Approach to the Patient with Thyroid Cancer: Selection and Management of Candidates for Lobectomy

Abstract

Thyroid lobectomy has gained increasing popularity over the past decade as a treatment for differentiated thyroid cancer (DTC), largely due to a rise in the diagnosis of low-risk cancers and evidence showing no benefit from radioiodine in low-risk disease. Multiple studies have confirmed lobectomy as an effective and safe option. Its advantages over total thyroidectomy include lower complication rates and a reduced need for lifelong levothyroxine (LT4) therapy. Recent research has broadened the indications for lobectomy, extending its use to patients with contralateral benign nodules and several "adverse" histological features, such as minimal ETE, small lymph node metastases, or multifocality-provided these are of minimal size. For patients with follicular thyroid carcinoma, who typically undergo surgery for Bethesda III-IV cytology, minimally invasive disease should be treated with lobectomy alone. In patients with angioinvasion, the risk of metastasis increases with the number of vessels involved (>2-3 vessels), larger tumor size, and advanced patient age. Following surgery, current evidence supports a TSH target within the normal range, reducing the need for LT4 treatment to only 30% of patients. Follow-up is based on neck US, as thyroglobulin levels have limited value in detecting recurrence. In cases where further treatment is required, completion thyroidectomy is as safe as upfront total thyroidectomy. Overall, lobectomy is the preferred treatment option for many, if not most, DTC patients with low to low-intermediate risk disease, offering lower complication rates, reduced need for LT4 therapy, and excellent long-term outcomes.

Keywords: Lobectomy; complications; disease recurrence; extra-thyroidal extension; follicular thyroid carcinoma; lymph node metastases; papillary thyroid cancer; quality of life; tall cell variant; thyroid hormones replacement.