International Journal of Surgery 41 (2017) S34eS39

Contents lists available at ScienceDirect

International Journal of Surgery

journal homepage: www.journal-surgery.net

Original Research

Partial thyroidectomy for papillary thyroid microcarcinoma: Is

completion total thyroidectomy indicated?
C. Dobrinja a, *, M. Pastoricchio a, M. Troian a, F. Da Canal a, S. Bernardi b, B. Fabris b,
N. de Manzini a
a
Division of General Surgery, Department of Medical, Surgical and Health Sciences, Cattinara Teaching Hospital, Strada di Fiume, 34149, Trieste, Italy
b
SS Endocrinologia (UCO Medicina Clinica), Azienda Ospedaliero-Universitaria di Trieste, Department of Medical, Surgical and Health Sciences, Cattinara
Teaching Hospital, Strada di Fiume, 34149, Trieste, Italy

h i g h l i g h t s

The best surgical approach for PTMC is still object of debate.

Hemithyroidectomy may be adequate for low-risk patients, with no need for routine completion thyroidectomy.

Total thyroidectomy or completion thyroidectomy is rather indicated in selected patients with risk factors for mortality and recurrence.

Accurate patient selection is important to achieve the best results.

a r t i c l e i n f o a b s t r a c t

Article history:
Aim: Papillary thyroid microcarcinoma (PTMC) is increasing in incidence. Despite its excellent clinical
Received 23 December 2016
outcomes, there is still debate regarding which surgical approach is more appropriate for PTMC, pro-
Received in revised form
4 February 2017 cedures including hemithyroidectomy (HT), total thyroidectomy (TT), and completion thyroidectomy
Accepted 8 February 2017 (CT) after initial HT and histopathologic examination confirming a PTMC. Here we report our experience
in the surgical management of PTMC.
Methods: We conducted a retrospective evaluation of all patients who received a postoperative diagnosis
Keywords: of PTMC between January 2001 and January 2016. Every patient was divided according to the type of
Papillary thyroid microcarcinoma surgery performed (TT or HT alone). Follow-up consisted of regular clinical and neck ultrasonographic
Surgical management examination. Clinical and histopathological parameters (e.g. age, sex, lesion size, histological features,
Hemithyroidectomy multifocality, lymph node metastases, BRAF status when available) as well as clinical outcomes (e.g.
Total thyroidectomy complications rates, recurrence, overall survival) were analyzed.
Completion thyroidectomy Results: Group A consisted of 86 patients who underwent TT, whereas Group encompassed 19 patients
Risk stratification
who underwent HT. Mean follow-up period was 58.5 months. In Group A, one patient (1.2%) experienced
recurrence in cervical lymph nodes with need for reoperation. In Group B, eight patients (42%) under-
went completion thyroidectomy after histopathological examination confirming PTMC, while one patient
(5.3%) developed PTMC in the contralateral lobe with need for reoperation at 2 years after initial surgery.
Multifocality was found in 19 patients in Group A (22%). Of these, 14 presented bilobar involvement,
whereas in 3 cases multifocality involved only one lobe. 1 patient in Group B (5.3%) presented with
unilateral multifocal PTMC (p ¼ 0.11).

* Corresponding author. Division of General Surgery, Department of Medical,

Surgical and Health Sciences, Cattinara Teaching Hospital, Universita  degli Studi di
Trieste, Strada di Fiume 447, 34149, Trieste, Italy Tel.: þ390403994-
152, þ393472514845.
E-mail addresses: ch_dobrinja@yahoo.it (C. Dobrinja), manuela.pastoricchio@
gmail.com (M. Pastoricchio), marina_troian@yahoo.it (M. Troian),
francescadacanal@hotmail.it (F. Da Canal), stella.bernardi@aots.sanita.fvg.it
(S. Bernardi), bruno.fabris@aots.sanita.fvg.it (B. Fabris), ndemanzini@units.it (N. de
Manzini).

http://dx.doi.org/10.1016/j.ijsu.2017.02.012
1743-9191/© 2017 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.
 C. Dobrinja et al. / International Journal of Surgery 41 (2017) S34eS39 S35

Conclusions: Low-risk patients with PTMC may benefit from a more conservative treatment, e.g. HT
followed by close follow-up. However, appropriate selection of patients based on risk stratification is the
key to differentiate therapy options and gain better results.
© 2017 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.

