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Aim: Recent guidelines have attempted to de-escalate treatment pathways for low-risk papillary thyroid carcinoma (PTC) to reduce long-term morbidities associated with treatment. The literature supporting either hemithyroidectomy or total thyroidectomy for PTC between 1 and 4 cm is conflicting and dependent on the accuracy of clinical staging. We examined the variability between clinical and pathological tumor staging for PTC 1 to 4 cm. Materials and methods: This study is a single center, retrospective cohort study of all patients who underwent surgery for confirmed PTC between 1 and 4 cm, from January 2010 to August 2017. Results: The cohort included 38 patients, of which 20 patients (53%) had no high-risk features on histopathology, and 18 patients (47%) had one or more high-risk feature. Fiftyfive percent of patients had a 5mm or more variance between preoperative and postoperative sizing. Among the patients with no high-risk features, preoperative ultrasound overestimated the size (p = 0.0007) and stage (55% downgraded) when compared to postoperative histopathology reports. 80% of patients that underwent hemithyroidectomy had no high-risk features and avoided completion thyroidectomy. Conclusion: We identified a particular cohort of patients that had no high-risk features on final histopathology that had greater differences in preoperative and postoperative tumor sizes. Overestimation of size and stage of PTC has the potential for the overtreatment of these patients. This study has shown the importance of determining high-risk features and other PTC parameters, such as size and staging. We have highlighted the potential importance of preoperative or intraoperative tumor evaluation in identifying patients who could benefit from conservative surgical approaches. Clinical significance: Identification of papillary thyroid cancer patients without high-risk features either preoperatively or intraoperatively can provide surgeons with a stratified guideline to decide which patients are suitable for conservative surgery compared to total thyroidectomy.

Clinical Staging Variability and Surgery in Papillary Thyroid Cancers with Tumor Size 1 to 4 cm