Is routine dissection of level II-B and V-A necessary in patients with papillary thyroid cancer undergoing lateral neck dissection for FNA-confirmed metastases in other levels

Level II lateral neck dissection for papillary thyroid carcinoma: A retrospective cohort study

BACKGROUND

For N1b papillary thyroid carcinoma (PTC) patients, lateral neck dissection encompassing levels Ⅱ-Ⅴ is generally recommended. However, routine level Ⅱ dissection is controversial given the low incidence of metastasis, and potential complications such as increased shoulder syndrome.

METHODS

Retrospective analysis of consecutive patients with papillary thyroid carcinoma who underwent lateral neck dissection at a single institution from January 2019 to April 2021 was performed. Clinicopathological features such as age, gender, tumor location, tumor size, TgAb and TPOAb levels, capsular invasion, multifocality and lymph node metastases were examined to evaluate the occurrence of metastatic Level Ⅱ lymph nodes.

RESULTS

Overall and occult level Ⅱ metastases were observed in 51.83% and 34.84% of cN1b PTC patients. Multivariant analysis showed that primary tumor, location of primary tumor and positive level Ⅴ can serve as independent risk factors of metastasis in level Ⅱ. For cN1b PTC patients not suspected of level Ⅱ lymph nodes preoperatively, independent risk factors for predicting occult level Ⅱ metastases may include the location of primary tumor, positive level Ⅲ and positive level Ⅴ.

CONCLUSION

A significant number of patients with PTC and lateral neck disease experienced Level Ⅱ metastasis, with the location of primary tumor and multilevel lymph node involvement being the independent risk factors. If the tumor is less than 1 cm and located at lower 2/3 lobe, there is minimal possibility of level Ⅱ lymph node metastasis.

Extended Level IV Neck Dissection for Limited Prophylactic Clearance of Level V in Node-Positive Papillary Thyroid Carcinoma: a Homogenous Study Population

There is near consensus that prophylactic lateral neck dissection has no role in the management of differentiated thyroid cancer, but the extent of lateral neck dissection in differentiated thyroid cancer remains controversial, especially whether level V should be addressed or not. There is lot of heterogeneity in reporting of the management of level V in papillary thyroid cancer. We at our Institute address the lateral neck positive papillary thyroid cancer with selective neck dissection involving levels II-IV, performing extended level IV dissection with inclusion of the triangular area delineated by the sternocleidomastoid muscle, the clavicle, and the perpendicular line drawn to the clavicle from the point where the horizontal line at the level of cricoid cuts the posterior border of sternocleidomastoid muscle. Retrospective analysis of the departmental data set related to thyroidectomy with lateral neck dissection from 2013 to mid-2019 for papillary thyroid cancer, was carried out. Patients with recurrent papillary thyroid cancer were excluded as were patients with involvement of level V. Data related to the demography of patients, histological diagnosis, and postoperative complications were compiled and summarized. Note was made of the incidence of ipsilateral neck recurrence and the neck level involved with recurrence noted. Data was analyzed for fifty-two patients of non-recurrent papillary thyroid cancer who had undergone total thyroidectomy and lateral neck dissection involving levels II-IV, with extended dissection at level IV. It should be noted that none of the patients had clinical involvement of level V. Only two patients had lateral neck recurrence, both the recurrences were in level III, one on the ipsilateral side and the other on the contralateral side. Recurrence in the central compartment was noted in two patients, with one of these patients also having ipsilateral level III recurrence. One of the patients had distal metastasis to the lungs. Transient paresis of the unilateral vocal cords was noted in seven patients which got resolved within 2 months in all of them. Transient hypocalcemia was noted in four patients. Although our series has a small sample size with limited follow-up, it is one of the few studies in which prophylactic level V dissection has been studied in a homogenous study population of non-recurrent papillary thyroid cancer. Our study has shown that prophylactic dissection of level V may have a limited role, but further large multi-institutional studies need to be carried out to come up with a definite answer.

Accuracy of papillary thyroid cancer prognostic nomograms: a systematic review

Objective

Current staging and risk-stratification systems for predicting survival or recurrence of patients with differentiated thyroid carcinoma may be ineffective at predicting outcomes in individual patients. In recent years, nomograms have been proposed as an alternative to conventional systems for predicting personalized clinical outcomes. We conducted a systematic review to evaluate the predictive performance of available nomograms for thyroid cancer patients.

Design and methods

PROSPERO registration (CRD42022327028). A systematic search was conducted without time and language restrictions. PICOT questions: population, patients with papillary thyroid cancer; comparator prognostic factor, single-arm studies; outcomes, overall survival, disease-free survival, cancer-specific survival, recurrence, central lymph node metastases, or lateral lymph node metastases; timing, all periods; setting, hospital setting. Risk of bias was assessed through PROBAST tool.

Results

Eighteen studies with a total of 20 prognostic models were included in the systematic review (90,969 papillary thyroid carcinoma patients). Fourteen models were at high risk of bias and four were at unclear risk of bias. The greatest concerns arose in the analysis domain. The accuracy of nomograms for overall survival was assessed in only one study and appeared limited (0.77, 95% CI: 0.75-0.79). The accuracy of nomograms for disease-free survival ranged from 0.65 (95% CI: 0.55-0.75) to 0.92 (95% CI: 0.91-0.95). The C-index for predicting lateral lymph node metastasis ranged from 0.72 to 0.92 (95% CI: 0.86-0.97). For central lymph node metastasis, the C-index of externally validated studies ranged from 0.706 (95% CI: 0.685-0.727) to 0.923 (95% CI: 0.893-0.946).

Conclusions

Our work highlights the extremely high heterogeneity among nomograms and the critical lack of external validation studies that limit the applicability of nomograms in clinical practice. Further studies ideally using commonly adopted risk factors as the backbone to develop nomograms are required.

Significance statement

Nomograms may be appropriate tools to plan treatments and predict personalized clinical outcomes in patients with papillary thyroid cancer. However, the nomograms developed to date are very heterogeneous, and their results seem to be closely related to the specific samples studied to generate the same nomograms. The lack of rigorous external validation procedures and the use of risk factors that sometimes appear to be far from those commonly used in clinical practice, as well as the great heterogeneity of the risk factors considered, limit the ability of nomograms to predict patient outcomes and thus their current introduction in clinical practice.

