Management of Recurrent/Persistent Nodal Disease in Patients with Differentiated Thyroid Cancer: A single institutional experience

  • Background
    In a subset of patients with differentiated thyroid cancer there is an incomplete response to surgical and radioiodine treatment resulting in persistent disease or locoregional recurrence.
    High sensitive thyroglobulin associated with high-resolution ultrasound allows the identification of persistent/recurrent disease. The routine implementation of ultrasonography increased the detection of small, subclinical disease.

    Methods
    In this retrospective study, we reviewed 475 patients treated for papillary thyroid cancer. Of these patients, 60 (8%) with abnormal lymph nodes (LN)  in the central or lateral neck identified on postoperative US examination were evaluated. Serial US studies over time were used to monitor the size of each LN, along with sensitive thyroglobulin serum levels change. 

    Results
    The mean follow-up was  7 years. Median size of the LN  was 7 mm (range 4-11 mm).

    During the follow-up time  38 patients had persistent stable disease, 22 patients showed an increase in size of the cervical LN. The rate of growth was 1.1 mm/year in 16 patients. Six patients showed a more significant increase in size; these patients underwent reoperation. The rising serum thyroglobulin provided useful information regarding the likelihood of the increase in size of the abnormal LN.

    Conclusion
    Suspicious small cervical LN  usually remains stable for a long time. Active surveillance with serial ultrasonography and sensitive thyroglobulin assay can be safe for a subset of patients with stable disease. The management of the residual disease requires a multidisciplinary approach involving physicians and patients.  Some aspects of management of this subset of patients,  such as the concern of a prolonged suppressive therapy with levothyroxine and the cost-effectiveness of the prolonged surveillance, need to be addressed.

 

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