Individualized optimal surgical extent of the lateral neck in papillary thyroid cancer with lateral cervical metastasis

Comparison of surgical outcomes between patients undergoing trans-oral endoscopic thyroid surgery combined with trans-thoracoareolar approach and conventional open surgery

Over the past decades, remote-access thyroid surgery has been widely developed in the treatment of thyroid carcinoma, which can help patients to avoid cosmetically displeasing scarring. In this research, we collected and review our experience with endoscopic thyroidectomy with neck dissection via trans-thoracoareolar approach combined with trans-oral approach over a 3-year period. They were all diagnosed with thyroid carcinoma, and two of them had a complication of Hashimoto's thyroiditis. No patients were dissatisfied with the postoperative cosmetic results. One patient had numbness in the lower lip, but the symptom disappeared 1 month later. No infection, hemorrhage, or air embolism occurred. Pain and numbness in the endoscopic thyroid surgery group were slighter than in those who had open surgery. The present study aims to compare the feasibility and safety of trans-thoracoareolar approach combined with trans-oral approach to conventional open surgery.

Diagnostic Accuracy of Ultrasound for the Evaluation of Lateral Compartment Lymph Nodes in Papillary Thyroid Carcinoma

AIMS

To evaluate the diagnostic accuracy of ultrasound (US) assessing the lateral compartment lymph node metastasis in patients with primary papillary thyroid carcinoma (PTC), and to demonstrate the incidence and patterns of the lateral lymph node metastasis.

METHODS

We retrospectively reviewed 198 patients with primary PTC who underwent thyroidectomy in addition to modified lateral neck dissections (MLND) involving level II to level V due to clinically positive lateral neck disease. A skilled and experienced single operator performed all US examinations. Surgical pathology results were accepted as the reference method and sensitivity, specificity, and diagnostic accuracy of US in detecting metastatic lymph nodes established using level-by-level analysis.

RESULTS

In the study cohort, 10.1% of the patients had lateral compartment lymph node metastases without any central compartment involvement. For the lateral compartment, 48.5% had level II, 74.7% had level III, 64.6% had level IV, and 29.3% of the patients had level V metastasis. None of the patients had isolated level V metastasis. The sensitivity, specificity, and diagnostic accuracy of US in identifying lateral lymph compartment metastasis ranged from 87% to 91.4%, 92% to 98.6% 92.4% to 96%, respectively. However, the sensitivity (74.7%) and diagnostic accuracy (76.2%) of US significantly decreased for the central compartment while specificity (90%) remained similar.

CONCLUSION

US performed by a skilled operator has an excellent diagnostic accuracy for the evaluation of lateral cervical lymph nodes in primary PTC; thus, might enable precise tailoring of the management strategies. Moreover, the high incidence of level V involvement favors MLND over selective approaches.

High rate of IIA/IIB neck groups involvement supports complete lateral neck dissection in thyroid carcinoma

Background

Although therapeutic lateral neck dissection (LND) may be indicated in thyroid carcinoma, the cervical lymph node groups IIA and IIB, according to Robbins classification, are often not removed. The aim of our study was to determine the relevance of complete comprehensive LND in thyroid carcinoma.

Methods

We conducted a retrospective study between January 2011 and August 2018 in a university teaching hospital. Histopathological analysis of LND performed during total thyroidectomy in thyroid carcinoma was reviewed according to lymph node level. To demonstrate that neck dissection of upper groups, IIA/IIB, is necessary when therapeutic LND is indicated in thyroid carcinoma, we compared histopathological involvement in complete comprehensive LND of the upper groups IIA/IIB to the lower groups III/IV/V.

Results

A total of 30 LND (24 patients) were suitable for analysis. Analysis by neck side revealed that comprehensive LND dissection samples were negative in 3 cases, and positive in 27. In those 27 positive LND, 15 demonstrated involvement of the groups IIA/IIB, and 12 were positive for involvement of the III/IV/V groups only. The combined presence of positive IIA/IIB and positive III/IV/V was observed in 15 of the 27 neck sides. There was no positive IIA/IIB without positive involvement of III/IV/V groups.

Conclusions

The high rate of positive cervical lymph nodes in the upper groups IIA/IIB supports complete comprehensive LND rather than selective III/IV/V LND in thyroid carcinoma surgery. However, impact on survival and whether postoperative radioactive iodine treatment may be modulated remain to be studied.

Prevalence, Risk Factors And Location Of Skip Metastasis In Papillary Thyroid Carcinoma: A Systematic Review And Meta-Analysis

Background

Skip metastasis is a special type in cervical lymph node metastasis (LNM) of patients diagnosed with papillary thyroid carcinoma (PTC) which induced poor prognosis. There are few studies about skip metastasis and conclusions remained uncertain. Therefore, this study aims to explore the frequency and to investigate risk factors of skip metastasis in PTC.