1. Introduction Total thyroidectomy (TT) was immediately performed in case of:

malignant or suspicious lesions (TIR 5 or TIR 4 on FNAC) of 10 mm
Papillary thyroid carcinoma (PTC) accounts for about 80e90% of in diameter at preoperative ultrasound (US), multifocal PTC, bilat-
all thyroid cancers and its incidence has been increasing in the last eral goiters, prior neck irradiation, history of familial thyroid ma-
three decades worldwide [1]. According to the American Cancer lignancies, age > 45 years, and/or presence of BRAF and/or nRAS
Society, about 64,300 new cases were estimated to be diagnosed in mutation (when available) [22]. When nodal metastases were
2016 [2,3]. In Italy, PTC is the second most frequent cancer in identified at the time of surgical procedure or during follow-up, the
women below 45 years of age and its incidence has almost doubled patients underwent either unilateral or bilateral central neck
between 1991e1995 and 2001e2005 [3,4]. Despite this growth in dissection (CND) or lateral neck dissection (LND) according to the
incidence, mortality rate has remained the same (0.5 death per American Thyroid Association (ATA) guidelines [23].
100,000) and long-term prognosis is usually excellent, with 10-year Patients were considered to be “low-risk” when presenting
survival rates up to 98% [3,5e7]. This upward trend in incidence can <2 cm papillary thyroid cancer without preoperatively apparent
be easily explained by the wide availability and use of both neck cervical lymph node metastases. Patients were classified as “high-
ultrasonography and fine-needle aspiration cytology (FNAC), which risk” when unfavourable histological features (i.e. tall cells, onco-
allow an increased detection of papillary thyroid cancers measuring genic mutations as BRAF or nRAS, vascular invasion), extrathyroidal
1 cm or smaller, the so-called papillary thyroid microcarcinomas extension or spread of the cancer to the neck lymph node with
(PTMCs) [8e11]. Papillary carcinoma represents the most common potential risk factors (i.e. sex, age, and familiarity) were present
type of thyroid carcinoma in patients >45 years old [2,8e11] and [22e24].
PTMC accounts for 49% of the overall increased incidence in thyroid HT was the treatment of choice for patients with preoperative
cancer, as reported by the Surveillance Epidemiology and End Re- TIR2 or TIR3 diagnosis [25], monolateral, unifocal, and intra-
sults (SEER) database [8,10]. PTMCs are also frequently identified thyroidal lesions, negative BRAF and/or nRAS status on FNAC, no
incidentally upon histopathological examination of surgical speci- history of previous head and neck irradiation, no clinical nor
mens from presumed benign thyroid disease. radiological evidence of nodal disease or distant metastases, no
However, since PTMC generally exhibits an overall excellent other specific risk factors. HT group included also 6 cases with BRAF
prognosis, the most appropriate management of this disease re- negative, TIR 4 lesions (i.e. suspicious for malignancy), who un-
mains a matter of debate and strategies range from observation derwent HT alone by choice of the single patients. Completion
alone [12] to surgical resection [13,14]. Still, there is no consensus thyroidectomy (CT) was performed when definitive pathology
yet about the extent of surgery ensuring oncologic completeness found one or more of the following features associated with
and low risk of complications and surgical approaches may consist potentially aggressive PTMCs: multifocal disease with an overall
of either simple lobectomy or total thyroidectomy, sometimes sum of all lesions' diameters > 10 mm, actual size of papillary
associated with neck dissection and/or postoperative radioactive thyroid carcinoma >10 mm at definitive histology, microscopic
iodine (RAI) therapy [6,9,15e21]. extrathyroid extension, aggressive features (tall cell, columnar cell,
In order to better clarify whether the extent of surgery affects or diffuse sclerosing variants).
the outcomes of PTMC patients, we aimed to evaluate patients Radioactive iodine (RAI) ablation therapy was administered on
undergoing total thyroidectomy versus those undergoing simple the basis of stage and prognostic risk factors [23e27]. In detail,
hemithyroidectomy by comparing complications, reoperation patients received RAI therapy after total thyroidectomy or
rates, and overall survival. completion thyroidectomy in case of: aggressive histological sub-
types (i.e. tall cells, columnar cells, or diffuse sclerosant variants),
2. Materials and methods multifocality, extrathyroid invasion, and lymph node metastases,
which potentially increase the risk for local recurrence and me-
A retrospective analysis was carried out considering all papillary tastases. Successful thyroid ablation was defined by the disap-
thyroid cancer operations performed at the General Surgery pearance of any visible area of uptake in the thyroid bed (1%), and
Department of the University Hospital of Treiste between January undetectable serum Tg levels of levothyroxine (TSH > 30mUI/mL).
2001 and January 2016. 105 consecutive patients with histological All patients in Group An underwent long-term follow-up every
diagnosis of PTMC (major diameter  10 mm) were enrolled in the 6 months for the first two years and on a yearly basis thereafter,
study and assigned to two independent groups according to whereas patients in Group B were followed every 6 months for the
whether they received total thyroidectomy (TT, Group A) or hem- first three years and every year thereafter. Every follow-up visit
ithyroidectomy (HT, Group B). Preoperative work-up consisted of consisted of clinical examination, cervical US, measurement of
full clinical examination, ultrasonography of the thyroid gland and serum thyroglobulin (Tg) levels and anti-thyroglobulin antibodies
regional lymph nodes, and FNAC. In most cases, PTMC was diag- (Ab-Tg).
nosed preoperatively on FNAC analysis. In a minority of cases, Recurrence was defined by the presence of thyroid carcinoma
diagnosis was incidental on pathological specimens after surgery within the thyroid bed, regional lymph nodes metastates, distant
for presumed benign thyroid disease. Patients with preoperative site metastases, or, in Group B patients, lesions to the contralateral
evidence of lymph node disease, those with extrathyroidal exten- lobe.
sion at clinical and/or ultrasound examination, and papillary tu- Histopathologic data (e.g. multifocality, aggressive features,
mors larger than 1 cm were not included in the analysis. extracapsular invasion, lymph node metastases) were recorded for
S36 C. Dobrinja et al. / International Journal of Surgery 41 (2017) S34eS39

