Efficacy of nodal dissection for treatment of persistent/recurrent papillary thyroid cancer

Long term outcomes after repeat lymph node dissections for persistent or recurrent differentiated thyroid cancer

BACKGROUND

The primary treatment for locoregional recurrent/persistent differentiated thyroid cancer (DTC) is repeated lymph node dissection; however, there are limited reports on the safety and long-term efficacy of multiple operations.

METHODS

Patients who underwent a cervical lymph node dissection between 1998 and 2022 were included in this study. Demographics, initial thyroid surgery, subsequent lymph node dissections, follow up information, and response to therapy were acquired.

RESULTS

After one, two, three and four re-operations, 112/314 (35.7 ​%), 16/79 (20.3 ​%), 3/25 (12 ​%), and 0/3 (0 ​%) patients (p ​< ​0.001) had an excellent response, respectively, resulting in a cumulative rate of 41.7 ​% (131/314). The risk for permanent hypoparathyroidism (2.9 ​%) or recurrent laryngeal nerve injury (2.2 ​%) was 5.1 ​% (14/272). This was higher in patients undergoing re-operative central neck dissection (CNDx) (8.7 ​%, 10/114) versus those who did not undergo a previous CNDx (2.5 ​%, 4/158, p ​< ​0.02).

CONCLUSIONS

Surgery remains the primary treatment for recurrent/persistent DTC, however, the likelihood of an excellent response decreases with additional operations. The risk of permanent complications is low but is more likely to occur during redo CNDx.

Medium- and long-term recurrence after radioiodine therapy for differentiated thyroid carcinoma with recombinant human thyrotropin: a meta-analysis

Introduction

Radioactive iodine (RAI) is commonly used in the management of differentiated thyroid cancers (DTCs). However, the long-term efficacy and the risk of tumor recurrence associated with it remain unclear. In particular, the comparison between recombinant human thyrotropin (rhTSH) and thyroid hormone withdrawal (THW) in terms of medium- and long-term recurrence rate in DTC patients has not been fully elucidated.

Methods

A systematic search was carried out to identify articles comparing medium- and long-term outcomes (> 2 years) based on treatment with either rhTSH or THW. Ten studies, consisting of six randomized controlled trials (RCTs) and four retrospective studies with a total of 2,833 patients, were included in the analysis.

Results

There was no significant difference in the medium- and long-term recurrence rates between the rhTSH group and the THW group. This was also the case in subgroup analyses of only RCTs or only retrospective studies. The structural incomplete response (SIR) rate was slightly higher in the rhTSH group, but a subgroup analysis of RCTs alone showed no significant difference in SIR between the two groups.

Discussion

rhTSH is comparable to THW in achieving successful ablation of residual disease and maintaining low recurrence rates. However, further RCTs are required to investigate whether rhTSH can increase the risk of SIR.

Diagnostic Accuracy of Ultrasonography in Revision Thyroid Surgery: Can It Predict Disease Outcomes?

Revision thyroid surgery for residual/recurrent disease is known to have higher complication rates because of parathyroid injury and recurrent laryngeal nerve (RLN) damage. The aim of this study is to evaluate the accuracy of USG in predicting recurrent disease and disease outcomes in patients undergoing reoperation for recurrent/residual thyroid cancer. We performed a retrospective analysis of all thyroid reoperations from 2015 to 2017. Preoperative USG findings were categorized as per prespecified disease stations in the neck and compared with histopathology to calculate sensitivity, specificity, positive predictive value, and negative predictive value of USG. Survival analysis was performed using Kaplan-Meier curves. Two hundred fifty patients were included in the analysis. In a reoperative setting, USG had an overall sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 89%, 77%, 89%, 94%, and 60%, respectively. We found a significantly lower disease-free survival in patients who had radiologically detected recurrent disease as compared to disease detected only on histopathology. USG has a reasonable accuracy in determining status of lesions in patients undergoing revision thyroid surgeries.

Surgical and Biochemical Outcomes in Nerve Monitored Reoperation Surgery for Recurrent Papillary Thyroid Carcinoma

OBJECTIVE

To study the surgical and biochemical outcomes in nerve-monitored reoperation or revision surgery for recurrent thyroid cancers.

STUDY DESIGN

A single-center retrospective study.

SETTING

Tertiary center.

METHODS

We identified patients with recurrent papillary thyroid carcinoma (PTC) who underwent reoperation/revision surgery. Study outcomes were surgical complications frequency, recurrence, distant metastasis, and biological complete response (BCR) by comparing preoperative and postoperative thyroglobulin (Tg) levels.

RESULTS

Out of 227 patients, 33.9% presented for ≥2 reoperation surgeries. Nineteen (8.4%) had permanent preoperative hypoparathyroidism while 22 patients (9.7%) had preoperative vocal cord paralysis (VCP). Following reoperation surgery, there were 12 cases (5.3%) of permanent hypocalcemia and no cases of unexpected postoperative VCP. BCR was achieved in 31 patients (35.2%) with complete Tg data. Mean preoperative Tg was 47.7 ng/mL and was 19.7 ng/mL postoperatively (p = .003). The cervical nodal recurrence rate after final surgery was 7.0% (n = 16).

CONCLUSION

Reoperation surgery for recurrent PTC may help achieve biochemical remission regardless of age or the number of prior surgeries.

Recurrent Differentiated Thyroid Cancer: The Current Treatment Options

Differentiated thyroid carcinomas (DTC) have an excellent prognosis, but this is sometimes overshadowed by tumor recurrences following initial treatment (approximately 15% of cases during follow-up), due to unrecognized disease extent at initial diagnosis or a more aggressive tumor biology, which are the usual risk factors. The possible sites of recurrence are local, regional, or distant. Local and regional recurrences can usually be successfully managed with surgery and radioiodine therapy, as are some isolated distant recurrences, such as bone metastases. If these treatments are not possible, other therapeutic options such as external beam radiation therapy or systemic treatments should be considered. Major advances in systemic treatments have led to improved progression-free survival in patients previously considered for palliative treatments; among these treatments, the most promising results have been achieved with tyrosine kinase inhibitors (TKI). This review attempts to give a comprehensive overview of the current treatment options suited for recurrences and the new treatments that are available in cases where salvage surgery is not possible or in cases resistant to radioiodine.

Active surveillance in differentiated thyroid cancer: a strategy applicable to all treatment categories response

Currently, the differentiated thyroid cancer (DTC) management is shifted toward a tailored approach based on the estimated risks of recurrence and disease-specific mortality. While the current recommendations on the management of metastatic and progressive DTC are clear and unambiguous, the management of slowly progressive or indeterminate disease varies according to different centers and different physicians. In this context, active surveillance (AS) becomes the main tool for clinicians, allowing them to plan a personalized therapeutic strategy, based on the risk of an unfavorable prognosis, and to avoid unnecessary treatment. This review analyzes the main possible scenarios in treated DTC patients who could take advantage of AS.

The outcomes and prognostic factors of patients who underwent reoperation for persistent/recurrent papillary thyroid carcinoma

BACKGROUND

While the most suitable approach for treating persistent/recurrent papillary thyroid carcinoma (PTC) remains controversial, reoperation may be considered an effective method. The efficacy of reoperation in patients with locoregional persistent/recurrent PTC, especially those with unsatisfactory radioactive iodine (RAI) ablation results, is still uncertain. This study aimed to clarify the clinical management strategies for locoregional persistent/recurrent PTC and to explore factors that may affect long-term patient outcomes after reoperation.

