The Management of the Persistent and Recurrent Cervical Lymph Node Metastases

  • J. D. Pasternak
  • W. T. ShenEmail author


Although well-differentiated thyroid cancer (WDTC) has a very favorable prognosis, a substantial portion of patients have recurrence of disease throughout their lifetime. It is important for the clinician to stratify the surveillance of each patient according to their risk of recurrence. Once recurrence is detected, risks and benefits must be weighed before intervention is considered. Reoperation is generally safe and can often provide a durable result. Patients with multiple recurrences can be treated with alternative local therapies, but a multidisciplinary approach to these patients produces the best outcomes.


Recurrent thyroid cancer Surveillance Reoperation Lymph nodes Neck dissection Operative risks Ethanol ablation Radiofrequency ablation 


  1. 1.
    Ahn HS, Kim HJ, Welch HG. Korea’s thyroid-cancer “epidemic”–screening and overdiagnosis. N Engl J Med. 2014;371(19):1765–7.CrossRefPubMedGoogle Scholar
  2. 2.
    Wada N, Duh QY, Sugino K, Iwasaki H, Kameyama K, Mimura T, Ito K, Takami H, Takanashi Y. Lymph node metastasis from 259 papillary thyroid microcarcinomas: frequency, pattern of occurrence and recurrence, and optimal strategy for neck dissection. Ann Surg. 2003;237(3):399–407.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Mazzaferri EL. Management of low-risk differentiated thyroid cancer. Endocr Pract. 2007;13:498–512.CrossRefPubMedGoogle Scholar
  4. 4.
    Hay ID. Management of patients with low-risk papillary thyroid carcinoma. Endocr Pract. 2007;13:521–33.CrossRefPubMedGoogle Scholar
  5. 5.
    Qubain SW, Nakano S, Baba M, Takao S, Aikou T. Distribution of lymph node micrometastasis in pN0 well-differentiated thyroid carcinoma. Surgery. 2002;131:249–56.CrossRefPubMedGoogle Scholar
  6. 6.
    Arturi F, Russo D, Giuffrida D, Ippolito A, Perrotti N, Vigneri R, Filetti S. Early diagnosis by genetic analysis of differentiated thyroid cancer metastases in small lymph nodes. J Clin Endocrinol Metab. 1997;82:1638–41.CrossRefPubMedGoogle Scholar
  7. 7.
    Tuttle RM, Tala H, Shah J, Leboeuf R, Ghossein R, Gonen M, Brokhin M, Omry G, Fagin JA, Shaha A. Estimating risk of recurrence in differentiated thyroid cancer after total thyroidectomy and radioactive iodine remnant ablation: using response to therapy variables to modify the initial risk estimates predicted by the new American Thyroid Association staging system. Thyroid. 2010;20:1341–9.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Vaisman F, Momesso D, Bulzico DA, Pessoa CH, Dias F, Corbo R, Vaisman M, Tuttle RM. Spontaneous remission in thyroid cancer patients after biochemical incomplete response to initial therapy. Clin Endocrinol (Oxf). 2012;77:132–8.CrossRefGoogle Scholar
  9. 9.
    Castagna MG, Maino F, Cipri C, Belardini V, Theodoropoulou A, Cevenini G, Pacini F. Delayed risk stratification, to include the response to initial treatment (surgery and radioiodine ablation), has better outcome predictivity in differentiated thyroid cancer patients. Eur J Endocrinol. 2011;165:441–6.CrossRefPubMedGoogle Scholar
  10. 10.
    Pitoia F, Bueno F, Urciuoli C, Abelleira E, Cross G, Tuttle RM. Outcomes of patients with differentiated thyroid cancer risk-stratified according to the American thyroid association and Latin American thyroid society risk of recurrence classification systems. Thyroid. 2013;23:1401–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Wu JX, Beni CE, Zanocco KA, Sturgeon C, Yeh MW. Cost-effectiveness of long-term every three-year versus annual postoperative surveillance for low-risk papillary thyroid cancer. Thyroid. 2015;25(7):797–803.CrossRefPubMedGoogle Scholar
