LRR were observed consis-
ment on ultrasonography almost is invariably tently regardless of LRR type.
present in coexisting CLT. This might be why TT The relationship between LRR and age remains
was primarily performed in PTC patients with unclear, with some studies showing higher rates in
CLT.25 older patients,30,31 and some in younger pa-
Although guidelines recommend performing tients.32,33 In this study, age did not have a signifi-
lobectomy to treat PTMC,3,4 5,387 (62.1%) con- cant prognostic impact on conventional PTMC.
ventional PTMC patients underwent TT in our Large tumor size,6 multifocality,8,9 ETE,34,35 and
study. As shown in Table I, among 8,676 conven- regional LN (central or lateral) metastasis8,9,36
tional PTMC patients, 3,723 patients (42.9%) had were independent predictors of LRR. Recurrence
microscopic ETE and 2,325 patients (26.8%) had was noted to be less frequent in PTC patients
central LN metastasis. Among 5,387 conventional with CLT rather than without CLT.37-39 However,
PTMC patients who underwent TT, 1,407 patients in our study, CLT did not significantly decrease
(26.1%) exhibited bilaterality. The prevalence of the risk of LRR in conventional PTMC patients.
bilaterality, microscopic ETE, and central LN Central neck dissection significantly decreased
metastasis was relatively greater than reported in the risk of LRR. Because central LN metastasis
previous studies that were mainly conducted in may remain undetected in those who do not un-
Western countries.17 Moreover, the incidence of dergo central neck dissection,40,41 their prognosis
BRAF mutation positivity in the subset tested was may be inferior to those who undergo central
almost 80% and similar results were seen in previ- neck dissection.
ous studies conducted in Korea.26-28 Strong associ- As mentioned in the Introduction, LRR in the
ations between BRAF mutation and aggressive contralateral remnant lobe after LT can be
clinicopathologic characteristics of PTC have managed safely by completion thyroidectomy,
been demonstrated previously,29 supporting the which carries a similar operative risk to that of
existence of a geographic bias. primary TT.18-20 However, reoperation for opera-
As shown in previous studies, the average rate of tion bed (thyroidectomy site) or regional LN (cen-
recurrence is very low in PTMC patients.17 In our tral or lateral) recurrence is associated with a
study, LRR was observed in only 1.6% of enrolled greater risk of morbidity than primary operation.21
conventional PTMC patients (Table II). And No prior studies have selectively analyzed LRR ac-
similar to the results of previous studies,8 most cording to recurrence site.6-9,36 Therefore, we
Surgery Kim et al 7
Volume j, Number j

analyzed overall LRR and LRR outside of the ablation generally is recommended for tumors
contralateral remnant lobe separately. After adjust- with aggressive features,3,4 but the final decision
ment of the Cox proportional hazard model for was made based on physician or patient prefer-
clinicopathologic characteristics (Table III), TT ence. Therefore, there was a possible selection
significantly decreased the risk of overall LRR bias with regard to whether RAI therapy was per-
(adjusted HR 0.398, P < .001). However, TT did formed or not. Fourth, in the preoperative period,
not significantly decrease the risk of LRR outside imaging modalities and the radiologist might miss
of the contralateral remnant lobe (adjusted HR the malignancies in the contralateral remnant
0.880, P = .640). lobe. Fifth, LRR may be detected more readily in
Furthermore, as shown in Table IV, TT did not patients who undergo TT due to the availability
significantly decrease the risk of LRR outside of of follow-up modalities including whole body
the contralateral remnant lobe, even in patients scan and the use of thyroglobulin marker. Finally,
with BRAF mutation positivity (adjusted HR our results may not be applicable to patients
1.038, P = .939), tumor size >0.5 cm (adjusted from other ethnicities or countries because of
HR 0.799, P = .505), microscopic ETE (adjusted the high prevalence of the BRAF mutation in our
HR 0.724, P = .360), and central LN metastasis population (82.9%), which can be explained by
(adjusted HR 0.946, P = .895). However, in conven- geographic bias.26,27
tional PTMC patients with multifocality, TT signifi- However, this study also had several strengths.
