Algorithm for safe and effective reoperative thyroid bed surgery for recurrent/persistent papillary thyroid carcinoma

Background The aim of this study was to review our experience with reoperative thyroid bed surgery (RTBS) for recurrent/persistent papillary thyroid cancer (PTC), and present an algorithm for safe and effective RTBS. Methods This is a retrospective study. Records of 33 consecutive patients who underwent RTBS for recurrent/persistent PTC in a previously operated thyroid bed, and were operated upon by the senior author (R.P.T.) July 2001 to January 2006 were reviewed. Reports of the pre‐ and post‐RTBS serum thyroglobulin (TG) levels, the high‐resolution thyroid bed ultrasound examination, pre‐RTBS FNA cytopathology, as well as the post‐RTBS final histopathology were reviewed. Recurrent laryngeal nerve (RLN) monitoring was used for all patients. Reports of the intra‐RTBS condition of the RLN and any reported surgical complications were reviewed. In addition, reports of the pre‐ and post‐RTBS fiberoptic laryngoscopy as well as pre‐ and post‐RTBS serum calcium levels were reviewed. Results In our study, 33 consecutive patients underwent RTBS for recurrent/persistent PTC with or without lateral neck dissection. In 30 patients, recurrent/persistent PTC was suspected because of rising serum TG levels, interpreted in conjunction with serum anti‐TG‐antibody titers by the endocrinology service at our institution. Three patients had serum anti‐TG antibodies and their disease was detected and FNA confirmed by a regularly scheduled surveillance ultrasound examination. All patients underwent pre‐RTBS high‐resolution thyroid bed ultrasound examination and FNA for all suspicious masses. All patients had FNA‐confirmed PTC in the thyroid bed. All patients had detailed diagrams localizing areas of FNA‐confirmed PTC in the thyroid bed provided to the surgeon. In all study patients, post‐RTBS histopathologic findings confirmed sites of recurrent/persistent PTC determined by pre‐RTBS US guided FNA. All RLNs (53/53) that were at risk were successfully identified. In 3 patients, the RLN was electively resected because of the envelopment by a large paratracheal mass or tumor densely adherent to the RLN insertion point at the cricothyroid region. There was no incidence of unexpected RLN injury, permanent hypocalcemia, or any other surgery‐related complication. Post‐RTBS serum TG levels were significantly decreased or undetectable in most patients (2 patients had concurrent lung metastases), when compared with pre‐RTBS levels. No patient exhibited thyroid bed recurrent/persistent PTC in the post‐RTBS period based on semiannual high resolution neck ultrasound examination with a median follow‐up of 2 years. Conclusions Safe and effective RTBS is based on a multidisciplinary approach that enables the identification and localization of recurrent/persistent PTC. The surgical algorithm for RTBS described, provides a pathway that all endocrine‐head and neck surgeons can comfortably utilize to treat this complex and challenging patient population. © 2007 Wiley Periodicals, Inc. Head Neck 2007