all patients and analyzed in order to determine whether comple- PTMC, n ¼ 1 patient with diffuse sclerosing PTMC). Three patients
tion thyroidectomy or total thyroidectomy were appropriate or required completion thyroidectomy after HT for personal prefer-
should have been considered an overtreatment. ence on the basis of perceived risk of recurrence.
Mean follow-up period was 58.5 months (range 6e128 months)
2.1. Statistical analysis and consisted of regular physical examination and neck US
imaging.
The statistical analysis was performed with GraphPad Software No significant difference was found between the two groups in
and by using Chi-squared test or Fisher's exact test, when appro- terms of recurrence rates (p ¼ 0.33). One patient in Group A (1.2%)
priate. A p-value less than 0.05 was considered statistically developed regional lymph node recurrence 7 months after surgery
significant. and required a central and lateral neck dissection. To date, this
patient is still alive and disease-free.
3. Results Morbidity rates were not significantly different between the two
sets of patients, although incidence was slightly higher in the TT
Analyzed data and results are summarized in Table 1. A total of group (16.3% in group A vs. 10.5% in group B, respectively;
105 patients with PTMC underwent surgery over a 15-year period. (p ¼ 0.73). Transient nerve palsy was reported in 4 cases (4.6%) in
Group A consisted of 86 patients (81.9%), 66 women and 20 men, Group A and 1 case in Group B (5.3%), respectively (p ¼ 0.68).
mean age 54 years (range 12e77 years), who underwent TT. Group Transient hypoparathyroidism, defined by serum Calcium levels
B consisted of 19 patients (18.1%), 14 women and 5 men, mean age <8.5 mg/dL), was recorded in 9 patients in Group A (10.4%) and in 1
56 years (range 30e79 years), who underwent HT. 64 patients patient in Group B (5.3%), respectively (p ¼ 0.18). Permanent nerve
(61%) presented with TIR 4 or TIR 5 lesions, whereas 41 patients damage was found only in 1 patient in Group A (1.2%, p ¼ 1.00),
(39%) presented with TIR 2 or TIR 3 lesions on preoperative cyto- whereas permanent hypoparathyroidism was not reported in any
logical diagnosis, respectively. group.
Multifocality was found in 19 patients in Group A (22%). Of The one patient in Group A who required further surgery for
these, 14 (16.3%) presented bilobar involvement, whereas 3 cases nodal recurrence suffered from transient hypoparathyroidism,
presented with unilateral multifocal PTMC. In Group B, 1 patient whereas no complications occurred in Group B patients requiring
(5.3%) presented with multifocal unilobar PTMC (p ¼ 0.11). completion thyroidectomy.
Mean tumor size was 6 mm (range 1e10 mm) in Group A and Postoperative RAI therapy was performed in 37 patients out of
5.3 mm in Group B (range 1e10 mm) (p ¼ ns). BRAF mutation was 86 in Group A (43%) and in 7 patients out of 10 in Group B after
tested preoperatively only in a minority of cases (n ¼ 16 patients) completion thyroidectomy (70%). The mean time-interval between
and resulted positive in 9 patients with either TIR 3 or TIR 4 cyto- thyroidectomy and 131I administration for postsurgical remnant
logical diagnosis. ablation was 3,5 months.
Either unilateral or bilateral central neck dissection (CND) was Mean disease-free survival was 72 months (range 6e192
performed in 24 patients in Group A (27.9%) due to suspicious months) in Group A and 78 months (range 8e137 months) in Group
lymph nodes determined intraoperatively. Central nodal metasta- B, whereas the 5-year disease free survival was 98.8% and 93.7%
ses were reported in 14 patients (58.3%). respectively (p ¼ 0.33). During the study period, 8 patients died for
8 patients out of 19 (42.1%) in group B underwent completion causes unrelated to thyroid cancer. In Group A, 3 patients died
thyroidectomy at a mean time of 30 days after initial surgery on the because of other cancers (lung cancer, gastric cancer, and chol-
basis of definitive histology. Reasons for completion thyroidectomy angiocarcinoma, respectively) and 4 died for cardiovascular events,
included: evidence of microscopic extrathyroid extension of tumor 96, 17, 83, 36, 58, 94 and 101 months after TT, respectively. In Group
(n ¼ 2 patients), multifocal unilateral disease (n ¼ 1 patient), B, 1 patient died for a stroke at 137 months after HT. No PTMC-
aggressive histopathologic variants (n ¼ 1 patient with tall cells related death was recorded during the follow-up period.

Table 1
Age, sex, tumor features, pathologic findings and outcome in two groups of patients.

Group A (TT) Group B (HT) p value

Number of patients (%) 86 (81.9%) 19 (18.1%) <0.0001

Mean age (range) 54 (12e77) 56 (30e79) -
Sex (M:F) 20:66 5:14 ns
Mean follow-up months (range) 57 (6e154) 64 (12e168) ns
Mean tumor size in mm (range) 6 (1e10) 5.3 (1e10) ns
Multifocal PTMC (%) 19 (22%) 1 (5.3%) 0.11
Bilateral PTMC (%) 14 (16.3%) 0 ns
Aggressive variants (%) 7 (8.1%) 2 (10.5%) ns
Extrathyroid invasion (%) 11 (12.8%) 2 (10.5%) ns
Lymph node metastases/lymph node dissection (%) 14/24 (58.3%) 0/0 e
Morbidity rates 16,3% 10.5% 0.73
Reoperation (%) 1 (1.2%)a 9 (47.3%)b <0.0001
Transient nerve palsy (%) 4 (4.6%) 1 (5.3%) 0.68
Transient hypoparatiroidism (%) 9 (10.4%) 1 (5.3%) 0.18
Permanent nerve palsy (%) 1 (1.2%) 0 1.00
Permanent hypoparatiroidism (%) 0 0 /
Recurrence rate (%) 1 (1.2%) 1 (5.3%) 0.33
Disease free survival (range) 72 (6e192) 78 (8e137) ns
5-year disease free survival 98.8% 93.7% 93.7% 0.33

