There has been a constant debate about whether to do a total thyroidectomy or a lobectomy for "mini" papillary carcinomas.
I cant understand the iea of minimallizing of radicality for a thyroid tissue and so strong higher agggresivity for lymf nodes system. I do the lobectomy for a WDTC and low risk population if they are in one lobe only.
If we recommand some neck dissection for a small lypmph node metastase we prefer the central neck dissection ref. IV , if the another lymph node are positive we do the selective neck dissection on the site of positive lymph nodes. No elective neck dissection fro WDTC.
This debate is going on and on across institutions and even accros the atlantic ocean. I believe both options are equally effective. Doing a lobectomy is a smaller and safer operation with fewer complications that will be sufficient for the majority of patients. Also, you can always go back to do a completion thyroidectomy if things go wrong.
On the other hand, total thyroidectomy eliminates the problem with a higher complication rate.
The answer is not a straight forward one. It requires consideration of other parameters as well.
Imagine a patient that is not well educated, lives alone in a village, far away from regular medical care. Imagine another one who is not very cooperative with follow ups. For these patients, a total thyroidectomy would seem a better choice.
On the other hand, imagine a patient who is young and works as a lawyer or teacher. For him, I would prefer to not risk his voice and to have him at a close follow up.
Imagine a female patient at the age of 75 with comorbidities. For her, a lobectomy seems a more reasonable choice.
Personally, in my practice, people are not very cooperative with follow ups. I prefer to do a total thyroidectomy for most of my patients. If, on the other hand, I have a VERY cooperative patient, I offer a lobectomy instead.
It depends on the patient's risk. If there is a positive family history of DTC or there is a history of radiation exposure it is better to do total thyroidectomy. we have to know if the patient needs iodine therapy, diagnostic whole body iodine scan, thyroglobulin assessment during follow up and ... it is necessary for thyroid gland to be completely removed.
Check this video on youtube: http://www.youtube.com/watch?v=Xxe7f5OruF0
as NK Ayati said: it depends on patient' risk and also on specific tumor features such as histology and type of PTC ( classic, follicular variant or tall cell variant) as perhaps on Ki-67 (only little data) but also on localisation of the tumor ( capsule or inside the thyroid) and procedures may lead to different numbers of locoregional recurrence but not on different long term survival. This is very good, independent on the surgical procedure. Answers like: "I do it.." are of little help as the guidelines are of little help, since they differ, depending on the group and country, they are coming from. Since we still lack prospective randomized trials and long term results from such trial the answers between hemithyroidectomy up to thyroidectomy plus cetral lymph node dissection will come and have to be weighed between surgical risk and freedom from recurrence - still influenced by experience, individual prevalence and prejudice. Sorry, but this is all we have of realy sound data.
I agree with idea of Mr Goretzki. I agree with trail, but the trail must be going under protocol with clear rules for indication. ¨
This debate is very long and the history of this controversy is going last 25 years in more papers, books and meetings. The dbate is about
public health
presonalised medicine
type of health and care system
acces of patients to helath system
compliance of patients
education of patients,
local history ( Cherobyl area, Fukusima area and other)
I personally think that the decision of doing a lobectomy or total thyroidectomy depends on many factors. Just to share with you is that in our institution recently, we encountered 2 patients with micropapillary who had undergone total thyroidectomy; and subsequently underwent ablative RAI. And, the findings of whole body scan showed diffuse lung uptake suggestive of micrometastases to lungs. Probably, these may be exceptional cases. I personally think that the cut-off of 1mm size is very ambiguous. And, the clinician's perception of salvageable surgery on subsequent finding of lymph node recurrence is not a right thing to do as well. Sorry for not providing the conclusive answer. But, involvement of patient in decision making by looking at socioeconomic background (such as patient's perception of the disease and subsequent follow up or patient's accessibility to health care system) and other human factor apart from clinical evidence may be the right thing to do in current clinical practice.
In pediatric patients is still discussed. personally I approach each patient individually.
Many factors in deciding on the surgical procedure. I have a child patients (PTC mini), where I performed lobectomy, and "same" case where i did total thyroidectomy.
One size fits all-- is not applicable for PTC. 1cm, in a low risk, unicentric >>lobectomy should suffice. Let the punishment fit the crime !!
According to our experience especially if the patient is over 40 then you see other focuses on the other lobe. So we suggest to perform total thyroidectomy for all type of carcinomas.
I think the recommended treatment is total thyroidectomy. It facilitates the postoperative follow-up.
so i would like give my clear answer. I dont suggest less radical approaches. A more authors disscesed about thrue argument here. The radical surgery for PTC associate with good control of disease ( we can use thyreoglobulin like a marker after radical surgery only, the effect of radioiodine therapy asscociate with radical surgery as well). The dichotic philosophy of more authors there advocate the hemithyreoidectomy on secon hand this same athors advocate for elective neck dissections.
I think that the trail is necessary for the evidence about the pure argumantation in this discusion.
Papillary thyroid cancer -except some variant types- is eventually a "good" tumor. I agree with total thyroidectomy choice in multifocal cases or those cases with apparent metastatic disease or having a focus larger than 1 cm, but in response to above question I would do and suggest only a total lobectomy for the involved side.
If the tumor is encapsulated, a lobectomy will suffice. Older age does not confer a worse outcome. There is little evidence that "microcarcinomas" require anything more. There are several authors questioning the risk benefit ratio of postoperative radioactive iodine use. Therefore, simply performing a total thyroidectomy to allow use of radioactive iodine is not necessarily valid. Keep in mind that taking levothyroxine every day for the rest of your life is not so simple and is associated with osteoporosis in older women. The total thyroidectomy is associated with an increased chance of hypocalcemia and vocal disturbance. Professor Ito from Japan is NOT even operating many of his 1 cm biopsy proven papillary cancers.
I prefer to perform a total thyroidectomy for the high rate of controlateral multifocality.
Lobectomy makes harder follow up and useless TG monitoring.
I prefer to perform total thyroidecytomy and consider lobectomy only in selected patients with poor risk factors
The new ATA guidelines will come out to support lobectomy only for some patients with thyroid cancer measuring up to 4 cm in size
"For patients with thyroid cancer >1 cm and
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