Management Issues in Recurrent and Metastatic Thyroid Cancer

The study, which retrospectively reviewed the outcomes of 183 patients who underwent neck dissection for treatment of papillary thyroid cancer, compared recurrence rates between patients based on different surgical techniques used. Of the 183 patients, 77 underwent lymph node plucking (excision of lymph nodes in the operative bed) for removal of gross metastatic nodes at the time of thyroid surgery, and the rest of the patients underwent formal lymphadenectomy, ranging from a central compartment dissection to a unilateral or bilateral lateral neck dissection.

According to the lead author of the study, Jonas Johnson, MD, Professor and Chair of the Department of Otolaryngology at the University of Pittsburgh School of Medicine, patients who had node plucking had a very high incidence of recurrence. This suggests that this was inadequate therapy, he said. However, when we looked at the group of patients who had a more formal metastatic resection, the incidence of recurrence was still reasonably high, which suggests that even formal neck dissection may not be adequate to completely eliminate the disease.

The study found that the presence of pathologic lymph nodes in neck dissection specimens was associated with disease recurrence: 56% of patients with positive nodes had recurrences, whereas only 4.3% of node negative patients did.

An interesting but difficult to interpret observation, said Dr. Johnson, is that only one patient in the full cohort of 183 patients died. That suggests that the presence of cervical metastases, even cervical metastases that are not completely controlled, does not have a terribly serious effect on prognosis.

Reiterating the favorable prognosis that patients with papillary thyroid cancer can expect overall, Dr. Johnson said that it is hard to prove that more surgery is better in these patients. The patients do very well with limited surgery, so when you do more surgery you probably will confer a little more morbidity, and it is hard to prove that the morbidity is worth it.

In light of the high rate of cervical recurrence found in their study, Dr. Johnson and his colleagues are starting to implant a parathyroid gland at the time of total thyroidectomy to reduce the exposure to potential hypoparathyroidism in the event that recurrence requires re-exploration of the neck.

Role of Ultrasound-Surveillance and Management of Recurrent and Metastatic Disease in the Neck

Both Dr. Terris and Dr. Johnson agreed that ultrasound, when used in conjunction with the serum test thyroglobulin, has emerged as a critical tool for detection of recurrent and metastatic disease.