Evaluating the effectiveness of prophylactic central neck dissection with total thyroidectomy for cN0 papillary thyroid carcinoma: An updated meta-analysis

Risk factors analysis of lateral cervical lymph node metastasis in papillary thyroid carcinoma: a retrospective study of 830 patients

OBJECTIVE

The aim of this study is to investigate the risk factors for lateral cervical lymph node metastasis in papillary thyroid carcinoma (PTC).

METHODS

Clinicopathological data (age, gender, Hashimoto's thyroiditis, preoperative circulating tumor cells (CTCs), multifocal, maximum lesion diameter, invaded capsule, T stage, and lymph node metastasis) of 830 PTC patients diagnosed and treated in Meizhou People's Hospital from June 2021 to April 2023 were collected. The related factors of lateral cervical lymph node metastasis were analyzed.

RESULTS

There were 334 (40.2%), and 103 (12.4%) PTC patients with central lymph node metastasis, and lateral cervical lymph node metastasis, respectively. Compared with patients without lateral cervical lymph node metastasis, PTC patients with lateral cervical lymph node metastasis had a higher proportion of multifocal, maximum lesion diameter > 1 cm, invaded capsule, T3-T4 stage. Regression logistic analysis showed that male (odds ratio (OR): 2.196, 95% confidence interval (CI): 1.279-3.769, p = 0.004), age < 55 years old (OR: 2.057, 95% CI: 1.062-3.988, p = 0.033), multifocal (OR: 2.759, 95% CI: 1.708-4.458, p < 0.001), maximum lesion diameter > 1 cm (OR: 5.408, 95% CI: 3.233-9.046, p < 0.001), T3-T4 stage (OR: 2.396, 95% CI: 1.241-4.626, p = 0.009), and invaded capsule (OR: 2.051, 95% CI: 1.208-3.480, p = 0.008) were associated with lateral cervical lymph node metastasis.

CONCLUSIONS

Male, age < 55 years old, multifocal, maximum lesion diameter > 1 cm, T3-T4 stage, and invaded capsule were independent risk factors for lateral cervical lymph node metastasis in PTC.

Application of Carbon Nanoparticles in Transoral Endoscopic Thyroidectomy Vestibular Approach for Unilateral Papillary Thyroid Cancer

BACKGROUND

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is newly applied technology. Carbon nanoparticles (CNs) are novel lymph node tracers that have been widely used in China to help remove central lymph nodes (CLNs) and protect the parathyroid glands (PGs) in open thyroid cancer surgery. This study is to evaluate the effectiveness and safety of CNs in TOETVA.

MATERIALS AND METHODS

A total of 158 patients who underwent TOETVA with unilateral papillary thyroid carcinoma were enrolled in this study from March 2019 to February 2022. The participants were divided into a CNs group (n=88) and a control group (n=70), based on whether they received a intraoperative injection of CNs or not. Meanwhile, the CNs group were additionally divided into 2 subgroups, leakage subgroup (n=26) and standard subgroup (n=62). The 2 groups and subgroups were compared in terms of patient characteristics, perioperative clinical results, and postoperative outcomes.

RESULTS

All common metrics had no significant differences were found between the CNs group and the control group ( P >0.05). The standard subgroup of CNs group had advantage over the control group on PGs identification (59/62 vs. 59/70 for superior PG, 56/62 vs. 52/70 for inferior PG, P <0.05). Moreover, the standard subgroup harvested more CLNs than the control group (8.97±2.96 vs. 7.47±2.93, P <0.05). More operation time was spent on the leakage subgroup of CNs group than the control group (160.00±17.61 vs. 140.00±13.32, P <0.05). Meanwhile, the leakage subgroup had disadvantage on intraoperative hemorrhage (26.15±10.80 vs. 21.21±7.09, P <0.05) and hospital durations (4.96±0.72 vs. 4.57±0.69, P <0.05). Furthermore, the leakage group identified fewer inferior PG than the control group (7/26 vs. 52/70, P <0.05). Contrary to the standard subgroup, the CLNs of the leakage subgroup was also unsatisfactory compared with the control group (4.96±1.84 vs. 7.47±2.93, P <0.05).

CONCLUSIONS

The application of CNs suspension tracing technology has a definite effect in TOETVA. It can improve the thoroughness of lymph node dissection in the central region and enhance recognition of the PG. However, refined extracapsular anatomy is indispensable to prevent CN leakage. Leaked CNs will also be counterproductive to the operation.

