Context: Reoperative surgery is the most efficient treatment of cervical persistent thyroid carcinoma. The extent of the surgery should be guided by the preoperative imaging findings, the primary surgery and the patients prognosis. However, there is no consensus concerning the optimal surgical strategy.
Objective: Primary objective was to evaluate morbidity of a reoperative surgery. Secondary objectives were to evaluate performances of preoperative modalities, clinical and biochemical outcomes.
Methods: Thirty-two consecutive patients were operated on, by the same experienced surgeon, for cervical persistent disease. Surgical approach was based on imaging findings and initial surgery. Patients with initial adequate surgery were treated with focalized approach. By contrast, in patients with inadequate initial surgery, surgical re-dissection was performed. Follow-up included laryngeal examination, calcium measurement, assessment of TSH stimulated-Tg levels (after THW or rhTSH) and imaging procedures.
Results: Among 32 patients, mean age ranged from 13 to 76 years. All tumors corresponded to papillary carcinomas with aggressive histotypes in 41%. Initial pTNM stages were pT3-T4 and/or N1 in 81% of patients.
Preoperative stimulated-Tg was positive in 87% of patients (n=30). Palpation was positive in only 21.8% of patients. Sensitivity, specificity, PPV and NPV of combination of neck US and FDG-PET scan were 95.8, 96.2, 82.1 and 99.2%, respectively.
Most of patients (11/12) with persistent disease in the central compartment have been previously operated with an inadequate central LN dissection. In patients with inadequate lateral LN dissection, residual LN were distributed throughout the both lateral compartments. By contrast, only superior and inferior groups of the ipsilateral lateral compartment were concerned in patients who were previously treated with an adequate lateral LN dissection. Morbidity rate related to reoperation was low (6%) and transitory. At the end of follow up, 53% reached remission criteria, 20% had low TSH-stimuated Tg levels, Tg<5 ng/ml under rhTSH or Tg<10 ng/ml under THW) with negative imaging study and 27% had high residual Tg values.
Conclusion: Surgical strategy for persistent/recurrent disease based on imaging study and compartment oriented approach can be performed with low morbidity and acceptable efficacy rates.
25 - 29 Apr 2009
European Society of Endocrinology