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Revision and Reoperative Thyroid Surgery

  • Author: Ron Mitzner, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Aug 07, 2014
 

Problem

Revision or reoperative thyroid surgery is often technically challenging because of anatomic changes following primary surgery.

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Presentation

Most thyroid cancers are differentiated, slow-growing, easily treatable tumors with an excellent prognosis after surgical resection and targeted medical therapy. Approximately one third of patients with differentiated thyroid cancer (DTC) have tumor recurrence; most are diagnosed within 10 years of treatment.[1, 2, 3] Locoregional recurrences may arise in the central or lateral neck, thyroid remnant, mediastinum, or, rarely, in the trachea or the muscle overlying the thyroid bed. The mortality from locally recurrent disease in the low-risk group (according to the Age, Metastases, Extent, and Size [AMES] prognostic index) with DTC is 4%. However, patients who are male and older than age 45 years experience a mortality rate of 27% once DTC recurs.[4]

Clinical or radiologic evidence of locally recurrent DTC is generally treated with surgical removal of the focus of disease and postoperative iodine-131 (131 I).

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Indications

Reoperative thyroid surgery may be performed under a number of circumstances. A patient may have had a previous thyroid lobectomy and require a completion thyroidectomy for differentiated thyroid cancer (DTC). Recurrence of thyroid cancer may require reexploration of the thyroid bed or cervical lymph node dissection, including the central compartment (level VI). Additionally, occurrence of cancer in the thyroid remnant after operation for benign thyroid diseases or symptomatic disease in a partially removed nodular or multinodular goiter may also require reoperation.[5]

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Relevant Anatomy

Normal anatomy

The thyroid is a highly vascular gland in the neck that overlies the proximal trachea and thyroid cartilage. It is composed of right and left lateral lobes joined at their medial aspects by an isthmus (see image below). In approximately 50% of patients, an appendage to the gland (termed the pyramidal lobe) courses cephalad from the isthmus. The strap muscles overlie the thyroid lobes.

Thyroid gland, anterior and lateral views. Thyroid gland, anterior and lateral views.

The arterial blood supply to the gland is composed of the superior thyroid artery and the inferior thyroid artery, branches of the external carotid artery and the thyrocervical trunk, respectively (see the first image below). Approximately 3% of individuals also have a thyroid ima artery that supplies the gland. The thyroid is attached to the trachea by the ligament of Berry. The recurrent laryngeal nerves (RLN) are in close proximity to the thyroid as they course from the tracheoesophageal groove to the cricothyroid membrane. The tubercle of Zuckerkandl is an important landmark of the RLN.[6] The parathyroid glands lie in close proximity to the thyroid, usually as paired structures adjacent to the upper and lower poles of the thyroid gland (see the second image below).

Distribution of thyroid arteries with associated l Distribution of thyroid arteries with associated laryngeal nerve, anterior view.
Axial CT scan of a patient with a thyroid lesion p Axial CT scan of a patient with a thyroid lesion prior to thyroidectomy.

Anatomical changes following thyroidectomy

Changes in cervical anatomy may take place following thyroidectomy. The carotid sheath is an important landmark in thyroid surgery. It provides the lateral boundary of dissection and is an important landmark when initially identifying the RLN.[7] Realizing that the great vessels of the neck may medialize following thyroidectomy and may be directly adjacent to the trachea (see the image below) is important. Scarring and fibrosis from prior surgery may cause increased difficulty in identifying and dissecting important structures. When reoperating the area of the ipsilateral thyroid remnant, the recurrent laryngeal nerve is often difficult to identify and dissect because it is buried in scar tissue. The tracheoesophageal groove itself may be scarred and distorted.

Axial CT scan of a patient one year after total th Axial CT scan of a patient one year after total thyroidectomy. The great vessels of the neck are significantly medialized.

For more information about the relevant anatomy, see Thyroid Anatomy.