METHODS

In total, 124 patients who initially underwent thyroidectomy and variable extents of RAI therapy and finally received reoperation for locoregionally persistent/recurrent PTC were included. The parameters associated with recurrence-free survival (RFS) were analysed using a Cox proportional hazards model.

RESULTS

Overall, 124 patients presented with structural disease after initial therapy and underwent secondary surgical resection, of whom 32 patients developed further structural disease during follow-up after reoperation. At the time of reoperation, metastatic lymph nodes with extranodal extension (P = 0.023) and high unstimulated thyroglobulin (unstim-Tg) levels after reoperation (post-reop) (P = 0.001) were independent prognostic factors for RFS. Neither RAI avidity nor the frequency and dose of RAI therapies before reoperation affected RFS.

CONCLUSIONS

Reoperation is an ideal clinical treatment strategy for structural locoregional persistent/recurrent PTC, and repeated empirical RAI therapies performed prior to reoperation may not contribute to the long-term outcomes of persistent/recurrent PTC patients. Metastatic lymph nodes with extranodal extension and post-reop unstim-Tg > 10.1 ng/mL may predict a poor prognosis.

Second Adjuvant Radioiodine Therapy after Reoperation for Locoregionally Persistent or Recurrent Papillary Thyroid Carcinoma

Introduction Differentiated thyroid carcinoma (DTC) has increased incidence. Intermediate- and high-risk patients have lymph node relapse rate ranging from 10 to 50%, and receive multiple reinterventions, increasing the morbidity of the disease. Currently, there are no established guidelines for the use of second radioactive iodine (RAI) therapy after the reintervention for local recurrence.

Materials and Methods This is a retrospective review of the medical records of 1,299 patients treated from January 2016 to July 2019 with DTC. We included 48 patients who received total thyroidectomy, RAI remnant ablation, surgery to remove the locally recurrent/persistent papillary thyroid carcinoma (PTC), and received a second RAI therapy.

Results There were no significant differences between thyroglobulin (Tg) levels before reoperation (Tg0), Tg levels postoperatively (Tg1), and Tg levels after 6 months of second adjuvant RAI therapy (Tg2). However, we evidenced a 69.79% drop in first Tg levels (Tg0: 24.7 vs. Tg1: 7.56, p=0.851) and 44.4% decrease in second Tg levels (Tg1: 7.56 vs. Tg2: 4.20, p=0.544). Also, 77.1% of the patients did not have another documented recurrence. The median relapse-free time was 10.9 months (range: 1.3–58.2 months).

Conclusion The results of the study cannot assess that a second RAI treatment after reoperation for locoregionally persistent or recurrent disease have a significant impact on treatment outcomes in intermediate- or high-risk patients with PTC. However, the 77.1% of patients have not presented a second documented recurrence and the median values of Tg and TgAb levels showed a substantial decrease after surgery and second RAI treatment.

Treatment Efficacy of Radiofrequency Ablation for Recurrent Tumor at the Central Compartment After Hemithyroidectomy

OBJECTIVE. The aim of this study was to evaluate the efficacy of ultrasound (US)-guided radiofrequency ablation (RFA) for recurrent tumor in the central compartment after hemithyroidectomy. MATERIALS AND METHODS. The medical records of patients who underwent RFA for recurrent tumor after hemithyroidectomy between January 2008 and December 2018 were reviewed. Eight patients who underwent RFA for 10 recurrent tumors after hemithyroidectomy were included in our study population. Patients underwent follow-up US 1, 6, and 12 months after treatment and annually thereafter. The tumor volume reduction rate (VRR) was calculated as follows: VRR = ([initial volume - final volume] × 100) / initial volume. All patients were advised to undergo contrast-enhanced CT after tumor ablation. Complete tumor disappearance was defined as no visible treated tumor on follow-up US or CT. RESULTS. Mean tumor VRR was 97.8% ± 7.0% (SD) (range, 77.8-100%). Complete tumor ablation was achieved for all 10 recurrent tumors. Complete disappearance was confirmed in nine recurrent tumors, and one recurrent tumor showed a VRR of 77.8% on US but there was no enhancement on CT. All eight patients achieved no evidence of disease during mean follow-up of 33.0 months. RFA was tolerated by all patients; there were no major complications or procedure-related deaths. One patient experienced transient voice change during RFA. CONCLUSION. RFA can be considered to be an effective and safe alternative treatment method for recurrent tumor in the central compartment after hemithyroidectomy.

[Follow-up of differentiated thyroid cancer]

The management of differentiated thyroid carcinoma has shown considerable changes in recent years, moving away from a fixed therapy regimen towards individual treatment strategies. The aim of our work (literature research) is to present current developments in the follow-up of differentiated thyroid cancer.For the management of individual follow-up, an initial evaluation and, at later time points, the re-evaluation of the risk of recurrence is crucial. The performance of I-131-diagnostics after radioiodine therapy can provide essential information and can be seen as a survey of a new baseline situation, in order to be able to draw a comparison in case of a rising Thyreoglobulin (Tg).The measurement of Tg with a highly sensitive assays shows a high negative predictive value. Negative Tg measurements with these assays seem to indicate complete remission even with Tg antibodies being present. An increasing Tg value in follow-up implies further diagnostic work-up, primarily neck ultrasonography. Sonographically suspicious findings should be subjected to fine needle biopsy, whereby in addition to cytological processing, determination of Tg from the sample can be recommended. If the suspicious lesion cannot be displayed sonographically and Tg values keep rising, computed tomography (CT) and magnetic resonance imaging (MRI) of the neck region can provide further information. FDG-PET/CT has also shown an excellent performance in this setting.The previously fixed therapy regimen has been realigned towards an individual treatment management. Current studies and guidelines lead to a repetitive recurrence risk evaluation and the adjustment of the aftercare planning to the individual risks with appropriately selected examination methods and personalized intervals of assessment.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.

BACKGROUND

Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.

METHODS

The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

Risk Factors and Outcomes of Postoperative Recurrent Well-Differentiated Thyroid Cancer: A Single Institution's 15-Year Experience

OBJECTIVE

Identify risk factors and outcomes of recurrent well-differentiated thyroid cancer.

STUDY DESIGN

Retrospective case-control analysis.

SETTING

Tertiary care academic center in Nashville, Tennessee.

SUBJECTS AND METHODS

This single-center analysis reviews 478 patients who underwent initial surgical management of well-differentiated thyroid carcinoma between 2002 and 2017. Patients were dichotomized with or without recurrent well-differentiated thyroid cancer. Demographic and clinicopathologic risk factors were carefully reviewed. Univariate, multiple regression, and survival analyses were used to evaluate predictors of recurrence.