Abbreviations: * TT ¼ Total thyroidectomy; HT¼ Hemithyroidectomy.

a
1 lymph node metastases.
b
2 cases of PTMC in the controlateral lobe found at final pathology, no pathologic findings in the other specimens.
 C. Dobrinja et al. / International Journal of Surgery 41 (2017) S34eS39 S37

4. Discussion difficult to estimate preoperatively. But, in all patients, other po-

tential risk factors, i.e. sex, age, familiarity, BRAFV600E mutation
Papillary thyroid microcarcinoma (PTMC) is increasing in inci- status (when available), are evaluable preoperatively ant the
dence, partly due to increased detection determined by even more extrathyroidal extension of tumor and/or the presence of suspi-
sensitive imaging techniques. However, both morbidity and mor- cious lymph nodes are evident in most cases at the time of surgery.
tality rates of thyroid cancer have not increased, suggesting that the According to the latest ATA Guidelines [23], HT should be
upward trend in incidence more likely reflects an increased considered the treatment of choice for PTMC patients. However,
detection of subclinical disease which was previously discovered several Authors [12,31,32] now advocate clinical observation for
only casually on autopsy [8,26,27]. these tumor considering the demonstrated indolent course of this
Prognosis is generally excellent, with 10-year survival rates of tumor. Thus, the question of CT versus HT is possibly not worth
90e95%. However, the best surgical management for PTMC is not asking and current guidelines suggest that CT for PTMC would not
established yet. ATA latest management guidelines [23] suggest be indicated unless there is a history of head and neck irradiation
that hemithyroidectomy in patients with PTMC may be appropriate and/or in presence of strong family history [23]. Nonetheless, the
treatment. Nonetheless, others Authors support only strict clinical purpose of the study was to retrospectively evaluate our personal
observation [12]. Lin et al. [28], in a series of 7818 patients with experience trying to determine whether immediate TT and CT after
PTMC, reported overall survival rates at 10 and 15 years of 96.6% HT were to be considered appropriate surgical management of
and 96.3%, respectively, and a disease-specific survival of 99.9%. Yu PTMC patients.
et al. [29] achieved similar good results analyzing 18,445 patients Another concern is represented by the fact that the study design
with PTMC treated between 1988 and 2007, with 10 and 15-year is somewhat flawed since the two groups presenting different
overall survival of 94.6% and 90.7%, respectively, and disease- preoperative characteristics (i.e FNAC, and other specific risk fac-
specific survival of 99.5%. These findings are supported by the tors) and different interventions were employed based on high or
meta-analysis of Roti et al. [30], who reviewed 17 series of PTMC low risk characteristics. However, the analysis was retrospective in
reporting an overall distant recurrence rate of 0.37% and a cancer- nature and data were collected on the basis of postoperative
related death of 0.34%. definitive histology (demonstrating PTMCs in both groups), thus
The present study aimed to assess the most appropriate surgical enabling us to compare the two sets of patients.
management for PTMC patients, considering as primary goals the The most interesting question that needs to be answered is what
completeness of resection associated with acceptable morbidity risk factors (molecular or demographic) are predictive of recur-
risk, accurate tumor staging and adequate follow-up. In our study, rence or multifocality in PTMCs, where a TT should be performed
we tried to determine whether immediate TT could be considered initially to avoid re-operation in a hostile surgical field. According
appropriate treatment compared to HT and whether CT was to literature data, hereditary conditions, gender (Women are
required after initial HT. In particular, we analyzed how many pa- diagnosed with 3 of every 4 thyroid cancers), age (<45 years), and
tients in the TT group presented on histopathologic examination oncogenic mutation (BRAF/nRAS) on FNAC, can be predictive of
multifocality lesions involving the contralateral lobe and/or recurrence or multifocality in PTMCs. Other factors that may be
aggressive features and/or extracapsular invasion and/or lymph taken into account and be further analyzed could include low-
node metastases. We further tried to determine in how many pa- iodine diet, radiation exposure, race (Caucasians and Asians are
tients treated by means of a TT for a PTMC a simple HT could have more likely to develop thyroid cancer), and association with breast
been considered sufficient and adequate treatment. Last but not cancer [22e24,33].
least, we evaluated the results of histopathological examination of In literature, conflicting data have been reported with regard to
the contralateral lobectomy in patients undergoing completion the extent of surgery in order to ensure oncologic completeness.
thyroidectomy, in order to determine whether the procedure rep- Hemithyroidectomy generally presents lower complication rates
resented an overtreatment. and determine a minimal impact on patient's life, allowing for the
The retrospective nature of the present study is a known po- preservation of thyroid functions by avoiding the need for substi-
tential bias. Obviously, it is important to differentiate patients tutive hormonal therapy in about 30e40% of cases [23,34,35].
diagnosed with PTMC preoperatively from those diagnosed after However, HT present the risk for reoperation to the controlateral
initial HT. lobe after definitive histology and follow-up is usually limited
But, I underline, that the treatment option probably should be because of the impossibility to perform radioiodine therapy and to
no different. In fact, until 2015 our local protocols, in accordance check Tg levels.
with our endocrinologists, (perhaps wrongly or maybe doing an Total thyroidectomy is a more radical surgical procedures which
overtreatment) suggested TT as a treatment of choice for all PTC allows for: 1) a complete removal of the tumor, especially for
(FNAC demonstrating malignancy) independently from size and multifocal/bilateral disease, with lower local recurrence, 2) an ac-
localization (unilobar vs bilobar). The same local guidelines pro- curate staging of the disease, and 3) the possibility to both detect
posed HT for all patients with unilobar benign or indeterminate and treat any local or distant recurrence by means of RAI and serum
cytology (TIR 2 and 3). In case of thyroid cancer on definitive his- Tg levels. This surgical approach has been corroborated by Baudin
tology, CT was then proposed independently from the presence of et al. and other more recent studies [36e39], which demonstrated
extrathyroid extension or other acknowledged major risk factors. that total thyroidectomy reduces the risk of recurrence and
On the basis of ATA revised guidelines and availability of germline apparently improves survival rates. However, there is no definitive
mutation assessment of BRAF and nRAS on FNAC, our local policy evidence in literature regarding the improvement in both recur-
was updated after January 2015. To date, low-risk PTMC patients rence and survival rates in low-risk patients treated with more
are proposed to undergo HT and, of course, to avoid a completion aggressive approaches other than lobectomy [27,31,40e43].
thyroidectomy in case of malignancy, discovered postoperatively, in Conversely, some authors believe these patients are being over-
absence of risk factors acknowledged risk factors. treated and exposed to higher risks of complications [44]. A recent
Another limitation of the present study is the small sample size, large study analyzing data from the National Cancer Data Base
hindering us to draw any definitive conclusion. Moreover, certain between 1985 and 1998, for a total patients of 12,469 with PTMC,
risk factors, as histological features, vascular invasion, extra- confirmed these remarks by demonstrating that the extent of sur-
thyroidal extension, and spread to regional lymph nodes, are gery did not impact on recurrence nor on survival (p ¼ 0.24 and
S38 C. Dobrinja et al. / International Journal of Surgery 41 (2017) S34eS39