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Contributor Information and Disclosures
Author

Ron Mitzner, MD Resident Physician, Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, Penn State University College of Medicine, Milton S Hershey Medical Center

Ron Mitzner, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

David Goldenberg, MD, FACS Chief of Otolaryngology-Head and Neck Surgery, Professor of Surgery and Oncology, Pennsylvania State University College of Medicine; Director of Head and Neck Surgery, Department of Surgery, Division of Otolaryngology-Head and Neck Oncology, Milton S Hershey Medical Center

David Goldenberg, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Thyroid Association, Israeli Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Karen H Calhoun, MD, FACS, FAAOA Professor, Department of Otolaryngology-Head and Neck Surgery, Ohio State University College of Medicine

Karen H Calhoun, MD, FACS, FAAOA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, Association for Research in Otolaryngology, Southern Medical Association, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Rhinologic Society, Society of University Otolaryngologists-Head and Neck Surgeons, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

David J Terris, MD, FACS Porubsky Professor and Chairman, Department of Otolaryngology, Medical College of Georgia, Georgia Regents University

David J Terris, MD, FACS is a member of the following medical societies: American Association for the Advancement of Science, Federation of American Societies for Experimental Biology, International Association of Endocrine Surgeons, Alpha Omega Alpha, Triological Society, Radiation Research Society, American Academy of Otolaryngology-Head and Neck Surgery, American Bronchoesophagological Association, American College of Surgeons, American Head and Neck Society, Phi Beta Kappa, Society of University Otolaryngologists-Head and Neck Surgeons

Disclosure: Nothing to disclose.

References
  1. Sturgeon C, Angelos P. Identification and treatment of aggressive thyroid cancers. Part 2: risk assessment and treatment. Oncology (Williston Park). 2006 Apr. 20(4):397-404; discussion 404, 407-8. [Medline].

  2. Mazzaferri EL, Jhiang SM. Long-term impact of initial surgical and medical therapy on papillary and follicular thyroid cancer. Am J Med. 1994 Nov. 97(5):418-28. [Medline].

  3. Mazzaferri EL, Jhiang SM. Differentiated thyroid cancer long-term impact of initial therapy. Trans Am Clin Climatol Assoc. 1995. 106:151-68; discussion 168-70. [Medline].

  4. Cady B, Sedgwick CE, Meissner WA, et al. Risk factor analysis in differentiated thyroid cancer. Cancer. 1979 Mar. 43(3):810-20. [Medline].

  5. Rudolph N, Dominguez C, Beaulieu A, De Wailly P, Kraimps JL. The Morbidity of Reoperative Surgery for Recurrent Benign Nodular Goitre: Impact of Previous Unilateral Thyroid Lobectomy versus Subtotal Thyroidectomy. J Thyroid Res. 2014. 2014:231857. [Medline]. [Full Text].

  6. Gravante G, Delogu D, Rizzello A, et al. The Zuckerkandl tubercle. Am J Surg. 2007 Apr. 193(4):484-5. [Medline].

  7. Myers EN, RL Carrau. Operative otolaryngology. head and neck surgery. Philadelphia: W.B. Saunders. 2 v. (xv, 1578, xxxii p.); 1997.

  8. Kouvaraki MA, Shapiro SE, Fornage BD, et al. Role of preoperative ultrasonography in the surgical management of patients with thyroid cancer. Surgery. 2003 Dec. 134(6):946-54; discussion 954-5. [Medline].

  9. Krishnamurthy S, Bedi DG, Caraway NP. Ultrasound-guided fine-needle aspiration biopsy of the thyroid bed. Cancer. 2001 Jun 25. 93(3):199-205. [Medline].

  10. Stulak JM, Grant CS, Farley DR, et al. Value of preoperative ultrasonography in the surgical management of initial and reoperative papillary thyroid cancer. Arch Surg. 2006 May. 141(5):489-94; discussion 494-6. [Medline].

  11. Lesnik D, Cunnane ME, Zurakowski D, Acar GO, Ecevit C, Mace A, et al. Papillary thyroid carcinoma nodal surgery directed by a preoperative radiographic map utilizing CT scan and ultrasound in all primary and reoperative patients. Head Neck. 2014 Feb. 36(2):191-202. [Medline].

