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THYROID CANCER
2025 ATA Differentiated Thyroid Cancer Guidelines: Extent of surgery
BACKGROUND
A major aspect of the treatment of thyroid cancer is the extent of initial surgery once a diagnosis of thyroid cancer is made. The 2009 ATA thyroid cancer guidelines recommended total thyroidectomy for nearly all thyroid cancers >1 cm in size and lobectomy for cancers <1 cm in size. The recommendations changed in 2015 to suggest lobectomy as an option for cancer that is located only in 1 lobe and is <4 cm in size with low-risk features and no spread outside of the thyroid. Since 2015, several studies evaluating lobectomy versus total thyroidectomy have been performed and form the basis for the new recommendations in the 2025 ATA guidelines.
This paper summarizes the changes in the initial extent of surgery in the 2025 ATA differentiated thyroid cancer guidelines.
THE FULL ARTICLE TITLE
Ringel MD et al. 2025 American Thyroid Association management guidelines for adult patients with differentiated thyroid cancer. Thyroid 2025;35(8):841-985.
SUMMARY OF THE STUDY
The 2025 ATA guidelines refer to patients with differentiated thyroid cancer diagnosed prior to surgery, almost all of which are papillary thyroid carcinoma. The recommended surgical approach planned should be determined after a discussion with shared decision making with the patient. Additional factors, including patient sex, family history of thyroid cancer, and history of radiation exposure may also impact decision-making.
- Patients with cancer limited to one lobe ≤2 cm without extension outside of the thyroid or spread to lymph nodes in the neck should undergo a lobectomy.
- Patients with cancer limited to one lobe >2 and ≤4 cm without extension outside of the thyroid or spread to lymph nodes in the neck may undergo lobectomy or total thyroidectomy depending on the cancer features, presence of nodules in the other lobe, and patient preference. If lobectomy is performed, the patient should be advised on the 20% risk of conversion to a total thyroidectomy during the operation or potential for completion thyroidectomy after the pathology returns.
- Patients with cancer >4 cm in size extension outside of the thyroid or spread to lymph nodes in the neck or elsewhere in the body should receive a total thyroidectomy and resection of all concerning lymph nodes in the neck.
WHAT ARE THE IMPLICATIONS OF THIS STUDY?
While prior guidelines recommended a lobectomy as an option for low-risk thyroid cancer limited to 1 lobe, the 2025 ATA cancer guidelines recommend that lobectomy is now the recommended surgical option based on a large body of evidence supporting lobectomy for low-risk thyroid cancers. These recommendations should help patients and surgeons feel more comfortable offering a lobectomy in these situations. The final plan for a lobectomy or total thyroidectomy still should rest with a shared decision making discussion between the surgeon and the patient.
ATA RESOURCES
Thyroid Cancer (Papillary and Follicular): https://www.thyroid.org/thyroid-cancer/
Thyroid Surgery: https://www.thyroid.org/thyroid-surgery/
Radioactive Iodine Therapy: https://www.thyroid.org/radioactive-iodine/
ABBREVIATIONS & DEFINITIONS
Differentiated thyroid cancer: the most common type of thyroid cancer, includes papillary, follicular and oncocytic thyroid cancer
Papillary thyroid cancer: the most common type of differentiated thyroid cancer. There are 4 variants of papillary thyroid cancer: classic, follicular, tall-cell and noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP).
Papillary microcarcinoma: a papillary thyroid cancer smaller than 1 cm in diameter.
Follicular thyroid cancer: the second most common type of differentiated thyroid cancer.
Noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP): a new term has been used to describe a type of papillary thyroid cancer which is non-invasive. These cancers behave less aggressively than typical papillary thyroid cancer and have been shown to have low risk for recurrence and low risk for spread outside of the thyroid.
Follicular variant of papillary thyroid cancer: one of the subtypes of papillary thyroid carcinoma, which has been classified to three different forms: non-invasive follicular thyroid neoplasm with papillary-like nuclear features, invasive encapsulated and infiltrative FVPTC.
Oncocytic thyroid cancer: least common type of differentiated thyroid cancer, which has a higher rate of recurrence outside of the neck. Further, oncocytic thyroid cancer is more resistant to radioactive iodine therapy than other forms of differentiated thyroid cancer.
Thyroidectomy: surgery to remove the entire thyroid gland. When the entire thyroid is removed it is termed a total thyroidectomy. When less is removed, such as in removal of a lobe, it is termed a partial thyroidectomy.
Lobectomy: surgery to remove one lobe of the thyroid.
Completion thyroidectomy: surgery to remove the remaining thyroid lobe in thyroid cancer patients who initially had a lobectomy.
Radioactive iodine (RAI): this plays a valuable role in diagnosing and treating thyroid problems since it is taken up only by the thyroid gland. I-131 is the destructive form used to destroy thyroid tissue in the treatment of thyroid cancer and with an overactive thyroid. I-123 is the nondestructive form that does not damage the thyroid and is used in scans to take pictures of the thyroid (Thyroid Scan) or to take pictures of the whole body to look for thyroid cancer (Whole Body Scan).
Active Surveillance: following a small, low-risk thyroid cancer with ultrasound and deferring surgery until the cancer grows significantly
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