p ¼ 0.83, respectively) [40]. Similar results have been reported by whereas any patients of group B underwent completion thyroid-
other studies, including Hay et al. (on 900 patients treated during a ectomy presented a contralateral papillary carcinoma on final his-
60-year period) [31], Lee et al. (on 2014 patients treated for PTMC topathologic examination.
between 1986 and 2006) [41], Lin et al. (on 7818 patients) [28] and Based on our findings hemithyroidectomy would be maybe
Ito et al. (on 2638 patients) [42]. Siassakos et al. [43] also reported sufficient for low risks PTCs patients if followed by periodic follow
no recurrences or deaths during a 6-year follow-up after HT for up and ultrasound and after accurate selection.
incidentally diagnosed PTMC patients.
Considering the indolent course of the disease, management of 5. Conclusions
PTMC is still debated and recent proposals include close observa-
tion without surgical treatment [12,31,32]. Ito et al. [42] prospec- In conclusion, the results of the present study do not support the
tively followed up a large group of PTMC patients who did not routine TT in the treatment of PTMC patients while it is in accord
undergo any intervention and they concluded that these patients with the latest ATA Guidelines suggesting to perform for “low-risk”
did not show a poorer prognosis when compared to those surgically PTMC the hemithyroidectomy. The risk for postoperative compli-
treated. Additionally, a more recent observation trial by the same cation is significantly increased in TT patients, without clear evi-
author showed that only 6.7% of low-risk PTMC ultimately become dence of reduction in recurrence or added benefit survival.
enlarged during a 5-year follow-up [45]. Therefore, a less aggressive treatment may be adequate for most
All these data substantiate the hypothesis that PTMC probably PTMCs, with no need for routine completion thyroidectomy.
does not require an aggressive surgical management, which, on the Although the best surgical approach for PTMC has to be adequately
contrary, may determine overtreatment and unnecessary tailored, a careful patient selection is of paramount importance to
morbidity. The present study is in accordance with these conclu- determine the best treatment for each patient and achieve the
sion. We confirmed the benign course of PTMC after a mean follow- better results. More prospective studies with longer follow-up
up period of 58.5 months, during which both groups presented periods are needed to further clarify the extent of surgery for
excellent results in terms of disease-free and disease-specific sur- PTMC and to recognize what risk factors (molecular or de-
vival, and no disease-specific death was observed. The study did not mographic) are predictive of recurrence or multifocality in PTMCs,
yield statistically significant differences in survival, recurrence and where a total thyroidectomy should be performed initially to avoid
complication rates between the two groups, even if surgical com- re-operation in a hostile surgical field.
plications occurred more frequently following total thyroidectomy
than hemithyroidectomy. In our case series, one patient (5.3%) of Ethical approval
Group B developed transitory hypoparathyroidism defined by cal-
cium serum levels as low as 8.5 mg/dL at postoperative day one. The Ethical approval was not requested.
above mentioned patient was asymptomatic and required oral
substitutive therapy for 48 h. No definitive hypocalcemia requiring Sources of funding
long-life substitutive treatment was recorded.
The lack of differences in recurrence or survival between the All Authors have no source of funding.
two groups is in agreement with findings from other large series
and recent guidelines suggest there is no need for completion Author contribution
thyroidectomy in low-risk patients, for whom close follow-up may
be adequate. Nevertheless, for those high-risk PTMC cases which Chiara Dobrinja: Participated substantially in conception,
are more likely to recur and exhibit a worse prognosis compared design, and execution of the study and in the analysis and inter-
with low-risk PTMCs, aggressive strategies should be indicated. pretation of data; also participated substantially in the drafting and
Many studies have emphasized the need for a patient stratification editing of the manuscript.
based on the analysis of possible risk factors for mortality and Manuela Pastoricchio: Participated substantially in the execu-
recurrence (e.g. extrathyroidal invasion, aggressive histological tion of the study and in the analysis and interpretation of data; also
subtypes, lymph node involvement, multifocality), in order to participated substantially in the drafting and editing of the
determine the most appropriate treatment by maximizing the manuscript.
benefits of surgery [29,42,46,47]. In fact, the vast majority of PTMC Marina Troian: Participated substantially in the analysis and
remain quiescent, causing no symptoms or threat to life. On the interpretation of data; also participated substantially in the drafting
contrary, there are other situations where central lymph node and editing of the manuscript.
metastases(CLNM) are described. Some tumor characteristics that Francesca Da Canal: Participated substantially in conception,
are used to predict the CLNM and that justified a TT to PTMC pa- design, and execution of the study and in the analysis and inter-
tients. YI-Li Zhou et al. [48] reported in their series that CND needs pretation of data.
to be considered in PTMC male patients, aged <50 years, or foci Stella Bernardi: Participated substantially in conception, design,
>7 mm based on preoperative US. Also in our series we founded a and execution of the study and in the analysis and interpretation of
relatively high percentage of patients with preoperative diagnosis data.
of simple PTMC who presented at the surgical exploration, central Bruno Fabris: Participated substantially in conception, design,
neck lymph nodes involvement (16.3%). and execution of the study and in the analysis and interpretation of
Another important aspect of PTCs is their multifocality. The data.
multifocality is heterogeneous and it can involve either a single Nicolo de Manzini: Participated substantially in conception,
thyroid lobe or both. As reported by Anulekha Mary John et al. [49] design, and execution of the study and in the analysis and inter-
in his retrospective study where a multifocal tumor was found in pretation of data; also participated substantially in the drafting and
the 44,1% of the patients where 19,5% of multifocal disease was editing of the manuscript.
restrict to a single lobe. On the contrary, in other previous studies
the incidence of bilateral PTMC reported is approximately 10e30% Conflicts of interest
[9e11].
In our study, we found 16.3% of bilateral PTMC in group A All Authors have no conflict of interests.
 C. Dobrinja et al. / International Journal of Surgery 41 (2017) S34eS39 S39

