we investigated 383 consecutive classical ptmc patients from the department of pathology , kangbuk samsung hospital , sungkyunkwan university school of medicine ( seoul , korea ) from january 1 , 2010 to december 31 , 2011 .
the correlations between multifocality and clinicopathological characteristics including age , sex , tumor size , extrathyroidal extension , lymph node metastasis , ptnm stage , and us findings were evaluated by reviewing medical charts , pathology records , and glass slides and based on the seventh edition ajcc tnm classification system .
patients had undergone either total thyroidectomy ( n = 237 ) or lobectomy ( including hemithyroidectomy ) ( n = 146 ) with lymph node dissection . the decisions to perform lymph node dissection and the extent of dissection were made by the surgeon based on ata management guidelines   and various risk - evaluation systems .
the mean age of patients was 45.4  10.4 years , the mean tumor size of the largest dominant tumor was 0.65  0.20 cm , and the sex ratio ( male : female ) was 1:3.85 . by ajcc stage grouping , there were 295 cases in stage i , 0 cases in stage ii , 86 cases in stage iii , and two cases in stage iv .
the study protocol was approved by the institutional review board ( irb ) of kangbuk samsung hospital ( irb no .
kbc12202 ) , who confirmed informed consents . sections were cut to a thickness of 0.2 cm for postoperative pathological examination .
all tumors detected during inspection were histologically examined . for evaluation of extrathyroidal extension , peritumoral parenchyma with thyroidal
in addition , one section with normal - appearing parenchyma was included from each lobe .
mptmcs were defined as tumors with an intertumoral distance greater than 0.5 cm in the ipsilateral lobe or contralateral lobe of the primarytumor . the number of tumors ranged from two to six ( mean , 2.36  0.70 ) , and we designated ptmcs other than the largest tumor as supplemental tumors .
the first group included suspicious mptmcs , the second group included uptmcs accompanied by benign or indeterminate nodules , and the third group included suspicious uptmcs .
within the second and third groups , incidental mptmcs were defined as those discovered on pathological examination , which were not detected on preoperative us .
us evaluation was performed by radiologists at our institution , and results were reported according to standard criteria .
relevant articles were obtained by searching pubmed and medline databases up to january 15 , 2015 .
searches were performed using the keywords  papillary thyroid carcinoma  and  multifocal . 
search results were then scanned according to the following inclusion and exclusion criteria : ( 1 ) ptc investigated in human tissue , ( 2 ) available information regarding tumor recurrence in uptmc and mptmc , ( 3 ) case reports or non - original articles were excluded , and ( 4 ) non - english language publications were excluded .
the following data were extracted from each of the eligible studies : the first author s name , year of publication , number of patients analyzed , and number of patients with tumor recurrence .
the significance of tumor multifocality and correlations with clinicopathological parameters were determined by either chi - squre test or the fisher exact test ( two - sided ) .
the relationship between tumor multifocality and tumor size was analyzed using a two - tailed student s t test .
linear regression analysis was conducted to investigate correlations between primary tumor size and tumor multifocality , number of tumor , and supplemental tumor size .
in addition , multivariate logistic regression analysis was performed to identify the most influential variables associated with tumor multifocality . to perform the meta - analysis , comprehensive meta - analysis ver .
odds ratio ( or ) with a 95% confidence interval ( ci ) was calculated by fixed - effect and random - effect models and used to evaluate the correlation between tumor multifocality and recurrence .
heterogeneity between studies was evaluated with the q test , i , and p - values .
we investigated 383 consecutive classical ptmc patients from the department of pathology , kangbuk samsung hospital , sungkyunkwan university school of medicine ( seoul , korea ) from january 1 , 2010 to december 31 , 2011 .
the correlations between multifocality and clinicopathological characteristics including age , sex , tumor size , extrathyroidal extension , lymph node metastasis , ptnm stage , and us findings were evaluated by reviewing medical charts , pathology records , and glass slides and based on the seventh edition ajcc tnm classification system .
patients had undergone either total thyroidectomy ( n = 237 ) or lobectomy ( including hemithyroidectomy ) ( n = 146 ) with lymph node dissection . the decisions to perform lymph node dissection and the extent of dissection were made by the surgeon based on ata management guidelines   and various risk - evaluation systems .
the mean age of patients was 45.4  10.4 years , the mean tumor size of the largest dominant tumor was 0.65  0.20 cm , and the sex ratio ( male : female ) was 1:3.85 . by ajcc stage grouping , there were 295 cases in stage i , 0 cases in stage ii , 86 cases in stage iii , and two cases in stage iv .
