title: Staged Surgery for Advanced Thyroid Cancers: Safety and Oncologic Outcomes of Neural Monitored Surgery.
abstract: Objective Thyroidectomy with extensive multicompartment bilateral neck dissections for advanced-stage thyroid cancer may lead to increased risk of complications, including bilateral recurrent laryngeal nerve (RLN) paralysis and hypoparathyroidism. A planned staged approach derived from a detailed preoperative radiographic map is associated with a low complication profile. This study evaluates oncologic results and safety of neural monitored, staged thyroid cancer surgery for management of advanced thyroid cancer. Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods With institutional review board approval, 35 consecutive patients with advanced thyroid malignancy and extensive nodal disease managed with staged surgery between January 2004 and May 2013 by the senior author (G.W.R.) were identified, and the oncologic and surgical outcomes were reviewed. Results In total, 37.2% of patients had stage III or IV disease, with extrathyroidal extension in 71.4%, vascular invasion in 51.4%, and RLN invasion in 17% of patients. A total of 34% patients had positive lymph nodes in more than 5 nodal compartments; the average positive lymph node yield was 17, and extranodal extension was present in 51%. Three patients had RLN sacrifice, and there were no other cases of temporary or permanent RLN paralysis; permanent hypoparathyroidism and chyle leak occurred in one patient each. Locoregional recurrence occurred in 5.7% of patients after a 147-week mean follow-up. In patients with papillary thyroid carcinoma, median postoperative nonstimulated and stimulated thyroglobulin levels were 0.2 and 0.75 ng/mL, respectively. Conclusion A neural monitored, staged surgical approach was conducted without significant adverse events in this small sample and represents and effective alternative strategy option to simultaneous bilateral surgery in the management of thyroid cancer with extensive neck metastases.
authors.affiliation: 1 Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary & Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Behzad
authors.initials: B
authors.lastname: Salari
authors.affiliation: 1 Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary & Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Rebecca J
authors.initials: RJ
authors.lastname: Hammon
authors.affiliation: 1 Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary & Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Dipti
authors.initials: D
authors.lastname: Kamani
authors.affiliation: 1 Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary & Harvard Medical School, Boston, Massachusetts, USA.|2 Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, & Harvard Medical School Boston, Massachusetts, USA.
authors.forename: Gregory W
authors.initials: GW
authors.lastname: Randolph
mesh_terms: D000368:Aged; D002277:Carcinoma / Q000473:pathology / Q000601:surgery*; D002291:Carcinoma, Papillary; D015331:Cohort Studies; D004576:Electromyography / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007037:Hypothyroidism / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D037981:Neck Dissection / Q000009:adverse effects / Q000379:methods*; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D061214:Patient Safety / Q000706:statistics & numerical data; D061226:Recurrent Laryngeal Nerve Injuries / Q000517:prevention & control*; D012189:Retrospective Studies; D018570:Risk Assessment; D000077273:Thyroid Cancer, Papillary; D013964:Thyroid Neoplasms / Q000473:pathology / Q000601:surgery*; D013965:Thyroidectomy / Q000009:adverse effects / Q000379:methods*; D016896:Treatment Outcome
keywords: bilateral surgery; complications; extensive thyroid cancer; intraoperative nerve monitoring; neck dissection; recurrent laryngeal nerve; staged surgery