Page 70 - Read Online

Shaha. J Cancer Metastasis Treat 2023;9:22 https://dx.doi.org/10.20517/2394-4722.2022.101 Page 7 of 9

Table 7. Risk of recurrence
Modified 2009 risks Risk of recurrence
High risk High risk
Gross extrathyroidal extension, incomplete tumor resection, distant metastases, or lymph node >3 cm 50%
Intermediate risk Intermediate risk
Aggressive histology, minor extrathyroidal extension, vascular invasion, or > 5 involved lymph nodes (0.2-3 cm) 20%
Low risk Low risk
Intrathyroidal DTC ≤ 5 LN micrometastases (< 0.2 cm) 5%

Table 8. Factors affecting management of recurrent nodal disease

• Time of recurrence
• Location of recurrent disease
• Size of recurrent disease
• Doubling time
• Surgical complications
• Patients’ wishes and anxieties

Table 9. Localization of recurrent thyroid cancer

Preoperative imaging
- Ultrasound, ultrasound-guided fine-needle aspiration
- Cytology - thyroglobulin wash
- CT with contrast
- MRI
- PET scan
- RAI
Preoperative
- Ultrasound on the operating table
Intra-operative
- Charcoal
- Methylene blue
- Guide wire
- I 131 probe
- PET probe
- Intraoperative ultrasound
- Radio guidance
Postoperative
- Follow-up U/S & imaging studies

Table 10. Ten commandments in the management of recurrent thyroid cancer

1. Evaluate the initial surgical procedure and the reasons for recurrence
2. Evaluate the extent of the disease, biology of the disease, and vocal cord evaluation
3. If possible, discuss with the previous surgeon about first operation- timing of recurrence.
4. Appropriate imaging- US localization, CT with contrast, and PET scan
5. Be prepared to manage the patient now from A to Z
6. Observation for small tumors is a good choice
7. Work in a multidisciplinary group-may need adjuvant RT
8. Intraoperative monitoring of recurrent laryngeal nerve-parathyroids
9. Start the surgery from a non-dissected area- altered anatomy due to scarring and fibrosis
10. Monitor the patient for future recurrence and appropriate treatment
• Don’t miss the boat
• Avoid multiple operations, second, third, and fourth-make it one complete operation

mediastinum. Finding small-volume disease in the supraclavicular area may be quite difficult due to
extensive vascularity and fear of injuring the pleura. Certain alternate non-surgical approaches may be
considered in selected patients, such as continuous monitoring, active surveillance, and ethanol injection.
The experience with radiofrequency ablation appears to be limited at this time for nodal metastasis. There is
a sizeable experience from Mayo Clinic with alcohol injection. However, it does require sonographic
expertise. [See Tables 5-10].