Papillary thyroid microcarcinoma: decision-making, extent of surgery, and outcomes

The optimal extent of surgery for patients with papillary thyroid microcarcinoma (PTMC), tumors ≤1 cm, is controversial because survival is excellent regardless of approach. The objective of this study was to investigate patient and surgeon decision-making about the extent of surgery for PTMC.

We conducted a retrospective review of thyroid cancer patients operated on at a single institution from 2008-2016. To examine decision-making about the extent of surgery, we performed a discourse analysis on all available documentation looking for patient or surgeon reasons.

Of the 853 thyroid cancer patients, 125 (14.7%) had a PTMC as their largest tumor. Overall, 27.2% of the PTMC patients underwent a thyroid lobectomy, whereas 72.8% had a total thyroidectomy (TT). Of those patients diagnosed with PTMC preoperatively (19/125), a significantly higher proportion underwent a TT (94.7% versus 68.9%, P = 0.02). In all cases, documentation indicated that these preoperatively diagnosed patients followed the surgeon's recommendation regarding the extent of surgery. Reasons surgeons cited for recommending a TT included patient and disease factors (34.6%), belief that TT was the standard treatment (21.7%), ease of follow-up (8.7%), and referring provider preference (4.3%). Of the 19 patients diagnosed preoperatively, four (21.1%) patients had a complication, one (5.3%) of which was permanent and potentially avoidable with less extensive surgery.

These data suggest that surgeons drive decision-making about the extent of thyroidectomy in patients with preoperatively diagnosed PTMC. With recent guidelines recommending thyroid lobectomy, closer examination of decision-making is needed to ensure that patients make well-informed, preference-based decisions.