ORIGINAL ARTICLE ALGORITHM FOR SAFE AND EFFECTIVE REOPERATIVE THYROID BED SURGERY FOR RECURRENT/PERSISTENT PAPILLARY THYROID CARCINOMA Tarik Y. Farrag, MD, 1* Nishant Agrawal, MD, 1* Sheila Sheth, MD, 2 Chetan Bettegowda, MD, PhD, 1 Marjorie Ewertz, BSN, 3 Matthew Kim, MD, 3 Ralph P. Tufano, MD 1 1 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine; Baltimore, Maryland. E-mail: rtufano@jhmi.edu 2 Radiology Johns Hopkins School of Medicine; Baltimore, Maryland 3 Division of Endocrinology and Metabolism; Johns Hopkins School of Medicine; Baltimore, Maryland Accepted 10 September 2006 Published online 11 June 2007 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hed.20634 Abstract: Background. The aim of this study was to review our experience with reoperative thyroid bed surgery (RTBS) for recurrent/persistent papillary thyroid cancer (PTC), and present an algorithm for safe and effective RTBS. Methods. This is a retrospective study. Records of 33 con- secutive patients who underwent RTBS for recurrent/persistent PTC in a previously operated thyroid bed, and were operated upon by the senior author (R.P.T.) July 2001 to January 2006 were reviewed. Reports of the pre- and post-RTBS serum thyro- globulin (TG) levels, the high-resolution thyroid bed ultrasound examination, pre-RTBS FNA cytopathology, as well as the post- RTBS final histopathology were reviewed. Recurrent laryngeal nerve (RLN) monitoring was used for all patients. Reports of the intra-RTBS condition of the RLN and any reported surgical com- plications were reviewed. In addition, reports of the pre- and post-RTBS fiberoptic laryngoscopy as well as pre- and post- RTBS serum calcium levels were reviewed. Results. In our study, 33 consecutive patients underwent RTBS for recurrent/persistent PTC with or without lateral neck dissection. In 30 patients, recurrent/persistent PTC was sus- pected because of rising serum TG levels, interpreted in con- junction with serum anti-TG-antibody titers by the endocrinology service at our institution. Three patients had serum anti-TG anti- bodies and their disease was detected and FNA confirmed by a regularly scheduled surveillance ultrasound examination. All patients underwent pre-RTBS high-resolution thyroid bed ultra- sound examination and FNA for all suspicious masses. All patients had FNA-confirmed PTC in the thyroid bed. All patients had detailed diagrams localizing areas of FNA-confirmed PTC in the thyroid bed provided to the surgeon. In all study patients, post-RTBS histopathologic findings confirmed sites of recurrent/ persistent PTC determined by pre-RTBS US guided FNA. All RLNs (53/53) that were at risk were successfully identified. In 3 patients, the RLN was electively resected because of the envel- opment by a large paratracheal mass or tumor densely adherent to the RLN insertion point at the cricothyroid region. There was no incidence of unexpected RLN injury, permanent hypocalce- mia, or any other surgery-related complication. Post-RTBS serum TG levels were significantly decreased or undetectable in most patients (2 patients had concurrent lung metastases), when compared with pre-RTBS levels. No patient exhibited thy- roid bed recurrent/persistent PTC in the post-RTBS period based on semiannual high resolution neck ultrasound examina- tion with a median follow-up of 2 years. Conclusions. Safe and effective RTBS is based on a multi- disciplinary approach that enables the identification and local- ization of recurrent/persistent PTC. The surgical algorithm for RTBS described, provides a pathway that all endocrine-head and neck surgeons can comfortably utilize to treat this complex Correspondence to: R. P. Tufano *Tarik Y. Farrag and Nishant Agrawal contributed equally to this work. V V C 2007 Wiley Periodicals, Inc. Reoperative Thyroid Bed Surgery for Recurrent/Persistent PTC HEAD & NECK—DOI 10.1002/hed December 2007 1069