Benefits and Harms of Hemithyroidectomy, Total or Near-Total Thyroidectomy in 1– 4 cm Differentiated Thyroid Cancer

Yang Xu; Kunzhai Huang; Peiyin Huang; Najun Ke; Jinyang Zeng; Liying Wang; Changqin Liu; Xiulin Shi; Fangting Guo; Lijia Su; Mingzhu Lin; Xuejun Li; Fangsen Xiao


Clin Endocrinol. 2021;95(4):668-676. 

In This Article

Abstract and Introduction


Objective: For 1–4 cm differentiated thyroid cancer (DTC), current ATA guideline recommended hemithyroidectomy (HT) as an acceptable alternative initial procedure to total or near-total thyroidectomy (TT). The aim of this study was to evaluate benefits and harms of HT, TT in 1–4 cm DTC.

Design: Retrospective cohort study.

Patients: DTC patients aged 18 years or older who underwent initial thyroidectomy in a tertiary medical centre were included from January 2008 to July 2018.

Measurements: The structural persistent/recurrent disease, reoperation rates and surgical complications were compared using Cox proportional regression and logistic regression. Propensity score matching was performed to adjust for related clinicopathological variables.

Results: Among 1824 DTC patients, 795 patients sized 1–4 cm were included. A total of 286 patients underwent HT and 509 patients underwent TT. In the matched analysis, no significant difference in disease-free survival (DFS) between HT and TT was observed during the median follow-up period of 56.5 months (hazard ratio [HR] 0.86; 95% CI, 0.37–2.00; p = .733). The difference in DFS between two groups was consistent regardless of age, sex, tumour size, follow-up duration. Meanwhile, HT was associated with a decreased risk of surgical complications (odds ratio [OR] 0.47, 95% CI 0.31–0.71, p < .001), as well as lower proportion of levothyroxine replacement (p = .007). Two cases in HT group received reoperation. Further multivariate analysis showed surgical procedure was not associated with structural persistence/recurrence (HR 0.68; 95%CI, 0.29–1.58, p = .367).

Conclusions: For patients with 1–4 cm DTC without clinical evidence of lymph node metastasis or extrathyroidal extension, HT was associated with lower risk of surgical complications than TT while provided similar benefits as TT.


Thyroid cancer is the most prevalent endocrine malignancy, and its incidence rates have been continuously rising worldwide over the last few decades. Among all thyroid malignancies, differentiated thyroid cancer (DTC) accounts for more than 90%.[1,2] Despite the rising prevalence, the thyroid cancer-related death rate is reported to be stable at approximately 0.5 cases per 100,000 persons.[3] As a result, many experts advocated for more conservative management for DTC due to concerns about overdiagnosis and overtreatment.[4–6]

For the treatment of DTC, especially those larger than 1cm, surgery remains the mainstay. In the United States, over 100,000 thyroid operations are performed annually. Currently, there are two surgical procedures for DTC, namely bilateral procedure [total or near-total thyroidectomy (TT)] and unilateral procedure [hemithyroidectomy (HT)]. The 2015 American Thyroid Association (ATA) guidelines recommended that for patients with thyroid cancer 1–4 cm without extrathyroidal extension (ETE), and clinical evidence of any lymph node (LN) metastases, the initial surgical procedure can be either unilateral or bilateral procedure.[7] Therefore, shared decision-making may be frequently encountered clinical scenarios in the practice of DTC. To better guide shared decision-making conversation, evidence about options of surgical procedure, their potential benefits and possible harms is needed. Previous evidence indicated TT would improve survival[8,9] and reduce the risk of recurrence[10–12] as compared with HT. Meanwhile, TT provides advantages such as enabling the routine use of radioactive iodine (RAI) remnant ablation, clearing microscopic cancer foci in the contralateral lobe and facilitating detection of thyroglobulin for monitoring recurrent/persistent disease during follow-up. In addition, those who chose TT as the initial surgical procedure might be at lower risk of reoperation. However, recent data suggested that clinical outcomes are very similar following HT or TT in patients with 1–4 cm DTC.[13,14] And more importantly, it was reported that HT is associated with lower rates of surgical complications.[15–17] It has also been recognized that HT preserves thyroid function, thereby reducing the requirement of a lifelong need for hormone replacement therapy.[18] As a result, it is essential to balance the potential benefits versus possible harms to define the optimal extent of initial treatment. So far, few studies have assessed both benefits and harms of either surgical procedure. Therefore, the present study aimed to evaluate the benefits and harms of HT, TT in patients with 1–4 cm DTC.