As the authors of the paper state, the management of low-risk differentiated thyroid cancer (DTC) remains controversial because of the indolent nature of the disease and the challenge of balancing morbidity of treatments with the risk of disease progression. The extent of thyroid resection is still a matter of debate: total thyroidectomy (TT) versus hemithyroidectomy (HT) (lobectomy plus isthmusectomy) using either a conventional neck incision or, in selected patients, a remote-access procedure, in this case the Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA)¹.

In the article published in this issue, Sacco et al. report the results of an observational study analyzing retrospective data obtained from the electronic medical records of a cohort of 114 patients with low-risk DTC managed with HT though different surgical approaches (neck incision and remote trans-oral approach) between January 2015 and April 2023. The number of TH procedures increased from 3.07% in 2015 to 29.3% in 2023².

The preoperative ultrasound characteristics, fine needle aspiration (FNA) cytology results, and TNM stage were analyzed. Additionally, the survival curve and the risk of recurrence according to the American Thyroid Association (ATA) and the pathological findings in 114 patients were evaluated.

Strikingly, patients with Bethesda I and II nodules were included for surgical management. Bethesda III nodules are not divided in FLUS and AUS. Regarding the FNA cytology results, the authors state that patients with a Bethesda category other than V and VI were included in this series due to the postoperative or intraoperative pathology report of carcinoma.

Among the results, 4 patients with isthmusectomy were included, and this inclusion is not consistent with the article title.

Size and multifocality should be considered in recurrences. In this study, the presence of multifocality did not modify the indication of the lobectomy performed.

Nodules > 4 cm seem to have a slightly higher recurrence rate at 10 years after TH compared to TT, and patients with nodules < 4 cm have a better disease-free survival than those > 4 cm. In this study, two patients with nodules > 4 cm were included. The authors do not report how these patients evolved during follow-up.

The complication rate reported by the authors is low, temporary recurrent laryngeal palsy in one case and mild ecchymosis in those patients who underwent the remote approach.

The final diagnosis of the pathology report (Table 3) indicated that 14 patients had follicular variant of papillary thyroid carcinoma and that 8 patients had high-risk variants, although the specific variants and the extent of their involvement were not specified. In the material and methods section only the usual papillary carcinoma is included.

The authors mention that there are only two categorical indications for completion thyroidectomy: vascular invasion > 4 vessels and aggressive histology (tall cells) if the percentage of cells with these characteristics is > 30%.

In this series, 95% of the patients were classified as low risk of recurrence in the initial assessment, the authors do not report death or regional or distant metastases, and 5 patients were considered in the intermediate risk category based on the findings of the delayed pathology report. In these patients, total thyroidectomy was not performed based on the recommendation of the treating team or patient preference. We do not count with information about the long-term follow-up outcomes in these intermediate risk patients.

Patients should be informed preoperatively about the possibility of completion thyroidectomy based on the intraoperative findings or pathological examination of the surgical specimen (6-20%) and accept the risk of reintervention for diagnostic or therapeutic purposes during follow-up (5-10%) for completion thyroidectomy.

In this study, the initial risk of recurrence after HT can be determined, but this baseline risk cannot be modified over time due to the short follow-up period. The series is relatively small, and the follow-up period is relatively short, as noted by the authors (the mean follow-up period was 33.4 months, with a range of 2 to 101 months).

The authors did not compare these results with a series of patients with total thyroidectomy.

In addition to the extent of surgery, the remote approach (TOETVA) and patient satisfaction should have been evaluated, as this is a selective approach that is important for aesthetic outcomes. According to the ATA recommendations,

thyroid lobectomy is an adequate treatment for small, unifocal, intrathyroidal carcinoma in the absence of prior head and neck radiation therapy, familial thyroid carcinoma, or clinically detectable neck lymph node metastases³.

I agree with the authors and the ATA recommendations that thyroid lobectomy is an appropriate surgical management option for differentiated thyroid carcinoma with a low risk of recurrence. It is crucial to have a longer follow- up period to perform a dynamic follow-up over an extended period.