One (BIG) reason for the de-escalation of thyroid surgery extension.
- Carlos E Costa Almeida
- há 29 minutos
- 3 min de leitura
The traditional “total thyroidectomy plus RAI” is coming down. This idea was introduced by Mazzaferri et al. in a 1977 work, showing that radioiodine (RAI) substantially reduced the recurrence rate and mortality rate in differentiated thyroid cancer (DTC) greater than 1.5 cm. This “led to an era recommending total thyroidectomy to nearly all patients with primary DTC greater than 1 cm”. In fact, this was my practice since 2005, when I began my residency in General Surgery. However, a couple of years ago, we started doing things differently, supporting a patient-based treatment. The idea of “one treatment fits all” has been erased from our minds.
There are several reasons for the de-escalation of thyroidectomy extension in low-risk DTC. One important reason comes from recent works about RAI, presented and discussed in a 2025 BJS paper by Dr. Kate Newbold and Dr. David Scott-Coombes. According to these authors, a reduction in the number of patients treated with RAI was observed at Mayo Clinic since 1990, following a retrospective analysis which found “that the 20-year cause-specific mortality rate was less than 1%” for low-risk papillary cancer patients. Additionally, the authors tell us that a study from France concluded that RAI could be omitted in low-risk tumors < 2 cm with no nodal involvement, and they also tell us that the IoN (Iodine or Not) trial from the UK (The Lancet, 2025) concluded there is no benefit in using RAI in DTC < 4 cm with negative lymph nodes. The authors state that this trial “will bring an end to an era of RAI ablation for most patients with thyroid cancer”, and “should end the tradition of prescribing RAI ablation to low-risk DTC patients (up to 40 mm)”.
It is easy to conclude that the management of low-risk DTC is changing. If we know that RAI is not necessary because there is no survival advantage in low-risk DTC, the idea of removing all thyroid tissue to allow RAI treatment is now obsolete. In my opinion, this is a strong (if not the strongest) reason to support de-escalation from total thyroidectomy to hemithyroidectomy. In fact, the 2025 ATA Guidelines already present hemithyroidectomy as the preferred approach for DTC < 2 cm, and hemithyroidectomy may be considered for DTC 2-4 cm. This de-escalation of thyroidectomy extension will greatly reduce (or avoid) postoperative hypoparathyroidism and bilateral recurrent laryngeal nerve injury. So, there are big advantages for patients and surgeons.
In addition to the results presented above, the authors also tell us that treatment of advanced thyroid cancer is also changing. Today we know that molecular changes (namely mutations in TERT, in BRAF, in tumor suppression genes TP53, and fusions in RET) are “associated with dedifferentiation of the tumor and the loss of sodium iodine symporter (NIS) expression leading to RAI refractory disease”. Treatment with multikinase inhibitors (sorafenib, levantinib) offers a progression-free survival advantage and the possibility of redifferentiation with a re-expression of NIS by the tumor cells, regaining the ability to use RAI. This concept of redifferentiation is amazing and can be game-changing, I think.
New concepts and knowledge are increasing the support for the de-escalation of low-risk DTC treatment. Abandoning total thyroidectomy because RAI will not be necessary is a strong reason to support this new approach for low-risk DTC. However, follow-up with thyroglobulin analysis after a hemithyroidectomy for a DTC will be eliminated from our armamentarium. This biochemical sign of a possible recurrence will not be helpful. Additionally, following a hemithyroidectomy, the multifocality of a DTC will not be accurately evaluated, and ultrasonographies will have to be more frequently performed to diagnose a recurrence or lymph node involvement. But in the end, we will decrease important morbidity for patients suffering from a low-risk cancer.
As we usually say about low-risk DTC: the patient will not die from it, the patient will die with it.
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Dr. Carlos Eduardo Costa Almeida
General Surgeon
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