the study protocol was approved by the institutional review board ( irb ) of kangbuk samsung hospital ( irb no .
sections were cut to a thickness of 0.2 cm for postoperative pathological examination . all tumors detected during inspection
in addition , one section with normal - appearing parenchyma was included from each lobe .
mptmcs were defined as tumors with an intertumoral distance greater than 0.5 cm in the ipsilateral lobe or contralateral lobe of the primarytumor . the number of tumors ranged from two to six ( mean , 2.36  0.70 ) , and we designated ptmcs other than the largest tumor as supplemental tumors .
the first group included suspicious mptmcs , the second group included uptmcs accompanied by benign or indeterminate nodules , and the third group included suspicious uptmcs .
within the second and third groups , incidental mptmcs were defined as those discovered on pathological examination , which were not detected on preoperative us .
us evaluation was performed by radiologists at our institution , and results were reported according to standard criteria .
relevant articles were obtained by searching pubmed and medline databases up to january 15 , 2015 .
searches were performed using the keywords  papillary thyroid carcinoma  and  multifocal . 
search results were then scanned according to the following inclusion and exclusion criteria : ( 1 ) ptc investigated in human tissue , ( 2 ) available information regarding tumor recurrence in uptmc and mptmc , ( 3 ) case reports or non - original articles were excluded , and ( 4 ) non - english language publications were excluded .
the following data were extracted from each of the eligible studies : the first author s name , year of publication , number of patients analyzed , and number of patients with tumor recurrence .
statistical analyses were conducted using spss ver . 18.0 software ( spss inc . , chicago , il , usa ) .
the significance of tumor multifocality and correlations with clinicopathological parameters were determined by either chi - squre test or the fisher exact test ( two - sided ) .
the relationship between tumor multifocality and tumor size was analyzed using a two - tailed student s t test .
linear regression analysis was conducted to investigate correlations between primary tumor size and tumor multifocality , number of tumor , and supplemental tumor size .
in addition , multivariate logistic regression analysis was performed to identify the most influential variables associated with tumor multifocality . to perform the meta - analysis , comprehensive meta - analysis ver .
odds ratio ( or ) with a 95% confidence interval ( ci ) was calculated by fixed - effect and random - effect models and used to evaluate the correlation between tumor multifocality and recurrence .
heterogeneity between studies was evaluated with the q test , i , and p - values .
we initially investigated the correlations between tumor multifocality and clinicopathological parameters in 383 resected classical ptmcs .
tumor multifocality was noted in 103 of 383 ptmcs ( 26.9% ) , and nodal metastasis occurred at significantly higher rates in mptmcs than in uptmcs ( p=.003 ) .
patients who underwent total thyroidectomy showed a higher incidence of tumor multifocality than patients who underwent lobectomy ( p<.001 ) .
for the 83 mptmcs in which total thyroidectomy was undertaken , tumor bilaterality was 62.7% ( 52 of 83 ) .
there were no significant differences with respect to age , sex , tumor size , or extrathyroidal extension ( table 1 ) .
on multivariate analysis , tumor multifocality was significantly correlated with lymph node metastasis ( p=.002 ) but not age ( 45 years ) , sex , or extrathyroidal extension . on preoperative us ,
tumor multiplicity was found in 180 cases including 54 suspicious mptmc cases . among suspicious mptmcs ,
41 cases were confirmed as mptmcs ( non - incidental mptmcs ) on pathological examination . for the remaining 126 suspicious uptmcs accompanied by benign or indeterminate nodules ,
nineteen cases ( three suspicious mptmc cases and 16 non - suspicious mptmc cases ) involved incidentally found ptmcs ( incidental mptmcs ) that were not identified preoperatively . in 203 cases regarded as uptmcs on preoperative us , 23 supplemental ptmcs were incidentally discovered on pathological examination ( incidental mptmcs ) . in total , 103 mptmcs ( 61 non - incidental and 42 incidental ) of 383 ptmcs were identified ( fig .
the distribution of mptmcs based on primary tumor size was investigated and is shown in fig .
the rate of mptmc occurrence was 0%34.4% and was shown to increase with increasing primary tumor size on linear regression analysis ( r=0.519 and p=.019 ) .
ptmcs were divided with a cutoff of 0.3 cm , and the mptmc rate was 5.9% in ptmcs smaller than 0.3 cm and 27.9% in ptmcs larger than 0.3 cm .
in addition , the number of tumors and supplemental tumor size were significantly increased according to primary tumor size ( r=0.014 , p=.021 and r=0.117 , p=.023 , respectively ) ( fig .
