1. Management of the Locoregional Recurrence in Well-differentiated Thyroid Carcinoma 陳漢文

2. Bias #1 Lymph node is not a prognostic factor in well-differentiated thyroid carcinoma, so prophylactic lymphadenectomy is not indicated

3. Bias #2 Routine systemic node dissection which included central neck, lateral neck, even radical neck dissection showed that nodal metastasis near 80% in well-differential thyroid carcinoma. Clinically significant Nodes is around 25% only. Is locoregional recurrence is unavoidable?

4. Recurrence in WDTC n Low risk group :10-30% recurrent rate n High risk group :20-50% recurrent rate n Overall disease mortality : 30-50% n Shorter disease-free interval

5. Classification of the Recurrence n Local recurrence (thyroid bed, 28%) n Regional recurrence (neck nodes, 53%) n Locoregional recurrence (both, 6%) n Distal metastasis (others, 13%) Coburn, 1994, Ann Surgery

6. How to detect locoregional recurrence in thyroid carcinoma? n Clinically detected n Radioiodine scan detected n TSH-stimulated thyroglobulin level n PET Stulak, Arch Surg 2006

7. Central Neck Recurrence n Residual tumor in thyroid bed n Invasion to trachea, esophageal, laryngx, vessels, etc., n pretracheal nodes, mediastinal nodes, paratracheal nodes (79.7%)

8. Lateral Neck Recurrence n Level III, IV, V, (23.1%) n Level II III IV V (23.8%) n Berry picking (36.9%) n Selective dissection (16.2%) n Central neck exploration is benefit n Sono-guided dissection is benefit Roh, Head & Neck 2007

9. Surgical considerations in the recurrent thyroid carcinoma ( I ) n The extent of reoperation is related to the extent of primary surgery, stage, and distant metastasis n Completion total thyroidectomy and central and therapeutic lateral neck dissection for the thyroid remnant, residual tumor, palpated lateral neck nodes n Anterior approach or lateral approach n Long incision or separated incision will be needed

10. Surgical considerations in the recurrent thyroid carcinoma ( II ) n Laryngoscopy exam should be finished, or recurrent laryngeal nerve resection needed due to invasion n Two stage surgery with 6 weeks interval for the bilateral jugular veins resection n Complication included hypoparathyroidism, recurrent laryngeal nerve injury, thoracic duct injury, Horner syndrome and etc., Vogelsang, Chirurg 2005 Duren, Current treatment options in oncology 2000

11. Surgical Safety n Experienced surgeon n Neuromonitoring system n Sono-guided or radio-guided surgery Schuff, Laryngoscope 2008 Kim, Arch Otolaryngol Head Neck Surg 2004 Stulak, Arch Surg 2006 Farrag, Head & Neck 2007

12. Postoperative Radioactive iodine Ablation (ATA guideline) n Stage III and IV disease n Stage II in patients older than 45 yrs n Stage I disease with multifoci, nodal metastases, extrathyroidal extension, vascular invasion or more aggressive histology Cooper, Thyroid 2006

13. Postoperative radioiodine ablation n Therapeutic ablation -- locoregional -- distant metastases n Prophylactic ablation (<1.5cm)

14. External radiation n Incomplete surgical resection due to invasion into vital structures n Tumor at the margins of resection in a high surgical risk patient n Metastases in support bones after surgical debulking when possible

15. Distal metastasis n Surgical removal of discrete local or distant metastases to lung and bone when it can be done safety n Therapeutic radioactive ablation n External radiation

16. Take Home Message n Total or near-total thyroidectomy is the standard procedure in WDTC n Routine central neck dissection is needed n Remove all palpated nodes in lateral neck compartment n Remove non-palpated nodes which was detected by preoperative sonogram n Postoperative ablation for the selective cases

17. Take Home Message n Surgery is still the primary management of the recurrent thyroid carcinoma n Careful preoperative workup is very important Lower morbidity in experienced surgeon ’ s hands is achieved n Understanding the map of nodal recurrence is the key of the surgical treatment

18. DISCUSSION