Thyroid and Parathyroid

process and always should be meticulously cleared along with paratracheal nodes
(central neck node dissection). In patients with palpable cervical nodes or involved
central neck nodes, ipsilateral or bilateral, bilateral modified radical neck dissection is
recommended. Similarly, patients with MTCs larger than 2 cm should undergo
ipsilateral prophylactic modified radical neck dissection, because more than 60
. percent of these patients have nodal metastases
If superior mediastinal lymph nodes are noted at operation they also should be
removed, although it is rarely necessary to perform a median sternotomy. Surgeons
should be prepared to sacrifice the recurrent laryngeal nerve when it is involved in the
tumor mass. Though this does not occur frequently, the possibility should be
. discussed with the patient preoperatively
Tumor debulking in cases of metastatic disease or local recurrence should be
undertaken. This frequently ameliorates symptoms of flushing and diarrhea, and it
. helps in decreasing the risk of death resulting from recurrent central neck disease
External-beam radiotherapy for patients with tumors at resection margins or
unresectable tumors is controversial. It is recommended for patients with unresectable
residual or recurrent tumor, although the results are debatable. There is no effective
. chemotherapy regimen
When patients have associated conditions such as pheochromocytoma or
hyperparathyroidism, these conditions also require careful evaluation.
Pheochromocytomas should be operated on first, before thyroidectomy is performed.
In most cases pheochromocytomas can be removed laparoscopically. In patients who
have hypercalcemia at the time of thyroidectomy, the parathyroid glands should be
identified and, when abnormal, selectively removed. In patients with normocalcemia,
efforts should be made to preserve the parathyroid glands, which should be marked
with a stitch or clip in patients with MEN IIA. When a normal parathyroid cannot be
maintained on a vascular pedicle, it should be removed, biopsied to confirm that it is a
. parathyroid, and then autotransplanted to the forearm of the nondominant arm
Postoperative Follow-up and Prognosis
Patients should be assessed at regular postoperative intervals, and serum calcitonin
and CEA levels should be monitored regularly. Calcitonin level is more sensitive for
detecting persistent or recurrent disease, and CEA for predicting outcome. In a study
of 123 patients with MTC, Russell and colleagues reported that 67 percent of the
patients whose MTC was confined to the thyroid were clinically and biochemically
(calcitonin) free of disease (mean follow-up time 5.5 years), compared to only 8
percent of patients who had extrathyroidal spread. A later paper from the same group
reported on 31 patients who, despite having adequate primary operations for MTC,
had persistently raised calcitonin levels. The 5- and 10-year survival rates for these
patients were 90 percent and 86 percent, respectively, with only two patients dying
from MTC. Postoperatively raised calcitonin levels are frequently encountered and
. are a cause for concern signaling the need for evaluation
When recurrent or metastatic MTC is suspected and suggested by rising calcitonin
levels, localization studies for occult or clinically apparent disease should be used.
The investigative tools available include CT, MRI of the neck and mediastinum,