RESULTS

Thirty-eight patients (7.9%) who received initial surgical intervention for well-differentiated thyroid carcinoma at our institution recurred, with an average time to recurrence of 24 months. Male sex, tumor size, multifocality, extrathyroidal extension, lymphovascular invasion, number of positive lymph nodes, and low lymph node yield were all significantly associated with locoregional recurrence (P < .05). Multiple regression analysis showed that extrathyroidal extension, number of positive lymph nodes, and low lymph node yield were independent factors predictive of posttreatment recurrence (P < .05). Metastatic lymph node ratio, the ratio of positive lymph nodes extracted to lymph node yield, of ≥0.3 is associated with increased risk of recurrence (P < .001) and decreased 5-year recurrence free survival (P < .001).

CONCLUSION

Extrathyroidal extension, number of positive lymph nodes, and low lymph node yield are independent clinicopathologic risk factors for postoperative recurrence of well-differentiated thyroid cancer. Metastatic lymph node ratio is uncommonly used but can be an important prognosticator of recurrence. Patients with metastatic lymph node ratio ≥0.3 should be counseled on their increased risk of recurrence and should undergo close surveillance following surgery.

Identifying risk factors of recurrence for clinically node negative papillary thyroid carcinoma with pathologic N1a

Background

Whether or not to perform prophylactic central lymph node dissection (CLND) in the case of clinically node-negative papillary thyroid cancer (PTC) is controversial. The purpose of this study was to investigate the risk factors for recurrence in clinically node-negative PTC patients who underwent total thyroidectomy plus bilateral central neck dissection and was verified pathologic N1a.

Methods

We retrospectively reviewed the medical records of 1082 PTC patients who underwent total thyroidectomy and prophylactic bilateral CLND between January 2004 and December 2012. We used Cox-proportional hazard regression analyses in order to explore potential predictive factors for recurrence.

Results

During a median follow-up (range) of 78 (12–158) months, recurrence occurred in 62 (5.7%) patients. Main tumor size more than 1 cm, gross extrathyroidal extension (ETE), positive lymph node (LN) more than 3, and LN ratio > 0.5 were all significantly associated with recurrence according to univariate analysis. In model I multivariate analysis (tumor size, gross ETE, LN ratio), LN ratio > 5 (hazards ratio [HR], 4.794; 95% confidence interval [CI], 2.674–8.595; p < 0.001) was found to be predictive of recurrence. Gross ETE (HR, 1.794; 95% CI, 1.024–3.143; p = 0.041) and positive LN more than 3 (HR, 2.505; 95% CI, 1.513–4.146; p < 0.001) were predictors for recurrence in model II multivariate analysis (tumor size, gross ETE, the number of positive LN).

Conclusions

We recommend that surgeons try to focus completely on performing prophylactic CLND for patients with suspicious gross ETE during preoperative evaluation. Close monitoring and thorough management are needed for clinically node-negative PTC patients with LN ratio of more than 0.5 and more than 3 positive LN in the central compartment.

Outcome of Cervical Lymph Nodes Dissection for Thyroid Cancer with Nodal Metastases: A Southeast Asian 3-Year Experience

Introduction

Therapeutic nodal dissection is still the mainstay of treatment for patients with lymph node metastases in many centres. The local data, however, on the outcome of therapeutic LND remains limited. Hence, this study aims to inform practice by presenting the outcomes of LND for thyroid cancer patients and our experience in a tertiary referral centre.

Methods

This is a single-centre retrospective observational study in a Malaysian tertiary endocrine surgery referral centre. Patients who underwent total thyroidectomy with lymph node dissection between years 2013 and 2015 were included and electronic medical records over a 3-year follow-up period were reviewed. The outcomes of different lymph node dissection (LND), including central neck dissection, lateral neck dissection, or both, were compared.

Results

Of the 43 subjects included, 28 (65.1%) had Stage IV cancer. Among the 43 subjects included, 8 underwent central LND, and 15 had lateral LND while the remaining 20 had dissection of both lateral and central lymph nodes. Locoregional recurrence was found in 16 (37.2%) of our subjects included, with no statistical difference between the central (2/8), lateral (7/15), and both (7/20). Postoperative hypocalcaemia occurred in 7 (16.3%) patients, and vocal cord palsy occurred in 5 (11.6%), whereas 9 patients (20.9%) required reoperation. Death occurred in 4 of our patients.

Conclusion

High recurrence and reoperative rates were observed in our centre. While the routine prophylactic LND remains controversial, high risk patients may be considered for prophylactic LND. The long-term risk and benefit of prophylactic LND with individualised patient selection in the local setting deserve further studies.

Long-Term Efficacy of Lymph Node Reoperation for Persistent Papillary Thyroid Cancer: 13-Year Follow-Up

BACKGROUND

Current recommendations for persistent or recurrent locoregional papillary thyroid cancer (PTC) include consideration of surgical resection versus active surveillance. The purpose of this study is to determine long-term outcomes after surgical resection of recurrent or persistent metastatic PTC in cervical lymph nodes after failure of initial surgery and radioactive iodine therapy using newer validated clinical outcomes measures.

METHODS

Outcomes of 70 patients who underwent cervical lymphadenectomy (n = 110) from 1999 to 2013 for recurrent or persistent locoregional PTC metastases were reviewed. Measures included biochemical remission (BCR) based on Tg levels, American Thyroid Association classifications for response to treatment [biochemical incomplete response (BIR), structural incomplete response (SIR), indeterminate response (IR), and excellent response (ER)], need for reoperation, surgical complications, disease progression, and death.

RESULTS

The median follow-up was 13.1 years, with only two additional reoperations since 2010, one of which had no metastasis on pathology with the other developing anaplastic thyroid cancer in background PTC. ER was achieved in 31 (44%) patients, all of whom remained in ER at time of last follow-up (median 14.1 years). There were no structural recurrences in patients with persistent BIR or IR after reoperation. Patients with SIR had stable disease, except for one who died due to anaplastic thyroid cancer.

CONCLUSIONS

Patients who achieved ER after reoperation had no need for further treatment. Patients with persistent detectable Tg levels after reoperation rarely developed structural recurrence. ATA outcomes can be safely used to guide treatment decisions over a decade after reoperation for PTC.

Central compartment revision surgery for persistent or recurrent thyroid carcinoma: analysis of survival and complication rate

PURPOSE

Locoregional recurrence of thyroid carcinoma is relatively common and reported rate are between 5 and 20%. Cervical nodes are usually involved, especially at the central compartment. The management of recurrent thyroid carcinoma at central compartment still remains challenging because of higher incidence of complication rate. The aim of the study is to evaluate the survival and complications rate after revision surgery.

METHODS

Retrospective cohort study on a group of patients that underwent revision surgery for persistent or recurrent thyroid carcinoma from January 1, 2003 to December 31, 2017. Survival outcomes were calculated using Kaplan-Meier method. Significant variables on univariate analysis were subjected to a Cox proportional hazards regression multivariate model.

RESULTS

Fifty-two patients involved, 22 male (40%) and 30 female (60%). Mean age was 54 years old (range 24-85). Mean follow-up was 79 months, median follow-up was 85 months, with a range between 8 and 153 months. The 5-year overall survival was 90.8% while at 10 years it was 69.8%. The 5-year disease-specific survival was 93.5%, while at 10 years it dropped to 77.9%. The rate of recurrent laryngeal nerve paralysis and persistent hypocalcemia in our series were 1.3% and 5.9%, respectively. No evidence of thoracic duct, esophageal or laryngeal and tracheal injury was found in this case series. Regarding prognostic factors, univariate and multivariate analysis highlighted as statistically significant: the aggressive histological variants, the presence extranodal extension or soft-tissue metastasis.

