title: Is it time to reconsider lobectomy in low-risk paediatric thyroid cancer?
abstract: 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.
  
  
  METHODS
  Retrospective analysis of prospectively maintained database.
  
  
  METHODS
  Seventy-three children with WDTC treated between 2004 and 2015.
  
  
  METHODS
  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.
authors.affiliation: Division of General Surgery, University Health Network Toronto, Toronto, Ontario, Canada.|Department of General Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Wouter P
authors.initials: WP
authors.lastname: Kluijfhout
authors.affiliation: Division of General Surgery, University Health Network Toronto, Toronto, Ontario, Canada.
authors.forename: Jesse D
authors.initials: JD
authors.lastname: Pasternak
authors.affiliation: Division of Paediatric Endocrinology, Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: Danielle
authors.initials: D
authors.lastname: van der Kaay
authors.affiliation: Department of General Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Menno R
authors.initials: MR
authors.lastname: Vriens
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Evan J
authors.initials: EJ
authors.lastname: Propst
authors.affiliation: Division of Paediatric Endocrinology, Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Wasserman
mesh_terms: D000293:Adolescent; D002648:Child; D013507:Endocrine Surgical Procedures / Q000379:methods; D005260:Female; D006801:Humans; D008207:Lymphatic Metastasis; D008297:Male; D009364:Neoplasm Recurrence, Local; D012189:Retrospective Studies; D018570:Risk Assessment; D013964:Thyroid Neoplasms / Q000473:pathology / Q000601:surgery*; D013965:Thyroidectomy / Q000379:methods*