Role and Extent of Neck Dissection for Neck Lymph Node Metastases in Differentiated Thyroid Cancers

Differentiated thyroid cancers (DTC) consist of 95% of thyroid tumors and include papillary thyroid cancer (PTC), follicular thyroid cancer (FTC), and Hurthle cell thyroid cancer (HTC). Rates of lymph node metastases are different depending on histologic subtypes and <5% in FTC and between 5% and 13% in HTC. Lymph node metastasis is more frequent in PTC and while rate of clinical metastasis can be seen approximately 30% rate of routine micrometastasis can be seen up to 80%. Lymph node metastasis of DTC mostly develops first in the Level VI lymph nodes at the central compartment starting from the ipsilateral paratracheal lymph nodes and then spreading to the contralateral paratracheal lymph nodes. Spread to the Level VII is mostly after Level VI invasion. Subsequent spread is to the lateral neck compartments of Levels IV, III, IIA, and VB and sometimes to the Levels IIB and VA. Occasionally skip metastasis to the lateral neck compartments develop without spreading to the central compartments and this situation is more frequent in upper pole tumors. Although application of prophylactic central neck dissection (pCND) in DTC increases the rate of complication, due to its unclear effects on oncologic results and quality of life, the interest to the pCND is decreasing and debate on its surgical extent is increasing. pCND is not essential in DTC and characteristics of patient and tumor and experience of surgeon should be considered when deciding for pCND. Due to lower complication rate of one sided pCND compared to bilateral central neck dissection (CND), low possibility of contralateral central neck metastasis and low risk of recurrence, application of one-sided CND is logical. Although therapeutic CND (tCND) is the standart treatment when there is a clinically involved lymph node, extent of dissection is a matter of debate. A case-based decision for the extent of tCND can be made by considering patient and tumor characteristics and experience of the surgeon. Due to the higher complication risk of bilateral CND, unilateral tCND can be performed if there is no suspicious lymph node on the contralateral side and bilateral tCND can be applied when there is a suspicion for metastasis only on the contralateral side or there are features for risk of metastasis to the contralateral side. In patients with clinical central metastasis owing to intra-operative pathology results by frozen section procedure are compatible with post-operative pathology results, when there is a suspicion for contralateral metastasis, a decision for one- or two-sided dissection can be made using frozen section procedure. In DTC, it can be stated that there is a consensus in the literature about not performing prophylactic lateral neck dissection (LND), but performing therapeutic LND (tLND). In addition, there is a debate on the extent of tLND. In a meta-analysis about lateral metastasis, the rates of metastasis to the Levels IIA, IIB, III, IV, VA, and VB were 53.1%, 15.5%, 70.5%, 66.3%, 7.9%, and 21.5%, respectively. Ultrasonography (USG) is an effective procedure for detection of cervical nodal metastasis on lateral compartment. Pre-operative imaging with USG and/or combination with the fine needle aspiration biopsy (cytology/molecular test/Thyroglobulin test) can allow pre-operative detection and verification of lateral lymph node metastasis. Extent of tLND can be determined to minimize morbidity considering pre-operative USG findings, pre-operative tumor and clinical features of lateral metastasis. Especially in the presence of limited lateral metastases, limited selective LND such as Levels III, IV or Levels IIA, III, IV can be applied according to the patient. Levels IIB and VB should be added to the dissection in the presence of metastases in these regions. In cases that increase the risk of Level IIB involvement, such as presence of metastasis at Level IIA, extranodal tumor involvement, presence of multifocal tumor, and in cases that increase the risk of Level VB involvement such as macroscopic extranodal spread, and simultaneous metastases at Levels II, III, IV; Levels IIB and VB can be added to dissection material. Levels I and VA should be added to the dissection in the presence of clinically detected metastases.

Patterns of Occult Metastasis to Level Va and Vb in Clinically Lateral Node-Positive Papillary Thyroid Carcinoma

BACKGROUND

The optimal extent of therapeutic lateral neck dissection (ND) in papillary thyroid carcinoma (PTC) continues to be debated. We analyzed the frequency, patterns, and predictive factors of occult level Va and Vb metastasis in clinically lateral node-positive PTC patients.

METHODS

We reviewed the data of PTC patients who underwent thyroidectomy and therapeutic lateral ND from level II to V between May 2008 and August 2020. In our study, 46 patients without clinically positive metastatic lymph nodes (LNs) at level V on the preoperative evaluation were included to analyze occult metastasis at level Va and Vb, respectively. Patient demographics, including age, sex, distribution of pathologic LNs, and characteristics of the primary tumors, were reviewed. In addition, clinicopathologic factors associated with occult level Va and Vb metastasis were analyzed.

RESULTS

Of the 46 patients, 14 (30.4%) patients had occult metastases at level Vb. No occult metastases were found at level Va. Clinically positive level II metastasis (p = 0.015) and simultaneous level II, III, and IV metastases (p = 0.010) in the preoperative evaluation were significantly associated with occult level Vb metastasis. Patients without LN metastasis at level IV or with three or fewer metastatic LNs in the lateral neck never had occult LN metastases at level Vb.

CONCLUSIONS

Occult metastasis at level Va is rare in PTC with lateral LN metastasis. Occult metastasis at level Vb may occur in PTC patients with multilevel involvement, including level II and/or four or more lateral LN metastases.

Lateral Neck Dissection for Well-Differentiated Thyroid Carcinoma: Is Prophylactic Level V Neck Dissection Necessary? A Retrospective Cohort Study

OBJECTIVE

The presence of clinically detectable papillary thyroid carcinoma (PTC) metastases in the lateral neck is an indication for neck dissection (ND) and thyroidectomy. Although there is a consensus regarding the importance of therapeutic selective ND of involved levels II to IV in patients with clinically evident locoregional metastatic disease, the prognostic benefit of level V prophylactic ND remains debatable.

METHODS

All patients who underwent thyroidectomy with ND for metastatic PTC between 2006 and 2019 were included in a single-institution retrospective study. Preoperative characteristics at initial presentation, imaging workup, intraoperative findings, and the final histopathological reports were retrieved from the institutional database.

RESULTS

A total of 189 patients with locally advanced PTC were identified, of whom 22 (11.6%) patients underwent therapeutic selective ND at levels II to IV together with level V dissection due to clinical involvement. Comparison of the patients who were operated on level V to those who were not revealed no significant difference. The disease recurrence rate was 20.1% throughout an average follow-up of 5.1±3.1 years. No significant differences in recurrence rate were found between patients who underwent and those who did not undergo level V ND (22.7% vs 19.8%, P = .648). No recurrence at resected level V was detected during follow-up, while recurrence at level V was found in 4 (2.1%) patients who did not undergo level V dissection. Evidence of macroscopic and microscopic extrathyroidal extension was significant predictors of disease recurrence risk.

CONCLUSION

There were no significant associations between level V dissection and risk for recurrence. Recurrence at level V was rare (4/189 patients, 2.1%). Our study's findings suggest a low prophylactic benefit of an elective level V ND. Elective level V ND should not be done routinely when lateral ND is indicated but should rather be considered after careful evaluation in high-risk patients.

Endoscopic Thyroidectomy With Level Vb Dissection Via a Chest-breast Approach: Technical Updates for Selective Lateral Neck Dissection

OBJECTIVE

To determine the feasibility of endoscopic thyroidectomy with level Vb dissection using a chest-breast approach.

METHODS

Lateral neck level Vb dissection by endoscopic surgery using a chest-breast approach was performed as an update to the previously reported endoscopic selective lateral neck dissection. The demographic data, surgical outcomes, and adverse events were analyzed.

