title: Algorithm for safe and effective reoperative thyroid bed surgery for recurrent/persistent papillary thyroid carcinoma.
abstract: BACKGROUND
  The aim of this study was to review our experience with reoperative thyroid bed surgery (RTBS) for recurrent/persistent papillary thyroid cancer (PTC), and present an algorithm for safe and effective RTBS.
  
  
  METHODS
  This is a retrospective study. Records of 33 consecutive patients who underwent RTBS for recurrent/persistent PTC in a previously operated thyroid bed, and were operated upon by the senior author (R.P.T.) July 2001 to January 2006 were reviewed. Reports of the pre- and post-RTBS serum thyroglobulin (TG) levels, the high-resolution thyroid bed ultrasound examination, pre-RTBS FNA cytopathology, as well as the post-RTBS final histopathology were reviewed. Recurrent laryngeal nerve (RLN) monitoring was used for all patients. Reports of the intra-RTBS condition of the RLN and any reported surgical complications were reviewed. In addition, reports of the pre- and post-RTBS fiberoptic laryngoscopy as well as pre- and post-RTBS serum calcium levels were reviewed.
  
  
  RESULTS
  In our study, 33 consecutive patients underwent RTBS for recurrent/persistent PTC with or without lateral neck dissection. In 30 patients, recurrent/persistent PTC was suspected because of rising serum TG levels, interpreted in conjunction with serum anti-TG-antibody titers by the endocrinology service at our institution. Three patients had serum anti-TG antibodies and their disease was detected and FNA confirmed by a regularly scheduled surveillance ultrasound examination. All patients underwent pre-RTBS high-resolution thyroid bed ultrasound examination and FNA for all suspicious masses. All patients had FNA-confirmed PTC in the thyroid bed. All patients had detailed diagrams localizing areas of FNA-confirmed PTC in the thyroid bed provided to the surgeon. In all study patients, post-RTBS histopathologic findings confirmed sites of recurrent/persistent PTC determined by pre-RTBS US guided FNA. All RLNs (53/53) that were at risk were successfully identified. In 3 patients, the RLN was electively resected because of the envelopment by a large paratracheal mass or tumor densely adherent to the RLN insertion point at the cricothyroid region. There was no incidence of unexpected RLN injury, permanent hypocalcemia, or any other surgery-related complication. Post-RTBS serum TG levels were significantly decreased or undetectable in most patients (2 patients had concurrent lung metastases), when compared with pre-RTBS levels. No patient exhibited thyroid bed recurrent/persistent PTC in the post-RTBS period based on semiannual high resolution neck ultrasound examination with a median follow-up of 2 years.
  
  
  CONCLUSIONS
  Safe and effective RTBS is based on a multidisciplinary approach that enables the identification and localization of recurrent/persistent PTC. The surgical algorithm for RTBS described, provides a pathway that all endocrine-head and neck surgeons can comfortably utilize to treat this complex and challenging patient population.
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
authors.forename: Tarik Y
authors.initials: TY
authors.lastname: Farrag
authors.forename: Nishant
authors.initials: N
authors.lastname: Agrawal
authors.forename: Sheila
authors.initials: S
authors.lastname: Sheth
authors.forename: Chetan
authors.initials: C
authors.lastname: Bettegowda
authors.forename: Marjorie
authors.initials: M
authors.lastname: Ewertz
authors.forename: Matthew
authors.initials: M
authors.lastname: Kim
authors.forename: Ralph P
authors.initials: RP
authors.lastname: Tufano
mesh_terms: D000293:Adolescent; D000328:Adult; D000465:Algorithms; D000906:Antibodies / Q000097:blood; D044963:Biopsy, Fine-Needle; D002291:Carcinoma, Papillary / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D037981:Neck Dissection; D009364:Neoplasm Recurrence, Local / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies; D013954:Thyroglobulin / Q000097:blood / Q000276:immunology; D013961:Thyroid Gland / Q000473:pathology / Q000601:surgery*; D013964:Thyroid Neoplasms / Q000601:surgery*; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional
chemical_list: D000906:Antibodies; D013954:Thyroglobulin