ARTICLE IN PRESS

Total thyroidectomy versus

lobectomy in conventional
papillary thyroid
microcarcinoma: Analysis of
8,676 patients at a single
institution
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
2016;j:j-j.)

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

THE CURRENT INCREASE IN THE INCIDENCE OF PAPILLARY

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

SURGERY 1
 ARTICLE IN PRESS
2 Kim et al
Association and British Thyroid Association guide-
lines recommend lobectomy alone for primary
operative treatment of PTMC without multifocality,
extrathyroid extension (ETE), or regional lymph
node (LN; central or lateral) metastasis,3,4 a recent
survey study showed that 30% of surgeons felt the
need to proceed with TT for a single PTMC focus.5
TT has several advantages, including facilitating
iodine-131 scan, RAI ablation, and the use of
thyroglobulin as a tumor marker, in PTC patients.
However, 2 recent large group studies showed that
there were no significant difference in long-term
rates of recurrence and death between lobectomy
and TT.6,7 In addition, several studies have not
found any benefit of RAI ablation after TT in
PTMC.8-10 Moreover, it is clear that the incidence
of morbidity is directly proportional to the extent
of operation.11-14 Although many lobectomy pa-
tients do not require lifelong thyroid hormone
replacement due to a remnant functioning lobe,
lifelong thyroid hormone replacement always is
required after TT.15,16 Therefore, the clinical
benefit of TT in PTMC has been questioned.
The purpose of this study was to compare
lobectomy and TT as a primary operative treat-
ment for PTMC. Because mortality is extremely low
in PTMC,17 we adopted loco-regional recurrence
(LRR) as the primary end point. Because the
contralateral remnant lobe remains intact after lo-
bectomy, LRR in the contralateral remnant lobe
can be managed safely by completion thyroidec-
tomy via the previous scar.18-20 However, reopera-
tion for operation bed (thyroidectomy site) or
regional LN (central or lateral) recurrence gener-
ally is associated with a greater risk of morbidity.21
Therefore, to assess clinical risk and benefit based
on the extent of thyroidectomy, we separately
analyzed overall LRR and LRR outside of the
contralateral remnant lobe. Because different
pathologic variants of PTC have different behav-
iors and prognoses,22 we included only conven-
tional PTMC.
PATIENTS AND METHODS
Patient selection. We conducted a retrospective
cohort study at a single institution. Between
January 1997 and June 2015, 20,030 patients
underwent thyroidectomy with or without neck
dissection at the Thyroid Cancer Center of
Samsung Medical Center, a tertiary referral center
in Korea. A total of 11,354 patients with the following
conditions were excluded: a history of previous
thyroidectomy, age <18 years, non-PTC carcinoma
(follicular/medullary/anaplastic), mixed-type PTC,
pathologic variants other than conventional PTC,
Surgery
j 2016
tumor size >1 cm, sub-/near-TT cases, presence of
distant metastasis at the time of diagnosis, or a
follow-up duration of <6 months (residual tumor
or suspicious LN detected within 6 months after
initial operations, reoperation within 6 months after
initial operation, or loss to follow-up within
6 months).
Because there was no patient with gross ETE or
lateral LN metastasis in the lobectomy group, we
excluded TT group patients with gross ETE and
lateral LN metastasis to reduce potential selection
bias. Finally, a total of 8,676 pathologically proven
conventional PTMC patients were included in the
analyses.
Surgical methods. In our institution, lobectomy
or TT is the standard operative option for the
treatment of PTMC patients; sub-total/near-TT is
rarely performed. TT was performed according to
published guidelines.3,4 Therapeutic central neck
dissection was performed when suspicious central
LN metastasis was detected during preoperative
or intraoperative examination. Prophylactic cen-
tral neck dissection was performed on clinically
node-negative PTMC patients with gross ETE3,4
or according to the surgeons personal preference
at the time of operation. At our institution, we only
performed therapeutic lateral neck dissection
when lateral LN metastasis was demonstrated on
fine needle aspiration biopsy. Lateral neck dissec-
tion, which included modified radical neck dissec-
tion and selective neck dissection, was performed
as previously described in the literature.23 Open
(conventional low collar approach) or oncoplastic
(endoscopic or robotic) thyroidectomy was chosen
based on patient preference after a thorough dis-
cussion of the pros and cons of each approach.
Histopathologic examination of operative spec-
imens. Operative specimens were microscopically
examined by $2 experienced pathologists, and the
following histopathologic factors were assessed:
cell type of the main lesion, primary tumor size
(longest diameter of the largest lesion), multi-
focality, bilaterality, ETE (microscopic or gross),
regional LN metastasis (central or lateral), and
underlying conditions of the thyroid, such as
chronic lymphocytic thyroiditis (CLT). To distin-
guish bilaterality from multifocality, multifocality
was defined as the presence of $2 lesions of
conventional PTMC in a single lobe, regardless of
the presence of bilaterality. The staging of thyroid
cancer was determined in accordance with the
American Joint Committee on Cancer.24
Postoperative follow-up and management. After
the initial operation, all patients underwent reg-
ular follow-up at 6- to 12-month intervals with
 ARTICLE IN PRESS
Surgery Kim et al 3
Volume j, Number j