RESULTS

A total of 12 cases were performed successfully, and no patient was converted to the open procedure. The sex ratio was 16/2 (female/male). The average age and primary lesion diameter were 36.3±5.8 years old, and 1.97±0.58 cm, respectively. The average total and lateral lymph nodes dissection time of duration was 154.6±17.0 and 276.3±19.2 minutes, respectively. The lymph node ratio (mean number of metastasis/total number of dissected nodes) at levels II, III+IV, VI, and Vb were 1.6±1.4/6.8±2.0, 5.8±2.4/14.4±3.6, 3.2±1.1/6.5±1.9, and 0.8±0.9/5.8±1.6, respectively. One of 12 patients had lymphatic leakage and 2 of 12 patients had transient hypocalcemia. There was no incidence of uncontrolled bleeding, mental nerve injury, permanent hypoparathyroidism, permanent recurrent laryngeal nerve injury, skin bruise on neck, infection, asphyxia/dyspnea, large blood vessel injury or other complications like tracheal injury, esophageal injury, etc., nor was there any death or recurrence in either of the 2 groups during a short follow-up period.

CONCLUSIONS

It is feasible to perform endoscopic thyroidectomy with level Vb dissection using a chest-breast approach. Such strategy represents another option for selective papillary thyroid carcinoma patients with levels II, III, IV, and Vb lymph node metastasis.

Factors Affecting Central Node Metastasis and Metastatic Lymph Node Ratio in Papillary Thyroid Cancer

OBJECTIVE

Despite the growing evidence that metastatic lymph node ratio (MLNR) is a valuable predictor for the prognosis of papillary thyroid carcinoma, it has not yet been fully determined which factors give the ratio predictive value independent of the number of metastatic lymph nodes (MLNs).

STUDY DESIGN

Retrospective cohort study.

SETTING

A comprehensive cancer center.

METHODS

Recurrence and clinicopathologic factors were analyzed in 2409 patients with papillary thyroid carcinoma who underwent total thyroidectomy and central node dissection.

RESULTS

Cutoff values of MLNs ≥2 and MLNR ≥28.2% increased the recurrence risk (hazard ratio [95% CI], 9.97 [4.73-21.0] and 11.4 [5.53-23.3], respectively). Younger age, male sex, multifocality, tumor size, lymphatic and vascular invasion, and gross extrathyroidal extension positively correlated with MLN and MLNR (all P < .05). Meanwhile, lymphocytic thyroiditis negatively correlated with MLNR in female patients (P < .001), by increasing total lymph node yields as compared with papillary thyroid carcinoma without lymphocytic thyroiditis. In multivariate analysis, younger age, tumor size, and lymphatic invasion remained significant in male and female patients for MLN and MLNR; lymphocytic thyroiditis was also significantly correlated with MLNR in female patients.

CONCLUSION

Our study demonstrates that MLN and MLNR are independently observed prognostic markers for tumor recurrence. However, lymphocytic thyroiditis in female patients seems to have lower MLNR by increasing total lymph node yields. In light of their association, a different cutoff for MLNR needs to be applied according to the presence or absence of underlying lymphocytic thyroiditis in the use of MLNR for predicting the recurrence.

LEVEL OF EVIDENCE

4.

Prediction of level V metastases in papillary thyroid microcarcinoma: a single center analysis

Background

The rate of level V metastases is significantly low and the necessity of routine level V dissection for papillary thyroid microcarcinoma (PTMC) with clinically lateral lymph node metastasis (LNM) is still controversial.

Methods

This study enrolled 114 consecutive PTMC patients with clinically suspected lateral LNM (N1b) who underwent modified radical neck dissection (levels II to V) at Xiangya Hospital of Central South University from September 2016 to July 2019. Univariate and multivariate analyses were performed to investigate the predictive factors of level V metastasis. The area under the receiver operating characteristic (ROC) curve (AUC), accuracy, specificity and sensitivity were used to determine the predictive value.

Results

The overall and occult rate of level V metastasis were 29.82% (34/114) and 7.02% (8/114), respectively. Univariate analysis showed that level V metastasis was significantly associated with gross extrathyroidal extension (ETE), level IV metastasis and 2-level simultaneous metastasis (all P<0.05). Gross ETE (OR =11.916, 95% CI, 1.404-102.19; P=0.023) and level IV metastasis (OR =8.497, 95% CI, 2.119-34.065; P =0.03) served as independent predictors of level V metastasis in N1b PTMC patients. The sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of gross ETE and level IV metastasis in predicting the level V metastasis were 25.3% vs. 82.4%, 97.5% vs. 73.8%, 82.69% vs. 76.32%, 80% vs. 57.04% and 75% vs. 90.77%, respectively. The AUC of gross ETE was lower than level IV metastasis (0.605 vs. 0.781, P=0.041).

Conclusions

Routine level V dissection is necessary in N1b PTMC patients with level IV metastasis or gross ETE. Compared with gross ETE, level IV metastasis is superior in predicting level V metastasis.

Metastasis predictors for neck sublevel IIb in papillary thyroid carcinoma

OBJECTIVE

To investigate possible metastasis predictors for neck sublevel IIb in papillary thyroid carcinoma (PTC) with lateral neck metastasis and to determine the reliability of preoperative ultrasound-guided fine-needle aspiration biopsy (FNAB) as a method of detecting positive lymph nodes in sublevel IIa in comparison with the finding of definitive pathohistological analysis.

DESIGN

Prospective study with patients with proven lateral neck metastases from PTC at the time of initial diagnosis. All patients had total thyroidectomy, central neck dissection (level VI) and selective neck dissection (levels II-V). Potential predictive factors for the occurrence of metastasis in sublevel IIb were analysed. Sensitivity and specificity tests were used to determine the reliability of preoperative ultrasound-guided FNAB. Patients were monitored for recurrence for at least ten years.

SETTING

Single-centre study.

PARTICIPANTS

Study included 53 patients with proven lateral neck metastases from PTC at the time of initial diagnosis.

RESULTS

Predictive factors for the occurrence of metastasis in sublevel IIb that have reached statistical significance are positive sublevel IIa, number of positive lymph nodes and positive levels IIa + III + IV + V. None of the patients who fulfilled predefined criterion for minimum 10-year follow-up had local recurrence in operated lateral levels.

CONCLUSION

Highest clinical significance has positivity of sublevel IIa. Therefore, it is necessary to prove or exclude metastasis in sublevel IIa, preoperatively or intraoperatively, to decide whether to include sublevel IIb in dissection. Preoperative ultrasound-guided FNAB is a reliable method for the detection of positive lymph nodes in sublevel IIa in comparison with the definitive histopathological analysis.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.

BACKGROUND

Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.

METHODS

The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

Development and validation of web-based nomograms for predicting lateral lymph node metastasis in patients with papillary thyroid carcinoma

Background

The purpose of this study was to evaluate the factors associated with lateral lymph node metastasis (LLNM) in patients with papillary thyroid carcinoma (PTC), and to develop two web-based nomograms that predict the probability of level-II and level-III/IV LLNM in these patients.

Methods

The records of 653 patients with PTC were retrospectively reviewed. Univariate and multivariate analyses were performed to identify risk factors associated with LLNM in 460 patients ("derivation group"). Two models [including and excluding the subregions of central lymph node metastasis (CLNM)] were used to predict the probability of level-II LLNM; the same two models were also used for level-III/IV LLNM. Model performance was assessed using receiver operating characteristic (ROC) analysis and decision curve analysis (DCA) in 193 patients ("validation group"). Two web-based nomograms were established.