  12. 12.
    Haugen BR, Alexander EK, Bible KC, Doherty G, Mandel SJ, Nikiforov YE, Pacini F, Randolph G, Sawka A, Schlumberger M, Schuff KG, Sherman SI, Sosa JA, Steward D, Tuttle RM, Wartofsky L. 2015 American Thyroid Association Management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2015; 26(1):1–133.Google Scholar
  13. 13.
    Baudin E, Do CC, Cailleux AF, Leboulleux S, Travagli JP, Schlumberger M. Positive predictive value of serum thyroglobulin levels, measured during the first year of follow-up after thyroid hormone withdrawal, in thyroid cancer patients. J Clin Endocrinol Metab. 2003;88:1107–11.CrossRefPubMedGoogle Scholar
  14. 14.
    Padovani RP, Robenshtok E, Brokhin M, Tuttle RM. Even without additional therapy, serum thyroglobulin concentrations often decline for years after total thyroidectomy and radioactive remnant ablation in patients with differentiated thyroid cancer. Thyroid. 2012;22:778–83.CrossRefPubMedGoogle Scholar
  15. 15.
    Torlontano M, Crocetti U, Augello G, D’Aloiso L, Bonfitto N, Varraso A, Dicembrino F, Modoni S, Frusciante V, Di Giorgio A, Bruno R, Filetti S, Trischitta V. Comparative evaluation of recombinant human thyrotropin-stimulated thyroglobulin levels, 131I whole-body scintigraphy, and neck ultrasonography in the follow-up of patients with papillary thyroid microcarcinoma who have not undergone radioiodine therapy. J Clin Endocrinol Metab. 2006;91(1):60–3.CrossRefPubMedGoogle Scholar
  16. 16.
    Kim E, Park JS, Son KR, Kim JH, Jeon SJ, Na DG. Preoperative diagnosis of cervical metastatic lymph nodes in papillary thyroid carcinoma: comparison of ultrasound, computed tomography, and combined ultrasound with computed tomography. Thyroid. 2008;18:411–8.CrossRefPubMedGoogle Scholar
  17. 17.
    Lesnik D, Cunnane ME, Zurakowski D, Acar GO, Ecevit C, Mace A, Kamani D, Randolph GW. 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;36(2):191–202.CrossRefPubMedGoogle Scholar
  18. 18.
    Harari A, Sippel RS, Goldstein R, Aziz S, Shen W, Gosnell J, Duh QY, Clark OH. Successful localization of recurrent thyroid cancer in reoperative neck surgery using ultrasound-guided methylene blue dye injection. J Am Coll Surg. 2012;215(4):555–61.CrossRefPubMedGoogle Scholar
  19. 19.
    Clayman GL, Shellenberger TD, Ginsberg LE, et al. Approach and safety of comprehensive central compartment dissection in patients with recurrent papillary thyroid carcinoma. Head Neck. 2009;31:1152–63.CrossRefPubMedGoogle Scholar
  20. 20.
    Farrag TY, Agrawal N, Sheth S, et al. Algorithm for safe and effective reoperative thyroid bed surgery for recurrent/persistent papillary thyroid carcinoma. Head Neck. 2007;29:1069–74.CrossRefPubMedGoogle Scholar
  21. 21.
    Onkendi EO, McKenzie TJ, Richards ML, Farley DR, Thompson GB, Kasperbauer JL, Hay ID, Grant CS. Reoperative experience with papillary thyroid cancer. World J Surg. 2014;38(3):645–52. doi: 10.1007/s00268-013-2379-9.CrossRefPubMedGoogle Scholar
  22. 22.
    Shah MD, Harris LD, Nassif RG, et al. Efficacy and safety of central compartment neck dissection for recurrent thyroid carcinoma. Arch Otolaryngol Head Neck Surg. 2012;138:33–7.CrossRefPubMedGoogle Scholar
  23. 23.