Methods

Through searching the keyword by PubMed and Embase databases which articles published up to 1^st August 2018 about skip metastasis in papillary thyroid carcinoma, we extract data in order to assure whether those materials meet the criteria.

Results

The prevalence of skip metastasis is 12.02% in light of our meta-analysis of 18 studies with 2165 patients. The upper pole location (RR = 3.35, 95% CI =1.65-6.79, P = 0.0008) and tumors size ≤1 cm (RR = 2.65, 95% CI =1.50-4.70, P = 0.0008) are significantly associated with skip metastasis, whereas lymphovascular invasion (RR = 0.33, 95% CI =0.15-0.75, P = 0.0083) exists lower rate of skip metastasis. Multifocality, gender, age, bilaterality, thyroiditis and Extrathyroidal extension (ETE) are insignificantly associated with skip metastasis. Level II and level III are the most frequently affected areas.

Conclusion

The lateral compartment should be carefully examined especially for those PTC patients who present primary tumors in the upper lobe with a primary tumor size ≤10 mm which could be detected with skip metastasis.

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.

Analysis of Survival and of Time Until Recurrence of Disease of Patients With Papillary Thyroid Carcinoma-Multivariant Analysis

BACKGROUND

We examined survival and time until recurrence of disease by multivariant analysis in patients treated for papillary thyroid carcinoma (PTC).

PATIENTS AND METHODS

In the period from January 2003 to January 2018, we analyzed 102 patients with PTC in Public Health Institution-Hospital "Sveti Vracevi" in Bijeljina. Survival and time until recurrence of the disease were analyzed using patients' general data and factors based on preoperative, intraoperative and postoperative examinations. Many prognostic factors were analyzed together; the AGES prognostic score, consisting of age, grade, extent and size, and the AMES prognostic score, consisting of age, metastases, extent and size.

RESULTS

We analyzed 102 patients with PTC. Out of these 87 patients had AGES p.s ≤ 3.99 and 15 patients had AGES p.s> 4. The survival of patients was affected by the presence of distant metastases at the time of diagnosis p = 0.00109 and age p = 0.0436. Recurrence of the disease was recorded in 14 patients. Most patients had recurrence of the disease in the first 5 years after initial surgery. Analyzing the time until recurrence, we concluded that, statistically speaking, AGES p.s> 4 affect recurrence of the disease p = 0.0355 in a significant way, while distant metastases affect it in a very significant way (p = 0.008).

CONCLUSIONS

Prognostic factors of papillary thyroid carcinoma can be divided into 4 categories, patients' general data and factors based on preoperative, intraoperative and postoperative examinations.

Risk factors of central lymph node metastasis in papillary thyroid carcinoma: A retrospective cohort study

OBJECTIVE

The aim of this study was to explore the risk factors that were associated with central lymph node metastases (CLNM) in papillary thyroid carcinoma (PTC) patients.

METHODS

A total of 180 patients with PTC who underwent surgery in our hospital between January 2014 and December 2016 were identified retrospectively. The relationship between clinicopathological factors and CLNM were analyzed by univariate and multivariate logistic regression.

RESULTS

The incidence of CLNM was 67.8% (122/180) in PTC patients. Univariate analysis showed that multifocality (p = 0.002), HT (p < 0.001) and LVI (p < 0.001) were significant associated with CLNM. No significant associations were found between factors and CLNM, including age, gender, tumor size and ETE. Multivariate logistic regression analysis showed that multifocality (p = 0.011), HT (p < 0.001) and LVI (p < 0.001) were independent predictors of CLNM in PTC patients.

CONCLUSIONS

Our study identified several independent risk factors predicting CLNM in PTC patients, such as multifocality, HT and LVI. The CLNM is very common in PTC patients, and routine prophylactic central neck dissection (PCND) may recommended in PTC patients with those risk factors of CLNM.

Low transverse incision for lateral neck dissection in patients with papillary thyroid cancer: improved cosmesis

Background

Various incisions and approaches have been developed for lateral neck dissection. The purpose of this study was to compare the surgical and cosmetic outcomes of a single low transverse incision with the hockey stick incision for lateral neck dissection (LND) in patients with papillary thyroid carcinoma (PTC).

Methods

We retrospectively analyzed 97 patients with PTC who underwent therapeutic LND and total thyroidectomy by low transverse incision (62 patients) or hockey stick incision (35 patients). We compared the operative results, cosmetic outcomes, objective scar measurement, and sensory disturbance between the two groups.

Results

The number of harvested and metastatic lymph nodes, Vancouver Scar Scale scores, and sensory change were not significantly different between the two groups. The mean number of harvested lymph nodes in level II was 9.82 vs. 9.63 (P = 0.885) (transverse incision vs. hockey stick incision, respectively) and in level V was 6.36 vs. 5.63 (P = 0.597). However, subjective satisfaction with the scar and neck contour was higher in the low transverse incision group compared with the hockey stick incision group. Scores for scar consciousness and sensory change were not significantly different between the two groups.