Results

Increased tumor size, a tumor in the upper lobe, and prelaryngeal and ipsilateral paratracheal lymph node metastasis (LNM) were significantly associated with level-II LNM (P<0.05). Increased tumor size, a tumor in the upper lobe, and certain subregions of CLNM were associated with level-III/IV LNM (P<0.05). Use of ROC analysis of each model indicated that including subgroups of CLNM led to better model performance than excluding these subgroups. We quantified the benefit of each model by using DCA analysis in the validation group.

Conclusions

Our web-based nomograms provide quantification of risk for LLNM in patients with PTC before and during surgery.

Risk factors for local recurrence following lateral neck dissection for papillary thyroid carcinoma

PURPOSE

We aimed to evaluate risk factors for local recurrence following lateral neck dissection (LND) for papillary thyroid carcinoma (PTC).

METHODS

Two hundred and nine patients who underwent therapeutic primary or reoperative LND for PTC were included.

RESULTS

One hundred eighty-one patients underwent primary LND at our Institution, the remaining 28 were referred for recurrence following LND outside the Institution. Comparing patients who required reoperation for recurrent lateral neck disease with those who did not recur, no significant difference was found concerning sex, tumor size, multifocal disease, extracapsular invasion, histological variant, pT stage (P = NS). At univariate analysis, age, mean number of removed lateral neck nodes at first operation, the extent of initial LND and surgery performed outside the Institution were risk factors for recurrence (P < 0.001).

CONCLUSIONS

Limited LND and surgery performed at non referral Centers were non tumor-related risk factors for recurrence following therapeutic LND for PTC.

Comprehensive Lateral Neck Dissection in Papillary Thyroid Carcinoma may Reduce Lateral Neck Recurrence Rates

OBJECTIVE

To Identify predictors of recurrent disease following lateral neck dissection (LND) for papillary thyroid carcinoma (PTC).

METHODS

A retrospective review of patients who underwent first-time LND for PTC at our institution (2000-2015) was performed. Medical records were examined for biopsy or pathologically proven lateral neck recurrence. Differences between the groups with and without recurrence were compared. All LNDs were then classified in to two groups: "comprehensive" (CND), involving levels IIa-Vb at minimum, or "selective", labelling less extensive dissection (SND).

RESULTS

Four hundred nine patients underwent 467 LNDs. Surveillance data were available for 317 patients who underwent 362 LNDs (mean age 45 ± 16; range 18-88). The median follow-up was 64 ± 48 months (range 3-197). Recurrence was detected in 71 lateral necks (20%). The total number of lymph nodes was greater in the group without recurrence compared to those with recurrence (23 vs. 19, p = 0.02). Among patient demographics, radioactive iodine treatment, primary tumor characteristics and characteristics of nodal metastases, only an older patient age (mean 50 vs. 43 years) was associated with lateral neck recurrence (p < .01). CND was performed in 102 lateral necks and SND in 143 necks. There were 12 recurrences recorded in the CND group (12%) vs. 31 in the SND group (22%, p = .04). The majority of recurrences (70%) involved levels included in the original dissection.

CONCLUSIONS

Younger patients, more extensive dissection and a higher total number of lymph nodes removed are associated with a lower incidence of lateral neck recurrence after LND for papillary thyroid carcinoma.

Regional Node Distribution in Papillary Thyroid Cancer with Microscopic Metastasis

Background

Optimal neck lymphadenectomy in patients with papillary thyroid cancer (PTC) and microscopic lymph node metastasis needs to be defined in order to aid surgeons in their decision about the best way to proceed in these cases.

Methods

Patients who underwent total thyroidectomy and lymphadenectomy at levels IIa to VI were divided into two groups: Group 1 (G1) with macroscopic metastasis detected before surgery and Group 2 (G2) with microscopic metastasis detected in sentinel node during surgery. Odds ratio (OR) was computed for age, sex, tumor size, multicentricity, capsular invasion, vascular/lymphatic permeation, and nodes with metastasis.

Results

Primary tumor size was (G1 versus G2, respectively) 3.8 cm versus 1.98 cm (P<0.001); only lymphatic permeation was correlated to an increase in metastasis in lymph nodes 65.4% versus 25% (OR=5.6, p<0.001); metastatic frequency by region was IIa 18.5% versus 1.5%, III 24.3% versus 9.9%, IV 17.4% versus 18.1%, and VI 25.9% versus 71,2%. Metastasis to level V was found only in G1.

Conclusion

Selective lymphadenectomy at levels III, IV, and VI is optimal for PTC patients without preoperative evidence of lymph node disease, but who present with lymph node microscopic metastasis in an intraoperative assessment.

Standards and Definitions in Neck Dissections of Differentiated Thyroid Cancer

Papillary and follicular thyroid carcinomas arising from the follicular epithelial cells and forming differentiated thyroid cancer (DTC) consist of >95% of thyroid cancers. Lymph node metastasis to the neck is common in DTC, especially in papillary thyroid cancer. The removal of only the metastatic lymph nodes (berry picking) does not help to achieve a potential positive contribution to the survival and recurrence of lymph node dissection in the DTC. Thus, systematic dissection of the cervical lymph nodes is needed. Today, according to the widely accepted and commonly used definitions and lymph node staging, the deep lymph nodes of the lateral side of the neck are divided into five regions. Based on the fact that some groups have biologically independent regions, Groups I, II, and V are divided into the A and B subgroups. The central region lymph nodes contain VI and VII region lymph nodes, which consist of the prelaryngeal, pretracheal, and right and left paratracheal lymph node groups. Radical neck dissection (RND) is accepted as the standard basic procedure in defining neck dissections. In this method, in addition to all the regions of the Groups I-V lymph nodes at one side, the ipsilateral spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle are removed. Sparing of one or more of the routinely removed non-lymphatic structures in the RND is called modified RND (MRND), whereas the preservation of one or more of the routinely removed lymph node groups in the RND is termed as selective neck dissection (SND). In difference, the procedure with an addition of a lymph node and/or non-lymphatic structures to routinely removed neck structures in RND is called extended RND. Generally, involving one or more regions of SND are applied for DTC. The removal of the paratracheal, prelaryngeal, and pretracheal lymph node groups at one side is termed as ipsilateral central dissection, whereas the removal of the bilateral paratracheal lymph node groups, in other words, the excision of four lymph node groups in the central region (Groups VI and VII), is defined as bilateral central dissection. In conclusion, bilateral central neck dissection (CND) is the SND in which the regions of VI and VII are removed. In the DTC, CND is prophylactically and therapeutically applied, whereas lateral neck dissection is performed only therapeutically in the presence of clinical metastasis (N1b) in the lateral neck region. Debates on the extent of SNDs to be made in the central and lateral neck regions are still ongoing. Central dissection should be made at least unilaterally. In the lateral side of the neck, SNDs can be applied in different combinations in which at least one region from Groups I to V is removed. The main variables that determine the extent of SND in the central and lateral regions in DTC are the complication rates, the effect of the procedure, and its effect on prognosis and recurrence.