forty - two cases ( 40.8% ) were incidentally diagnosed as mptmc via postoperative pathological examination . to understand the significance of incidentally discovered supplemental tumors in mptmc , we compared clinicopathological characteristics between incidental and non - incidental mptmcs .
the mean sizes of supplemental tumors were 0.23  0.12 cm in incidental mptmcs and 0.41  0.17 cm in non - incidental mptmcs .
as expected , supplemental tumor size was significantly smaller in incidental mptmcs than in non - incidental mptmcs ( p<.001 ) , even though the largest tumor size did not differ ( p=.870 ) .
the rate of extrathyroidal extension was higher in incidental mptmcs than in non - incidental mptmcs ( p=.016 ) , but there was no difference in lymph node metastasis ( p=.199 ) ( table 2 ) .
we performed a systematic review and meta - analysis to confirm the difference of tumor recurrence between uptmc and mptmc .
one hundred fifty - six studies were identified through a database search and were screened ( fig .
3 ) ; 148 of these studies were excluded due to no or insufficient information ( 123 ) , studies on other disease ( 10 ) , case reports or non - original articles ( 13 ) , and non - english - language articles ( 2 ) . eight eligible studies and 5,665 patients were included in the current meta - analysis [ 15 - 22 ] .
tumor multifocality was found in 1,844 of 5,665 overall ptmcs ( 32.6% ) . in the eligible studies , the rates of tumor multifocality were 24.0%42.5% .
our meta - analysis showed significant correlation between tumor recurrence and mptmcs in fixed - effect ( or , 2.002 ; 95% ci , 1.475 to 2.719 ; p<.001 ) and random - effect ( or , 2.118 ; 95% ci , 1.323 to 3.390 ; p=.002 ) models ( fig .
4 ) . on sensitivity analysis , or ranges were 1.7362.277 and 1.9072.417 in fixed - effect and random - effect models , respectively , and estimated ors were not affected by eligible studies .
there was no definite asymmetry in begg s funnel plot ( data not shown ) .
we initially investigated the correlations between tumor multifocality and clinicopathological parameters in 383 resected classical ptmcs .
tumor multifocality was noted in 103 of 383 ptmcs ( 26.9% ) , and nodal metastasis occurred at significantly higher rates in mptmcs than in uptmcs ( p=.003 ) .
patients who underwent total thyroidectomy showed a higher incidence of tumor multifocality than patients who underwent lobectomy ( p<.001 ) .
for the 83 mptmcs in which total thyroidectomy was undertaken , tumor bilaterality was 62.7% ( 52 of 83 ) .
there were no significant differences with respect to age , sex , tumor size , or extrathyroidal extension ( table 1 ) .
on multivariate analysis , tumor multifocality was significantly correlated with lymph node metastasis ( p=.002 ) but not age ( 45 years ) , sex , or extrathyroidal extension . on preoperative us ,
tumor multiplicity was found in 180 cases including 54 suspicious mptmc cases . among suspicious mptmcs ,
41 cases were confirmed as mptmcs ( non - incidental mptmcs ) on pathological examination . for the remaining 126 suspicious uptmcs accompanied by benign or indeterminate nodules ,
nineteen cases ( three suspicious mptmc cases and 16 non - suspicious mptmc cases ) involved incidentally found ptmcs ( incidental mptmcs ) that were not identified preoperatively . in 203 cases regarded as uptmcs on preoperative us , 23 supplemental ptmcs were incidentally discovered on pathological examination ( incidental mptmcs ) . in total , 103 mptmcs ( 61 non - incidental and 42 incidental ) of 383 ptmcs were identified ( fig .
the distribution of mptmcs based on primary tumor size was investigated and is shown in fig .
2a . the rate of mptmc occurrence was 0%34.4% and was shown to increase with increasing primary tumor size on linear regression analysis ( r=0.519 and p=.019 ) .
ptmcs were divided with a cutoff of 0.3 cm , and the mptmc rate was 5.9% in ptmcs smaller than 0.3 cm and 27.9% in ptmcs larger than 0.3 cm .
in addition , the number of tumors and supplemental tumor size were significantly increased according to primary tumor size ( r=0.014 , p=.021 and r=0.117 , p=.023 , respectively ) ( fig .
forty - two cases ( 40.8% ) were incidentally diagnosed as mptmc via postoperative pathological examination . to understand the significance of incidentally discovered supplemental tumors in mptmc , we compared clinicopathological characteristics between incidental and non - incidental mptmcs .
the mean sizes of supplemental tumors were 0.23  0.12 cm in incidental mptmcs and 0.41  0.17 cm in non - incidental mptmcs . as expected , supplemental tumor size was significantly smaller in incidental mptmcs than in non - incidental mptmcs ( p<.001 ) , even though the largest tumor size did not differ ( p=.870 ) .
the rate of extrathyroidal extension was higher in incidental mptmcs than in non - incidental mptmcs ( p=.016 ) , but there was no difference in lymph node metastasis ( p=.199 ) ( table 2 ) .
we performed a systematic review and meta - analysis to confirm the difference of tumor recurrence between uptmc and mptmc .
one hundred fifty - six studies were identified through a database search and were screened ( fig .
