BACKGROUND
Thyroid cancer is common and the most common type of thyroid cancer is papillary thyroid cancer. Fortunately, papillary thyroid cancer usually has very good outcomes and prognosis as we have very effective therapies. Initial treatment is usually surgery, and this can be either removal of the lobe that contains cancer (lobectomy) or removal of the entire thyroid gland (total thyroidectomy). For more advanced cancers, surgery can be followed with radioactive iodine therapy, which works as a magic bullet to seek out and destroy any remaining thyroid cancer cells. Years ago, most thyroid cancer patients would get a total thyroidectomy and radioactive iodine therapy. We now know that most patients do not need such aggressive therapy. The 2025 American Thyroid Association guidelines for treatment of thyroid cancer took this into account and now recommends separating patients into low-, low-intermediate-, intermediate- high-, and high-risk groups based on what the cancer looks like after surgery and on the risk of the cancer coming back after the initial surgery. Patients in the low and lowintermediate groups usually have surgery only, and most will end up with a lobectomy only. Total thyroidectomy and radioactive iodine therapy is recommended as the risk of thyroid cancer recurrence increases.

Specifically, total thyroidectomy and radioactive iodine therapy is the recommendation for intermediate-high risk patients. However, this is a rather diverse group of patients and maybe all do not need this aggressive treatment. In this study, researchers examine the outcomes for intermediate-high risk patients treated with 3 different approaches: (1) lobectomy with lymph node dissection, (2) total thyroidectomy with lymph node dissection and (3) total thyroidectomy with lymph node dissection followed by radioactive iodine therapy.

THE FULL ARTICLE TITLE
Fujiwara T, et al. Are total thyroidectomy and adjuvant radioactive iodine treatment required in all patients with N1b intermediate-high risk papillary thyroid carcinoma? Thyroid 2026;36(1):36–45

SUMMARY OF THE STUDY
This study included patients with intermediate-high risk thyroid cancer who underwent thyroidectomy with lymph node dissection between 2010 and 2022. Three management approaches were compared: (1) lobectomy with lymph node dissection (109 patients), (2) total thyroidectomy with lymph node dissection (170 radioactive iodine therapy), and (3) total thyroidectomy with lymph node dissection followed by radioactive iodine therapy (279 patients). They looked at patient survival with no evidence of thyroid cancer recurrence as well as how many patients died of their cancer.

The group included a total of 593 patients (60.6% female; average age, 58 years) who had an average follow-up duration of 71.5 months. The average cancer size was 18 mm, and several foci of cancer were present in 242 patients (43.4%), with predominant classical papillary thyroid cancer. Spread of the cancer outside of the thyroid was observed in 226 patients (40.5%) and spread of the cancer outside of lymph nodes was seen in 144 patients (24.3%). Thyroid cancer recurrence was reported in 75 patients (12.6%).

Patients who underwent total thyroidectomy followed by radioactive iodine therapy were more likely to have thyroid cancer recurrence, although this was not significant. Patients with larger cancers and larger lymph nodes with cancer were associated with shorter time to thyroid cancer recurrence. Conversely, the extent of thyroid surgery and use of radioactive iodine therapy were not independent predictors of recurrence.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
This study suggests that radioactive iodine therapy may decrease the frequency of thyroid cancer recurrence in selected patients with high-risk features and extensive spread of the cancer to the lymph nodes. However, the use of radioactive iodine therapy likely should not be routine across all intermediate-high-risk patients with papillary thyroid cancer. In those with smaller cancers with less spread to the lymph nodes, lobectomy or total thyroidectomy with lymph node dissection alone could be appropriate. As in all cases, personalized risk stratification and management is necessary to provide the best treatment for thyroid cancer patients.

— Alan Farwell, MD

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