CONCLUSION

The surgical option remains the gold standard in locoregional recurrences of thyroid carcinoma and should be performed by experienced surgeons to reduce postoperative complications.

Persistent/Recurrent Differentiated Thyroid Cancer: Clinical and Radiological Characteristics of Persistent Disease and Clinical Recurrence Based on Computed Tomography Analysis

BACKGROUND

The natural course of persistent/recurrent differentiated thyroid cancer (DTC) has not been fully elucidated. The purpose of this study was to assess the relative incidence and clinico-radiological characteristics of persistent disease and clinical recurrence based on computed tomography (CT) analysis in patients with persistent/recurrent DTC.

METHODS

From January 2005 to December 2016, this retrospective study included 107 patients (M:F = 28:79; M_age = 53.5 years) with surgically proven cervical locoregional recurrence of DTC. Two neck CT examinations (median interval 1.92 years; range 0.17-7.58 years) before the last thyroid cancer surgery within the study period were reevaluated. Based on the presence of the lesion on the first CT and its progression on the second CT, the locoregional recurrence was classified into the following categories: stable persistence (decrease, no change, or increase by <2 mm in short dimension on the second CT), progressive persistence (increase by ≥2 mm), and clinical recurrence (newly appeared on the second CT). Clinical and radiological characteristics of the three groups were compared using univariate and multivariate logistic regression analyses.

RESULTS

The relative incidences of stable persistence, progressive persistence, and clinical recurrence were 56.1% (60/107), 15.0% (16/107), and 29.0% (31/107), respectively. Multivariate analysis between the clinical recurrence (29.0%) and persistence (71.0%) groups revealed various independent factors for prediction of clinical recurrence. These included longer interval between the two CT examinations (median 2.67 vs. 1.79 years; p = 0.021), a smaller number of thyroid surgeries (1.16 ± 0.45 vs. 1.55 ± 0.81; p = 0.002), and a history of neck dissection at the location of the largest locoregional recurrence (70.0% vs. 31.4%; p < 0.001). There was no significant independent factor for differentiation between the stable persistence (78.9%; 60/76) and progressive persistence (21.1%; 16/76) groups. The results may have been influenced by selection bias because this study included only surgically proven cases.

CONCLUSIONS

With regard to cervical locoregional recurrence of DTC, active surveillance may be favored because more than a half of the cases are structurally persistent and stable. However, meticulous evaluation is necessary to detect progressive persistence and clinical recurrence, considering various clinical factors.

Treatment of lateral neck papillary thyroid carcinoma recurrence after selective lateral neck dissection

BACKGROUND

There is a paucity of data regarding optimal treatment options and outcomes for recurrent disease after lateral neck dissection in patients with papillary thyroid carcinoma.

METHODS

Retrospective review of patients who underwent either percutaneous ethanol injection or surgery for first-time ipsilateral recurrences after ipsilateral lateral neck dissection for papillary thyroid carcinoma was performed.

RESULTS

Follow-up data were available for 54 patients with recurrences in 57 lateral necks treated by either percutaneous ethanol injection (n = 32) or surgery (n = 25). Tumor burden at the time of lateral neck recurrence differed between the groups including the largest lymph node diameter (mean: 13 mm vs 18 mm, P < .01) and the mean number of metastatic lymph nodes identified on ultrasound (1.3 vs 1.9, P = .04). Each modality alone achieved similar estimated rates of disease control at 36 months (75% for percutaneous ethanol injection and 74% for surgery, P = .8) with similar number of reinterventions (1.8 for percutaneous ethanol injection, 1.6 for surgery, P = .6).

CONCLUSIONS

Both ethanol ablation and surgery can achieve disease control in the majority of patients with recurrences after ipsilateral lateral neck dissection for papillary thyroid carcinoma. Ethanol ablation, when used for treatment of a single small lymph node, can result in outcomes that are similar to reoperative surgery for larger and multiple lymph nodes.

Surgical Perspectives in Head and Neck Cancer

Head and neck cancer treatment is a complex multidisciplinary undertaking. Cancer cure and survival is a primary goal, yet safe-guarding appearance and function to preserve the quality of life are similarly critical. The head and neck surgeon remains central to multidisciplinary cancer care, with deep knowledge of operative technique and an even deeper understanding of cancer biology. The surgeon models practice based on the highest levels of scientific evidence, but also takes into consideration the approaches that may best suit an individual patient. The surgeon's role moreover spans the life history of a head and neck cancer patient, from diagnosis to surveillance. The intimacy of this role makes the surgeon a trusted and frequent frame of reference for the patient. In this chapter, we provide an overview of the surgeon's role in head and neck cancer management. We discuss surgical perspectives within the multidisciplinary care team and selectively highlight some of the more provocative clinical scenarios in the field.

Management and outcome of clinically evident neck recurrence in patients with papillary thyroid cancer

BACKGROUND

The aim of this study was to report our incidence of clinically evident neck recurrence, salvage neck management and subsequent outcomes in patients with papillary thyroid cancer. This is important to know so that patients with thyroid cancer can be properly counselled about the implications of recurrent disease and subsequent outcome.

METHODS

An institutional database of 3664 patients with thyroid cancer operated between 1986 and 2010 was reviewed. Patients with nonpapillary histology and gross residual disease and those with distant metastases at presentation or distant metastases prior to nodal recurrence were excluded from the study. Of these, 99 (3.0%) patients developed clinically evident nodal recurrence. Details of recurrence and subsequent therapy were recorded for each patient. Subsequent disease-specific survival (sDSS), distant recurrence-free survival (sDRFS) and nodal recurrence-free survival (sNRFS) were determined from the date of first nodal recurrence using the Kaplan-Meier method.

RESULTS

Of the 99 patients, 59% were female and 41% male. The median age was 41 years (range 5-91). The majority of patients had pT3/4 primary tumours (63%) and were pN+ (78%) at initial presentation. The median time to clinically evident nodal recurrence was 28 months (range: 3-264). Nodal recurrence occurred in the central neck in 15 (15%) patients, lateral neck in 74 (75%) patients and both in 10 (10%) patients. After salvage treatment, the 5-year sDSS was 97.4% from time of nodal recurrence. The 5-year sDRFS and sNRFS were 89.2% and 93.7%, respectively.

CONCLUSION

In our series, isolated clinically evident nodal recurrence occurred in 3.0% of patients. Such patients are successfully salvaged with surgery and adjuvant therapy with sDSS of 97.4% at 5 years.

Impact of Radioguided Occult Lesion Localization (ROLL) in the management of cervical recurrences from differentiated thyroid cancer

BACKGROUND

Surgery is the elective treatment for cervical relapse from differentiated thyroid cancer (DTC) but it is technically challenging, with risk of failure and morbidity. We explored the feasibility and the efficacy of Radioguided Occult Lesion Localization (ROLL) with intratumoral 99mTc radiolabeled human albumin macroaggregates ([99mTc]MAA) injection in this setting.

