Risk-adapted surgical approach for differentiated thyroid carcinoma-is less more?

BackgroundChanges in the World Health Organization (WHO) classification of thyroid neoplasms as well as recently published study results on active surveillance for papillary thyroid microcarcinomas (PTMC) diagnosed by fine needle biopsy, imply that the potential malignancy of certain subgroups of thyroid neoplasms may have been overrated in the past.ObjectiveThe question is raised whether the recent insights obtained from studies and guidelines justify aless aggressive surgical approach to the management of differentiated thyroid carcinomas.Material and methodsThe current recommendations for the management of malignant thyroid diseases established by the surgical working group on endocrinology (CAEK) and the recently revised recommendations of the American Thyroid Association (ATA) are summarized and the potential need for adaptation of the recommendations is critically discussed.Results and conclusionThe ATA recommendations enable an active surveillance in cases of PTMC. Furthermore, low-risk differentiated thyroid carcinoma >1cm <4cm can be optionally treated with lobectomy only as an alternative to total thyroidectomy. In contrast, the CAEK generally recommends total thyroidectomy for differentiated thyroid carcinomas, with the exception of PTMC and minimally invasive follicular thyroid carcinoma without angioinvasion, for which lobectomy is considered asufficient treatment. Changes in the WHO classification of thyroid neoplasms necessitate an adaptation of surgical management to the preoperative risk stratification of the tumor. Comprehensive preoperative diagnostics (including molecular biology) are therefore crucial for an up to date, risk-adapted surgical appoach.