Pattern of and clinicopathologic risk factors for lateral lymph node metastases in papillary thyroid carcinoma patients with lateral cervical lymphadenopathy

The surgical extension of lateral neck dissection (LND) in papillary thyroid carcinoma (PTC) with clinical lateral lymph node metastases (LLNM) remains controversial. The aim of this study was to explore the pattern of and clinicopathologic risk factors for LLNM in PTC with clinical unilateral LND to determine the rational extent of therapeutic LND.This retrospective study reviewed the records of 246 consecutive patients with PTC who simultaneously underwent total thyroidectomy, bilateral central lymph node dissection, and unilateral therapeutic LND. The frequency and pattern of LLNM were analyzed.Grossly, LLNM were present in 80.9% of patients, and level II to V lymph node metastases (LNM) were present in 45.9%, 62.6%, 56.1%, and 11.8% patients, respectively. Superior tumor location, extrathyroidal extension, and ipsilateral, contralateral, and bilateral central LNM (CLNM) were independent risk factors for gross LLNM. Age ≥45 years, superior lobe tumors, extrathyroidal extension, and ipsilateral and contralateral CLNM were independent risk factors for level II LNM. Age ≥45 years, superior and middle lobe tumors, extrathyroidal extension, and ipsilateral CLNM were independent risk factors for level III LNM. Superior lobe tumors and ipsilateral, contralateral, and bilateral CLNM were independent risk factors for level IV LNM. Only contralateral CLNM was an independent risk factor for level V LNM.In PTC patients with clinical LLNM, the predominant sites of LLNM were levels II to IV and not level V. Therapeutic elective LND should include the lateral nodal levels associated with independent risk factors, especially superior tumors location and CLNM.

Level V Clearance in Neck Dissection for Papillary Thyroid Carcinoma: A Need for Homogeneous Studies

Introduction  Papillary thyroid carcinoma has a very high rate of lateral neck node metastases, and there is almost unanimity concerning the fact that some sort of formal neck dissection must be performed to address the clinical neck disease in these cases. Although there is an agreement that levels II to IV need to be cleared in these patients, the clearance of level V is debatable.

Objectives  We herein have tried to analyze various papers that have documented a structured approach to neck dissection in these patients. Moreover, we have also tried to consider this issue through various aspects, like spinal accessory nerve injury and the impact of neck recurrence on survival.

Data Synthesis  The PubMed, Medline, Google Scholar, Surveillance, Epidemiology, and End Results (SEER), and Ovid databases were searched for studies written in English that focused on lateral neck dissection (levels II–IV or II–V) for papillary thyroid carcinoma. Case reports with 10 patients or less were excluded.

Conclusions  The current evidence is equivocal whether to clear level V or not, and the studies published on this issue are very heterogeneous. Level II-IV versus level II-V selective neck dissections in node-positive papillary thyroid carcinoma patients is far from categorical, with pros and cons for both approaches. Hence, we feel that there is a need for more robust homogeneous data in order to provide an answer to this question.

Therapeutic lateral neck dissection in well-differentiated thyroid cancer: Analysis on factors predicting distribution of positive nodes and prognosis

BACKGROUND

Neck dissection is considered the treatment of choice in patients with lateral neck metastases from well-differentiated thyroid cancer.

METHODS

A multicenter, retrospective review of patients who underwent therapeutic lateral neck dissection for well-differentiated thyroid carcinoma was carried out.

RESULTS

The study included a total of 405 lateral neck dissections performed in 352 patients; 197 women (56%) and 155 men (44%). When considering ipsilateral neck metastases, levels IIa, IIb, III, IV, Va, Vb, and V (not otherwise specified) were involved in 42%, 6%, 73%, 67%, 11%, 31%, and 35% of cases, respectively. Five-year and 10-year overall survival (OS) were 93% and 81%, respectively. Age >55 years, pathologic T (pT)4 category, tumor diameter >4 cm, aggressive variants of well-differentiated thyroid carcinoma, endovascular invasion, and number of positive nodes >5 turned out to be the most important prognostic factors.

CONCLUSION

Neck dissection is a valid treatment option in the presence of neck metastasis from well-differentiated thyroid carcinoma. Levels IIa, III, IV, and Vb should always be removed.

Accuracy of preoperative MRI to assess lateral neck metastases in papillary thyroid carcinoma

Primary treatment of papillary thyroid carcinoma (PTC) with lateral lymph node metastasis is surgery, but the extent of lateral neck dissection remains undefined. Preoperative imaging is used to guide the extent of surgery, although its sensitivity and specificity for defining the number and level of affected lymph nodes on the lateral neck is relatively modest. Our aim was to assess the role of preoperative magnetic resonance imaging (MRI) in predicting the requisite levels of neck dissection in patients with regionally metastatic PTC, with a focus on Levels II and V. All patients with PTC and lateral neck metastasis who had undergone neck dissection at the Department of Otorhinolaryngology—Head and Neck Surgery, Helsinki University Hospital, Helsinki, Finland from 2013 to 2016 and had a preoperative MRI available were retrospectively reviewed. A head and neck radiologist re-evaluated all MRIs, and the imaging findings were compared with histopathology after neck dissection. In the cohort of 39 patients, preoperative MRI showed concordance with histopathology for Levels II and V as follows: sensitivity of 94 and 67%, specificity of 20 and 91%, positive predictive value of 56 and 75%, and negative predictive value of 75 and 87%, respectively. In PTC, MRI demonstrated fairly high specificity and negative predictive value for Level V metastasis, and future studies are needed to verify our results to omit prophylactic dissection of this level. Routine dissection of Level II in patients with regionally metastatic PTC needs to be considered, as MRI showed low specificity.

Patterns of regional recurrence in papillary thyroid cancer patients with lateral neck metastases undergoing neck dissection

Background

Practice variability exists for the extent of neck dissection undertaken for papillary thyroid carcinoma (PTC) metastatic to the lateral neck nodes, with disagreement over routine level V dissection.

Methods

We performed a retrospective medical record review of PTC patients with lateral neck nodal metastases treated at University Health Network from 2000 to 2012. Predictive factors for regional neck recurrence, including extent of initial neck dissection, were analyzed using Cox regression.

Results

Out of 204 neck dissections in 178 patients, 110 (54%) underwent selective and 94 (46%) had comprehensive dissection including level Vb. Mean follow-up was 6.3 years (SD). Significant predictors of regional failure were the total number of suspicious nodes on preoperative imaging (p = 0.029), largest positive node on initial neck dissection (p < 0.01), and whether patients received adjuvant radiotherapy (p = 0.028). The 5-year ipsilateral regional recurrence rate was 8 and 9% with selective and comprehensive dissection, respectively (p = 0.89).

Conclusion

The extent of neck dissection did not predict the probability of regional recurrence in PTC patients presenting with lateral neck metastases.

Risk factors for level V lymph node metastases in solitary papillary thyroid carcinoma with clinically lateral lymph node metastases

The extent of lateral neck dissection (LND) in surgical resection of papillary thyroid carcinoma (PTC) with clinically lateral LNM (LLNM) remains controversial. We aimed to explore the frequency of and risk factors for level V LNM in patients with solitary PTC and clinically LLNM. To analyze the frequency and risk factors for level V LNM, we retrospectively reviewed 220 solitary PTC patients who underwent total thyroidectomy, bilateral central neck dissection, and therapeutic LND. LLNM were present in 82.3% patients, and levels II-V LNM were present in 45.9%, 62.7%, 55.5%, and 12.3% patients, respectively. Ipsilateral level V LNM was significantly associated with tumor size >10 mm, extrathyroidal extension, ipsilateral central LNM ratio ≥50%, and contralateral central LNM (CLNM), bilateral CLNM, and simultaneous levels II-IV LNM. Contralateral CLNM was an independent risk factor for level V LNM. In patients with solitary PTC and clinically LLNM, level V LNM was relatively uncommon. Therefore, routine level V lymphadenectomy may be unnecessary in these patients unless level V LNM is suspected on preoperative examination or associated risk factors, especially contralateral CLNM, are present.