METHODS

Fifteen patients who underwent ROLL by ultrasonography (US)-guided intratumoral injection of [99mTc]MAA between December 2013 and October 2016 for DTC recurrence were considered for this study. An hand-held gamma-probe was employed for intrasurgical lesion detection. Mini-invasive ROLL-guided excision for soft tissue recurrence and ROLL-assisted modified radical neck dissection for lymph-node metastases were performed respectively.

RESULTS

DTC recurrence was located in loco-regional lymph-nodes (n=8 patients) and in thyroid bed (n=7 patients). A total of 27 lesions was identified and injected before surgery. On a total of 124 lesions resected, histology showed 38 DTC metastases. In particular, 26 out of 27 lesions injected with [99mTc]MAA were correctly detected intra-operatively and resected without surgical complications. Ten patients received subsequent radioactive iodine (RAI) treatment to verify the complete recurrence resection. At a median follow-up of 16 months patients were classified in complete response (n=4), biochemical incomplete response (n=3), indeterminate response (n=1) with no evidence of structural disease. The remaining 7 patients were classified as structural incomplete response for cervical persistent disease (n=2), for cervical recurrence (n=2) and for both cervical and lung metastases progression (n=3).

CONCLUSIONS

ROLL is a simple and safe procedure in the surgical management of DTC loco-regional relapse.

Risk Stratification of Neck Lesions Detected Sonographically During the Follow-Up of Differentiated Thyroid Cancer

CONTEXT

The European Thyroid Association (ETA) has classified posttreatment cervical ultrasound findings in thyroid cancer patients based on their association with disease persistence/recurrence.

OBJECTIVE

The objective of the study was to assess this classification's ability to predict the growth and persistence of such lesions during active posttreatment surveillance of patients with differentiated thyroid cancer (DTC).

DESIGN

This was a retrospective, observational study.

SETTING

The study was conducted at a thyroid cancer center in a large Italian teaching hospital.

PATIENTS

Center referrals (2005-2014) were reviewed and patients selected with pathologically-confirmed DTC; total thyroidectomy, with or without neck dissection and/or radioiodine remnant ablation; abnormal findings on two or more consecutive posttreatment neck sonograms; and subsequent follow-up consisting of active surveillance. Baseline ultrasound abnormalities (thyroid bed masses, lymph nodes) were classified according to the ETA system. Patients were divided into group S (those with one or more lesions classified as suspicious) and group I (indeterminate lesions only). We recorded baseline and follow-up clinical data through June 30, 2015.

MAIN OUTCOMES

The main outcomes were patients with growth (>3 mm, largest diameter) of one or more lesions during follow-up and patients with one or more persistent lesions at the final visit.

RESULTS

The cohort included 58 of the 637 DTC cases screened (9%). A total of 113 lesions were followed up (18 thyroid bed masses, 95 lymph nodes). During surveillance (median 3.7 y), group I had significantly lower rates than group S of lesion growth (8% vs 36%, P = .01) and persistence (64% vs 97%, P = .014). The median time to scan normalization was 2.9 years.

CONCLUSIONS

The ETA's evidence-based classification of sonographically detected neck abnormalities can help identify papillary thyroid cancer patients eligible for more relaxed follow-up.

Contemporary Management of Recurrent Nodal Disease in Differentiated Thyroid Carcinoma

Differentiated thyroid carcinoma (DTC) comprises over 90% of thyroid tumors and includes papillary and follicular carcinomas. Patients with DTC have an excellent prognosis, with a 10-year survival rate of over 90%. However, the risk of recurrent tumor ranges between 5% and 30% within 10 years of the initial diagnosis. Cervical lymph node disease accounts for the majority of recurrences and in most cases is detected during follow-up by ultrasound or elevated levels of serum thyroglobulin. Recurrent disease is accompanied by increased morbidity. The mainstay of treatment of nodal recurrence is surgical management. We provide an overview of the literature addressing surgical management of recurrent or persistent lymph node disease in patients with DTC.

2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer

BACKGROUND

Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association's (ATA's) guidelines for the management of these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer.

METHODS

The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations for therapeutic interventions. We developed a similarly formatted system to appraise the quality of such studies and resultant recommendations. The guideline panel had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members.

RESULTS

The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, use of molecular markers, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to screening for thyroid cancer, staging and risk assessment, surgical management, radioiodine remnant ablation and therapy, and thyrotropin suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using imaging and serum thyroglobulin, thyroid hormone therapy, management of recurrent and metastatic disease, consideration for clinical trials and targeted therapy, as well as directions for future research.

CONCLUSIONS

We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.

Preoperative localization of neck recurrences from thyroid cancer: charcoal tattooing under ultrasound guidance

BACKGROUND

Reoperation for thyroid cancer recurrence is a surgical challenge in previously dissected necks, and there is a need for a reliable procedure for surgeon guidance. In this study, the usefulness of preoperative charcoal tattooing for surgical guidance was evaluated.

METHODS

From July 2007 to May 2010, 53 patients (40 females; Mage=44 years, range 19-76 years) were prospectively included for preoperative localization of neck recurrences from differentiated (n=46) or medullary thyroid cancer (n=7). Preoperative cytological assessment was performed for at least one lesion in each patient. Ultrasound (US) imaging was performed with high-frequency probes (8-14 Mhz). Micronized peat charcoal (0.5-3 mL) was injected under US guidance using a 25 gauge needle, 0-15 days preoperatively.

RESULTS

A total of 106 lesions were selected for charcoal tattooing. Of these, 101 had been tattooed, and 102 were removed (85 metastases, 17 benign on pathology). The tolerance of charcoal injection was good in all but three patients. A mean volume of 1 mL of charcoal was injected with a mean of two targets per patient. Charcoal labeling facilitated intraoperative detection in 56 "difficult" lesions (i.e., small size, dense fibrosis, anatomical pitfalls), and charcoal trace facilitated intraoperative guidance in 17 lesions. Feasibility and usefulness rates were 83% and 70.7% respectively.

CONCLUSION

These findings suggest that charcoal tattooing under US guidance is an easy to implement, safe, and useful procedure for surgeon guidance in neck reoperation for thyroid cancer.

Management of recurrent/persistent nodal disease in patients with differentiated thyroid cancer: a critical review of the risks and benefits of surgical intervention versus active surveillance

BACKGROUND

The primary goals of this interdisciplinary consensus statement are to define the eligibility criteria for management of recurrent and persistent cervical nodal disease in patients with differentiated thyroid cancer (DTC) and to review the risks and benefits of surgical intervention versus active surveillance.

METHODS

A writing group was convened by the Surgical Affairs Committee of the American Thyroid Association and was tasked with identifying the important clinical elements to consider when managing recurrent/persistent nodal disease in patients with DTC based on the available evidence in the literature and the group's collective experience.

SUMMARY

The decision on how best to manage individual patients with suspected recurrent/persistent nodal disease is challenging and requires the consideration of a significant number of variables outlined by the members of the interdisciplinary team. Here we report on the consensus opinions that were reached by the writing group regarding the technical and clinical issues encountered in this patient population.

CONCLUSIONS

Identification of recurrent/persistent disease requires a team decision-making process that includes the patient and physicians as to what, if any, intervention should be performed to best control the disease while minimizing morbidity. Several management principles and variables involved in the decision making for surgery versus active surveillance were developed that should be taken into account when deciding how best to manage a patient with DTC and suspected recurrent or persistent cervical nodal disease.