Table I. Clinicopathologic characteristics of 8,676 conventional PTMC patients according to the extent of
thyroidectomy
Total LT TT
No. (%) No. (%) No. (%) P value
Total 8,676 (100.0) 3,289 (37.9) 5,387 (62.1) NA
Sex
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
Multifocality
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
Bilaterality
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
ETE
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
CLT
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,
iodine-131 scans, and serum thyroglobulin. After
TT, levothyroxine was administered based on
weight in kilograms to suppress thyroid stimu-
lating hormone levels of <0.5 mU/L. Although
RAI ablation generally was proposed for
lished guidelines,3,4 the final decision was based
on physician or patient preference. LRR was
defined as newly detected tumor or metastatic
LN >6 months after the initial operation as
confirmed by fine needle aspiration biopsy and/
or histopathology.
 ARTICLE IN PRESS
4 Kim et al
Table II. Recurrence sites in 139 conventional
PTMC patients with LRR
LT TT
No. (%) No. (%)
Contralateral lobe 29 (58.0) 0 (0.0)
Operation bed 1 (2.0) 4 (4.5)
(thyroidectomy site)
Regional LN 10 (20.0) 18 (20.2)
(central neck)
Regional LN 10 (20.0) 67 (75.3)
(lateral neck)
LT, Lobectomy.
Statistical analysis. Statistical analyses were per-
formed using SPSS software (version 22.0; IBM
Corp, Armonk, NY). Continuous variables are
presented as mean standard deviation (SD),
and categorical variables are presented as the
number and percentage of cases; v2 test and
linear-by-linear association were used for categori-
cal variables, and the Student t test for continuous
variables. The Kaplan-Meier method was adopted
to analyze time-dependent variables. The adjusted
hazard ratio (HR) and 95% confidence interval
(CI) for LRR were calculated using Cox regression
models. To verify the prognostic impact of RAI
ablation on TT, additional subgroup analysis was
performed.
RESULTS
Clinicopathologic characteristics of 8,676 con-
ventional PTMC patients according to the extent
of thyroidectomy. Of the 8,676 conventional
PTMC patients, 3,289 (37.9%) underwent lobec-
tomy and 5,387 (62.1%) underwent TT (Table I).
Age >45 years (P < .001), central neck dissection
(P < .001), tumor size >0.5 cm (P < .001), multifo-
cality (P < .001), microscopic ETE (P < .001), CLT
(P < .001), and central LN metastasis (P < .001)
were significantly more frequent in the TT group
than the lobectomy group. However, male sex
(P < .001) and oncoplastic thyroidectomy
(P < .001) were significantly less frequent in the
TT group than the lobectomy group. BRAF positiv-
ity was not significantly associated with the extent
of thyroidectomy (P = .188).
Prognostic impact of the extent of thyroidec-
tomy on LRR in 8,676 conventional PTMC pa-
tients. The mean follow-up time was 64.6 months
(range, 6.0230.9 months). Because cause-specific
death was only noted in 9 (0.1%) of the 8,676
conventional PTMC patients, survival analysis was
not performed. As shown in Table II, overall LRR
was observed in 139 patients (1.6%): 50 (1.6%)
Surgery
j 2016
in the lobectomy group and 89 (1.7%) in the TT
group. LRR outside of the contralateral remnant
lobe in the lobectomy group was observed in 21
patients (0.6%).
Recurrence sites in the lobectomy group
included the contralateral remnant lobe in 29
patients (58.0%), regional LN (central or lateral)
in 20 patients (40.0%), and the operation bed
(thyroidectomy site) in 1 patient (2.0%). Recur-
rent sites in the TT group included regional LN
(central or lateral) in 85 patients (95. 5%) and the
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
5 years, 91.8% at 10 years, and 90.6% at 15 years,
while recurrence-free survival in the TT group was
98.5% at 5 years, 97.5% at 10 years, and 97.0% at
15 years (Fig, A).
With regard to LRR outside of the contralateral
remnant lobe, recurrence-free survival in the
lobectomy group was 99.2% at 5 years, 96.7% at
10 years, and 95.5% at 15 years, while recurrence-
free survival in the TT group was 98.5% at 5 years,
97.5% at 10 years, and 97.0% at 15 years (Fig, B).
After adjustment for clinicopathologic characteris-
tics in the Cox proportional hazard model
(Table III), TT significantly decreased the risk of
overall LRR in conventional PTMC patients
(adjusted HR 0.398, P < .001). However, TT did
not significantly decrease the risk of LRR outside
of the contralateral remnant lobe in conventional
PTMC patients (adjusted HR 0.880, P = .640).
On further subgroup analysis (Table IV), TT did
not significantly decrease the risk of LRR outside
of the contralateral remnant lobe in patients with
BRAF mutation positivity (adjusted HR 1.038,
P = .939), tumor size >0.5 cm (adjusted HR
0.799, P = .505), microscopic ETE (adjusted HR
0.724, P = .360), or central LN metastasis (adjusted
HR .946, P = .895). In conventional PTMC patients
with multifocality, TT significantly decreased the
risk of overall LRR (adjusted HR 0.284, P = .002)
and LRR outside of the contralateral remnant
lobe (adjusted HR 0.342, P = .020).
We also verified the prognostic impact of RAI
ablation on TT. We compared conventional PTMC
patients who underwent lobectomy without RAI
ablation (n = 3,289), TT without RAI ablation
(n = 1,524), and TT with RAI ablation
(n = 3,863). Regardless of RAI ablation, TT signifi-
cantly decreased the risk of overall LRR compared
with lobectomy: TT without RAI (adjusted HR
0.228, P = .001) and TT with RAI (adjusted HR
0.443, P < .001). However, TT did not significantly
decrease the risk of LRR outside of the
 ARTICLE IN PRESS
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
Thyroidectomy
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
increment)
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
HR 0.545, P = .850) or without RAI (adjusted
HR = 0.597, P = .275).
DISCUSSION
In this study, age >45 years, open thyroidec-
tomy, central neck dissection, tumor size >0.5 cm,
multifocality, microscopic ETE, and central LN
metastasis were associated with an increased likeli-
hood of TT (Table I). This reflects the fact that TT
was preferred in patients with aggressive features.3
Because we generally performed TT in PTC pa-
tients with gross ETE, there was no patient with
gross ETE in the lobectomy group. Therefore, we
excluded all patients with gross ETE and lateral
LN metastasis from the TT group in order to
 ARTICLE IN PRESS
6 Kim et al Surgery
j 2016

