Management Issues in Recurrent and Metastatic Thyroid Cancer

According to Dr. Terris, it is not uncommon for patients with head and neck cancer to undergo much prophylactic neck surgery that proves to have been unnecessary, because if they are not cured the first time around, curing them later is more difficult. However, that doesn’t make as much sense [in thyroid cancer], because so many patients will do great, and even if you are not successful the first time, you will have a good chance down the road to treat a recurrence, he said.

That’s why I tend toward less treatment at the start, he continued. I think it is important to do a thorough thyroidectomy, but whether you treat the nodes up front is not as important.

If Not Treated Right the First Time, Try Again Later?

David L. Steward, MD

One issue at the center of the debate is whether doing a central neck dissection during initial thyroidectomy is associated with less morbidity than with reoperation for treatment of recurrent or metastatic disease.

Data recently presented at the Society of Surgical Oncology 61st Annual Meeting suggest that complications associated with reoperation are higher.

In the study, investigators from Washington University School of Medicine in St. Louis compared outcomes of 244 patients with thyroid cancer who underwent central lymph node dissection at the time of initial thyroidectomy (n = 87) or at reoperation (n = 157). Among the 244 patients, 173 had medullary disease, 55 papillary, 3 parathyroid cancer, and 4 other.1

The study found less morbidity in the patients treated during initial thyroidectomy compared with reoperation, with recurrent laryngeal nerve injury occurring in 1.1% of patients who underwent central node dissection during initial thyroidectomy and in 2.5% for those who underwent reoperation.

The risk of complications including recurrent laryngeal nerve injury and permanent hypoparathyroidism is higher with reoperation than with initial operation, said lead author of the study, Elizabeth A. Fialkowski, MD. The higher risk of these complications with reoperation is definitely a driving force to perform central neck dissection with initial operation.

Stating that these complications are still a risk during initial operation, she emphasized the need for an experienced surgeon to perform central neck dissection.

Effect of Neck Dissection on Outcomes

Even if cervical lymph nodes are dissected at the time of initial thyroidectomy, data suggest it may not completely eliminate disease, nor have much of an effect on prognosis.

In a study presented recently at a Triological Society section meeting, investigators at the University of Pittsburgh reported a reasonably high recurrence rate in patients who underwent a comprehensive neck dissection for treatment of papillary thyroid cancer, despite the type of surgical technique used.2