10.14639/0392-100X-N2247
text/xml
1827-675X
2247
en
Luca Giovanni Locatello
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
hemithyroidectomy
Total or partial thyroidectomy for low-risk differentiated thyroid cancer: that is the question!
Text.Serial.Journal
https://www.actaitalica.it/
42
Letters to the Editor-in-Chief
2022-11-23
2022-07-26
2022-12-13
2022-12-13
487-489
1
Luca Giovanni Locatello
2022/11/23
10.14639/0392-100X-N2247
487
Department of Otorhinolaryngology, Sant’Antonio Abate Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Tolmezzo, Italy
1827-675X
hemithyroidectomy
en
489
Total or partial thyroidectomy for low-risk differentiated thyroid cancer: that is the question!
https://www.actaitalica.it/article/download/2247/875
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42:487-489; doi: 10.14639/0392-100X-N2247




Letter to the Editor


Total or partial thyroidectomy for low-risk
differentiated thyroid cancer: that is the question!
Tiroidectomia totale versus emitiroidectomia nel carcinoma differenziato della tiroide
a basso rischio: questo è il problema!
Maria Gabriella Rugiu1, Cesare Miani2, Luca Giovanni Locatello1
1
    Department of Otorhinolaryngology, Sant’Antonio Abate Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Tolmezzo, Italy;
2
    Department of Otorhinolaryngology, Santa Maria della Misericordia Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy


KEY WORDS: thyroid nodule, thyroid cancer, total thyroidectomy, loboisthmectomy,
hemithyroidectomy
PAROLE CHIAVE: nodulo tiroideo, tumori della tiroide, tiroidectomia totale,
loboistmectomia, emitiroidectomia


Dear Editor,
We greatly appreciated the critical comparison between the 2015 American
Thyroid Association Guidelines (ATA-GL) and the 2018 joint Italian Consen-
sus (IC) on medical and surgical management of thyroid nodules, which Ar-
rigoni and colleagues have recently published in this Journal 1. The Authors
give a bird’s eye view of the current evidence-based recommendations for a
commonly encountered condition, yet we believe that some points of their
analysis need further insight.
For instance, a practical dilemma that every thyroid/head and neck surgeon
has to face in their clinical practice is the choice between total thyroidectomy                Received: July 26, 2022
(TT) versus loboisthmectomy (LI) for low-risk differentiated thyroid cancer                     Accepted: September 9, 2022
(DTC) 2,3. The incidence of DTC has strikingly increased in the last decades
                                                                                                Correspondence
(about 2-3 fold in the United States and in Europe, but nearly 10-fold higher in                Maria Gabriella Rugiu
South Korea), which is mainly attributed to overdiagnosis. In addition, almost                  Department of Otorhinolaryngology, Sant’Antonio
70% of these tumors have a maximum diameter of less than 2 cm (cT1, accord-                     Abate Hospital, Azienda Sanitaria Universitaria
                                                                                                Friuli Centrale, via GB Morgagni 18, 33028 Tol-
ing to the VIII Edition of the TNM staging system), and with no suspicious                      mezzo (UD), Italy
lymph nodes at neck ultrasound, i.e. with a low risk of nodal or distant metas-                 E-mail: maryolyna@icloud.com
tases and with a near-zero cancer-specific mortality 4. The LI procedure ob-
viously grants lower treatment-related risks (permanent hypoparathyroidism,                       How to cite this article: Rugiu MG, Miani
laryngeal nerve injury, or lifelong thyroid hormone supplementation), and it                      C, Locatello LG. Total or partial thyroidec-
                                                                                                  tomy for low-risk differentiated thyroid can-
has inferior operative time and costs. However, such a procedure is recom-                        cer: that is the question! Acta Otorhinolaryn-
mended only for cT1aN0 DTC, a situation that should represent a rare occur-                       gol     Ital    2022;42:487-489.    https://doi.
rence since the ATA-GL recommend against fine-needle aspiration of nodules                        org/10.14639/0392-100X-N2247
< 1 cm, whatever the radiological pattern identified 2.
                                                                                                © Società Italiana di Otorinolaringoiatria
The problem arises for cN0 DTC of 1-4 cm (sometimes referred to as “mac-                        e Chirurgia Cervico-Facciale
ro-carcinomas”) and without gross extrathyroidal extension: in such cases,
patients must incur into a second-stage completion surgery in case of ad-                                      OPEN ACCESS
verse pathological features (aggressive variants, vascular invasion, presence                   This is an open access article distributed in accordance with
                                                                                                the CC-BY-NC-ND (Creative Commons Attribution-Non-
of genetic mutations, etc.) 2,3. Both ATA-GL and IC consider TT to be a                         Commercial-NoDerivatives 4.0 International) license. The
reasonable choice in older patients (> 45 years), contralateral nodules, com-                   article can be used by giving appropriate credit and mentio-
                                                                                                ning the license, but only for non-commercial purposes and
pressive symptoms, personal history of radiation therapy to the neck, and                       only in the original version. For further information: https://
familial DTC 2,3. A recent retrospective large single-center series has con-                    creativecommons.org/licenses/by-nc-nd/4.0/deed.en




