Lobectomy Versus Total Thyroidectomy Across 2015 ATA Low-to-Intermediate-Risk Papillary Thyroid Carcinoma

CLINICAL QUESTION

Does thyroid lobectomy provide recurrence and survival outcomes comparable to total thyroidectomy in patients with low-to-intermediate-risk papillary thyroid carcinoma (PTC) defined by the 2015 American Thyroid Association (ATA) guidelines?

BOTTOM LINE

Across 10 studies including more than 17,000 patients, thyroid lobectomy demonstrated recurrence-free and disease-specific survival outcomes comparable to total thyroidectomy for low-to-intermediate-risk PTC. These findings support lobectomy as an oncologically adequate initial surgical option that may reduce treatment-related morbidity.

BACKGROUND: The 2015 ATA guidelines recommend risk-stratified surgical management of PTC, allowing lobectomy for selected tumors measuring 1–4 cm without high-risk features. Despite this shift, debate persists regarding whether total thyroidectomy confers superior oncologic outcomes in intermediate-risk disease. Clarifying long-term recurrence and survival outcomes is essential for guiding surgical decision-making and patient counseling.

STUDY DESIGN: Systematic review with meta-analysis conducted according to PRISMA guidelines and registered with PROSPERO. PubMed, Embase, and Cochrane Library were searched for studies published from 2015 to April 2025 comparing lobectomy and total thyroidectomy in ATA-defined low-to-intermediate-risk PTC. Random-effects models were used for pooled analyses where appropriate.

SETTING: International studies conducted across Asia and Europe, primarily in tertiary referral centers.

SYNOPSIS: Ten studies comprising 17,082 patients met the inclusion criteria, including nine cohort studies and one case-control study. Eight studies were included in the meta-analysis. For intermediate-risk PTC, pooled analysis of five studies (n = 3,881) demonstrated similar five-year recurrence-free survival between lobectomy (96%) and total thyroidectomy (95%), with no statistically significant difference in hazard ratios. Substantial heterogeneity was present, but sensitivity analyses confirmed result stability. In low-tointermediate-risk cohorts, pooled raw recurrence rates were likewise comparable: 3% after lobectomy and 4% after total thyroidectomy. Importantly, lobectomy maintained low recurrence rates despite minimal use of adjuvant radioactive iodine. Disease-specific survival data from two studies showed no mortality benefit associated with total thyroidectomy, with both surgical approaches achieving excellent longterm outcomes. Overall survival analyses similarly demonstrated no significant differences between procedures. The authors emphasize that many historical studies favoring total thyroidectomy predated modern ATA risk stratification and did not adjust for key prognostic features. While residual confounding and regional concentration of studies (predominantly from Asian centers) limit generalizability, the findings consistently support lobectomy as sufficient initial management for appropriately selected patients. Avoiding unnecessary total thyroidectomy may reduce complications such as hypoparathyroidism and recurrent laryngeal nerve injury without compromising oncologic control.

CITATION: Wong RSH, et al. Lobectomy versus total thyroidectomy across 2015 American Thyroid Association low-to-intermediate-risk papillary thyroid carcinoma. Otolaryngol Head Neck Surg. 2025;173:1099-1110. doi:10.1002/ohn.70009.

COMMENT: This systematic review and meta-analysis show that, for patients with low to intermediate risk papillary thyroid carcinoma, lobectomy provides recurrence-free and disease-specific survival outcomes comparable to total thyroidectomy. By demonstrating no survival advantage to more extensive surgery, the article supports guideline-aligned, risk-stratified decision-making that favors lobectomy when appropriate. These findings help clinicians counsel patients on the safety and efficacy of less aggressive surgery while reducing morbidity associated with total thyroidectomy.—Sarah Rapoport, MD