Lymph node metastases do not impact survival in follicular variant papillary thyroid cancer

INTRODUCTION

Follicular variant of papillary thyroid cancer (FVPTC) is the most common and fastest growing subtype of papillary thyroid cancer (PTC) with features of both PTC and follicular thyroid cancer (FTC). The purpose of this study was to determine the patient and tumor features associated with lymph node metastases (LNM) in FVPTC.

METHODS

This was a retrospective review of adult (≥18) patients with histologically confirmed diagnoses of FVPTC within the SEER database between 1988 and 2009. LNM were defined by at least two lymph nodes with metastatic disease. To determine factors associated with LNM, we constructed a multivariate logistic regression model from significant variables (p < 0.05) identified on univariate analysis. Similarly, we used a Cox proportional hazards model to understand the relative importance of LNM in determining disease-specific mortality (DSM).

RESULTS

Of the 20,357 cases of FVPTC with lymph node data available, 1,761 (8.7%) had LNM; 61.1% of these LNM were located in the central neck and 38.9% were in the lateral neck. Extrathyroidal extension (odds ratio [OR] 2.6, 95% confidence interval [CI] 2.2-3.0, p < 0.01) and multifocality (OR 3.0, 95% CI 2.5-3.6, p < 0.01) were the strongest predictors of LNM. Importantly, LNM did not independently predict DSM (p = 0.52). Tumor size >4 cm (hazards ratio [HR] 5.3, 95% CI 2.2-12.8, p < 0.01) and extrathyroidal extension (HR 8.2, 95% CI 3.0-22.0, p < 0.01) were the strongest predictors of DSM.

CONCLUSIONS

LNM occur in less than 10% of patients with FVPTC but do not impact DSM. Instead, DSM in FVPTC is related to size and local invasion.

The pros and cons of prophylactic central neck dissection in papillary thyroid carcinoma

Prophylactic central neck dissection (pCND) for management of papillary thyroid carcinoma (PTC) is controversial. Compared to many malignancies, PTC has a high overall survival but local recurrence due to lymph node metastases continue to present management challenges. Unlike lateral cervical nodal metastasis metastasis, central neck nodal metastasis are unable to be reliably detected clinically or radiologically at pre-operative assessment. Residual disease (recurrent or persistent) typically requires re-operative surgery in the central compartment, which carries a heightened risk of significant morbidity. These nodal groups can be accessed during the index thyroidectomy for PTC. Thus, pCND offers potential to reduce the rates of recurrence and the need for re-operative surgery in the central neck. This benefit needs to be balanced with the potential morbidity risk from pCND itself at the index resection. This review will discuss the advantages and disadvantages of pCND with regard to long-term outcomes and potential morbidity. The rationale of pCND will be discussed, along with the indications for ipsilateral and contralateral pCND, the role of re-operative surgery for recurrence and the use of selective versus routine pCND. Strategies to select higher risk patients for pCND with the use of molecular markers will be addressed, along with a discussion of quality of life (QoL) research in PTC.

Update on differentiated thyroid cancer staging

In this review, we demonstrate how initial estimates of the risk of disease-specific mortality and recurrent/persistent disease should be used to guide initial treatment recommendations and early management decisions and to set appropriate patient expectations with regard to likely outcomes after initial therapy of thyroid cancer. The use of ongoing risk stratification to modify these initial risk estimates is also discussed. Novel response to therapy definitions are proposed that can be used for ongoing risk stratification in thyroid cancer patients treated with lobectomy or total thyroidectomy without radioactive iodine remnant ablation.

Morbidity of central neck dissection: primary surgery vs reoperation. Results of a case-control study

PURPOSE

Complication rate in reoperative central neck node surgery is one of the main arguments to favor prophylactic central neck dissection at first operation in patients with papillary thyroid carcinoma. We evaluated if reoperative central neck dissection implies an increased postoperative morbidity. Secondarily, we aimed also to verify the effectiveness of the surgical resection of reoperative central neck dissection.

METHODS

Forty-one patients who underwent reoperative central neck dissection after initial thyroidectomy for papillary thyroid carcinoma between January 2008 and May 2012 were compared to 41 controls who underwent central neck dissection at initial operation.

RESULTS

The two groups were well matched for age, sex, and pN stage (P = 0.296, 0.199, and 1.000, respectively). Three patients had distant metastases at presentation. No significant difference was found concerning mean number of removed nodes (P = 0.064). No significant difference was found between the reoperative and the control groups concerning transient hypocalcemia (17 vs 19, respectively) (P = 0.901) and transient recurrent nerve palsy (2 vs 2) (P = 0.608). Follow-up was completed in 69 out of all the included patients (85.2 %). At a mean follow-up of 33 months, two patients (2.9 %) experienced nodal recurrence.

CONCLUSIONS

Morbidity of central neck dissection is similar for primary surgery and reoperation. In high-volume centers, reoperative central neck dissection can be safely accomplished when needed, allowing to achieve locoregional control in most of patients.

The feasibility and efficacy of secondary neck dissections in thyroid cancer metastases

The purpose of the study was to assess the feasibility of secondary neck dissections (ND) in different types of thyroid cancer (TC), to evaluate the influence of ND extent on morbidity and to describe biochemical and clinical outcomes. 51 patients previously operated for TC (33-well differentiated TC-WDTC, 15 medullary TC-MTC, 3 poorly differentiated TC-PDTC) presenting detectable nodal disease. Reoperations covered I–VII neck levels. Radical neck dissection was performed in 22 patients, selective neck dissection in 29 patients. 14 central compartment (CC), 10 mediastinal and 41 level IV excisions were performed. Postoperative complications occurred in 13 patients: 4 chyle leaks, 3 massive bleedings, 8 permanent vocal cord pareses, hypoparathyroidism in 22 patients (43.1 %), 2 patients expired in perioperative period. In WDTC: in seven patients thyroglobulin level normalized directly after ND, in ten patients in the follow-up; six patients developed distant metastases. None of the patients with MTC achieved calcitonin level <10 pg/ml; nine patients developed distant metastases. None of the patients with PDTC achieved Tg <2 mg/ml; two patients died, the third developed distant metastases. Secondary ND in TC present a challenge by means of surgical approach and possibility of complications. In MTC and PDTC the long-term results were unsatisfactory. In WDTC, the secondary ND should be performed due to strong indications. Metastases localization in levels IV, VI, VII were connected with high complication rate, but these surgeries were crucial for satisfactory oncological outcomes.

Lymph node ratio predicts recurrence in papillary thyroid cancer

BACKGROUND

Lymph node metastasis occurs in 20%-50% of patients presenting for initial treatment of papillary thyroid cancer (PTC). The significance of lymph node metastases remains controversial, and the aim of this study is to determine how the lymph node ratio (LNR) may predict the likelihood of disease recurrence.

METHODS

We conducted a retrospective review of patients undergoing total thyroidectomy for PTC at our institution from 2005 to 2010. A total LNR (positive nodes to total nodes) and central lymph node ratio (cLNR) was calculated. Regression was used to determine a threshold LNR that best predicted recurrence. Multivariate logistic regression then determined the influence of LNR on recurrence while accounting for other known predictors of recurrence. Kaplan-Meier analysis and the log-rank test were used to compare differences in disease-free survival.

