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Extent of Surgery for Papillary Thyroid Cancer Is Not Associated With Survival: An Analysis of 61,775 Patients

Adam, Mohamed Abdelgadir MD*; Pura, John MPH; Gu, Lin MS; Dinan, Michaela A. PhD; Tyler, Douglas S. MD*; Reed, Shelby D. PhD; Scheri, Randall MD*; Roman, Sanziana A. MD*; Sosa, Julie A. MD, MA*,‡

doi: 10.1097/SLA.0000000000000925
Papers of the 134th ASA Annual Meeting

Objective: To examine the association between the extent of surgery and overall survival in a large contemporary cohort of patients with papillary thyroid cancer (PTC).

Background: Guidelines recommend total thyroidectomy for PTC tumors >1 cm, based on older data demonstrating an overall survival advantage for total thyroidectomy over lobectomy.

Methods: Adult patients with PTC tumors 1.0–4.0 cm undergoing thyroidectomy in the National Cancer Database, 1998–2006, were included. Cox proportional hazards models were applied to measure the association between the extent of surgery and overall survival while adjusting for patient demographic and clinical factors, including comorbidities, extrathyroidal extension, multifocality, nodal and distant metastases, and radioactive iodine treatment.

Results: Among 61,775 PTC patients, 54,926 underwent total thyroidectomy and 6849 lobectomy. Compared with lobectomy, patients undergoing total thyroidectomy had more nodal (7% vs 27%), extrathyroidal (5% vs16%), and multifocal disease (29% vs 44%) (all Ps < 0.001). Median follow-up was 82 months (range, 60–179 months). After multivariable adjustment, overall survival was similar in patients undergoing total thyroidectomy versus lobectomy for tumors 1.0–4.0 cm [hazard ratio (HR) = 0.96; 95% confidence interval (CI), 0.84–1.09); P = 0.54] and when stratified by tumor size: 1.0–2.0 cm [HR = 1.05; 95% CI, 0.88–1.26; P = 0.61] and 2.1–4.0 cm [HR = 0.89; 95% CI, 0.73–1.07; P = 0.21]. Older age, male sex, black race, lower income, tumor size, and presence of nodal or distant metastases were independently associated with compromised survival (P < 0.0001).

Conclusions: Current guidelines suggest total thyroidectomy for PTC tumors >1 cm. However, we did not observe a survival advantage associated with total thyroidectomy compared with lobectomy. These findings call into question whether tumor size should be an absolute indication for total thyroidectomy.

Prognosis of papillary thyroid cancer is excellent with standard therapy. The mainstay of treatment is surgery; however, there is considerable debate regarding the appropriate extent of surgery. Although current guidelines recommend total thyroidectomy for tumors > 1 cm, this study demonstrates no survival benefit with total thyroidectomy versus lobectomy for tumors 1.0–4.0 cm.

*Department of Surgery, Duke University Medical Center

Department of Biostatistics, Duke University; and

Duke Clinical Research Institute.

Reprints: Julie A. Sosa MD, MA, Section of Endocrine Surgery, and Department of Surgery, Duke University Medical Center #2945, Durham, NC 27710. E-mail:

Data were presented at the 134th Annual Meeting of the American Surgical Association, April 11, 2014, Marriott Copley Place, Boston, MA.

Disclosure: The authors declare no conflict of interest.

The data used in the study are derived from a de-identified National Cancer Database file. The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methodology employed, or the conclusions drawn from these data by the investigator.

© 2014 by Lippincott Williams & Wilkins.