Guarantor European Thyroid Cancer Taskforce. European consensus for the management
of patients with differentiated thyroid carcinoma of the follicular epithelium,
Eur. J. Endocrinol. 154 (6) (2006) 787e803. No abstract available. Erratum in:
Chiara Dobrinja. Eur J Endocrinol. 155 (2006) 385.
[27] F. Pacini, M. Schlumberger, C. Harmer, G.G. Berg, O. Cohen, L. Duntas, F. Jamar,
B. Jarzab, E. Limbert, P. Lind, C. Reiners, F. Sanchez Franco, J. Smit,
References W. Wiersinga, Post-surgical use of radioiodine (131I) in patients with papil-
lary and follicular thyroid cancer and the issue of remnant ablation: a
[1] G. Pellegriti, F. Frasca, C. Regalbuto, et al., Worldwide increasing incidence of consensus report, Eur. J. Endocrinol. 153 (2005) 651e659.
thyroid cancer: update on epidemiology and risk factors, J. Cancer Epidemiol. [28] H.W. Lin, N. Bhattacharyya, Survival impact of treatment options for papillary
2013 (2013) 965212. microcarcinoma of the thyroid, Laryngoscope 119 (2009) 1983e1987.
[2] Cancer Facts & Figures, American Cancer Society, 2016. Available at: http:// [29] X.M. Yu, Y. Wan, R.S. Sippel, H. Chen, Should all papillary thyroid micro-
www.cancer.org/acs/groups/content/@research/documents/document/acspc- carcinomas be aggressively treated? An analysis of 18,445 cases, Ann. Surg.
047079.pdf (Accessed 6 April 2016). 254 (2011) 653e660.
[3] L. Davies, H.G. Welch, Current thyroid cancer trends in the United States, [30] E. Roti, E.C. DegliUberti, M. Bondanelli, L.E. Braverman, Thyroid papillary
JAMA Otolaryngol. Head. Neck Surg. 140 (2014) 317e322. microcarcinoma: a descriptive and meta-analysis study, Eur. J. Endocrinol. 159
[4] L. Dal Maso, M. Lise, P. Zambon, et al., Incidence of thyroid cancer in Italy, (2008) 659e673.
1991e2005: time trends and age-period-cohort effects, Ann. Oncol. 22 (2011) [31] I.D. Hay, M.E. Hutchinson, T. Gonzalez-Losada, B. McIver, M.E. Reinalda,
957e963. C.S. Grant, et al., Papillary thyroid microcarcinoma: a study of 900 cases
[5] M. Abdelgadir Adam, J. Pura, P. Goffredo, M.A. Dinan, T. Hyslop, S.D. Reed, observed in a 60-year period, Surgery 144 (2008) 980e988.
R.P. Scheri, S.A. Roman, J.A. Sosa, Impact of extent of surgery on survival for [32] S.B. Christensen, O. Ljungberg, S. Tibblin, Surgical treatment of thyroid carci-
papillary thyroid cancer patients younger than 45 years, J. Clin. Endocrinol. noma in a defined population: 1960 to 1979. Evaluation of the results after a
Metab. 100 (2015) 115e121. conservative surgical approach, Am. J. Surg. 146 (1983) 349e354.
[6] K. Matsuzu, K. Sugino, K. Masudo, M. Nagahama, W. Kitagawa, H. Shibuya, [33] K.R. Joseph, S. Edirimanne, G.D. Eslick, The association between breast cancer
K. Ohkuwa, T. Uruno, A. Suzuki, S. Magoshi, J. Akaishi, C. Masaki, M. Kawano, and thyroid cancer: a meta-analysis, Breast Cancer Res. Treat. 152 (2015)
N. Suganuma, Y. Rino, M. Masuda, K. Kameyama, H. Takami, K. Ito, Thyroid 173e181.
hemithyroidectomy for papillary thyroid cancer: long-term follow-up study of [34] C. Dobrinja, G. Trevisan, L. Piscopello, M. Fava, G. Liguori, Comparison between
1088 cases, World J. Surg. 38 (2014) 68e79. thyroidectomy and hemithyroidectomy in treatment of single thyroid nodules
[7] K.Y. Bilimoria, D.J. Bentrem, C.Y. Ko, A.K. Stewart, D.P. Winchester, identified as indeterminate follicular lesions by fine-needle aspiration
M.S. Talamonti, C. Sturgeon, Extent of surgery affects survival for papillary cytology, Ann. Ital. Chir. 81 (2010) 403e411.
thyroid cancer, Ann. Surg. 246 (2007) 375e384. [35] G. Conzo, N. Avenia, G.L. Ansaldo, P. Calo  , M. De Palma, C. Dobrinja, G. Docimo,
