Successful Localization of Recurrent Thyroid Cancer in Reoperative Neck Surgery Using Ultrasound-Guided Methylene Blue Dye Injection Avital Harari, MD, Rebecca S Sippel, MD, FACS, Ruth Goldstein, MD, Seerat Aziz, MD, Wen Shen, MD, FACS, Jessica Gosnell, MD, FACS, Quan-Yang Duh, MD, FACS, Orlo H Clark, MD, FACS BACKGROUND: Reoperation in the neck can be challenging and is associated with increased complication rates and operative times. Here we analyze our methylene blue dye injection method to localize reoperative neck pathology in patients with thyroid cancer and lymph node metastases. STUDY DESIGN: We retrospectively reviewed the records of all patients at a single university tertiary care center who had reoperative neck surgery for recurrent thyroid cancer between 2004 and 2009, and who also underwent intraoperative methylene blue dye injection. Outcomes measured were efficacy and safety of the injection technique as well as complication rates. RESULTS: Fifty-three operations were performed in 44 patients (average age, 51.2 years [range 16 to 83 years]). Ninety-one percent (48 of 53) of the operations resulted in successful resection of recurrent disease. Of these, 96% (46 of 48) were guided successfully by blue dye injection. Thyroglobulin became undetectable in 42% (11 of 26) of patients. Neck pathology included the following thyroid cancers: papillary (48 of 53), follicular (2 of 53), medullary (2 of 53), and tall cell variant (1 of 53). Among these patients, there were a total of 26 central and 38 lateral neck dissections. The average number of previous neck dissections was 2 (range 1 to 5). The mean intraoperative ultrasound/injection time was 21.3 min (n = 13). Median operative time was 90 minutes (range 40 to 300 minutes). Complications included 2 permanent vocal cord paralyses, 1 instance of permanent hypocalcemia, and 3 instances of temporary hypocalcemia. There were no complications related to the dye injection. CONCLUSIONS: Intraoperative, ultrasound-guided, methylene blue dye injection is a safe and effective tech- nique. It facilitates tumor localization and removal especially in patients requiring reoperative neck surgery. (J Am Coll Surg 2012;215:555–561. © 2012 by the American College of Surgeons) The incidence of thyroid cancer in the United States has been exponentially increasing in the past decade. In 2012, it is estimated that 56,460 new cases of thyroid cancer were detected in the United States. 1 The standard of care for differentiated thyroid cancer that is multifocal or 1 cm in size is a total thyroidectomy. 2 Lymphadenectomy should occur with primary thyroid sur- gery if lymph nodes appear to be abnormal at the time of operation or are positive for cancer on preoperative ultrasound-guided biopsy. 2 There has been substantial con- troversy about the need for prophylactic lymphadenec- tomy at the time of operation for possible occult lymph node metastases, especially in the central compartment. 3,4 Regardless of initial procedure type, if a patient was disease free after the initial operation, there is still up to a 10% to 25% recurrence rate in the neck. 5-7 This recurrence rate is affected by preoperative lymph node status, aggressive thy- roid cancer pathology, and adequacy of excision. 5 Reoperation for recurrent thyroid cancer can be chal- lenging and is associated with increased complication rates and operative times when compared with initial surgery. 8,9 Due to the significant amount of scarring in the neck after an initial surgical procedure, reoperations can be challeng- ing. It may be difficult for surgeons to identify and com- pletely excise recurrent tumor. 10 The recurrences may ap- pear very similar to scar tissue and are sometimes difficult Disclosure Information: Nothing to disclose. Received March 22, 2012; Revised May 29, 2012; Accepted June 13, 2012. From the University of California, Los Angeles, Section of Endocrine Surgery, Los Angeles, CA (Harari); the University of Wisconsin, Section of Endocrine Surgery, Madison, WI (Sippel); and the Department of Radiology (Gold- stein, Aziz), and the Division of Endocrine Surgery (Shen, Gosnell, Duh, Clark), University of California, San Francisco, San Francisco, CA. Correspondence address: Avital Harari, MD, Department of Surgery, Uni- versity of California, Los Angeles, 10833 LeConte Ave, Suite 72-232 CHS, Los Angeles, CA 90095. email: aharari@mednet.ucla.edu 555 © 2012 by the American College of Surgeons ISSN 1072-7515/12/$36.00 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jamcollsurg.2012.06.006