April 25, 2023

The standard of care for treatment of well-differentiated thyroid cancer has traditionally been total thyroidectomy. This strategy has been the standard of care for decades for several reasons — it allows for thyroglobulin to be used as a tumor marker for recurrence and clears the central compartment for surveillance with ultrasound.

In the last decade, well-differentiated thyroid cancers between 1 cm and 4 cm have been increasingly managed with hemithyroidectomy. In 2015, the American Thyroid Association issued a statement in support of this approach in appropriately selected patients. The advantages include lower operative morbidity, decreased reliance on thyroid replacement hormone and lower rates of hypoparathyroidism.

In a retrospective review of Mayo Clinic patients with papillary thyroid cancer of >1 cm ≤ 4 cm treated with partial thyroidectomy — either lobectomy or isthmusectomy — only five patients (6%) proceeded to completion thyroidectomy within the first postoperative year. Forty-three patients (60%) had new requirements for thyroid hormone supplementation postoperatively. No patient in this cohort required additional surgery or treatment for newly discovered nodal metastases. This was in part due to the practice of obtaining a comprehensive neck ultrasound with lymph node mapping in all patients undergoing planned thyroid surgery at Mayo Clinic. Study findings were published in a 2021 issue of The American Surgeon.

"It is a good option for our patients when they have smaller cancers," says Melanie L. Lyden, M.D., chair of Endocrine and Metabolic Surgery at Mayo Clinic in Rochester, Minnesota. "Those with bulky central lymph nodes, compressive symptoms or worrisome features should be offered a total thyroidectomy as these factors will not be adequately addressed with a hemithyroidectomy. After hemithyroidectomy, thyroglobulin trends can be monitored over time, and ultrasound still proves to be useful for monitoring."

Juan P. Brito Campana, M.B.B.S., an endocrinologist at Mayo Clinic in Rochester, Minnesota, adds: "Guidelines advocating for hemithyroidectomy as a viable option for treating some thyroid cancers have led to the necessity for shared decision-making discussions that consider the patient's unique situation and needs.

"Patients with similar tumor characteristics may choose different treatments based on their individual values and context. For example, some patients may opt for hemithyroidectomy to preserve thyroid function, while others may choose total thyroidectomy due to anxiety about monitoring and surveillance of thyroid nodules located in the opposite lobe of the thyroid."

Dr. Lyden concludes: "Patient selection is of utmost importance in choosing which option is appropriate for patients. We hope that by tailoring surgery and de-escalating care where possible, we can address the disease and maintain the best quality of life possible for the patient."

For more information

Merten MM, et al. Favorable early outcomes with thyroid lobectomy for low-risk papillary thyroid cancer: The Mayo Clinic experience. The American Surgeon. 2021;87:1374.

Refer a patient to Mayo Clinic.