Comparison of Robotic versus Conventional Selective Neck Dissection and Total Thyroidectomy for Papillary Thyroid Carcinoma

OBJECTIVE

To compare the surgical outcomes of robotic selective neck dissection (SND) with total thyroidectomy and conventional transcervical SND with total thyroidectomy.

STUDY DESIGN

Case series with chart review.

SETTING

University tertiary care facility.

SUBJECT AND METHODS

We retrospectively analyzed 66 patients who underwent total thyroidectomy with SND (≥3 levels of II-V) and bilateral central neck dissection for cN1b papillary thyroid carcinoma, of whom 41 underwent conventional SND and 25 of whom underwent robotic SND. Subjective pain, sensory change, and cosmetic satisfaction were evaluated regularly for 3 months with a questionnaire.

RESULTS

Compared with the conventional group, patients in the robotic group were younger (mean, 36.7 vs 47.5 years; P = .003) and more female dominant (96.0% vs 73.2%; P = .023). Mean total operative time was longer in the robotic group than the conventional group (298 vs 236 minutes; P < .001). Anterior chest pain was higher in the robotic group at postoperative 1 day (pain score, 1.88 vs 0.62; P = .011), 1 week (1.30 vs 0.43; P = .036), and 1 month (0.90 vs 0.18; P = .029). Postoperative cosmetic satisfaction was significantly superior in the robotic group.

CONCLUSION

Compared with conventional transcervical SND with total thyroidectomy, robotic SND with total thyroidectomy yields superior outcomes for cosmetic satisfaction, longer operative time, and higher chest pain in the short term. Further study with a larger number of patients is mandatory.

Intraoperative ultrasonography is useful in surgical management of neck metastases in differentiated thyroid cancers

Differentiated thyroid carcinomas are the most common malignancies of endocrine organs. Metastases to cervical lymph nodes occur in 20-50% of cases. Recurrence and survival rates are closely related to the type of surgery performed. High-resolution ultrasonography (USG) is a sensitive imaging method used to detect occult lymph node metastases in patients with thyroid cancer. We evaluated how intraoperative USG affected surgical success. This was a retrospective study comparing two groups of patients with thyroid carcinoma who underwent cervical lymph node dissection. A total of 101 patients (33 males and 68 females) were included. Group 1 included 53 patients who underwent surgery with intraoperative USG guidance. Group 2 included 48 patients who underwent surgery without the use of USG. All patients were followed up (mean 23 months; range 5-44 months) with thyroglobulin measurements and USG evaluations. Group 1 (intraoperative USG) had a residual/recurrent tumor rate of 1.9% (1/53 patients). Group 2 had a residual/recurrent tumor rate of 12.5% (6/48 patients). A statistically significant difference appeared between the residual/recurrent tumor rates in Groups 1 and 2 (p<0.05). In addition to its classical use in diagnosis and follow-up, intraoperative use of high-resolution USG can improve surgical success and may decrease the number of residual/recurrent tumors encountered during follow-up.

Lateral neck recurrence from papillary thyroid carcinoma: Predictive factors and prognostic significance

OBJECTIVES/HYPOTHESIS

The aim of this study was to identify any possible predictive factors of lateral neck recurrence in patients with papillary thyroid carcinoma with no ultrasonographic and/or cytological evidence of lymph node metastasis at time of diagnosis. The influence of lateral neck recurrence on survival was also investigated.

STUDY DESIGN

Observational retrospective study.

METHODS

Retrospective review of clinical records of 610 patients surgically treated for papillary thyroid carcinoma with clinically negative lymph nodes at the Otolaryngology Unit of the Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy, from January 1984 to December 2008.

RESULTS

Lateral neck recurrences were ipsilateral to the primary tumor in all cases and were associated with the occurrence of more aggressive histological variants and central neck metastasis. Lateral neck recurrences were more frequently observed in patients with distant metastases and were associated with a reduced disease-specific survival.

CONCLUSION

Lateral neck compartment ipsilateral to the tumor was the most common site of recurrence, with about half of cases appearing in the first 28 months of follow-up. In patients with papillary thyroid carcinoma, detection of lateral neck metastases prior to first surgery is crucial to surgical planning. Aggressive histological variants and postsurgical evidence of lymph node metastasis from papillary thyroid carcinoma in central neck compartment are associated with a higher risk of lateral neck recurrence. In these patients, a closer postsurgical ultrasound surveillance of the lateral neck compartments seems worthwhile.

LEVEL OF EVIDENCE

4.

Prophylactic level II neck dissection guided by frozen section for clinically node-negative papillary thyroid carcinoma: is it useful?

BACKGROUND

Prophylactic lateral neck dissection (PLND) is generally not performed for papillary thyroid carcinoma(PTC). When performed, occult metastases are found in upto 50 % of patients, although the incidence of occult level II nodes seems low. Our aim was to evaluate frozen section analysis-oriented elective level II PLND in patients with clinically node-negative (cN0) PTC.

METHODS

This retrospective study included patients with cN0 PTC treated with total thyroidectomy and prophylactic bilateral central and lateral neck dissection of ipsilateral levels III and IV. Frozen section analysis of PLND III and IV was performed. If positive, the PLND was extended to level II. We measured the accuracy of frozen section analysis, the incidence of occult level II metastasis, and oncologic outcomes.

RESULTS

A total of 295 patients were included. For frozen section analysis, the sensitivity was 71.0 %, specificity 99.6 %, positive predictive value 97.8 %, negative predictive value 92.4 %, overall accuracy 93.2 %. Definitive analysis found lateral node metastases in 63 of the 295(21 %) patients. Extension to level II was performed in 27 of 46 cases (59 %). Level II contained metastatic nodes in 12 of 27 (44 %) patients. There was no difference in total doses of 131I administered to patients with or without level II disease. Even when extension of PLND to level II was not performed, no cases of recurrent or persistent disease in level II occurred.

CONCLUSIONS

Frozen section analysis was highly accurate.The rate of occult metastases in level II was low. Detection of additional metastases in level II did not modify subsequent treatment or the rate of recurrence and is not useful for routine application.

Involvement of level IIb lymph node metastasis and dissection in thyroid cancer

Thyroid neoplasms are the most frequent neoplasm in the head and neck region. Most thyroid carcinomas are well-differentiated tumors of follicular cell origin. Thyroid papillary carcinoma (TPC) is the most common thyroid malignancy. It constitutes 60% to 90% of all the thyroid carcinomas and cervical lymph node metastases are commonly seen in these patients. Although cervical lymph node metastases are common in this cancer, the management and the prognostic role of lymph nodes in TPC remains controversial. In this paper we reviewed the currently available literature regarding the extent of lateral neck dissection in papillary thyroid carcinoma patients with lateral neck metastasis.