3 ) ; 148 of these studies were excluded due to no or insufficient information ( 123 ) , studies on other disease ( 10 ) , case reports or non - original articles ( 13 ) , and non - english - language articles ( 2 ) .
eight eligible studies and 5,665 patients were included in the current meta - analysis [ 15 - 22 ] .
tumor multifocality was found in 1,844 of 5,665 overall ptmcs ( 32.6% ) . in the eligible studies ,
our meta - analysis showed significant correlation between tumor recurrence and mptmcs in fixed - effect ( or , 2.002 ; 95% ci , 1.475 to 2.719 ; p<.001 ) and random - effect ( or , 2.118 ; 95% ci , 1.323 to 3.390 ; p=.002 ) models ( fig .
4 ) . on sensitivity analysis , or ranges were 1.7362.277 and 1.9072.417 in fixed - effect and random - effect models , respectively , and estimated ors were not affected by eligible studies .
there was no definite asymmetry in begg s funnel plot ( data not shown ) .
multifocal ptcs are associated with loco - regional recurrence and lymph node metastasis ; however , the clinicopathological significance and appropriate treatment modalities for mptmc remain unclear . in addition , little is known about the clinicopathological characteristics of incidental mptmcs . to the best of our knowledge ,
this is the first report showing the clinicopathological significance of incidental mptmcs and the correlation between tumor recurrence and mptmcs using meta - analysis .
the incidence of ptmcs has rapidly increased in recent years [ 23 - 25 ] .
it is debated whether ptmc is a normal finding , equivalent to disease , or a precursor of overt ptc .
reported that the rate of ptmc enlargement without unfavorable features was 6.4% at 5 years and 15.9% at 10 years .
in previous reports , distant metastasis and mortality occurred more rarely in ptmc than in overt ptc .
however , there are many reports showing that ptmcs show similar rates of extrathyroidal extension and nodal metastasis ( 40.3% to 64.1% ) [ 23 - 25,28,29 ] . in addition
, a recent meta - analysis showed that total thyroidectomy was significantly correlated with lower recurrence and mortality rates in ptmc .
patients who underwent total thyroidectomy showed a higher incidence of tumor multifocality than patients who underwent lobectomy ( p<.001 ) . in 83 mptmcs that underwent total thyroidectomy ,
still , the unfavorable factors that can result in aggressive behavior and impact prognosis in ptmcs remain unclear .
tumor multifocality is not considered a high - risk factor in systems including ages ( age , grade , extent , size ) , ames ( age , distant metastasis , extent , size ) , macis ( distant metastasis , age , completeness of resection , local invasion , size ) , and games ( grade , age , distant metastasis , extent , size ) .
our data showed that tumor multifocality was significantly associated with nodal metastasis in 26.9% of total ptmcs , as in previous studies [ 15,17 - 19 ] .
however , in the ptmcs of some previous studies , the correlation between tumor multifocality and recurrence wascontroversial [ 15 - 22 ] .
further cumulative prospective studies or meta - analysis should be performed to determine the clinicopathological significance of mptmc .
our meta - analysis showed that tumor recurrence was significantly higher in mptmc than in uptmc ( fig .
regrettably , our data could not be included in the meta - analysis due to limitations including no recurrence cases during follow - up and short follow - up period ( 3 years ) .
in addition , the current meta - analysis did not allow subgroup analysis based on positive or negative resection margins due to insufficient information provided in the eligible studies .
kuo et al .   reported that mptmc was associated with worse survival than uptmc but reported no difference in survival between multifocal overt ptc ( > 1 cm ) and mptmc .
our results and earlier studies suggest that tumor multifocality in ptmcs , regardless of tumor size , is a useful predictive factor of aggressive tumor behavior , such as lymph node metastasis and tumor recurrence
. it might be appropriate to manage patients with mptmc differently than patients with uptmc having no unfavorable factors .
incidental ptmc is defined as ptmc incidentally discovered and confirmed by gross and/or microscopic examination from surgical specimens resected for the evaluation of other disease entities .
however , no clear definition for incidental mptmc has been previously provided . in this study , we defined incidental mptmc as supplemental tumors not detected on preoperative us that were discovered on pathological examination .
although these supplemental tumors are important for diagnosis of multifocality , the characteristics of supplemental tumors have not been previously described . in the present study ,
however , the lower limit of tumor size detectable on us is unclear , and more controlled and careful histological examination for entirely submitted cases is needed to identify tumor multifocality .
the mean size of incidentally discovered supplemental tumors was 0.27  0.15 cm , which was significantly smaller than non - incidental tumors ( p<.001 ) .
