Impact of reflexive preoperative molecular testing for indeterminate nodules on lobectomy and completion thyroidectomy rates.

Objective: Guideline-based lobectomy criteria were adopted in July 2017, and reflexive molecular testing (MT) was introduced for all Bethesda III/IV indeterminate thyroid nodules (ITNs) in July 2020. This study evaluates how reflexive MT of ITNs influenced lobectomy and completion thyroidectomy (CT) rates. Methods: Patients with well-differentiated thyroid cancer who had undergone surgery were identified from a prospective database. Patients were categorized into three groups: i) Bethesda V/VI initial lobectomy, ii) Bethesda III/IV initial lobectomy without MT, iii) Bethesda III/IV lobectomy candidates with MT. The indications for and rates of lobectomy and CT, postoperative complications, and thyroid hormone replacement (THR) were assessed. Results: From July 2017 to October 2023, 227 of 799 (28%) patients with thyroid cancer underwent initial lobectomy, with 91, 70, and 64 patients in each group, respectively. Included in group 3 were 16 ITNs that would have undergone diagnostic lobectomy; however, due to the presence of a malignant mutation, they underwent total thyroidectomy (TT). TT was the appropriate surgery for 15 of 16 patients based on either preoperative lobectomy exclusion criteria or final pathology. CT rates by group were 26, 43, and 27%, respectively (P < 0.05). Vascular invasion, tumor size >4 cm, and aggressive histology were the most common indications for CT. ThyroSPEC was independently associated with a lower likelihood of CT in multivariate analysis. Surgical complications were lower with lobectomy (2%) versus CT (7%), with 44% of lobectomy patients requiring THR. Conclusion: Reflexive MT for ITNs decreased CT rates by increasing appropriate upfront TT. Lobectomy demonstrated lower rates of surgical complications and THR than two-stage thyroidectomy.