  12. Lind P, Kresnik E, Kumnig G, et al. 18F-FDG-PET in the follow-up of thyroid cancer. Acta Med Austriaca. 2003. 30(1):17-21. [Medline].

  13. Mosci C, Iagaru A. PET/CT Imaging of Thyroid Cancer. Clin Nucl Med. 2011 Dec. 36(12):e180-5. [Medline].

  14. Lind P. 131I whole body scintigraphy in thyroid cancer patients. Q J Nucl Med. 1999 Sep. 43(3):188-94. [Medline].

  15. Agarwal A, Mishra SK. Completion total thyroidectomy in the management of differentiated thyroid carcinoma. Aust N Z J Surg. 1996 Jun. 66(6):358-60. [Medline].

  16. Hurtado-López LM, Melchor-Ruan J, Basurto-Kuba E, Montes de Oca-Durán ER, Pulido-Cejudo A, Athié-Gutiérrez C. Low-risk papillary thyroid cancer recurrence in patients treated with total thyroidectomy and adjuvant therapy vs. patients treated with partial thyroidectomy. Cir Cir. 2011 Mar-Apr. 79(2):118-25. [Medline].

  17. Kupferman ME, Patterson M, Mandel SJ, et al. Patterns of lateral neck metastasis in papillary thyroid carcinoma. Arch Otolaryngol Head Neck Surg. 2004 Jul. 130(7):857-60. [Medline].

  18. Calabro S, Auguste LJ, Attie JN. Morbidity of completion thyroidectomy for initially misdiagnosed thyroid carcinoma. Head Neck Surg. 1988 Mar-Apr. 10(4):235-8. [Medline].

  19. Walgenbach S, Junginger T. [Is the timing of completion thyroidectomy for differentiated thyroid carcinoma prognostic significant?]. Zentralbl Chir. 2002 May. 127(5):435-8. [Medline].

  20. Makay O, Unalp O, Icoz G, et al. Completion thyroidectomy for thyroid cancer. Acta Chir Belg. 2006 Sep-Oct. 106(5):528-31. [Medline].

  21. Tan MP, Agarwal G, Reeve TS, et al. Impact of timing on completion thyroidectomy for thyroid cancer. Br J Surg. 2002 Jun. 89(6):802-4. [Medline].

  22. Sivanandan R, Soo KC. Pattern of cervical lymph node metastases from papillary carcinoma of the thyroid. Br J Surg. 2001 Sep. 88(9):1241-4. [Medline].

  23. Lang BH, Lee GC, Ng CP, Wong KP, Wan KY, Lo CY. Evaluating the morbidity and efficacy of reoperative surgery in the central compartment for persistent/recurrent papillary thyroid carcinoma. World J Surg. 2013 Dec. 37(12):2853-9. [Medline].

  24. Onkendi EO, McKenzie TJ, Richards ML, Farley DR, Thompson GB, Kasperbauer JL, et al. Reoperative experience with papillary thyroid cancer. World J Surg. 2014 Mar. 38(3):645-52. [Medline].

  25. Grant CS, Hay ID, Gough IR, et al. Local recurrence in papillary thyroid carcinoma: is extent of surgical resection important?. Surgery. 1988 Dec. 104(6):954-62. [Medline].

  26. Palme CE, Freeman JL. Surgical strategy for thyroid bed recurrence in patients with well-differentiated thyroid carcinoma. J Otolaryngol. 2005 Feb. 34(1):7-12. [Medline].

  27. Scurry WC, Lamarre E, Stack B. Radioguided neck dissection in recurrent metastatic papillary thyroid carcinoma. Am J Otolaryngol. 2006 Jan-Feb. 27(1):61-3. [Medline].

  28. Salvatori M, Rufini V, Reale F, et al. Radio-guided surgery for lymph node recurrences of differentiated thyroid cancer. World J Surg. 2003 Jul. 27(7):770-5. [Medline].

  29. Rubello D, Piotto A, Pagetta C, et al. (99m)Tc-MIBI radio-guided surgery for recurrent thyroid carcinoma: technical feasibility and procedure, and preliminary clinical results. Eur J Nucl Med Mol Imaging. 2002 Sep. 29(9):1201-5. [Medline].

