What is the recommended surgical approach, partial thyroidectomy versus total thyroidectomy, and the need for radioactive iodine (RAI) therapy in a 25-year-old male with a single 10x8 mm right bilobed nodule, classified as TIRAD (Thyroid Imaging Reporting and Data System) 4, with no enlarged lymph nodes (LN), and a fine-needle aspiration (FNA) diagnosis of papillary thyroid cancer?

From the Guidelines

For a 25-year-old man with a 10x8 mm papillary thyroid cancer in the right lobe (TIRADS 4), I recommend a total thyroidectomy followed by radioactive iodine (RAI) therapy. While partial thyroidectomy (lobectomy) might be considered for very small, low-risk tumors, several factors favor a more aggressive approach in this case. The patient's young age increases his lifetime risk of recurrence, and total thyroidectomy allows for better surveillance using thyroglobulin as a tumor marker. Additionally, total thyroidectomy facilitates effective RAI treatment, which is beneficial for ablating any microscopic disease and treating potential metastases. RAI therapy is particularly important in younger patients with papillary thyroid cancer as it reduces long-term recurrence rates and improves survival in those with higher risk features. The treatment would typically involve a total thyroidectomy followed by thyroid hormone withdrawal or rhTSH stimulation before administering a standard dose of I-131 (typically 30-100 mCi depending on risk stratification) 1. Post-treatment, the patient will require lifelong thyroid hormone replacement therapy with regular monitoring of thyroid function, thyroglobulin levels, and periodic neck ultrasounds to detect any recurrence. Some key points to consider in the management of this patient include:

• The role of molecular testing in the diagnosis and management of thyroid cancer 1
• The importance of preoperative and postoperative evaluation of vocal cord mobility 1
• The use of CT/MRI with contrast for fixed, bulky, or substernal lesions 1
• The consideration of thyroglobulin measurement and levothyroxine therapy to keep TSH low or normal 1
• The potential benefits and risks of prophylactic central neck dissection 1
• The use of active surveillance as a management strategy for low-risk papillary microcarcinoma 1

From the Research

Treatment Options for Papillary Thyroid Cancer

• The patient has a single right bilobe nodule, 10*8 mm, with a TI-RAD score of 4, and no enlarged lymph nodes, and fine-needle aspiration (FNA) revealed papillary thyroid cancer 2.
• The treatment options for papillary thyroid cancer include partial thyroidectomy (lobectomy) and total thyroidectomy, with or without radioactive iodine therapy.

Surgical Treatment

• Total or near-total thyroidectomy is recommended as the initial procedure of choice for papillary thyroid cancer, as it allows for the treatment of potential multicentric disease, facilitates maximal uptake of adjuvant radioactive iodine, and enables post-treatment follow-up by monitoring serum thyroglobulin (Tg) levels 2.
• A study of 2108 patients with thyroid cancer found that the overall metastasis rate was 57.23%, and that lymph node metastasis was as high as 48.97% in patients with papillary thyroid microcarcinoma (PTMC) 3.
• The same study recommended that initial treatment should comprise at least total thyroidectomy + central lymph node dissection to avoid the risks associated with secondary surgery and effects on patient quality of life 3.

Radioactive Iodine Therapy

• Radioactive iodine therapy is considered effective for patients with total or nearly total thyroidectomy, but its beneficial effects are still controversial 2, 4.
• A study of 909 patients with N1 stage papillary thyroid cancer found that delayed radioactive iodine therapy (beyond 88 days after total thyroidectomy) was associated with an increased risk of disease persistence/recurrence 5.
• Another study of 1286 patients with low- to intermediate-risk papillary thyroid carcinoma found that postoperative radioactive iodine therapy did not substantially influence recurrence or survival rates in most patients, but may be beneficial in specific subgroups, such as patients over 55 with pN1b disease or those presenting with five or more metastatic lymph nodes 6.

Recommendations

• Based on the patient's age (25 years) and tumor size (10*8 mm), total thyroidectomy may be recommended as the initial surgical treatment, with or without radioactive iodine therapy 2, 3.
• The decision to use radioactive iodine therapy should be based on individual patient characteristics, such as the presence of lymph node metastases, tumor size, and patient age 5, 4, 6.