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
RAI
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
frequent in patients with CLT. Pseudonodules are
occasionally difficult to distinguish from true nod-
ules in coexisting CLT, and reactive LN enlarge-
ment on ultrasonography almost is invariably
present in coexisting CLT. This might be why TT
was primarily performed in PTC patients with
CLT.25
Although guidelines recommend performing
lobectomy to treat PTMC,3,4 5,387 (62.1%) con-
ventional PTMC patients underwent TT in our
study. As shown in Table I, among 8,676 conven-
tional PTMC patients, 3,723 patients (42.9%) had
microscopic ETE and 2,325 patients (26.8%) had
central LN metastasis. Among 5,387 conventional
PTMC patients who underwent TT, 1,407 patients
(26.1%) exhibited bilaterality. The prevalence of
bilaterality, microscopic ETE, and central LN
metastasis was relatively greater than reported in
previous studies that were mainly conducted in
Western countries.17 Moreover, the incidence of
BRAF mutation positivity in the subset tested was
almost 80% and similar results were seen in previ-
ous studies conducted in Korea.26-28 Strong associ-
ations between BRAF mutation and aggressive
clinicopathologic characteristics of PTC have
been demonstrated previously,29 supporting the
existence of a geographic bias.
As shown in previous studies, the average rate of
recurrence is very low in PTMC patients.17 In our
study, LRR was observed in only 1.6% of enrolled
conventional PTMC patients (Table II). And
similar to the results of previous studies,8 most
LRR occurred in regional LN (central or lateral).
As shown in Table III, with the exception of the
extent of thyroidectomy (lobectomy or TT), inde-
pendent predictors for LRR were observed consis-
tently regardless of LRR type.
The relationship between LRR and age remains
unclear, with some studies showing higher rates in
older patients,30,31 and some in younger pa-
tients.32,33 In this study, age did not have a signifi-
cant prognostic impact on conventional PTMC.
Large tumor size,6 multifocality,8,9 ETE,34,35 and
regional LN (central or lateral) metastasis8,9,36
were independent predictors of LRR. Recurrence
was noted to be less frequent in PTC patients
with CLT rather than without CLT.37-39 However,
in our study, CLT did not significantly decrease
the risk of LRR in conventional PTMC patients.
Central neck dissection significantly decreased
the risk of LRR. Because central LN metastasis
may remain undetected in those who do not un-
dergo central neck dissection,40,41 their prognosis
may be inferior to those who undergo central
neck dissection.
As mentioned in the Introduction, LRR in the
contralateral remnant lobe after LT can be
managed safely by completion thyroidectomy,
which carries a similar operative risk to that of
primary TT.18-20 However, reoperation for opera-
tion bed (thyroidectomy site) or regional LN (cen-
tral or lateral) recurrence is associated with a
greater risk of morbidity than primary operation.21
No prior studies have selectively analyzed LRR ac-
cording to recurrence site.6-9,36 Therefore, we
 ARTICLE IN PRESS
Surgery
Volume j, Number j
analyzed overall LRR and LRR outside of the
contralateral remnant lobe separately. After adjust-
ment of the Cox proportional hazard model for
clinicopathologic characteristics (Table III), TT
significantly decreased the risk of overall LRR
(adjusted HR 0.398, P < .001). However, TT did
not significantly decrease the risk of LRR outside
of the contralateral remnant lobe (adjusted HR
0.880, P = .640).
Furthermore, as shown in Table IV, TT did not
significantly decrease the risk of LRR outside of
the contralateral remnant lobe, even in patients