RESULTS

Of the 217 patients undergoing total thyroidectomy for PTC, 69 patients had concomitant neck dissections. Sixteen (23.2%) patients developed disease recurrence. When disease-free survival functions were compared, we found that patients with a total LNR ≥0.7 (p < .01) or a cLNR ≥0.86 (p = .04) had significantly worse disease-free survival rates than patients with ratios below these threshold values. Considering other known predictors of recurrence, we found that LNR was significantly associated with recurrence (odds ratio: 19.5, 95% confidence interval: 4.1-22.9; p < .01).

CONCLUSIONS

Elevated total LNR and cLNR are strongly associated with recurrence of PTC after initial operation. LNR in PTC is a tool that can be used to determine the likelihood of the patient developing recurrent disease and inform postoperative follow-up.

Disease outcomes and nodal recurrence in patients with papillary thyroid cancer and lateral neck nodal metastases

BACKGROUND

The prognostic influence of lateral neck nodal metastases present at the time of diagnosis of papillary thyroid cancer (PTC) remains controversial. This study aims to document disease outcomes and nodal recurrence rates in such patients.

METHODS

Patients with PTC and lateral neck nodal metastases who underwent concurrent total thyroidectomy, central and lateral compartment neck dissection between 2000 and 2010 were identified from the prospectively maintained surgical databases of The University of Sydney and University of Wisconsin Endocrine Surgical Units. Disease outcomes and nodal recurrence rates were compared at 12 months post-operatively and in longer-term follow-up.

RESULTS

During this 11-year period, 121 patients were identified. Mean age was 45 years; 58% were female and 98% underwent post-operative radioactive iodine ablation. At a median follow-up of 31 months (range 12-140), there were no disease-specific deaths and disease-free survival (defined by stimulated serum thyroglobulin (Tg) < 2.0 μg/L, negative clinical and radiological examination) was 66%. Of the 50 patients with persistently elevated Tg measured 12 months post-operatively, 15 developed clinical lateral neck nodal recurrence. All have undergone re-operative surgery. Elevated stimulated Tg at 12 months post-operatively and a nodal ratio of >30% were significantly associated with an increased risk of lateral neck nodal recurrence.

CONCLUSION

With total thyroidectomy, formal compartmental neck dissection and radioactive iodine treatment, disease-free survival can be achieved in the majority of patients with PTC and synchronous lateral neck nodal metastases. A persistently elevated Tg post-operatively and a high ratio of metastatic nodes identify patients at increased risk of locoregional recurrence.

Thyroid carcinoma uptake of 18F-fluorodeoxyglucose in patients with elevated serum thyroglobulin and negative 131I scintigraphy

PURPOSE

To determine if FDG-PET results can predict for outcome in thyroid cancer patients with elevated Tg and negative I-131 imaging.

MATERIALS AND METHODS

We conducted a retrospective review of 76 patients who had elevated serum Tg and negative (131)I scintigraphy and who underwent FDG-PET. After FDG-PET, patients underwent neck dissection or radiation.

RESULTS

The 51 patients with positive FDG-PET had a 5-year survival of 63% compared to 100% (p<0.049) for the 25 patients with negative PET. Patients with FDG-avid disease isolated to the lymph nodes had 5-year CSS of 91% compared to 32% (p=0.0033) for those with disease outside the regional lymph nodes. Twenty-nine patients with disease isolated to the regional lymph nodes underwent salvage neck dissection and 22 remain NED after 28 months.

CONCLUSIONS

Negative FDG-PET with elevated Tg predicts an excellent outcome. FDG-avid disease isolated to the regional lymph nodes had a low likelihood of death due to thyroid cancer.

Update in utility of secondary node dissection for papillary thyroid cancer

BACKGROUND

Detection of recurrent/persistent thyroid cancer has improved significantly in the past decade. Disease is detected earlier in recently treated patients and localized in patients long out from initial treatment. This update reviews recent literature regarding the utility of secondary node dissection for papillary thyroid carcinoma. Outcomes include disease-free status measured biochemically and clinically.

RESULTS

The utility of secondary node dissection as measured by clinically detectable disease exceeds 70% for all series and 90% for most. The utility as measured biochemically is more modest, with rates of biochemical cure ranging from 27-81% depending upon strictness of definition and patient selection. In predominately radioiodine scan-negative patients, using the strictest definition of biochemical cure, undetectable stimulated thyroglobulin (Tg) of less than 0.5 ng/ml, a rate of 27% is reported. Biochemical cure rates are reportedly 30-51% for stimulated Tg of less than 2 ng/ml and 56-71% for basal Tg of less than 2 ng/ml, with higher preoperative Tg levels less likely to achieve biochemical cure. Radioiodine-avid disease appears more amenable to cure, with 81% of patients achieving negative stimulated Tg after repeat I131 treatment and radio-assisted surgery. Complication rates of secondary nodal surgery appear similar to initial surgery in experienced hands; however, bilateral reoperative central neck dissection is associated with significantly higher complication rates than unilateral.

SUMMARY

Surgical resolution of clinically detectable disease is likely. Biochemical cure rates are more modest, with the greatest likelihood of biochemical cure occurring in patients with radioiodine-avid disease. In radioiodine-negative patients, there may be a higher likelihood of biochemical cure for those with lower preoperative detectable Tg levels.

Postablation stimulated thyroglobulin level is an important predictor of biochemical complete remission after reoperative cervical neck dissection in persistent/recurrent papillary thyroid carcinoma

Background

The efficacy of reoperative cervical neck dissection (RND) in achieving biochemical complete remission (BCR) (or postreoperation stimulated thyroglobulin [sTg] of <0.5 ng/mL) remains unclear in persistent/recurrent papillary thyroid carcinoma (PTC). We hypothesized that lower postablation sTg levels would indicate a higher rate of BCR after RND. Our study examined the association between postablation sTg and BCR after one or more RNDs.

Methods

Of 199 patients who underwent RND, 81 patients were eligible. The postablation sTg levels (≤2 and >2 ng/mL) were correlated with the postreoperation sTg levels after RNDs. Patients’ clinicopathological characteristics, operative findings, and subsequent RNDs were compared between those with BCR after RNDs and those without.

Results

Those with postablation sTg levels of ≤2 ng/mL had significantly higher BCR rate after the first RND (77.8 vs. 5.6 %, p < 0.001), overall BCR after one or more RNDs (77.8 vs. 9.3 %, p < 0.001), and better 5-year recurrence-free survival after the first RND (80.0 vs. 60.1 %, p = 0.049) than those with postablation sTg levels of >2 ng/mL. Overall BCR gradually decreased after each subsequent RND. Postablation sTg significantly correlated with postreoperation sTg (ρ = 0.509, p < 0.001). After adjusting for the number of metastatic lymph nodes excised at first RND and presence of extranodal extension, postablation sTg of ≤ 0.2 ng/mL was the only independent factor for BCR after one or more RNDs (odds ratio 37.0, 95 % confidence interval 5.68–250.0, p = 0.001).

