Management of the Locoregional Recurrence in Well-differentiated Thyroid Carcinoma

Bias #1
Lymph node is not a prognostic factor in well-differentiated thyroid carcinoma, so prophylactic lymphadenectomy is not indicated

Bias #2
Routine systemic node dissection which included central neck, lateral neck, even radical neck dissection showed that nodal metastasis near 80% in well-differential thyroid carcinoma. Clinically significant Nodes is around 25% only. Is locoregional recurrence is unavoidable?

Recurrence in WDTC

Low risk group :10-30% recurrent rate High risk group :20-50% recurrent rate Overall disease mortality : 30-50% Shorter disease-free interval

Classification of the Recurrence

Local recurrence (thyroid bed, 28%) Regional recurrence (neck nodes, 53%) Locoregional recurrence (both, 6%) Distal metastasis (others, 13%)
Coburn, 1994, Ann Surgery

How to detect locoregional recurrence in thyroid carcinoma?

Clinically detected Radioiodine scan detected TSH-stimulated thyroglobulin level PET

Stulak, Arch Surg 2006

Central Neck Recurrence

Residual tumor in thyroid bed Invasion to trachea, esophageal, laryngx, vessels, etc., pretracheal nodes, mediastinal nodes, paratracheal nodes (79.7%)

Lateral Neck Recurrence

Level III, IV, V, (23.1%) Level II III IV V (23.8%) Berry picking (36.9%) Selective dissection (16.2%) Central neck exploration is benefit Sono-guided dissection is benefit
Roh, Head & Neck 2007

Surgical considerations in the recurrent thyroid carcinoma ( I )

The extent of reoperation is related to the extent of primary surgery, stage, and distant metastasis Completion total thyroidectomy and central and therapeutic lateral neck dissection for the thyroid remnant, residual tumor, palpated lateral neck nodes Anterior approach or lateral approach Long incision or separated incision will be needed

Surgical considerations in the recurrent thyroid carcinoma ( II )

Laryngoscopy exam should be finished, or recurrent laryngeal nerve resection needed due to invasion Two stage surgery with 6 weeks interval for the bilateral jugular veins resection Complication included hypoparathyroidism, recurrent laryngeal nerve injury, thoracic duct injury, Horner syndrome and etc.,
Vogelsang, Chirurg 2005 Duren, Current treatment options in oncology 2000

Surgical Safety

Experienced surgeon Neuromonitoring system Sono-guided or radio-guided surgery

Schuff, Laryngoscope 2008 Kim, Arch Otolaryngol Head Neck Surg 2004 Stulak, Arch Surg 2006 Farrag, Head & Neck 2007

Postoperative Radioactive iodine Ablation (ATA guideline)

Stage III and IV disease Stage II in patients older than 45 yrs Stage I disease with multifoci, nodal metastases, extrathyroidal extension, vascular invasion or more aggressive histology
Cooper, Thyroid 2006

Postoperative radioiodine ablation

Therapeutic ablation -- locoregional -- distant metastases Prophylactic ablation (<1.5cm)

External radiation

Incomplete surgical resection due to invasion into vital structures Tumor at the margins of resection in a high surgical risk patient Metastases in support bones after surgical debulking when possible

Distal metastasis

Surgical removal of discrete local or distant metastases to lung and bone when it can be done safety Therapeutic radioactive ablation External radiation

Take Home Message

Total or near-total thyroidectomy is the standard procedure in WDTC Routine central neck dissection is needed Remove all palpated nodes in lateral neck compartment Remove non-palpated nodes which was detected by preoperative sonogram Postoperative ablation for the selective cases

Take Home Message

Surgery is still the primary management of the recurrent thyroid carcinoma Careful preoperative workup is very important Lower morbidity in experienced surgeons hands is achieved Understanding the map of nodal recurrence is the key of the surgical treatment

DISCUSSION