Robotic modified radical neck dissection by bilateral axillary breast approach for papillary thyroid carcinoma with lateral neck metastasis

BACKGROUND

The purpose of this study was to evaluate the safety of robotic modified radical neck dissection compared to open modified radical neck dissection.

METHODS

We enrolled 78 patients who were diagnosed with papillary thyroid cancer and underwent total thyroidectomy, bilateral central neck dissection, and modified radical neck dissection between March 2011 and February 2013. Of these patients, 65 underwent an open procedure and 13 underwent a robotic procedure using the bilateral axillary breast approach (BABA). These 2 groups were retrospectively compared.

RESULTS

The mean age, sex, body mass index (BMI), and tumor size were not significantly different between groups. There were no differences in the number of retrieved lymph nodes, metastatic lymph nodes, or stimulated thyroglobulin level between the 2 groups. The operation time was longer in the robotic group than in the open group.

CONCLUSION

Robotic modified radical neck dissection using BABA is safe and shows oncologic and postoperative outcomes comparable to those of the open procedure.

Pattern, predictors, and recurrence of cervical lymph node metastases in papillary thyroid cancer

Aim of the study

This study investigated the pattern, predictors, and recurrence of node metastasis in papillary thyroid cancer patients.

Material and methods

One hundred and 65 papillary thyroid cancer (PTC) patients who underwent total thyroidectomy and cervical lymph node (LN) dissection (LND), in which more than 12 lymph nodes were dissected, were examined. The nodes were classified from levels I to VI. Final pathologic diagnosis of positive lymph node metastases in the differential node levels was determined.

Results

Cervical metastases of PTC were most commonly encountered in level VI, followed by levels III and IV, and then levels II and V. Metastases in level I seldom occurred. Skip metastases occurred in nine patients. Univariate analysis suggested that multifocality and extracapsular invasion were associated with LN metastases. The metastatic ratio for micro PTC and local canceration derived from benign lesions and encapsulation was low. Multivariate analysis showed that LN metastases were closely related to invasion of the thyroid capsule and primary PTC. Standardized estimation showed that the encapsulating pattern had the greatest impact on developing cervical LN metastases. Lymph node recurrence was observed in 11 patients.

Conclusions

The metastatic pattern of PTC assists in delineating the extent of selective LND. Routine bilateral central node dissection at the time of thyroidectomy is recommended. Comprehensive selective LND is recommended in multifocal PTC and with capsular invasion.

Pitfalls in the staging of cancer of thyroid

Thyroid cancer includes several neoplasms originating from the thyroid gland-from indolent and curable histologies of differentiated thyroid carcinoma to aggressive anaplastic thyroid carcinoma. Differentiation of thyroid nodules is problematic on CT and MR imaging unless there is evidence of extrathyroidal extension. Evaluation of regional lymph nodes is often performed clinically or with ultrasound. The retropharyngeal and mediastinal lymph nodes are better evaluated by CT and MR imaging. Nuclear scintigraphy is useful for staging and treatment of distant metastasis in differentiated thyroid carcinoma. PET may have a role in aggressive cancers. Accurate staging affects surgical management and subsequent therapy.

Pattern of spread to the lateral neck in metastatic well-differentiated thyroid cancer: a systematic review and meta-analysis

BACKGROUND

There remains controversy surrounding the extent of lateral neck dissection required in patients with papillary thyroid cancer (PTC) and suspicious or confirmed metastatic lateral neck lymphadenopathy. The evidence for this clinical dilemma has never been reviewed systematically nor has there been an attempt to meta-analyze the data by lymph node levels to better characterize the pattern of spread.

METHODS

This meta-analysis used MEDLINE and EMBASE including all cohort studies reporting the pattern of lateral neck disease in patients who underwent a neck dissection for clinically, radiographically, or cytologically suspicious or confirmed metastatic lymphadenopathy for PTC. Our main outcome was the number of patients with positive involvement at a given level as a percentage of the cohort of patients with positive lateral neck disease, each level being measured separately.

RESULTS

Eighteen studies with a total of 1145 patients and 1298 neck dissections were included in our meta-analysis. Levels IIa and IIb had disease in 53.1% [95% confidence interval (CI) 46.6-59.5%] and 15.5% [CI 8.2-27.2%], respectively. Studies that did not distinguish between level IIa and IIb or in which both were collapsed into one category showed a total level II involvement of 53.4% [CI 49.7-57.1%]. Level III and level IV were involved in 70.5% [CI 67.0-73.9%] and 66.3% [CI 61.4-70.9%] of specimens. Studies that did not distinguish between level Va and Vb or in which both were collapsed into one category showed a total level V involvement of 25.3% [CI 20.0-31.5%]. Levels Va and Vb had positivity in 7.9% [CI 2.8-20.0%] and 21.5% [CI 7.7-47.6%], respectively, but had only three studies that could be meta-analyzed.

CONCLUSIONS

This systematic review of the literature and meta-analysis of the pattern of spread indicates significant rates of lymph node metastasis to all lateral neck levels in patients with PTC with regional involvement. This evidence leads us to recommend a comprehensive selective neck dissection of levels IIa, IIb, III, IV, and Vb in patients with lateral neck disease from PTC. The evidence for level Va is lacking, as most studies did not distinguish between levels Va and Vb, and the border between the two levels was inconsistent. Future studies will need to address these sublevels separately.

Preoperative detection and predictors of level V lymph node metastasis in patients with papillary thyroid carcinoma

Background

Papillary thyroid carcinoma (PTC) frequently metastasizes to regional lymph nodes. Metastasis to the posterior neck, level V, is uncommon, and level V lymphadenectomy may lead to spinal accessory nerve injury and associated postoperative morbidities. The aim of this study was to assess the diagnostic efficiency of preoperative ultrasonography and to identify predictors of level V metastasis in patients with PTC.

Methods

This study involved patients with previously untreated PTC that had metastasized to the lateral neck, and who underwent total thyroidectomy with central and lateral neck dissection. Histopathological findings were compared with ultrasound results for various neck levels. Clinical and histopathological factors that predicted level V metastasis were identified.

Results

Of 143 patients, 26 (18·2 per cent) had lymph node metastasis at level V. The sensitivity and positive predictive value of ultrasonography for level V metastasis were 46·2 and 30·0 per cent respectively. Univariable analysis showed that male sex, extranodal disease extension, a metastatic lymph node ratio in the ipsilateral lateral neck of more than 0·2, and simultaneous involvement of ipsilateral levels II–IV or level III were associated with ipsilateral level V metastasis. Multivariable analysis revealed an independent association between macroscopic extranodal disease extension and level V metastasis (odds ratio 26·05, 95 per cent confidence interval 5·63 to 120·56; P &lt; 0·001).

Conclusion

Preoperative ultrasonography frequently failed to detect level V metastasis in patients with metastatic PTC. Level V lymphadenectomy may be considered in patients with lymph node metastasis in the ipsilateral lateral neck with macroscopic extranodal extension.