Conclusions

A single low transverse incision may provide equivalent surgical outcomes and superior cosmetic outcomes compared with the hockey stick incision for LND in PTC.

Tumor size interpretation for predicting cervical lymph node metastasis using a differentiated thyroid cancer risk model

Lymph node metastasis (LNM) is common in differentiated thyroid cancer (DTC), but management of clinically negative DTC is controversial. This study evaluated primary tumor size as a predictor of LNM. Multivariate logistic regression analysis was used for DTC patients who were treated with surgery between 2002 and 2012 in the Surveillance, Epidemiology, and End Results (SEER) database, to determine the association of tumor size at 10 mm increments with LNM. A predictive model was then developed to estimate the risk of LNM in DTC, using tumor size and other clinicopathological characteristics identified from the multivariate analysis. We identified 80,565 eligible patients with DTC in the SEER database. Final histology confirmed 9,896 (12.3%) cases affected with N1a disease and 8,194 (10.2%) cases with N1b disease. After the patients were classified into subgroups by tumor size, we found that the percentages of male sex, white race, follicular histology, gross extrathyroidal extension, lateral lymph node metastasis, and distant metastasis gradually increased with size. In multivariate analysis, tumor size was a significant independent prognostic factor for LNM; in particular, the odds ratio for lateral lymph node metastasis continued to increase by size relative to a 1–10 mm baseline. The coefficient for tumor size in the LNM predictive model waŝ0.20, indicating extra change in log(odds ratio) for LNM as 0.2 per unit increment in size relative to baseline. In conclusion, larger tumors are likely to have aggressive features and metastasize to a cervical compartment. Multistratification by size could provide more precise estimates of the likelihood of LNM before surgery.

Dissection of Levels II Through V Is Required for Optimal Outcomes in Patients with Lateral Neck Lymph Node Metastasis from Papillary Thyroid Carcinoma

BACKGROUND

Completeness of surgical resection is an important determinant of outcomes in patients with papillary thyroid carcinoma and regional lymph node metastasis. The extent of therapeutic lateral neck dissection remains controversial. This study aims to assess the impact of modified radical neck dissection of levels II to V in a large patient series.

STUDY DESIGN

Retrospective analysis of consecutive patients with papillary thyroid carcinoma who underwent lateral neck dissection at a single institution from June 1, 2006 to December 31, 2014 was performed.

RESULTS

A total of 241 lateral neck dissections were performed in 191 patients (118 [62%] women; median age 46 years [range 6 to 87 years]; median follow-up 14.3 months [range 0.1 to 107 months]). Overall, 202 initial neck dissections (195 modified radical neck dissections and 7 less extensive dissections) were performed. Among these initial dissections, 137 (68.8%), 132 (65.7%), 105 (52.0%), and 33 (16.9%) had positive lymph nodes in levels II, III, IV, and V, respectively. Ipsilateral lymph node persistence or recurrence occurred after 22 (10.9%) initial dissections, at level II in 10 (45.5%), level III in 8 (36.4%), level IV in 7 (31.8%), and level V in 3 (13.6%). Thirty-nine reoperative lateral neck dissection were performed, including 18 cases of persistence and recurrence after our initial dissections. In reoperative dissections, positive lymph nodes were confirmed in levels II, III, IV, and V in 18 (46.2%), 10 (25.6%), 13 (33.3%), and 5 (12.8%) dissections, respectively. Temporary nerve injury occurred in 6 (3.0%) initial and 4 (10.3%) reoperative dissections, respectively. There were no permanent nerve injuries.

CONCLUSIONS

Omitting levels II and V during lateral neck dissection for papillary thyroid carcinoma potentially misses level II disease in two-thirds of patients and level V disease in one-fifth of patients. Formal modified radical neck dissection is necessary to avoid the morbidity of reoperative surgery.

Local recurrence of papillary thyroid cancer

Management of advanced papillary thyroid cancer (PTC >10 mm) is changing its focus. Mortality was the main outcome measure for patients treated before the 90s. In the past two decades, however, most patients diagnosed with PTC belong to the very low risk of death group. On the other hand, local recurrence of PTC remains a clinical problem, with rates up to 25% depending on the presence of nodal metastasis, tumor diameter, and the skill of the surgeon to completely remove the primary tumor and the associated lymph node metastasis at first-time thyroidectomy. After optimized surgery (total thyroidectomy plus central neck dissection), radioiodine ablation has very little influence on lymph node recurrence that now presents mostly as lateral neck node metastasis that was overlooked or incompletely resected at the time of initial surgery.

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.