    Alvarado R, Sywak MS, Delbridge L, et al. Central lymph node dissection as a secondary procedure for papillary thyroid cancer: is there added morbidity? Surgery. 2009;145:514–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Tufano RP, Bishop J, Wu G. Reoperative central compartment dissection for patients with recurrent/persistent papillary thyroid cancer: efficacy, safety, and the association of the BRAF mutation. Laryngoscope. 2012;122:1634–40.CrossRefPubMedGoogle Scholar
  25. 25.
    Lang BH, Lee GC, Ng CP, et al. Evaluating the morbidity and efficacy of reoperative surgery in the central compartment for persistent/recurrent papillary thyroid carcinoma. World J Surg. 2013;37:2853–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Shen WT, Ogawa L, Ruan D, et al. Central neck lymph node dissection for papillary thyroid cancer: comparison of complication and recurrence rates in 295 initial dissections and reoperations. Arch Surg. 2010;145:272–5.CrossRefPubMedGoogle Scholar
  27. 27.
    Urken ML, Milas M, Randolph GW, Tufano R, Bergman D, Bernet V, Brett EM, Brierley JD, Cobin R, Doherty G, Klopper J, Lee S, Machac J, Mechanick JI, Orloff LA, Ross D, Smallridge RC, Terris DJ, Clain JB, Tuttle M. A review of the management of recurrent and persistent metastatic lymph nodes in well differentiated thyroid cancer: a multifactorial decision making guide created for the Thyroid Cancer Care Collaborative. Head Neck. 2015;37:605–14.CrossRefPubMedGoogle Scholar
  28. 28.
    Steward DL. Update in utility of secondary node dissection for papillary thyroid cancer. J Clin Endocrinol Metab. 2012;97:3393–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Heilo A, Sigstad E, Fagerlid KH, Haskjold OI, Groholt KK, Berner A, Bjoro T, Jorgensen LH. Efficacy of ultrasound-guided percutaneous ethanol injection treatment in patients with a limited number of metastatic cervical lymph nodes from papillary thyroid carcinoma. J Clin Endocrinol Metab. 2011;96:2750–5.CrossRefPubMedGoogle Scholar
  30. 30.
    Baek JH, Kim YS, Sung JY, Choi H, Lee JH. Locoregional control of metastatic well-differentiated thyroid cancer by ultrasound-guided radiofrequency ablation. AJR Am J Roentgenol. 2011;197:W331–6.CrossRefPubMedGoogle Scholar
  31. 31.
    Hay ID, Hutchinson ME, Gonzalez-Losada T, McIver B, Reinalda ME, Grant CS, Thompson GB, Sebo TJ, Goellner JR. Papillary thyroid microcarcinoma: a study of 900 cases observed in a 60-year period. Surgery. 2008;144:980–7.CrossRefPubMedGoogle Scholar
  32. 32.
    Palmedo H, Bucerius J, Joe A, et al. Integrated PET/CT in differentiated thyroid cancer: diagnostic accuracy and impact on patient management. J Nucl Med. 2006;47:616–24.PubMedGoogle Scholar
  33. 33.
    Schreinemakers JM, Vriens MR, Munoz-Perez N, et al. Fluorodeoxyglucose-positron emission tomography scan-positive recurrent papillary thyroid cancer and the prognosis and implications for surgical management. World J Surg Oncol. 2012;10:192.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Rosenthal MS, Angelos P, Cooper DS, Fassler C, Finder SG, Hays MT, Tendler B, Braunstein GD. Clinical and professional ethics guidelines for the practice of thyroidology. Thyroid. 2013;23:1203–10.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Division of General SurgeryUniversity Health NetworkTorontoCanada
  2. 2.Department of SurgeryMt Zion Hospital, University of California – San FranciscoSan FranciscoUSA

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