Optimal surgical extent of lateral and central neck dissection for papillary thyroid carcinoma located in one lobe with clinical lateral lymph node metastasis

BACKGROUND

The indications and extent of cervical lymph node dissection in papillary thyroid carcinoma (PTC) are still being debated. The aim of this study was to analyze the patterns of cervical lymph node metastasis in the lateral and central compartment and related factors and suggest the optimal extent of lateral and central neck dissection for PTC patients with clinical lateral lymph node metastasis.

METHODS

We retrospectively analyzed 72 patients with unilateral PTC who underwent therapeutic lateral neck dissections with concomitant total thyroidectomy and central neck dissection between January 2001 and December 2009.

RESULTS

The 72 patients underwent 79 sides of therapeutic lateral neck dissection. The most frequent metastatic level in the ipsilateral lateral compartment was level IV (75.0%), followed by level III (69.4%), level II (56.9%) and level V (20.8%). Multiple level metastases were common (77.8%) and were correlated with tumor size (≥ 10 mm). The central compartment lymph node metastasis rate was 87.5%, including 26.4% of contralateral central compartment metastases.

CONCLUSION

In PTC patients with clinical lateral lymph node metastasis, the optimal extent of lateral and central neck dissection should include levels II, III, IV and V as well as the bilateral central compartment.

Management of well-differentiated thyroid cancer

This review provides an overview of current guideline recommendations for the clinical evaluation and surgical management of well-differentiated thyroid cancer, and further examines the evidence for controversial topics such as the minimum degree of primary resection, the role of elective central neck dissection, and the extent of lateral neck dissection. Well-differentiated thyroid cancer comprises the majority of thyroid cancers, about 90%, and includes both papillary and follicular carcinomas. Despite convergence of the medical community in establishing treatment guidelines under the American Thyroid Association, there still remain many areas of disagreement.

Lateral cervical lymph node metastases in papillary thyroid cancer: a systematic review of imaging-guided and prophylactic removal of the lateral compartment

BACKGROUND

Papillary thyroid cancer (PTC) is a common endocrine cancer and frequently presents with lymph node (LN) metastases. The frequency of LN metastases in the lateral compartment and their surgical removal are poorly defined. There are no prospective randomised controlled trials addressing an eventual outcome difference relating to the extent of the initial surgical approach. The aim of this study was to define the extent of lateral LN involvement and the role of imaging in identification of these metastatic LN.

DESIGN AND METHODS

A systematic review of studies of patients with PTC undergoing either prophylactic or therapeutic lymphadenectomy of the lateral cervical compartment. Studies involving imaging modalities in the detection of lateral cervical LNs in PTC were also analysed.

RESULTS

Systematic review on the frequency of lateral LN metastases and their detection using various imaging tools identified 19 studies containing data on 5587 patients undergoing prophylactic or imaging-guided removal of the lateral compartment. Imaging-guided surgery retrieved cancerous lateral LNs in 446/3178 or 14% of eligible patients, whilst prophylactic lateral neck dissection yielded histopathological proof of cancer in 1177/204 or 57·5% of patients. The frequency of lateral compartment metastases increased with T stage. The sensitivity of ultrasound and CT was poor as low as 27% when accurately calculated.

CONCLUSION

Metastatic cervical LNs were found in more than half of patients when prophylactic lateral LN dissection was performed. Use of conventional imaging for the selection of the surgical approach to the lateral cervical compartment may commonly identify stage N1a instead of N1b and thus lead to false stage assignment as stage III rather than stage IV, concealing the severe prognostic implications of this stage progression in individual patients.

American Thyroid Association consensus review and statement regarding the anatomy, terminology, and rationale for lateral neck dissection in differentiated thyroid cancer

BACKGROUND

Cervical lymph node metastases from differentiated thyroid cancer (DTC) are common. Thirty to eighty percent of patients with papillary thyroid cancer harbor lymph node metastases, with the central neck being the most common compartment involved. The goals of this study were to: (1) identify appropriate methods for determining metastatic DTC in the lateral neck and (2) address the extent of lymph node dissection for the lateral neck necessary to control nodal disease balanced against known risks of surgery.

METHODS

A literature review followed by formulation of a consensus statement was performed.

RESULTS

Four proposals regarding management of the lateral neck are made for consideration by organizations developing management guidelines for patients with thyroid nodules and DTC including the next iteration of management guidelines developed by the American Thyroid Association (ATA). Metastases to lateral neck nodes must be considered in the evaluation of the newly diagnosed thyroid cancer patient and for surveillance of the previously treated DTC patient.

CONCLUSIONS

Lateral neck lymph nodes are a significant consideration in the surgical management of patients with DTC. When current guidelines formulated by the ATA and by other international medical societies are followed, initial evaluation of the DTC patient with ultrasound (or other modalities when indicated) will help to identify lateral neck lymph nodes of concern. These findings should be addressed using fine-needle aspiration biopsy. A comprehensive neck dissection of at least nodal levels IIa, III, IV, and Vb should be performed when indicated to optimize disease control.

Level V in therapeutic neck dissections for papillary thyroid carcinoma

Neck dissection for papillary thyroid carcinoma (PTC) is the standard of care for patients with clinical evidence of regional metastases. However, the extent of neck dissection is debatable. The purpose of the current study was to develop evidence-based recommendations for when to include level V, or 1 of its sublevels, among patients with PTC undergoing neck dissection. A literature review of all studies evaluating the occurrence of metastases in level V in patients with regional metastases from PTC undergoing neck dissection was performed. Occurrence of metastases at level V is low in most series (5% to 10%), although a wide range was noticed. In cases in which metastases were found at level V, they occurred almost exclusively at sublevel VB. Sublevel VA was rarely, if ever, involved with metastatic lymph nodes. However, only recently have investigators begun to specify which sublevels of level V are at risk. Therapeutic dissection of level V is indicated when there is clinical evidence of disease involving this zone. Elective dissection of sublevel VB is indicated when there is involvement of level IV, or possibly multiple nodes at levels II and III. Under these circumstances, dissection of sublevel VB is indicated but sublevel VA may be spared.

Patterns of cervical lymph node metastases in primary and recurrent papillary thyroid cancer

The incidence of thyroid cancer is rising in the United States with papillary thyroid cancer (PTC) being the most common type. We performed a retrospective study of 49 patients with PTC who underwent 57 lateral neck dissections (NDs). The extent of NDs varied, but 29 of 57 (51%) consisted of levels II–V. Twelve of 57 (21%) NDs consisted of levels I–V. Twelve of 57 (21%) NDs consisted of levels II–IV. One of 57 (1.8%) necks involved only levels I–IV. One of 57(1.8%) necks involved only levels I–V. One of 57(1.8%) necks involved only levels III–V. Two (3.5%) double-level (III–IV) neck surgeries were also performed. Metastatic PTC adenopathy was confirmed pathologically in 2%-level-I, 45%-level-II, 57%-level-III, 60%-level-IV, and 22%-level-V necks. Level-V was positive in 21% of primary and 24% of recurrent groups (P = 0.76). Comparing primary and recurrent disease, there was no difference in nodal distribution or frequency for levels I, II, III, and V. Level-IV was more common in the recurrent cases (P = 0.05). Based on the pathologic distribution of nodes, dissection should routinely include levels II–IV and extend to level-V in primary and recurrent cases. Our data does not suggest routine dissection of level-I.