Chasing Calcitonin: Reoperations for Medullary Thyroid Carcinoma

Excerpt

In their article, “Biochemical Cure Following Reoperations for Medullary Thyroid Carcinoma: A Meta-Analysis,” Rowland et al.1 provide a very insightful review of the optimal surgical approach for recurrent medullary thyroid cancer. Because no randomized studies exist to guide practicing thyroid surgeons, these authors conducted a thorough meta-analysis of existing studies to determine whether patients with persistently elevated calcitonin after their initial surgery should undergo a targeted procedure removing gross disease or a more extensive compartment-oriented approach. The overall success rate in their study, defined as normalization of calcitonin, was 16.2 %. When classified by surgical technique, a selective approach yielded a biochemical cure rate of 10.5 % (95 % confidence interval [CI], 6.4–14.7), whereas a compartment-oriented approach led to a biochemical cure for 18.6 % (95 % CI, 15.9–21.3). The higher rate of calcitonin normalization with a compartment-oriented surgery was balanced, however, by a higher complication rate that included recurrent laryngeal nerve injury in 5.7 % compared with 1.9 % in the selective surgery group. The compartment-oriented group also experienced an increased incidence of thoracic duct injury, Horner’s syndrome, spinal accessory nerve injury, wound infection, and seromas, but the rate of permanent hypoparathyroidism actually appeared to be higher in the targeted surgery group. The authors note that their data on complications should be interpreted cautiously because their study was not designed to assess this end point. However, it does seem reasonable that more extensive surgery leads to an overall higher complication rate. …