From the Guidelines
Lobectomy of the thyroid is indicated for selected low-risk tumors, such as those that are T1a-T1b-T2, N0, and have no evidence of extracapsular extension or lymph node metastases, as proposed by the ESMO clinical practice guidelines for diagnosis, treatment, and follow-up of thyroid cancer 1. The primary indications for a lobectomy of the thyroid include:
- Suspicious or indeterminate thyroid nodules confined to one lobe
- Known thyroid cancer less than 4 cm without evidence of extrathyroidal extension or lymph node involvement
- Follicular neoplasms
- Symptomatic unilateral goiters causing compression symptoms
- Toxic adenomas causing hyperthyroidism
- Diagnostic procedure when fine needle aspiration results are inconclusive
- Patients with a family history of thyroid cancer and radiation exposure to the neck area may also be candidates The procedure involves removing half of the thyroid gland while preserving the contralateral lobe, which typically maintains sufficient thyroid function without requiring lifelong hormone replacement therapy. However, approximately 20-30% of patients may still develop hypothyroidism after lobectomy, necessitating thyroid hormone supplementation. Post-operative monitoring of thyroid function is essential, with TSH levels checked 6-8 weeks after surgery and periodically thereafter, as recommended by the NCCN guidelines for thyroid carcinoma 1. It is also important to consider molecular diagnostics, which can help determine the risk of malignancy and guide treatment decisions, such as active surveillance or lobectomy, as suggested by the NCCN guidelines insights: thyroid carcinoma, version 2.2018 1. In general, the approach to thyroid lobectomy should balance the need to address the pathology while minimizing surgical risks and preserving thyroid function when possible.
From the Research
Indications for Lobectomy of the Thyroid
The indications for a lobectomy of the thyroid include:
- Indeterminate thyroid nodules (Bethesda 3 and 4) 2
- High-risk thyroid nodules (Bethesda 5 and 6) 2
- Atypia or a follicular lesion of undetermined significance, suspicious for follicular or Hürthle cell neoplasm 3
- Suspicious for malignancy or malignant thyroid nodules 2, 4
Considerations for Lobectomy
When considering a lobectomy, the following factors should be taken into account:
- The risk of hypothyroidism after lobectomy, which can be as high as 47% in some patient populations 3
- The risk of needing a completion thyroidectomy, which can be as high as 19.4% for indeterminate nodules and 26.5% for high-risk nodules 2
- The presence of multifocal disease, which can increase the risk of malignancy in the opposite lobe 5
- The size of the tumor, with larger tumors (>4cm) increasing the risk of malignancy in the opposite lobe 5
Postoperative Care
After a lobectomy, patients may require:
- Ongoing surveillance and intervention, including thyroid hormone replacement therapy and ultrasound surveillance 6
- Completion thyroidectomy if malignancy is found in the final pathology 2, 5
- Long-term follow-up with physical examination, whole body iodine scans, and thyroglobulin measurements to monitor for recurrence 4