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BRIEF REPORT |
Endocrine Surgical Oncology (F.T., R.Z., K.R., J.L., E.K., Q.-Y.D., O.H.C.), University of California/Mount Zion Medical Center, San Francisco, California 94143-1674; and Radiology (L.P., R.G., V.F.), University of California, San Francisco, California 94143
Address all correspondence and requests for reprints to: Frederic Triponez, M.D., Thoracic and Endocrine Surgery, University Hospital of Geneva, Rue Micheli-du-Crest 24, 1211 Geneva 14, Switzerland. E-mail: frederic.triponez{at}hcuge.ch.
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Abstract |
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Objective: The objective of this study was to investigate whether preoperative insertion of a hook needle under ultrasound guidance is useful in neck reoperations for recurrent thyroid cancer.
Patients: Ten consecutive patients presenting over a 4-month period with nonpalpable, ultrasound-visible, fine needle biopsy-proven recurrent thyroid cancer in previously operated neck compartment(s) were studied.
Main Outcome Measures: We measured whether it was technically possible to insert a hook needle preoperatively, rate of negative neck exploration, and complication rate.
Results: The hook needle was inserted in seven patients. In three patients, the hook needle was not inserted; one patient had palpable disease 4 months after the preoperative clinic visit, one patient had a tumor too close to the carotid artery, and one patient had multiple bilateral foci of recurrent disease in the central neck. One patient had bleeding after insertion of the needle due to a penetration of an anterior jugular vein that was easily managed at neck reexploration. No other complication occurred during the hook needle insertion, and the only surgical complication was a transient recurrent nerve palsy. All pathology reports showed malignant disease.
Conclusion: Hook needle-guided excision of recurrent thyroid cancer is feasible and appears to be a promising tool for safe and successful reoperation of patients with small recurrent thyroid cancer in cervical lymph nodes.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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Surgical excision is the only effective curative treatment of recurrent lymph node metastases (1, 8), although radiofrequency ablation or alcohol injection is reportedly effective in ablating metastases in the lateral lymph nodes (9, 10). However, alcohol ablation of parathyroid tumors was unfortunately associated with a high incidence of recurrent laryngeal dysfunction (11, 12).
Reoperations in a previously operated upon neck compartment are associated with an increased risk of complications, particularly to the recurrent laryngeal nerve and to the parathyroid glands (13, 14). Because nonpalpable tumors can be difficult to find intraoperatively, particularly in patients who have previously had an operation in the neck compartment, various strategies have been developed to guide the excision of recurrent disease, including radio-guided surgery after the injection of 131I (15) and intraoperative ultrasound (16).
It is reasonable to assume that more precise nodal identification would result in fewer complications in patients with recurrent thyroid tumors. In breast surgery, wire-guided biopsy and excision has been the standard of care for more than three decades for nonpalpable breast lesions. However, to our knowledge, this method has never been described as a treatment for nonpalpable recurrent thyroid cancer. Therefore, we undertook a preliminary prospective study of this promising method.
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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All patients had one or more suspicious cervical lymph nodes confirmed preoperatively by fine needle aspiration (FNA) cytology under ultrasound guidance.
After general anesthesia was induced in the operating room, the patient’s neck and upper chest were prepared in the usual fashion using chlorhexidine and sterile linen. A neck ultrasound was performed using a machine with a 10V5 or 8V5 probe (Acuson, Siemens Company, San Jose, CA) to confirm the location of the lesions described preoperatively. A 20-gauge, 5-cm-long hook needle (DKBL-20–5.0; Cook Incorporated, Bloomington, IN) was then inserted in the identified node. Ultrasound images were obtained to ensure that the hook was properly placed into or directly next to the mass.
An incision was then made via the previous neck incision, and superior and inferior subplatysmal flaps were created in a standard fashion. Careful dissection was carried out following the hook needle until the mass and any other immediately adjacent nodal mass were identified and excised. The mass was then sent for definitive histological examination, and the neck was closed in a standard fashion without drainage. All operations were performed in the presence of an experienced endocrine surgeon, with the help of residents and/or fellows. Problems and complications during needle placement and the operation were recorded prospectively.
All patients were discharged from the hospital on the first postoperative day and were seen in our clinic 7–21 d postoperatively.
