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\begin{document}

\title{Wire-localised excision of unpalpable recurrent papillary thyroid
carcinoma}



\author[1]{Eric Farrell}%
\author[1]{Richard Speaker}%
\author[1]{Donal O'Driscoll}%
\author[1]{Liam Skinner}%
\affil[1]{Waterford Regional Hospital}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
Ultra sound wire guided markers are safe and effective for unpalpable
suspicious nodes Particularly useful on the setting of the previously
operated neck Placement by an experienced radiologist in the presence of
the operating surgeon is advocated%
\end{abstract}%



\sloppy


All authors have nothing to declare or disclose.

There are no conflicts of interest to report

\emph{3 succinct points:}

\begin{enumerate}
\tightlist
\item
  Ultra sound wire guided markers are safe and effective for unpalpable
  suspicious nodes
\item
  Particularly useful on the setting of the previously operated neck
\item
  Placement by an experienced radiologist in the presence of the
  operating surgeon is advocated
\end{enumerate}

Introduction

The use of wire-localised nodal excision is standard of care in breast
cancer patients. The technique has also garnered momentum in other
specialties because of its increased accuracy in identifying targets pre
operatively, limiting dissection and morbidity associated with its use.

Due to advancing technology and quality of radiological imaging,
incidental findings of potentially pathological nodes and lesions are
increasing in the field of head and neck surgery. Lesions that are found
and reported on scans may not be clinically palpable. Consequentially,
subclinical nodes that are identified incidentally or on routine follow
up scans create a diagnostic challenge for surgeons and radiologists. In
a region as complex as the head and neck where accuracy is a cornerstone
of surgical practice, precision is a useful adjunct to mitigate
potential morbidity. Further more, in an operative field that has
already been exposed to surgery, adjuvant therapy or complications,
increased accuracy of nodal biopsy cannot be understated.

Technical note:

This technique was applied in the case of a 38 year old female who had
undergone a total thyroidectomy, selective neck dissection and central
neck compartment clearance for a pT3N1b multifocal papillary thyroid
carcinoma. Her post-operative course was complicated by a chylous leak
which was successfully treated with conservative measures and parenteral
feeding. Subsequently she underwent radioactive iodine with no focal
tracer uptake in the neck or elsewhere after treatment.

Upon routine ultra sound follow up 18 months after primary treatment
ended, a unifocal 22mm x 8mm conglomerate lesion was identified.

It was impalpable on examination. FNA of this mass confirmed nodal
recurrence of her papillary thyroid carcinoma. As the node was
identified in a previously operated field, ultra sound guided wire
localisation (USGWL) was undertaken by a consultant radiologist
preoperatively. This is shown in figure 1 below.

The lesion was retrieved through a 3cm incision in the previous scar.
Following elevation of subplatysmal flaps, the targeted mass was rapidly
identified. The stepwise process is outlined in figure 2 below.
Histology confirmed 3 nodes of metastatic papillary thyroid carcinoma,
the largest of which was 9mm. The patient did not suffer any
complications and was discharged on the same day of surgery. On
subsequent follow up she remains well.

Discussion

The first use of the USGWL technique for head and neck patients was
reported by Zimmerman in 2004\textsuperscript{1}. This technique appears
particularly useful in cases that have been previously operated on and
in which the operative field may be distorted\textsuperscript{2}. Samara
et al provided a contemporary summary of the application of USGWL in
various pathologies demonstrating the heterogeneity of it's use from
oncocytomas to decompressed branchial cysts and thyroglossal duct
cysts\textsuperscript{3}.

While USGWL has predominantly been reported as a useful pre operative
tool, it has also be recorded as a useful intraoperative adjunct in a
case of paratracheal nodes that could not be identified during open
exploration\textsuperscript{4}.

In the management of thyroid nodal recurrence choice of treatment
depends on proximity to vital structures, whether the recurrence lies in
a previously operated field and the character of the node in question.
We advocate a targeted approach to the previously operated on neck. A
measured decision regarding suspicious nodes post total thyroidectomy
and RAI for papillary thyroid cancer must also be made to retrieve
suspicious lymph nodes, particularly in the sub centimetre category as
these nodes may have limited potential to progress, with some even
regressing as demonstrated in a retrospective review of 166
patients\textsuperscript{5}. In our case, the conglomerate of nodes in
question was larger than two centimetres and the previously reported
histology showed non encapsulated foci of tumour with limited
lymphovascular invasion.

The complication rate of USGWL has been minimal in single case reports
however in a retrospective review of 17 patients who underwent USGWL for
thyroid bed recurrence, complications documented included puncture of
the internal jugular vein, vocal cord injury, haematoma, chyle leak and
a seroma\textsuperscript{2}. In the next largest review, of 8 patients,
hookwire localisation was reported to take only 5-10 minutes with all
targets being retrieved without complication\textsuperscript{6}. Other
reported complications include pain and vasovagal response to wire
insertion.

Wires should be placed by experienced radiologists, preferably in the
presence of the operating surgeon so they can appreciate the location of
the target nodes/lesions in question. There is an argument to be made
that wires should be placed while the patient is positioned and
anaesthetised on the table. This allows (i) anaesthesia for the patient,
avoiding pain and vasovagal events (ii) minimise the chance for
migration of the wire while patients are themselves moving or being
moved in to position on the operating table (iii) increases the chance
that both radiologist and surgeon can see exactly the course of the wire
and the proximity of nearby structures, this may be particularly
pertinent in the previously operated/irradiated neck.

Wire guided localisation has been shown to be an effective adjunct to
identifying clinically occult lesions in the head and neck. The
application to various pathologies is promising. While the procedure is
considered standard of care in other specialties, it has yet to move in
to the mainstream in Head and Neck surgery. This is an effective and
safe technique in the right hands.

References

1. Zimmerman P, DaSilva M, Izquierdo R, Cico L, Kort K, Numann P.
Intraoperative needle localization during neck reexploration. Am J Surg.
2004;188(1):92-3.

2. Eng OS, Grant SB, Weissler J, Simon M, Roychowdhury S, Davidov T, et
al. Operative bed recurrence of thyroid cancer: utility of a
preoperative needle localization technique. Gland Surgery.
2016;5(6):571-5.

3. Samara E, Williams M, Howlett DC. Current applications of
ultrasound-guided wire localization in head and neck surgery. Int J Oral
Maxillofac Surg. 2019;48(4):443-6.

4. Fletcher AM, Preston TW, Kuehn DM, Clark ED, Van Daele D, Hoffman H.
Ultrasound-guided needle localization of recurrent paratracheal thyroid
cancer. Ann Otol Rhinol Laryngol. 2009;118(7):475-8.

5. Robenshtok E, Fish S, Bach A, Dom\selectlanguage{ngerman}ínguez JM, Shaha A, Tuttle RM.
Suspicious Cervical Lymph Nodes Detected after Thyroidectomy for
Papillary Thyroid Cancer Usually Remain Stable Over Years in Properly
Selected Patients. The Journal of Clinical Endocrinology \& Metabolism.
2012;97(8):2706-13.

6. Park JY, Park NH, Yi SY, Ko MS, Park HJ. Preoperative US-guided
hookwire localization for nonpalpable cervical masses. J Clin
Ultrasound. 2012;40(4):195-9.\selectlanguage{english}
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Figure 1 Node being marked with a needle\selectlanguage{english}
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