Risks and Adequacy of an Optimized Surgical Approach to the Primary Surgical Management of Papillary Thyroid Carcinoma Treated During 1999–2006 Clive S. Grant • John M. Stulak • Geoffrey B. Thompson • Melanie L. Richards • Carl C. Reading • Ian D. Hay Published online: 10 December 2009 Ó Socie ´te ´ Internationale de Chirurgie 2009 Abstract Background Intense disease surveillance and frequent lymph node metastases (LNMs) in papillary thyroid cancer (PTC) have resulted in increased locoregional recurrences. We examined the safety and efficacy of an optimized surgical approach including preoperative ultrasonograpy (US), bilateral thyroidectomy, routine compartment VI dissection, and lateral neck dissection for LNM. Methods During 1999–2006, a total of 420 patients underwent optimized primary surgery; 291(69%) females, median age 46 years; follow-up 98%, median 4.4 years. Patients were reviewed for tumor characteristics, pattern of LNM, staging, and outcomes. Results Total or near-total thyroidectomy was performed in 212 (51%) and 208 (49%) patients, respectively. Tumors were multicentric, 40% (average 1.7 cm); were bilateral, 30%; and showed extrathyroidal extension, 17%. Overall, 223 (53%) patients had LNMs: 213 (51%) were central and 85 (20%) were lateral jugular. pTNM staging: I, 258 (61%); II, 35 (8%); III, 88 (21%); IV, 39 (9%). AGES (age, grade, extension, and size—thyroid tumor; and MACIS (metastasis, age, completeness of resection, invasion, and size) prognostic scores were low risk in 362 (86%) and 352 (84%), respectively. Relapse developed in 57 (14%) patients: LNM in 44, soft tissue local recurrence (LR) in 5, distant metastases (DM) in 8. Hypoparathyroidism occur- red in 5 (1.2%) patients and 1 had unintentional laryngeal nerve damage. Relapse with LNM occurred in previously operated fields in 19 (5%) patients, 11(3%) from disease virulence (LR or DM), preoperative false-negative (FN) US in 12 (3%), and combination of FN-US and recurrence in the operated field in 5 (1%) patients. Conclusions Recurrence was limited to 5% of patients when the extent of disease was accurately defined and potentially curable. This optimized surgical strategy is relatively safe. Introduction Over the past two and a decades, our understanding of papillary thyroid carcinoma (PTC) has increased consid- erably. Through intense analysis of several large retro- spective patient populations with PTC [1–3], the most important prognostic factors have been identified, which in turn can be utilized to predict the mortality risks even of individual patients. It has become clear that, with appro- priate treatment, disease-related mortality is rare in patients with PTC. Appropriately, investigations have progressed to secondary measures of treatment efficacy, and disease recurrence has emerged as the most important focus of the new millennium. Concurrent with this improved understanding of the disease, three major technologies have been introduced that have dramatically affected the management of PTC: serum thyroglobulin, recombinant human TSH, and high-resolu- tion ultrasonography (US). Detailed, intricate algorithms integrating these factors into intensive follow-up C. S. Grant (&) Á J. M. Stulak Á G. B. Thompson Á M. L. Richards Department of Gastrointestinal and General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA e-mail: cgrant@mayo.edu C. C. Reading Department of Diagnostic Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA I. D. Hay Division of Endocrinology and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA 123 World J Surg (2010) 34:1239–1246 DOI 10.1007/s00268-009-0307-9