2 ) . the smaller size explains the lack of detection during preoperative us . however , there was no difference in nodal metastasis rate between incidental and non - incidental mptmc .
this finding suggests that tumor multifocality itself , rather than the manner of detection , is related to lymph node metastasis .
in addition , the detection rate of incidental mptmc might influence the rate of mptmc .
if these supplemental tumors are missed in pathological examination , cases are diagnosed as uptmc and not mptmc .
therefore , detailed examination for multiple tumors using preoperative us study and adequate postoperative pathological examination is essential in the diagnosis of ptmc .
we previously reported that evaluation of tumor multifocality based on total surface area is useful to distinguish aggressive mptmc from less aggressive mptmc and uptmc . on that basis
, we concluded that careful detection of multifocal tumors is important despite discrepant reporting on multifocality .
the discrepancies largely seem to result from different manners of pathological examination and the number of sections analyzed .
although radiological tools have improved , tumors smaller than 0.3 cm are not easily detected via radiological examination . in the present study ,
only four of 383 ptmcs were smaller than 0.3 cm . among them , two cases were 0.2 cm on histological examination , after appearing larger than 0.3 cm on preoperative us .
suspicious nodules on preoperative us in the remaining two cases were confirmed as benign nodules on histological examination .
another two incidentally detected nodules ( 0.2 cm and 0.1 cm ) were diagnosed as ptmc .
in addition , it is difficult to confirm ptmc in preoperative fine - needle aspiration for tumors smaller than 0.5 cm , which require thin sections in postoperative gross examination for non - detected small nodules .
because it is difficult to cut 0.2-cm - thick slices of specimens prior to fixation , thin sectioning after proper fixation is required for assessment of tumor multifocality . in conclusion , this study demonstrates that tumor multifocality in ptmc is significantly correlated with lymph node metastasis .
our meta - analysis revealed a positive correlation between tumor multifocality and tumor recurrence in ptmc .
therefore , careful attention should be paid to detection of mptmc , which behaves differently from uptmc , on preoperative and postoperative examination .
 background : the clinicopathological characteristics and conclusive treatment modality for multifocal papillary thyroid microcarcinoma ( mptmc ) have not been fully established.methods:a retrospective study , systematic review , and meta - analysis were conducted to elucidate the clinicopathological significance of mptmc . 
 we investigated the multiplicity of 383 classical papillary thyroid microcarcinomas ( ptmcs ) and the clinicopathological significance of incidental mptmcs . 
 correlation between tumor recurrence and multifocality in ptmcs was evaluated through a systematic review and meta-analysis.results:tumor multifocality was identified in 103 of 383 ptmcs ( 26.9% ) . on linear regression analysis , primary tumor diameter was significantly correlated with tumor number ( r2=0.014 , p=.021 ) and supplemental tumor diameter ( r2=0.117 , p=.023 ) . of 103 mptmcs , 61 ( 59.2% ) were non - incidental , with tumor detected on preoperative ultrasonography , and 42 ( 40.8% ) were diagnosed ( incidental mptmcs ) on pathological examination . 
 lymph node metastasis and higher tumor stage were significantly correlated with tumor multifocality . however , there was no difference in nodal metastasis or tumor stage between incidental and non - incidental mptmcs . 
 on meta - analysis , tumor multifocality was significantly correlated with tumor recurrence in ptmcs ( odds ratio , 2.002 ; 95% confidence interval , 1.475 to 2.719 , p<.001).conclusions : our results show that tumor multifocality in ptmc , regardless of manner of detection , is significantly correlated with aggressive tumor behavior . 
MATERIALS AND METHODS
Patients
Definition and evaluation of tumor multifocality
Literature search and selection criteria
Data extraction
Statistical analysis
RESULTS
Clinicopathological features of mPTMCs
Distribution of mPTMC based on primary tumor size
Lymph node metastasis in incidental and non-incidental mPTMC
Systematic review and meta-analysis
DISCUSSION