  30. Rubello D, et al. (99m)Tc-sestamibi radio-guided surgery of loco-regional (131)Iodine-negative recurrent thyroid cancer. Eur J Surg Oncol. 2007.

  31. Fialkowski EA, Moley JF. Current approaches to medullary thyroid carcinoma, sporadic and familial. J Surg Oncol. 2006 Dec 15. 94(8):737-47. [Medline].

  32. Greenblatt DY, Elson D, Mack E, et al. Initial lymph node dissection increases cure rates in patients with medullary thyroid cancer. Asian J Surg. 2007 Apr. 30(2):108-12. [Medline].

  33. Roh JL, Park JY, Rha KS, et al. Is central neck dissection necessary for the treatment of lateral cervical nodal recurrence of papillary thyroid carcinoma?. Head Neck. 2007 Oct. 29(10):901-6. [Medline].

  34. Roh JL, Park JY, Rha KS, Park CI. Is central neck dissection necessary for the treatment of lateral cervical nodal recurrence of papillary thyroid carcinoma?. Head Neck. 2007 Oct. 29(10):901-6. [Medline].

  35. Lefevre JH, Tresallet C, Leenhardt L, et al. Reoperative surgery for thyroid disease. Langenbecks Arch Surg. 2007 Nov. 392(6):685-691. [Medline].

  36. Beahrs OH, Vandertoll DJ. Complications of Secondary Thyroidectomy. Surg Gynecol Obstet. 1963 Nov. 117:535-9. [Medline].

  37. Tollefsen HR, Shah JP, Huvos AG. Papillary carcinoma of the thyroid. Recurrence in the thyroid gland after initial surgical treatment. Am J Surg. 1972 Oct. 124(4):468-72. [Medline].

  38. Pasieka JL, Thompson NW, McLeod MK, et al. The incidence of bilateral well-differentiated thyroid cancer found at completion thyroidectomy. World J Surg. 1992 Jul-Aug. 16(4):711-6; discussion 716-7. [Medline].

  39. Seiler CA, Glaser C, Wagner HE. Thyroid gland surgery in an endemic region. World J Surg. 1996 Jun. 20(5):593-6; discussion 596-7. [Medline].

  40. Eroglu A, Berberoglu U, Buruk F, et al. Completion thyroidectomy for differentiated thyroid carcinoma. J Surg Oncol. 1995 Aug. 59(4):261-6; discussion 266-7. [Medline].

  41. Levin KE, Clark AH, Duh QY, et al. Reoperative thyroid surgery. Surgery. 1992 Jun. 111(6):604-9. [Medline].

  42. Hundahl SA, Cady B, Cunningham MP, et al. Initial results from a prospective cohort study of 5583 cases of thyroid carcinoma treated in the united states during 1996. U.S. and German Thyroid Cancer Study Group. An American College of Surgeons Commission on Cancer Patient Care Evaluation study. Cancer. 2000 Jul 1. 89(1):202-17. [Medline].

  43. Brooks JR, Starnes HF, Brooks DC, et al. Surgical therapy for thyroid carcinoma: a review of 1249 solitary thyroid nodules. Surgery. 1988 Dec. 104(6):940-6. [Medline].

  44. Spencer CA, LoPresti JS, Fatemi S, et al. Detection of residual and recurrent differentiated thyroid carcinoma by serum thyroglobulin measurement. Thyroid. 1999 May. 9(5):435-41. [Medline].

 
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Axial CT scan of a patient with a thyroid lesion prior to thyroidectomy.
Axial CT scan of a patient one year after total thyroidectomy. The great vessels of the neck are significantly medialized.
Central compartment dissections in the previously operated neck. The recurrent laryngeal nerve (arrow) was traced out from the scarred tracheoesophageal groove.
Revision neck dissection. Structures encountered that resemble a parathyroid should undergo frozen section biopsy. Exposed tissue adjacent to the great vessels was found to be metastatic papillary thyroid cancer.
Thyroid gland, anterior and lateral views.
Distribution of thyroid arteries with associated laryngeal nerve, anterior view.
 
 
 
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