with BRAF mutation positivity (adjusted HR
1.038, P = .939), tumor size >0.5 cm (adjusted
HR 0.799, P = .505), microscopic ETE (adjusted
HR 0.724, P = .360), and central LN metastasis
(adjusted HR 0.946, P = .895). However, in conven-
tional PTMC patients with multifocality, TT signifi-
cantly decreased the risk of overall LRR (adjusted
HR 0.284, P = .002) and LRR outside of the contra-
lateral remnant lobe (adjusted HR 0.342, P = .020).
And, TT significantly decreased the risk of overall
LRR regardless of whether RAI ablation was per-
formed. However, the significance of this relation-
ship disappeared when only LRR outside of the
contralateral remnant lobe was considered. There-
fore, this finding suggests that TT reduces the risk
of overall LRR via the removal of the contralateral
remnant lobe; however, RAI ablation after TT does
not reduce the risk of LRR outside of the contralat-
eral remnant lobe.
This finding is consistent with the results of
other studies, which suggested that RAI ablation
did not decrease the risk of recurrence in PTMC
patients.8-10 Moreover, the incidence of morbidity
is clearly and consistently proportional to the
extent of thyroidectomy, even among high-
volume surgeons.42 In addition, TT patients always
require lifelong hormone replacement.15,16 In
PTC patients, TT has several advantages including
facilitating iodine-131 scan, RAI ablation, and the
use of thyroglobulin as a tumor marker. However,
the clinical benefit of TT as a primary operative
treatment option is not evident in PTMC patients,
except in those with multifocality.
Our study has several limitations. First, this
study is a nonrandomized retrospective cohort
study. Therefore, the patient information in our
data might be incomplete, and we cannot rule out
the possibility of residual confounding variables.
Second, because there has been no universal
consensus regarding the operative extent required
to treat PTMC,2 decision-making regarding the
extent of thyroidectomy could have resulted in
additional selection bias in our study. Third, RAI
Kim et al 7
ablation generally is recommended for tumors
with aggressive features,3,4 but the final decision
was made based on physician or patient prefer-
ence. Therefore, there was a possible selection
bias with regard to whether RAI therapy was per-
formed or not. Fourth, in the preoperative period,
imaging modalities and the radiologist might miss
the malignancies in the contralateral remnant
lobe. Fifth, LRR may be detected more readily in
patients who undergo TT due to the availability
of follow-up modalities including whole body
scan and the use of thyroglobulin marker. Finally,
our results may not be applicable to patients
from other ethnicities or countries because of
the high prevalence of the BRAF mutation in our
population (82.9%), which can be explained by
geographic bias.26,27
However, this study also had several strengths.
First, this study was based on a large group of
conventional PTMC patients (8,676 cases) with a
relatively long-term follow-up period (maximum,
230.9 months). Second, we used data from a single
institution, and rigorous exclusion/inclusion criteria
for clear and accurate analysis.
In conclusion, although lobectomy is associated
with contralateral remnant lobe recurrence, lobec-
tomy did not increase the risk of LRR outside of
the contralateral remnant lobe in PTMC patients,
except in those with multifocality. Because recur-
rence in the contralateral remnant lobe can be
safely managed by completion thyroidectomy, lo-
bectomy may be a safe operative option for select
PTMC patients without multifocality.
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