Читать книгу Pearls and Pitfalls in Head and Neck Surgery - Группа авторов - Страница 23
ОглавлениеThyroid and Parathyroid Glands
Cernea CR, Dias FL, Fliss D, Lima RA, Myers EN, Wei WI (eds): Pearls and Pitfalls in Head and Neck Surgery. Basel, Karger, 2012, pp 34–35
DOI: 10.1159/000337473
1.17 Surgical Management of Recurrent/Persistent Differentiated Thyroid Cancer
Gary L. Clayman
The University of Texas MD Anderson Cancer Center, Houston, Tex., USA
P E A R L S
• All macroscopic disease should be excised. All anatomically uninvolved structures should be spared, unless grossly involved by disease.
• Reoperations should be delayed for at least 6 months to minimize difficulty in dealing with wound healing and dense scarring issues.
• Preoperative evaluation including laryngoscopy, high-resolution ultrasound (HRUS), and high-resolution CT scanning from the skull base to mid-thorax is imperative.
Pearls regarding the Lateral Neck
• Ultrasound evidence of lateral neck metastasis implies the necessity for level II—V dissection.
• Level IIB does not require comprehensive dissection, except in patients with level IIA or III diseases.
• Nodes posterior to the carotid sheet within level IV are a component of dissection.
• Postoperative shoulder rehabilitation should be performed on all patients undergoing lateral neck dissection.
Pearls regarding the Central Compartment
• In patients with more than one central compartment (CC) surgery, the sternothyroid muscle should be resected with CC contents.
• Parathyroid function should be preserved whenever possible. A portion of at least one parathyroid should be autotransplanted if it can be identified and pathologically confirmed. Assume every parathyroid gland is the last functioning gland.
• Recurrent laryngeal nerves (RLN) should be directly visualized and meticulously dissected. In general, the nerves should be located in previously untouched areas.
• The thymus is rarely involved with metastatic disease and may also be a site for inferior parathyroid tissue.
• The superior laryngeal nerve should be identified and spared whenever feasible.
• Delfian lymph node disease within the cricothyroid area should be removed in all patients. This must be performed in a subfascial fashion.
P I T F A L L S
• Surgical clips should be avoided due to production of artifact in cross-sectional imaging.
• Meticulous clamp, cut, and tie technique is required throughout level IV, the posterior carotid sheath structures, and near to the superior mediastinum to avoid chylous leakage.
• Injury to the RLN can be avoided with meticulous microdissection technique sparing all branches and avoiding electro cautery. Bipolar electrocautery can be utilized safely and in close proximity to the RLN, at 10 mA or less power settings.
Introduction
The term recurrent differentiated thyroid cancer (DTC) is often utilized, but the distinction between recurrent or persistent disease can often be difficult to discern. Persistent disease following definitive surgical excision for early stages I and II DTC has been reported to be as high as 11-30% [1]. Recurrent disease occurs in 10-30% of patients with stages I—III PTC [2]. Local and regional recurrences within the CC may add considerable risk to long-term morbidity. Local/CC recurrences may also carry considerable risk for tumor-related death among patients above 45 years of age [3].
The long-term follow-up of patients with DTC requires HRUS in the surveillance of the central and lateral neck and serologic analysis for thyroglobulin. A thorough understanding of the limitations of HRUS in the CC, posterior esophageal sites, mediastinal sites, and lateral retropharyngeal nodes must be understood by care providers.
Practical Tips
Meticulous surgery offers the patient a high likelihood for control of the central and lateral compartments of the neck and superior mediastinum [4, 5].
In general, redo surgery is not recommended before 6 months after the previous intervention. This delay allows for cicatrix maturation and offers patients a better understanding of the biology of their disease. In younger patients (<45 years of age), this delay may in fact be significantly longer.
