Reoperative central compartment dissection for patients with recurrent/persistent papillary thyroid cancer: efficacy, safety, and the association of the BRAF mutation.

OBJECTIVES/HYPOTHESIS: The aims of this study were to present our experience with reoperative central compartment dissection (RCCD) for recurrent/persistent papillary thyroid cancer (PTC), and to explore the association between the BRAF mutation status and the clinicopathologic characteristics and outcomes of a large cohort of PTC patients who have undergone RCCD. STUDY
DESIGN: Case series with chart review.
METHODS: This is a retrospective study. One hundred twenty consecutive patients between July 2001 and June 2010 who underwent RCCD for recurrent/persistent PTC performed by a single surgeon (r.p.t.) were reviewed. Data reviewed included demographic information; records from previous operations, RCCD, and any other concurrent procedures; pre- and postoperative serum and ionized calcium levels; pre- and postoperative fiberoptic laryngoscopic examination reports; postoperative notes; and pathology reports. V600E mutations in the BRAF gene were detected by performing pyrosequencing for the 107 patients deemed evaluable for the BRAF mutation.
RESULTS: The median time to tumor recurrence (TTR) was 36 months (range, 6-791 months). All recurrent laryngeal nerves (RLNs; 161/161) that were at risk were successfully identified. There were seven new findings of abnormal post-RCCD vocal fold (VF) motion that were the result of intentional RLN resection. Among them, six were because of the need for resection of a local recurrence, and one was because of bulky lymph nodes circumferentially involving the RLN. There were no findings of unexpected RLN injury or VF paralysis. Fifteen patients developed hypocalcemia as a result of RCCD that improved with oral calcium and vitamin D supplementation. Among them, 12 cases developed only post-RCCD transient hypocalcemia (≤6 months), and three patients developed permanent hypocalcemia. No patient exhibited central compartment recurrent/persistent PTC in the post-RCCD period based on semiannual high-resolution neck ultrasound examination with a median follow-up of 41.5 months (range, 6-123 months). Eighty (74.8%) of 107 cases demonstrated the BRAF V600E mutation. The presence of the BRAF mutation was significantly associated with a shorter TTR (P = .015) compared with the BRAF mutation-negative group. The BRAF mutation-positive group had a higher incidence of concurrent lateral lymph node metastases (P = .0064) than the BRAF mutation-negative group.
CONCLUSIONS: Recurrent/persistent PTC in the central compartment typically harbors the BRAF mutation. The time to central neck recurrence from initial treatment is significantly shorter in the BRAF-positive population of patients compared to the BRAF-negative group, making it more likely that a recurrence will be identified early in the surveillance period. Although we have demonstrated that RCCD can be performed safely and effectively for nodal metastases, there is still risk involved, and this must be carefully weighed by the multidisciplinary team and the patient in optimizing a tailored plan for management.