Treatment of persistent or recurrent papillary carcinoma of the thyroid--the good, the bad, and the unknown.

The diagnosis and treatment of recurrent or persistent papillary carcinoma of the thyroid can pose significant clinical dilemmas. The tumor generally has a relatively indolent biology; however, recurrent or persistent disease is not uncommon, although tumor-specific mortality is infrequent (1). The exquisite detection sensitivity of the combination of TSH-stimulated serum thyroglobulin (Tg) in conjunction with the ease, sensitivity, and availability of ultrasonography [including ultrasoundguided fine-needle aspiration (FNA)] yields a patient cohort with persistent or recurrent disease. The compulsive physicianemploysthesetechniquesandfrequentlydetects small-volumecervicaldisease,andthephysicianinconcert with the patient reacts by employing ablative or resectional therapy. Treatment options include 131 I, surgical resection, and ethanol or radiofrequency ablation (2–5). Allarecapableofdestroyingtargetlesions,and 131 Ihasthe advantage of ablating extracervical disease. Each technique has unique, but acceptable, morbidities. Surgery is generally the preferred technique for resectable loco-regional cervical disease (6). Careful observation alone may also be an option in select patients. In this edition of the Journal, Al-Saif et al. (7) report a cohortof70patientswithrecurrentorpersistentpapillary thyroid carcinoma (PTC) of the thyroid who had undergone a previous thyroidectomy (with or without nodal dissection) and 131 I therapy. Recurrent or persistent disease was detected by imaging studies or the presence of detectable TSH-stimulated serum Tg in patients who did not have anti-Tg antibodies. Each patient underwent one, two, or three remedial cervical reexplorations, and 19 (27%) achieved a biochemical complete remission as defined by an undetectable TSH-stimulated serum Tg level. Thefirstre-resectionachievedaremissionrateof17%(12 of 70), and the second re-resection achieved a remission rate of 18% (five of 28). No patient achieved remission (zero of seven) with a third re-resection. Two additional patients achieved complete biochemical remission during long-term follow-up without further intervention, presumably due to the latent effects of previous 131 I treatment. The duration of complete biological responses ranged from 4–116 months. It is noteworthy that in 10 (9%) of the lymphadenectomies, the intervention was nontherapeutic because the surgeonwasunabletoidentifyorresectresidualPTC.This emphasizes the difficulty of locating small-volume disease in the remedial neck even in the setting of a positive preoperative ultrasound-guided FNA. It is also worth noting that there were no cases of new long-term hypoparathyroidismorrecurrentnerveinjury.Athoracicductinjuryin one patient required reoperative intervention.