[8] L. Davies, H.G. Welch, Increasing incidence of thyroid cancer in the United C. Gambardella, M. Grasso, C.P. Lombardi, M.R. Pelizzo, A. Pezzolla, L. Pezzullo,
States, 1973-2002, Jama 295 (2006) 2164e2167. M. Piccoli, L. Rosato, G. Siciliano, S. Spiezia, E. Tartaglia, F. Tartaglia, M. Testini,
[9] D.T. Hughes, M.R. Haymart, B.S. Miller, P.G. Gauger, G.M. Doherty, The most G. Troncone, G. Signoriello, Surgical treatment of thyroid follicular neoplasms:
commonly occurring papillary thyroid cancer in the United States is now a results of a retrospective analysis of a large clinical series, Endocrine 55 (2017)
microcarcinoma in a patient older than 45 years, Thyroid 21 (2011) 231e236. 530e538.
[10] J.D. Cramer, P. Fu, K.C. Harth, et al., Analysis of the rising incidence of thyroid [36] S. Bonnet, D. Hartl, S. Leboulleux, E. Baudin, J.D. Lumbroso, A. Al Ghuzlan,
cancer using Surveillance, Epidemiology and End Results national cancer data L. Chami, M. Schlumberger, J.P. Travagli, Prophylactic lymph node dissection
registry, Surgery 148 (2010) 1147e1153. for papillary thyroid cancer less than 2 cm: implications for radioiodine
[11] S. Grodski, T. Brown, S. Sidhu, et al., Increasing incidence of thyroid cancer is treatment, J. Clin. Endocrinol. Metab. 94 (2009) 1162e1167.
due to increased pathologic detection, Surgery 144 (2008) 1038e1043. [37] M.R. Pelizzo, I.M. Boschin, A. Toniato, A. Piotto, P. Bernante, C. Pagetta, et al.,
[12] Y. Ito, T. Uruno, K. Nakano, et al., An observation trial without surgical Papillary thyroid microcarcinoma (PTMC): prognostic factors, management
treatment in patients with papillary microcarcinoma of the thyroid, Thyroid and outcome in 403 patients, Eur. J. Surg. Oncol. 32 (2006) 1144e1148.
13 (2003) 381e387. [38] I. Vasileiadis, T. Karatzas, D. Vasileiadis, S. Kapetanakis, G. Charitoudis,
[13] N.O. Kucuk, P. Tari, E. Tokman, et al., Treatment for microcarcinoma of the E. Karakostas, et al., Clinical and pathological characteristics of incidental and
thyroid e clinical experience, Clin. Nucl. Med. 32 (2007) 279e281. nonincidental papillary thyroid microcarcinoma in 339 patients, Head. Neck
[14] M.R. Pelizzo, I.M. Boschin, A. Toniato, et al., Papillary thyroid micro carcinoma 36 (2014) 564e570.
(PTMC): prognostic factors, management and outcome in 403 patients, Eur. J. [39] L.S. Wu, S.A. Milan, Management of microcarcinomas (papillary and medul-
Surg. Oncol. 32 (2006) 1144e1148. lary) of the thyroid, Curr. Opin. Oncol. 25 (2013) 27e32.
[15] A.H. Mendelsohn, D.A. Elashoff, E. Abemayor, M.A. St John, Surgery for [40] K.Y. Bilimoria, D.J. Bentrem, C.Y. Ko, A.K. Stewart, D.P. Winchester,
papillary thyroid carcinoma: is hemithyroidectomy enough? Arch. Otolar- M.S. Talamonti, et al., Extent of surgery affects survival for papillary thyroid
yngol. Head. Neck Surg. 136 (2010) 1055e1061. cancer, Ann. Surg. 24 (2007) 375e384.
[16] M.A. Adam, J. Pura, L. Gu, M.A. Dinan, D.S. Tyler, S.D. Reed, R. Scheri, [41] J. Lee, J.H. Park, C.R. Lee, W.Y. Chung, C.S. Park, Long-term outcomes of total
S.A. Roman, J.A. Sosa, Extent of surgery for papillary thyroid cancer is not thyroidectomy versus thyroid hemithyroidectomy for papillary thyroid
associated with survival: an analysis of 61,775 patients, Ann. Surg. 260 (2014) microcarcinoma: comparative analysis after propensity score matching,
601e607. Thyroid 23 (2013) 1408e1415.
[17] I.D. Hay, G.B. Thompson, C.S. Grant, E.J. Bergstralh, C.E. Dvorak, C.A. Gorman, [42] Y. Ito, H. Masuoka, M. Fukushima, H. Inoue, M. Kihara, C. Tomoda, et al.,