Patients were then returned to the care of their physician and endocrinologist with the usual recommendation to receive another dose of 131I.
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Results |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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).
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). Another patient had previously undergone a negative left lateral neck dissection and left central neck reexploration (0N+/32N) without finding the node that was described in the posterior left neck by ultrasound and was positive on FNA (patient 10, Table 1).
All 10 patients underwent reoperation with a planned hook needle localization. One patient had two hook needles inserted, one in the right central and one in the right lateral compartment. The hook needle was not used in three patients; in one, the nodal metastasis was palpated during the operation, although 4 months earlier, no mass was clinically identified. In another patient, the nodal metastases were deemed too close to the carotid artery, and in the third patient, a complete central neck dissection was required because numerous masses were identified. All the needles could be inserted into or just next to the mass (Fig. 1). One patient had a small amount of bleeding after insertion of the needle through an anterior jugular vein. The bleeding was controlled by gentle compression and rapidly and easily stopped after skin incision. No other complication occurred due to needle insertion.
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). Although all operations were performed in scar tissue, they took just 25–90 min (mean ± SD, 55 ± 25). The patient whose operation took 90 min had masses in central and lateral locations. The only surgical complication was a postoperative transient recurrent laryngeal nerve palsy in one patient.
After a follow-up time of 9–12 months, two patients were lost to follow-up, and one did not have the postoperative workup. Five of the seven remaining patients had no detectable disease in the neck on ultrasound examination. One patient had no detectable disease on one operated side, whereas suspicious lymph nodes were identified on the other operated side (on this side, this patient had undergone a total of three neck dissections including one performed elsewhere, the latest performed without needle localization). One patient had suspicious lymph nodes in the left lateral neck after left lateral neck dissection performed without needle localization. In the seven patients with follow-up data, all six locations identified with needle localization were negative postoperatively.
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Discussion |
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Our follow-up data show that all sites identified with needle localization were negative on follow-up ultrasound, confirming that this technique is useful to achieve local control of the disease. However, our sample size and study design rule out being able to conclude that hook needle localization is better than other localizing techniques or even better than standard blind neck reexplorations. Also still debatable is whether early neck reoperation using localizing techniques will result in a survival advantage over simple observation until the mass becomes clinically evident. However, once a patient is aware that cancer is present, he or she is usually anxious and wants to have the recurrent or persistent tumor removed.
The risk to the recurrent laryngeal nerve of inserting a hook needle should be minimal because the damage to the nerve after alcohol injection or radiofrequency ablation are thought to be chemical or thermal injuries and not direct traumatic injuries due to the insertion of the needle. We believe that the patient who experienced transient laryngeal nerve palsy did so because of the surgical dissection and not because of the needle insertion.
We think that lymph node sampling or berry picking should be abandoned for formal neck dissections. Functional lateral neck dissection (preserving the sternocleidomastoid muscle, the spinal nerve, and the internal jugular vein) should be performed only in case of preoperatively identified lateral disease and not systematically (17, 18). Whether level II should be routinely included in this dissection is still debatable (19). Routine central neck dissection is recommended by some groups (17) but not by others (18); however, all agree that a careful preoperative ultrasound and a careful per-operative exploration should reduce the frequency of recurrent or persistent postoperative nodal metastases (20).
Other techniques might also be employed to help identify cervical nodal metastases, such as injecting Indian ink or methylene blue dye into the node or giving the patient radioiodine. However, cervical node metastases frequently fail to take up much radioiodine, and most patients are 131I scan negative. Therefore, ultrasound-based techniques seem to provide the highest sensitivity to detect and localize cervical nodal metastasis in most of the patients.
In conclusion, this preliminary prospective investigation demonstrates that reoperation after hook needle localization under ultrasound guidance is feasible and safe for patients presenting with recurrent thyroid cancer in previously operated upon areas in the neck. We recommend this procedure and believe it will make these often difficult operations easier and safer and decrease the rate of negative explorations.
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Acknowledgments |
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Footnotes |
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First Published Online September 12, 2006
Abbreviations: DTC, Differentiated thyroid cancer; FNA, fine needle aspiration.
Received February 21, 2006.
Accepted September 6, 2006.
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References |
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