Surgical strategy for thyroid bed recurrence in patients with well-differentiated thyroid carcinoma

Well-differentiated thyroid carcinoma (WTC) has a low but definite rate of recurrence. The majority of these occur locoregionally and present a significant diagnostic and management challenge. It is the aim of this article to convey the complexities associated with revision surgery involving the thyroid bed and to present sound surgical strategies to deal with this problem in a manner that minimizes morbidity, adheres to oncologic principles, and achieves appropriate cure rates.

Between 1992 and 2002, 14 patients with revision surgery involving the thyroid bed were identified and managed according to an algorithm taking into account clinical, biochemical, and radiologic indices. All underwent revision surgery, and we applied our technique of wide field exposure by horizontally sectioning all of the ipsi- or bilateral strap muscles. We use blunt dissection to identify the recurrent laryngeal nerves and parathyroid glands.

There were six males and eight females, with a median age of 38 years (range 23-62 years). The median time between procedures was 25 months (range 6-120 months). The diagnosis was established by clinical examination, thyroglobulin determination, and/or imaging. All were treated with surgery and postoperative iodine 131 (I131). The median follow-up was 6 months (range 2-48 months). Complications included two cases of temporary recurrent laryngeal nerve palsy, two patients with permanent and two patients with temporary hypocalcemia, two cases of temporary chyle leaks, and one recurrence. One patient underwent a negative exploration.

The management of infield recurrence of WTC presents both a diagnostic and a therapeutic challenge owing to the disparity in presentation, the complexity of the anatomy, and indistinct tissue planes. The optimal treatment of these patients is surgical resection and postoperative I131. This can be accomplished safely and with little morbidity. The key to this type of surgery is a sound and systematic approach.