M.S. Maurer, B. McIver, B.P. Mullan, A.L. Oberg, C.C. Powell, J.A. van Heerden, Excellent prognosis of patients with solitary T1N0M0 papillary thyroid car-
J.R. Goellner, Papillary thyroid carcinoma managed at the Mayo Clinic during cinoma who underwent thyroidectomy and elective lymph node dissection
six decades (1940e1999): temporal trends in initial therapy and long-term without radioiodine therapy, World J. Surg. 34 (2010) 1285e1290.
outcome in 2444 consecutively treated patients, World J. Surg. 26 (2002) [43] D. Siassakos, S. Gourgiotis, P. Moustafellos, N. Dimopoulos, E. Hadjiyannakis,
879e885. Thyroid microcarcinoma during thyroidectomy, Singap. Med. J. 49 (2008)
[18] R. Udelsman, A. Shaha, Is total thyroidectomy the best possible surgical 23e25.
management for well-differentiated thyroid carcinoma? Lancet Oncol. 6 [44] S.B. Christensen, O. Ljungberg, S. Tibblin, Surgical treatment of thyroid carci-
(2005) 529e531. noma in a defined population: 1960 to 1979. Evaluation of the results after a
[19] P.I. Haigh, D.R. Urbach, L.E. Rotstein, Extent of thyroidectomy is not a major conservative surgical approach, Am. J. Surg. 146 (1983) 349e354.
determinant of survival in low- or high-risk papillary thyroid cancer, Ann. [45] Y. Ito, A. Miyauchi, A therapeutic strategy for incidentally detected papillary
Surg. Oncol. 12 (2005) 81e89. microcarcinoma of the thyroid, Nat. Clin. Pract. Endocrinol. Metab. 3 (2007)
[20] I.J. Nixon, I. Ganly, S.G. Patel, F.L. Palmer, M.M. Whitcher, R.M. Tuttle, A. Shaha, 240e248.
J.P. Shah, Thyroid hemithyroidectomy for treatment of well differentiated [46] F.I. Macedo, V.K. Mittal, Total thyroidectomy versus hemithyroidectomy as
intrathyroid malignancy, Surgery 151 (2012) 571e579. initial operation for small unilateral papillary thyroid carcinoma: a meta-
[21] C.S. Grant, Recurrence of papillary thyroid cancer after optimized surgery, analysis, Surg. Oncol. 24 (2015) 117e122.
Gland. Surg. 4 (2015) 52e62. [47] V. Marotta, C. Sciammarella, M. Capasso, A. Testori, C. Pivonello, M.G. Chiofalo,
[22] A.L. Melck, et al., The utility of BRAF testing in the management of papillary C. Gambardella, M. Grasso, A. Antonino, A. Annunziata, P.E. Macchia,
thyroid cancer, Oncologist 15 (12) (2010) 1285e1293. R. Pivonello, L. Santini, G. Botti, S. Losito, L. Pezzullo, A. Colao, A. Faggiano,
[23] B.R. Haugen, E.K. Alexander, K.C. Bible, et al., 2015 American thyroid associ- Germline polymorphisms of the VEGF-pathway predict recurrence in non-
ation management guidelines for adult patients with thyroid nodules and advanced differentiated thyroid cancer, J. Clin. Endocrinol. Metab. (2016).
differentiated thyroid cancer: the American thyroid association guidelines Nov 16:jc20162555, [Epub ahead of print] PMID: 27849428.
task force on thyroid nodules and differentiated thyroid cancer, Thyroid 26 [48] Y.L. Zhou, E.L. Gao, W. Zhang, H. Yang, G.L. Guo, X.H. Zhang, O.C. Wang, Factors
(2016) 1e133. predictive of papillary thyroid micro-carcinoma with bilateral involvement
[24] J.P. Brito, I.D. Hay, J.C. Morris, Low risk papillary thyroid cancer, BMJ 16 (2014) and central lymph node metastasis: a retrospective study, World J. Surg.
348 g3045. Oncol. 10 (2012) 67.
[25] Syed Z. Ali, Edmund S. Cibas, The Bethesda System for Reporting Thyroid [49] A.M. John, P.M. Jacob, R. Oommen, S. Nair, A. Nair, S. Rajaratnam, Our expe-
Cytopathology, 1 edizione, Springer, US, 6 febbraio 2010. rience with papillary thyroid microcancer, Indian J. Endocrinol. Metab. 18
[26] F. Pacini, M. Schlumberger, H. Dralle, R. Elisei, J.W. Smit, W. Wiersinga, (2014) 410e413.