cantly decreased the risk of overall LRR (adjusted First, this study was based on a large group of
HR 0.284, P = .002) and LRR outside of the contra- conventional PTMC patients (8,676 cases) with a
lateral remnant lobe (adjusted HR 0.342, P = .020). relatively long-term follow-up period (maximum,
And, TT significantly decreased the risk of overall 230.9 months). Second, we used data from a single
LRR regardless of whether RAI ablation was per- institution, and rigorous exclusion/inclusion criteria
formed. However, the significance of this relation- for clear and accurate analysis.
ship disappeared when only LRR outside of the In conclusion, although lobectomy is associated
contralateral remnant lobe was considered. There- with contralateral remnant lobe recurrence, lobec-
fore, this finding suggests that TT reduces the risk tomy did not increase the risk of LRR outside of
of overall LRR via the removal of the contralateral the contralateral remnant lobe in PTMC patients,
remnant lobe; however, RAI ablation after TT does except in those with multifocality. Because recur-
not reduce the risk of LRR outside of the contralat- rence in the contralateral remnant lobe can be
eral remnant lobe. safely managed by completion thyroidectomy, lo-
This finding is consistent with the results of bectomy may be a safe operative option for select
other studies, which suggested that RAI ablation PTMC patients without multifocality.
did not decrease the risk of recurrence in PTMC
patients.8-10 Moreover, the incidence of morbidity
is clearly and consistently proportional to the
1. Davies L, Welch HG. Increasing incidence of thyroid cancer
extent of thyroidectomy, even among high-
in the United States, 19732002. JAMA 2006;295:2164-7.
volume surgeons.42 In addition, TT patients always 2. Wu AW, Nguyen C, Wang MB. What is the best treatment for
require lifelong hormone replacement.15,16 In papillary thyroid microcarcinoma? Laryngoscope 2011;121:
PTC patients, TT has several advantages including 1828-9.
facilitating iodine-131 scan, RAI ablation, and the 3. American Thyroid Association Guidelines Taskforce on
Thyroid N, Differentiated Thyroid C, Cooper DS,
use of thyroglobulin as a tumor marker. However,
Doherty GM, Haugen BR, Kloos RT, et al. Revised American
the clinical benefit of TT as a primary operative Thyroid Association management guidelines for patients
treatment option is not evident in PTMC patients, with thyroid nodules and differentiated thyroid cancer. Thy-
except in those with multifocality. roid 2009;19:1167-214.
Our study has several limitations. First, this 4. Perros P, Boelaert K, Colley S, Evans C, Evans RM, Gerrard
Ba G, et al. Guidelines for the management of thyroid can-
study is a nonrandomized retrospective cohort
cer. Clin Endocrinol (Oxf) 2014;81(Suppl 1):1-122.
study. Therefore, the patient information in our 5. Wu AW, Wang MB, Nguyen CT. Surgical practice patterns in
data might be incomplete, and we cannot rule out the treatment of papillary thyroid microcarcinoma. Arch
the possibility of residual confounding variables. Otolaryngol Head Neck Surg 2010;136:1182-90.
Second, because there has been no universal 6. Bilimoria KY, Bentrem DJ, Ko CY, Stewart AK,
Winchester DP, Talamonti MS, et al. Extent of surgery af-
consensus regarding the operative extent required
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to treat PTMC,2 decision-making regarding the 246:375-81; discussion 81-4.
extent of thyroidectomy could have resulted in 7. Lee J, Park JH, Lee CR, Chung WY, Park CS. Long-term out-
additional selection bias in our study. Third, RAI comes of total thyroidectomy versus thyroid lobectomy for
8 Kim et al Surgery
j 2016

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