What Are the Parameters as to When to Re-Operate on Patients with Recurrent Well-Differentiated Thyroid Cancer?

by Adam Y. Xiao, MD, PhD, Jessa E. Miller, MD, and Maie A. St. John, MD, PhD •

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope article free of charge, visit Laryngoscope.

BACKGROUND

The incidence of well-differentiated thyroid cancer (WDTC), which includes both papillary and follicular carcinoma, has increased over the past several decades. This is partially attributed to more sensitive imaging and diagnostic modalities; however, tumor recurrence and cancer-specific mortality rates are increasing, suggesting a rise in the prevalence of more aggressive thyroid cancers. Cancer recurrence occurs in up to 30% of patients with WDTC and is most commonly identified in locoregional lymph nodes—this underscores the importance of appropriate management and continued postoperative surveillance in patients with WDTC (Thyroid. 2015;25:15-27).

Although the National Comprehensive Cancer Network recommends surgery for the management of resectable locoregional recurrence, revision surgery is technically challenging and is associated with higher complication rates, including vocal fold paralysis and hypoparathyroidism (Head Neck. 2016;38:1862-1869). For this reason, appropriate patient selection for revision surgery is critical. Furthermore, many lesions detected on postoperative surveillance are subclinical and the prognosis of patients with WDTC is favorable, with a 10-year survival ranging from 99% in stage I to 67% in stage IV. The combination of these factors creates a complex clinical scenario. Several reports have examined the role of surgery versus active surveillance in managing locoregional disease recurrence; however, the lack of prospective studies makes it difficult to assess the absolute benefit of surgery among individuals with recurrent WDTC (Thyroid. 2015;25:15- 27; Head Neck. 2016;38:1862-1869). The objective of this summary is to review the existing literature and discuss indications for surgical intervention for recurrent disease in WDTC.

BEST PRACTICE

Recommendations for the complex, dynamic, and patient-centered management of WDTC recurrence are limited by the lack of randomized controlled trials and prospective studies. Despite the increased morbidity and risks associated with revision surgery, however, select patients benefit from re-operation in the setting of recurrent WDTC. The reader is encouraged to refer to consensus statements published by the American Thyroid Association and American Head and Neck Society for more detailed information. Last, prospective studies should be conducted to further refine current recommendations.