Should a total or partial thyroidectomy be performed for a 10x8 mm papillary thyroid cancer nodule?

From the Guidelines

For a small (10x8 mm) papillary thyroid cancer classified as TIRAD 4 nodule, active surveillance is recommended as the initial management approach, rather than immediate surgery, as it is safer and less costly, and helps in avoiding adverse events of surgery, as supported by recent studies 1. This approach is based on the fact that papillary thyroid microcarcinomas (PMCs) are defined as papillary thyroid carcinoma ≤10 mm, and active surveillance of PMC without high-risk features has been shown to be effective in managing low-risk PMCs, with most PMCs growing very slowly or not growing, and none of the patients showing distant metastasis or dying of thyroid carcinoma 1. The key factors to consider in this approach are:

• The size of the tumor, which is 10x8 mm, making it a papillary microcarcinoma
• The absence of high-risk features, such as clinical node metastasis, distant metastasis, and clinical evidence of significant extrathyroid extension
• The patient's age, overall health status, family history, and patient preference, which should be discussed with the surgeon and endocrinologist to determine the best course of action As stated in the ESMO clinical practice guidelines for diagnosis, treatment, and follow-up of thyroid cancer, active US surveillance of the thyroid and neck lymph nodes (every 6–12 months) can be proposed for unifocal papillary microcarcinomas (10 mm) with no evidence of extracapsular extension or lymph node metastases 1. It is essential to note that the decision between active surveillance and surgery should be individualized based on specific patient factors, and regular monitoring with ultrasound and thyroid function tests should be expected if active surveillance is chosen.

From the Research

Surgical Approach for Papillary Thyroid Cancer

• The decision to perform a total or partial thyroidectomy for a small tirad 4 nodule 10x8 mm papillary thyroid cancer depends on various factors, including the size of the tumor, presence of lymph node metastasis, and patient's overall health 2, 3.
• A study published in the World Journal of Surgery in 2016 found that thyroid lobectomy is an effective surgical strategy to manage papillary microcarcinomas with low complications, and routine completion thyroidectomy is not mandatory 2.
• However, another study published in Cancer Medicine in 2021 recommended that initial treatment should comprise at least total thyroidectomy + central lymph node dissection, particularly among patients with risk factors for poor prognosis 4.

Considerations for Surgical Approach

• The size of the tumor is an important factor in determining the surgical approach, with larger tumors having a higher risk of lymph node metastasis 4.
• The presence of lymph node metastasis is also a significant factor, with studies showing that the rate of neck lymph node metastasis is high, particularly among patients with risk factors for poor prognosis 4.
• Patient selection is crucial, with appropriate selection excluding high-risk patients being of paramount importance in order to achieve the best results 2.

Alternative Management Options

• Active surveillance has emerged as an alternative to operative management for low-risk papillary thyroid microcarcinoma without lymph node involvement or distant metastasis 5.
• However, the decision to pursue active surveillance should be made on a case-by-case basis, taking into account the individual patient's risk factors and overall health 5.

Diagnostic Techniques

• Innovative technologies, such as contrast-enhanced ultrasonography, frozen section, and molecular detection, have brought great progress to the diagnosis of small and indeterminate lymph nodes 6.
• The implementation of these diagnostic techniques can help identify patients who are at higher risk of disease progression and metastasis, and guide the surgical approach accordingly 6.