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Management of the Locoregional Recurrence in Well-differentiated Thyroid Carcinoma. 陳漢文. 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

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management of the locoregional recurrence in well differentiated thyroid carcinoma

Management of the Locoregional Recurrence in Well-differentiated Thyroid Carcinoma

陳漢文

bias 1
Bias #1

Lymph node is not a prognostic factor in

well-differentiated thyroid carcinoma, so

prophylactic lymphadenectomy is not

indicated

bias 2
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
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
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
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
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
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
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
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
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
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
Postoperative radioiodine ablation
  • Therapeutic ablation

-- locoregional

-- distant metastases

  • Prophylactic ablation (<1.5cm)
external radiation
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
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
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 message1
Take Home Message
  • Surgery is still the primary management of the recurrent thyroid carcinoma
  • Careful preoperative workup is very important
  • Lower morbidity in experienced surgeon’s hands is achieved
  • Understanding the map of nodal recurrence is the key of the surgical treatment