Reoperative Neck Dissection in Papillary Thyroid Carcinoma - When Is It Worth Doing?

Abstract

The surgical management of recurrent thyroid cancer poses distinct challenges from those of initial treatment. The risks associated with operating upon recurrent disease are typically higher and so, the goals and the extent of resection should be tailored to the specific clinical situation. Technical demands of reoperative neck dissection and the potential to alter the natural history of the disease both warrant consideration. As a result, the decision regarding surgical intervention versus active surveillance after detection of biopsy-proven recurrent or persistent tumor should not be taken lightly. Factors to be considered include whether the primary tumor belongs to an adverse histology, the rate of change of thyroglobulin levels, the rate of growth of imaged lymph nodes, as well as the presence of extranodal extension to the trachea, the esophagus, or carotid artery. Additional factors to be considered include the inability of the tumor to concentrate radioactive iodine or produce thyroglobulin, molecular markers for aggressive behavior, as well as age, presence of other sites of metastases (and their progression), and comorbidities. In the 2015 American Thyroid Association guidelines, it was recommended that therapeutic compartmental central and/or lateral neck dissection in a previously operated compartment, sparing uninvolved vital structures, should only be performed for patients with biopsy-proven persistent or recurrent disease for central neck nodes ≥8mm and lateral neck nodes ≥10mm in the smallest dimension that could be localized on anatomic imaging. However, our experience would suggest that these criteria might be too stringent and the size limit could be raised further without compromising the subsequent surgical morbidity from a reoperative neck dissection. Also in addition to surgery, there are now other less invasive, non-surgical options available in treating small-volume persistent or recurrent neck diseases. The aim of the talk is to address some of these issues regarding to reoperative neck dissection for papillary thyroid carcinoma.