Back so soon? Is early recurrence of papillary thyroid cancer really just persistent disease?

Abstract

Background Papillary thyroid carcinoma (PTC) has excellent survival, yet recurrence remains a challenge. We sought to determine the proportion of re-operations performed for persistent, rather than truly recurrent disease. Methods We conducted a retrospective review of a prospectively maintained database. Patients with PTC that had re-operation for disease from 2000–2016 were included. We defined recurrence as disease that developed after a patient had an undetectable thyroglobulin and negative ultrasound within one year of surgery. Results A total of 69 patients underwent 92 re-operations. On initial pathology: mean tumor size was 2.6cm; 50.7% were multifocal; and 42% had extra-thyroidal extension. Half (46%) of the patients underwent a central/lateral neck dissection at initial surgery and 76.8% were treated with post-operative radioactive iodine. The median time to first re-operation was 21 months (range, 1–292), and 41.8% occurred within 1 year. Only three operations met criteria for true “recurrence”, while 71 operations were categorized as persistence. Conclusion Many re-operations for PTC are for management of persistent disease. Over half of the patients required re-operation within the first two years, which strongly suggests that improvements in the pre-operative assessment and adequacy of initial surgery need to be made to improve the care of patients with thyroid cancer.

Contemporary considerations in adjuvant radioiodine treatment of adults with differentiated thyroid cancer

“…The outcomes in patients who undergo diagnostic RAI imaging‐guided management are excellent and can be achieved in any contemporary practice that includes SPECT/CT 38 . Recently, it became clear that early recurrence simply represents residual disease left after the initial surgery, 39 which was previously thought to inexplicably reoccur. The theranostic approach aims to proactively identify patients with residual disease at their first post‐thyroidectomy assessment (Figures 2).…”

Patient Report of Recurrent and Persistent Thyroid Cancer

“…Recurrent and persistent thyroid cancer are thought to represent elements of the same pathological process (5,11). Persistent disease typically occurs in patients with high disease burden when cancer could not adequately be eradicated or in those with inadequate initial treatment resulting in residual treatable disease (5,12,13). Patients with recurrent disease either had microscopic disease following initial treatment that grew to a detectable level or they had inadequate initial treatment and at a later time, residual disease was noted (5,12,(14)(15)(16)(17).…”

“…Persistent disease typically occurs in patients with high disease burden when cancer could not adequately be eradicated or in those with inadequate initial treatment resulting in residual treatable disease (5,12,13). Patients with recurrent disease either had microscopic disease following initial treatment that grew to a detectable level or they had inadequate initial treatment and at a later time, residual disease was noted (5,12,(14)(15)(16)(17). Blurring the line between recurrent and persistent disease, in a smaller study of patients with papillary thyroid cancer who underwent a total thyroidectomy (n = 69), an alarming 40% of reoperations occurred within a year from the initial surgery, raising suspicion that some ''recurrences'' are actually persistent disease, that is disease that should have been detected at time of initial treatment (12).…”

Surgical Complications and Referral Patterns in 567 Patients with Differentiated Thyroid Cancer in the Northern Region of the Netherlands: A Population-Based Study Towards Clinical Management Implementation

“…Tg during substitution therapy) and/ or tumor detectable, either on diagnostic imaging or at physical examination, commonly with cytological or histological confirmation of tumor during follow-up after an initial curation. 18 Persistent disease was defined as a continuous existence of microscopic disease (i.e. cytopathologically/histopathologically and/or detectable Tg-on) or detectable macroscopic disease (i.e.…”

“…on physical examination, imaging, or last surgery), as previously described. 18,19 Transient or persistent RLN paralysis was defined as paralysis of one or both RLNs for a period of \ 1 year or [ 1 year, respectively. Nerve dysfunction was diagnosed either peroperatively, clinically, or through laryngoscopy.…”