Conclusions

Only a third of patients who underwent one or more RNDs for persistent/recurrent PTC had BCR afterward. Postablation sTg level was an independent factor for BCR. Completeness of the initial operation is important for the subsequent success of RND.

Suspicious cervical lymph nodes detected after thyroidectomy for papillary thyroid cancer usually remain stable over years in properly selected patients

CONTEXT

The risk of loco-regional recurrence in papillary thyroid cancer (PTC) patients ranges from 15-30%. However, the clinical significance of small-volume loco-regional recurrence detected by highly sensitive ultrasonography is unclear.

OBJECTIVE

Our objective was to describe the natural history of abnormal cervical lymph nodes (LN) diagnosed after initial treatment.

DESIGN

We conducted a retrospective cohort study.

PATIENTS

166 PTC with patients who had at least one abnormal LN outside the thyroid be on ultrasound and selected for active surveillance were included.

MAIN OUTCOME MEASURE

LN growth during a period of active surveillance was the primary outcome.

RESULTS

Most patients had classical PTC (85%) and an intermediate risk of recurrence (77%). The median LN size at the start of the observation period was 1.3 cm (range, 0.5-2.7 cm) in largest diameter, with all nodes having at least one abnormal sonographic characteristic (70% of patients had LN with at least two abnormal features). In almost all patients, the LN were in the lateral neck, primarily in levels 3 (43%) and 4 (58%). After a median follow-up of 3.5 yr, only 20% (33 of 166) grew at least 3 mm, 9% (15 of 166) grew at least 5 mm, and 14% (23 of 166) resolved. None of the clinical or sonographic features were predictive of LN growth (positive predictive value range = 0.21-0.57). There were no local complications (nerve damage or local invasion) related to the abnormal nodes and no disease-related mortality.

CONCLUSIONS

Suspicious cervical LN in the lateral neck usually remain stable for long periods of time in properly selected PTC patients and can be safely followed with serial ultrasounds.

Serum thyroglobulin level measured after thyroxine withdrawal is useful to predict further recurrence in whole body scan-negative papillary thyroid cancer patients after reoperation

The best treatment option for recurrent papillary thyroid carcinoma (PTC) is reoperation when the recurrent lesion is locoregional. The prognostic significance of serum thyroglobulin (Tg) levels before reoperation and the association between the outcome of reoperation and Tg level remain unclear. Our study aimed to determine the outcomes of patients who underwent reoperation and their association with serum Tg levels. We retrospectively studied 79 patients with PTC with locoregional recurrence whose whole-body scan results were negative for any recurrence but whose serum Tg levels were detectable after first-line treatment. All the patients underwent reoperation and follow-up examinations, which involved serial serum Tg measurements after thyroxine withdrawal (T4-off Tg), neck ultrasonography, chest computed tomography, and/or fluorodeoxyglucose-positron emission tomography, to detect further recurrence. During the median follow-up duration of 89 months (range, 38-332 months), 30 patients (38.0%) experienced a second recurrence even after the reoperation. Among all patients, only 12 whose Tg levels decreased postoperatively to undetectable levels showed no recurrence. Most recurrences were detected in the patients with high T4-off Tg levels after the reoperation (T4-off Tg level (ng/mL), number of patients with recurrence, %: <1, 0/12, 0%; 1-10, 9/31, 33.3%; >10, 16/22, 72.7%; P < 0.001). In conclusion, recurrence occurred in 38.0% of the patients even after the reoperation. The postoperative T4-off Tg level was a good indicator of recurrence after the reoperation. Therefore, patients who experience recurrence should undergo follow-up examinations that involve routine measurements of T4-off Tg levels, especially when postreoperative values exceed 10 ng/mL.

Long-term outcome of comprehensive central compartment dissection in patients with recurrent/persistent papillary thyroid carcinoma

BACKGROUND

Persistent or recurrent papillary thyroid carcinoma (PTC) occurs in some patients after initial thyroid surgery and often, radioactive iodine treatment. Here, we identify the efficacy, safety, and long-term outcome of our current surgical management paradigm for persistent/recurrent PTC in the central compartment in an interdisciplinary thyroid cancer clinical and research program at a tertiary thyroid cancer referral center.

METHODS

We retrospectively analyzed our standardized approach of comprehensive bilateral level VI/VII lymph node dissection (SND [VI, VII]) for cytologically confirmed PTC in the central compartment.

RESULTS

From 1994 to 2004, 210 patients, median age 42 (range 12-82) underwent SND (VI, VII). Most patients (106, 51%) had already undergone ≥2 surgical procedures for persistent or recurrent disease, and 31 (15%) had distant metastases at presentation. Postoperatively, 104 (71%) of the 146 patients who were thyroglobulin (Tg) positive had no evidence of disease. Anti-Tg antibodies were present in 38 patients (18%), 17 of whom (53%) did not have anti-Tg antibodies postoperatively. Fourteen patients (7%) were hypoparathyroid at presentation, and 2 more (1%) became permanently hypoparathyroid after surgery. Four patients (2%) experienced recurrent laryngeal nerve paralysis (RLNP) of a previously functioning nerve. Unanticipated RLNP was observed in only one nerve at risk. External beam radiation was given to 33 patients (17%). An additional 17 patients (8%) developed distant metastases during follow-up. At the last follow-up, 130 (66%) of the 196 patients had no detectable Tg; of these, 99 (76%) had no further evidence of disease. A median of 7.25 years after surgery, 167 (90%) of the 185 patients were without evidence of central disease, and 18 (10%) had developed central compartment recurrences within a median interval of 24.3 months. Of those with recurrence, 16 out of 18 patients (89%) underwent a subsequent surgical procedure, thus resulting in an overall 98% central compartment control rate. Kaplan-Meier disease-specific survival at 10 years was 98.9% for patients <45 years old and 77.9% for those ≥45 years old (log-rank p<0.00001). The only predictor of central compartment recurrence was malignancy in a thyroid remnant noted within the central compartment surgical specimen.

CONCLUSIONS

Bilateral comprehensive level VI/VII dissections are safe and effective for long-term control of recurrent/persistent PTC in the central lymphatic compartment.

Considerations for personalized surgery in patients with papillary thyroid cancer

BACKGROUND

Personalizing treatment for papillary thyroid cancer (PTC) requires a multidisciplinary approach. The surgical management of PTC has long been based on retrospective studies focusing on endpoints that are of debatable significance. There is considerable debate in the literature regarding the optimal initial treatment for PTC. Many of these issues are discussed in this review. These debates have hindered the development of a tailored treatment strategy.

SUMMARY

The ability to optimally personalize a surgical plan for the treatment of PTC is ultimately dependent on an understanding of the biological behavior of that individual patient's tumor. We are at the genesis of an age where molecular biology advances endeavor to profile a patient's tumor behavior. This review summarizes current strategies for managing PTC, where we are with personalizing surgery for these patients, and where we hope to go. Thyroid surgery is one of the newest fields for the application of minimally invasive techniques and can now be accomplished endoscopically or with robotic assistance in many patients who therefore may benefit from these alternative approaches.

CONCLUSION

When treating a patient with PTC, it seems prudent to weigh the many factors discussed in this review to individualize the most optimal surgical plan.