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Updated: Mar 11, 2026
Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy
Published on: May 12, 2023
Is it time to reconsider lobectomy in low-risk paediatric thyroid cancer?
Wouter P Kluijfhout1,2, Jesse D Pasternak1, Danielle van der Kaay3
1Division of General Surgery, University Health Network Toronto, Toronto, Ontario, Canada.
Insights
Many children with well-differentiated thyroid cancer (WDTC) may be candidates for less invasive lobectomy, not just total thyroidectomy. High-resolution imaging and risk criteria help identify these low-risk patients, avoiding unnecessary surgical morbidity.
Area of Science:
- Pediatric Endocrinology
- Surgical Oncology
- Thyroid Cancer Research
Background:
- Current guidelines advocate total thyroidectomy for most pediatric well-differentiated thyroid cancer (WDTC).
- These recommendations predate advanced high-resolution imaging techniques.
- A subset of pediatric WDTC patients may be suitable for less extensive surgery, such as lobectomy.
Purpose of the Study:
- To identify a subpopulation of children with WDTC who could be adequately treated with thyroid lobectomy.
- To evaluate the efficacy of risk-stratification criteria in identifying suitable candidates for lobectomy.
- To propose a framework for considering lobectomy in low-risk pediatric thyroid cancer cases.
Main Methods:
- Retrospective analysis of a prospectively maintained database of 73 children with WDTC treated between 2004 and 2015.
- Application of American Thyroid Association (ATA) 'low-risk' criteria and newly defined 'very-low-risk' histopathological criteria.
- Assessment of patient demographics, tumor characteristics, lymph node metastasis, and treatment response.
Main Results:
- 39% of patients met ATA low-risk criteria; 21.9% met 'very-low-risk' criteria.
- Pre-operative ultrasound accurately identified clinically significant nodal disease.
- All 'very-low-risk' patients showed excellent response to initial therapy with no recurrence after a mean follow-up of 36.4 months.
Conclusions:
- High-resolution ultrasound and specific histopathological criteria can identify pediatric WDTC patients suitable for lobectomy.
- Lobectomy may avoid the significant medical and psychosocial morbidity associated with total thyroidectomy.
- A clinical framework is proposed to guide the discussion of lobectomy for selected low-risk pediatric thyroid cancer patients.
Objective:
Current guidelines recommend total thyroidectomy for nearly all children with well-differentiated thyroid cancer (WDTC). These guidelines, however, derive from older data accrued prior to current high-resolution imaging. We speculate that there is a subpopulation of children who may be adequately treated with lobectomy.
Design:
Retrospective analysis of prospectively maintained database.
Patients:
Seventy-three children with WDTC treated between 2004 and 2015.
Measurements:
We applied two different risk-stratification criteria to this population. First, we determined the number of patients meeting American Thyroid Association (ATA) 'low-risk' criteria, defined as disease grossly confined to the thyroid with either N0/Nx or incidental microscopic N1a disease. Second, we defined a set of 'very-low-risk' histopathological criteria, comprising unifocal tumours ≤4 cm without predefined high-risk factors, and determined the proportion of patients that met these criteria.
Results:
Twenty-seven (37%) males and 46 (63%) females were included in this study, with a mean age of 13·4 years. Ipsilateral- and contralateral multifocality were identified in 27 (37·0%) and 19 (26·0%) of specimens. Thirty-seven (51%) patients had lymph node metastasis (N1a = 18/N1b = 19). Pre-operative ultrasound identified all cases with clinically significant nodal disease. Of the 73 patients, 39 (53·4%) met ATA low-risk criteria and 16 (21·9%) met 'very-low-risk' criteria. All 'very-low-risk' patients demonstrated excellent response to initial therapy without persistence/recurrence after a mean follow-up of 36·4 months.
Conclusions:
Ultrasound and histopathology identify a substantial population that may be candidates for lobectomy, avoiding the risks and potential medical and psychosocial morbidity associated with total thyroidectomy. We propose a clinical framework to stimulate discussion of lobectomy as an option for low-risk patients.
