Reoperative thyroid surgery

Abstract

Thyroid resection is often performed for a number of benign conditions including compression from multinodular goiter, for cosmetic reasons, or an inability to determine before surgery whether a thyroid nodule is benign or malignant. For goiters that are multinodular and bilateral, total thyroidectomy is definitive treatment and will prevent recurrent disease. Patients who have undergone partial thyroid resection for benign conditions may develop recurrent symptomatic disease in the remaining thyroid gland. The mass effect of recurrent thyroid disease, despite hormonal suppression, may progress to occlude adjacent anatomical structures such as the larynx, trachea, and/ or esophagus. The latter two structures can become compressed either in the neck or the mediastinum, and this compression necessitates not only dissection in the contralateral neck, but re-exploration of the ipsilateral thyroid bed to remove the offending thyroid tissue. Sometimes a large goiter may not necessarily cause compression, but is nonetheless deemed unsightly by an anxious patient Although uncommon, malignancy can subsequently develop in the remaining thyroid following partial thyroidectomy performed for benign disease.l” More commonly, partial thyroidectomy is initially performed for reported benign disease on frozen section examination, but is later determined postoperative11 as containing malignancy on final pathology sections. l, -6 Total thyroidectomy is the preferred surgical treatment for well-differentiated thyroid cancer greater than 1 cm in size, Hurthle cell cancer, cancer in a radiated thyroid, and early poorly differentiated thyroid cancer. The diagnosis of follicular variant of papillary cancer is particularly difficult to make on frozen section, as capsular invasion may be determined only on further sectioning of the permanent specimen.‘,* Patients, who underwent initial thyroid lobectomy for what is finally determined as thyroid cancer, are frequently considered for a second operation to “complete” the thyroidectomy. Few people advocate 1311 ablation of the remaining thyroid gland to achieve a total thyroidectomy because of the associated risks with multiple doses of radioactive treatment, secondary injury to adjacent parathyroid glands, and pulmonary fibrosis.4 The rationale for re-operation include four main reasons: 1) to identify and remove possible residual or multicentric foci of carcinoma in the contralateral lobe; 2) to allow for low-dose 1131 radioactive ablation of microscopic amounts of residual thyroid tissue postoperatively; 3) to facilitate the early detection of cancer recurrence with thyroglobulin levels and thyrogen-