                                                                                                                                                        487
M.G. Rugiu et al.




firmed this dichotomy: LI yielded an event-free survival
of 87.5% versus 95% for the TT group, but, despite an
adequate mean follow-up time of 79.9 months, this dif-
ference was non-significant (p = 0.067) 5. However, only
about 15% of the low-risk compared to 50% of the in-
termediate-risk microcarcinomas treated by LI ultimately
needed additional treatments, such as further surgery or
radiometabolic therapy 5.
In this regard, the recently published ESTIMABL2 trial has
just strengthened the evidence for avoiding postoperative
radioiodine (with its costs and side effects such as lacri-
mal discomfort) in low-risk DTC cases. This prospective
                                                                      Acronyms: RLN: recurrent laryngeal nerve; TT: total thyroidectomy. Picture is repro-
multicenter French study involved 730 patients receiving              duced under the Creative Commons Attribution-Share Alike 3.0 Unported license,
TT and its main endpoint was occurrence of any functional             and can be found at shorturl.at/bgmoU.
(e.g., foci of uptake), structural (nodules detected by ul-
trasound), or biologic (increase in thyroglobulin) events 6.      Figure 1. Practical issues to be evaluated when selecting the ideal operative
                                                                  approach for low-risk differentiated thyroid cancer.
Over 95% of patients were event-free after three years of
follow-up and without any significant difference between
those receiving post-operative radioiodine and those who          In conclusion, the Authors are to be praised for their ef-
were simply followed-up. Notably, less than 50% of pa-            forts to synthesise two of the currently available guidelines
tients had multifocal nodules, while T1a cases constituted        on thyroid nodules and thyroid cancer. We still have many
around 20% of the cohort.                                         difficulties in the identification of the perfect candidate for
Another understudied issue, and which is often overlooked         LI or for an active surveillance strategy, nor have we fully
by guidelines, is a clear definition of what are the “patients’   appreciated the role of the patient and their caregivers in
preferences” regarding the extent of surgery. For example,        the decision-making process. However, it looks obvious
in a recent well-designed study where the benefit-risk trade-     that without strong expertise in surgery, ultrasonography,
offs of TT versus LI were weighted against each other, the        and cytopathology (i.e., managing these patients in high-
risk of cancer recurrence impacted participants’ preference       volume referral centers), the Hamletic doubt between TT
the most, while TT was the preferred option unless the            and LI does not even arise. The Authors’ suggestion to draft
chance of needing completion surgery following LI is 30%          a future position paper on the subject from the Italian So-
or less 7. The latter procedure has the same complication         ciety of Otorhinolaryngology Head and Neck Surgery is
rates of TT in experienced hands and, when thorough pre-          therefore warmly welcome, and we are confident such a
operative evaluation is conducted, it is required only in less    project will be successful as long as we keep a holistic and
than 10% of cases 8. Another factor strongly influencing          evidence-based view on DTC management (Fig. 1).
this decision is the term (“cancer” versus “tumour” versus
“nodule”) used by the head and neck surgeon. For papillary        Conflict of interest statement
microcarcinomas (< 1 cm), we now have sound evidence              The authors declare no conflict of interest.
supporting not only LI but also an active surveillance strat-
egy approach 9. Knowing that only around 5.3% of these            Funding
tumors increase in size by around 3 mm after 5 years of           This research did not receive any specific grant from fund-
follow-up, that only 1.6% of patients develop nodal me-           ing agencies in the public, commercial, or not-for-profit
tastases, and that foci of DTC are incidentally found in          sectors.
11.2% (CI 6.7-16.1%) of autopsies, should not we change
our mind when we deal with DTC patients? Furthermore,             Author contributions
some subcategories of DTC such as the recently charac-            MGR and CM discussed the paper, LGL wrote the paper.
terised noninvasive follicular thyroid neoplasm with papil-
lary-like nuclear (NIFTP) features do not even deserve the
words “cancer” or “malignancy”. Unfortunately, accurate
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