Optimally, suspicious lymph node size should be larger than 8 mm. It is best to allow smaller nodes to increase in size prior to surgical interventions in order to avoid 'surgical misses'. Lateral neck disease can grow to considerably larger size without placing other cervical structures at risk. A thorough surgical map, based upon ultrasound and cross-sectional imaging, provides adequate strategic surgical planning. Intraoperative ultrasound can be utilized at the end of the procedure to verify the completeness of the intervention. This approach offers greater than 90% control of the cervical area. Among patients with detectable thyroglobulin and cervical disease with no evidence of distant disease, approximately 70% will exhibit both ultrasound and biochemical evidence of surgical cure [6, 7].
Soft tissue extension may invade the laryngotracheal and esophageal organs [6]. Functional organ-sparing surgery is then imperative to control the CC [8]. Postoperative radiation therapy produces outstanding long-term control, functional, and survival benefit [9].
Conclusion
Surgery for recurrent or persistent DTC requires a comprehensive understanding of the disease process as well as significant expertise in the surgery of the central and lateral neck. Meticulous and comprehensive surgery, by individuals with significant experience, offers excellent control of the local and regional environment, with minimal risk to laryngeal or parathyroid function or cosmesis. Parathyroid function can be maintained in the vast majority of patients.
References
1 Hundahl SA, Cady B, Cunningham MP, Mazzaferri E, McKee RF, Rosai J, Shah JP, Fremgen AM, Stewart AK, Holzer S: 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;89:202–217.
2 Sherman SI, Angelos P, Ball DW, Beenken SW, Byrd D, Clark OH, Daniels GH, Dilawari RA, Ehya H, Farrar WB, Gagel RF, Kandeel F, Kloos RT, Kopp P, Lamonica DM, Loree TR, Lydiatt WM, McCaffrey J, Olson JA Jr, Ridge JA, Robbins R, Shah JP, Sisson JC, Thompson NW: National Comprehensive Cancer Network: Thyroid carcinoma. J Natl Compr Cancer Netw 2005;3:404–457.
3 Waseem Z, Palme CE, Walfish P, Freeman JL: Prognostic implications of site of recurrence in patients with recurrent well-differentiated thyroid cancer. J Otolaryngol 2004;33:339–344.
4 Clayman GC, Shellenberger TD, Ginsberg LE, Edeiken BS, El-Naggar AK, Sellin RV, Waguespack SG, Roberts DB, Mishra A, Sherman SI: Approach and safety of comprehensive central compartment dissection in patients with recurrent thyroid cancer. Head Neck 2009;9:1152–1163.
5 Carty SE, Cooper DS, Doherty GM, Duh QY, Kloos RT, Mandel SJ, Randolph GW, Stack BC Jr, Steward DL, Terris DJ, Thompson GB, Tufano RP, Tuttle RM, Udelsman R: Consensus statement on the terminology and classification of central neck dissection for thyroid cancer. Thyroid 2009;19:1153–1158.
6 Clayman GL, Agarwal G, Edeiken BS, Waguespack SG, Roberts DB, Sherman SI: Long-term outcome of comprehensive central compartment dissection in patient with recurrent/persistent papillary thyroid carcinoma. Thyroid 2011;21:1309–1316.
7 Schuff KG, Weber SM, Givi B, Samuels MH, Andersen PE, Cohen JI: Efficacy of nodal dissection for treatment of persistent/recurrent papillary thyroid cancer. Laryngoscope 2008;118:768–775.
8 Samaan NA, Schulz PN, Hickey RC, Goepfert H, Haynie TP, Johnston DA, Ordonex NG: The results of various modalities of treatment of well differentiated thyroid carcinomas: a retrospective review of 1599 patients. J Clin Endocrinol Metab 1992;75:714–720.
9 Schwartz DL, Lobo MJ, Ang KK, Morrison WH, Rosenthal DI, Ahamad A, Evans DB, Clayman GL, Sherman SI, Garden AS: Postoperative external beam radiotherapy for differentiated thyroid cancer: outcomes and morbidity with conformal treatment. Int J Radiat Oncol Biol Phys 2009;74:1083–1091.
Dr. Gary L. Clayman, DMD, MD, FACS
Department of Head and Neck Surgery
The University of Texas MD Anderson
Cancer Center
1515 Holcombe Boulevard, Unit 1445
Houston, TX 77030 (USA)
E-Mail gclayman@mdanderson.org
