The preferred surgical choice for intermediate-risk papillary thyroid cancer: total thyroidectomy or lobectomy? A systematic review and meta-analysis

Background: The optimal surgical approach for intermediate-risk papillary thyroid carcinoma (IR-PTC) (according to ATA definition), whether total thyroidectomy (TT) or lobectomy (LT), has remained a contentious clinical gray area for several decades. This systematic review and meta-analysis aim to provide robust evidence and address this clinical dilemma comprehensively. Materials and methods: A comprehensive literature search was conducted in Pubmed, Embase, Web of Science, and the Cochrane Library from 1st January 2009 to 29th December 2023 to evaluate the impact of different surgical options (TT or LT) on patients with IR-PTC. The primary outcomes included survival, recurrence rates, and postoperative complications. I 2 and sensitivity analysis was used to explore the heterogeneity. Results: A total of 8 studies involving 2984 participants were included in this meta-analysis and systematic review. The results indicated that LT was a superior choice for mitigating complications compared to TT [risk ratio (RR), 0.32; 95% CI: 0.24–0.44, P<0.01], particularly for transient complications (RR, 0.24; 95% CI: 0.08–0.65, P<0.01), such as the transient parathyroid dysfunction (RR, 0.04; 95% CI: 0.01–0.15, P<0.01). However, TT did not increase the risk of recurrent laryngeal nerve palsy (RR, 0.78; 95% CI: 0.24–2.47, P=0.67), hemorrhage/seroma (RR, 0.77; 95% CI: 0.48–1.25, P=0.30), and permanent complications (RR, 0.18; 95% CI: 0.02–1.42, P=0.10). Besides, both LT and TT presented similar effect on survival outcomes (overall survival: RR, 1.00; 95% CI: 0.97–1.03, P=0.92, disease-specific survival: RR, 0.99; 95% CI: 0.97–1.02, P=0.69, recurrence-free survival: RR, 1.00; 95% CI: 0.96–1.05, P=0.86), recurrence (RR, 1.05; 95% CI: 0.76–1.46, P=0.76). Conclusion: The present meta-analysis revealed that TT did not yield improved outcomes in IR-PTC patients, but was associated with an increased incidence of temporary complications. In light of these findings, it may be advisable to consider LT as the optimal choice for IR-PTC patients.


Did the research questions and inclusion criteria for the review include the components of PICO?
For Yes:  Population  Intervention  Comparator group  Outcome Optional (recommended)  Timeframe for follow-up  Yes  No 2. Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol?
For Partial Yes: The authors state that they had a written protocol or guide that included ALL the following:  review question(s)  a search strategy  inclusion/exclusion criteria  a risk of bias assessment For Yes: As for partial yes, plus the protocol should be registered and should also have specified:

Did the review authors perform study selection in duplicate?
For Yes, either ONE of the following:  at least two reviewers independently agreed on selection of eligible studies and achieved consensus on which studies to include  OR two reviewers selected a sample of eligible studies and achieved good agreement (at least 80 percent), with the remainder selected by one reviewer.
 Yes  No

Did the review authors perform data extraction in duplicate?
For Yes, either ONE of the following:  at least two reviewers achieved consensus on which data to extract from included studies  OR two reviewers extracted data from a sample of eligible studies and achieved good agreement (at least 80 percent), with the remainder extracted by one reviewer.

Did the review authors explain their selection of the study designs for inclusion in the review
?For Yes, the review should satisfy ONE of the following: Explanation for including only RCTs  OR Explanation for including only NRSI  OR Explanation for including both RCTs and NRSI  Yes  No 4.

Did the review authors report on the sources of funding for the studies included in the review?
 Must have reported on the sources of funding for individual studies included in the review.Note: Reporting that the reviewers looked for this information but it was not reported by study authors also qualifies  Yes  No 11.

If meta-analysis was performed, did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis?
For Yes: included only low risk of bias RCTs  OR, if the pooled estimate was based on RCTs and/or NRSI at variable RoB, the authors performed analyses to investigate possible impact of RoB on summary estimates of effect.

Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?
For Yes: The authors reported no competing interests OR  The authors described their funding sources and how they managed potential conflicts of interest Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, Moher D, Tugwell P, Welch V, Kristjansson E, Henry DA.AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both.BMJ.2017 Sep 21;358:j4008.