Impact of fellowship training for specialists on thyroidectomy outcomes of patients with thyroid cancer

We aimed to evaluate the impact of fellowship training (FT) for thyroid specialists on the outcomes of patients with thyroid cancer. We reviewed surgeries performed for thyroid cancer before (non-FT group) and after (FT group) fellowship training and compared several variables, including length of stay of patients, tumor diameter, surgical method, lymph node dissection, parathyroid implantation, surgical duration, intraoperative blood loss, and postoperative complications. Compared with the non-FT group, the FT group had a shorter hospital stay, more adequate fine needle aspiration biopsy of the thyroid, less intraoperative blood loss, higher rate of parathyroid implantation, higher lymph node dissection rate, and lower nerve injury and hypoparathyroidism rates. When the surgical duration was < 200 min and/or only central lymph node dissection was performed, the FT group had a lower incidence of postoperative complications than the non-FT group. When, the incidence of postoperative complications, including postoperative nerve injury and hypoparathyroidism. In conclusion, FT for thyroid specialists is beneficial for patients with thyroid cancer and may allow a shorter hospital stay and reduced incidence of postoperative complication. Accordingly, FT may facilitate a more appropriate surgical approach with a preoperative pathological diagnosis.

Central node dissection from the perspective of lateral neck node metastasis in papillary thyroid carcinoma

OBJECTIVES

Controversy exists on how to handle central lymph nodes in papillary thyroid carcinoma, particularly regarding indications for prophylactic central neck dissection (CND). Central node metastases are more difficult to diagnose preoperatively than lateral node metastases.

METHODS

We enrolled 493 patients with papillary thyroid carcinoma treated at our department in the past 22 years. Metastatic lymph nodes were diagnosed preoperatively mainly by ultrasonography. In principle, CND was performed for all cases; ipsilateral CND was performed for hemithyroidectomy, and bilateral CND was performed for total thyroidectomy. Lateral neck dissection (levels II to V; LND) was performed for metastases to lateral neck lymph nodes (clinical node (cN) 1b).

RESULTS

The cN stage was cN0 in 365 patients, cN1a in 10, and cN1b in 118. Of the 357 patients with stage cN0 who underwent CND, 42.9 % had pathologically positive nodes (pN+) in level VI, and of the 118 with stage cN1b who underwent CND, 78.0 % had pN+ in level VI. Cases with advanced T stage were significantly more common with pN+ in level VI. Level VI metastases were significantly associated with pN+ in level IV. As the total number of pN+ at each level of the lateral neck increased, the rate of patients with pN+ in level VI increased, and in patients with 3 or more pN+, about 85 % had level VI metastases.

CONCLUSION

Because about half of the patients with cN0 patients had pN+ in level VI, and the rate of pN+ in level VI in each clinical T stage was 46 to 65 %, prophylactic CND should be performed, considering the various clinical benefits. Central nodes will have metastases in about 80 % of cases with lateral node metastases, requiring more accurate dissection. In lateral node metastases, there is a significant association between metastases in levels IV and VI.

Quantitative parameters of contrast-enhanced ultrasound effectively promote the prediction of cervical lymph node metastasis in papillary thyroid carcinoma

Papillary thyroid carcinoma (PTC), the most common endocrine tumor, often spreads to cervical lymph nodes metastasis (CLNM). Preoperative diagnosis of CLNM is important when selecting surgical strategies. Therefore, we aimed to explore the effectiveness of quantitative parameters of contrast-enhanced ultrasound (CEUS) in predicting CLNM in PTC. We retrospectively analyzed 193 patients with PTC undergoing conventional ultrasound (CUS) and CEUS. The CUS features and quantitative parameters of CEUS were evaluated according to PTC size ≤ 10 or > 10 mm, using pathology as the gold standard. For the PTC ≤ 10 mm, microcalcification and multifocality were significantly different between the CLNM (+) and CLNM (-) groups (both P < 0.05). For the PTC > 10 mm, statistical significance was noted between the two groups with respect to the margin, capsule contact, and multifocality (all P < 0.05). For PTC ≤ 10 mm, there was no significant difference between the CLNM (+) and CLNM (-) groups in all quantitative parameters of CEUS (all P > 0.05). However, for PTC > 10 mm, the peak intensity (PI), mean transit time, and slope were significantly associated with CLNM (all P < 0.05). Multivariate analysis showed that PI > 5.8 dB was an independent risk factor for predicting CLNM in patients with PTC > 10 mm (P < 0.05). The area under the curve of PI combined with CUS (0.831) was significantly higher than that of CUS (0.707) or PI (0.703) alone in the receiver operator characteristic curve analysis (P < 0.05). In conclusion, PI has significance in predicting CLNM for PTC > 10 mm; however, it is not helpful for PTC ≤ 10 mm.

Carbon nanoparticles beneficial for prophylactic central compartment lymph node dissection in cN0 papillary thyroid carcinoma

Objective

This study explored prophylactic central compartment lymph node dissection (pCCLND) for patients with cN0 papillary thyroid carcinoma (PTC) and the effect of carbon nanoparticles (CNP) on surgical outcomes.

Methods

This retrospective study reviewed PTC cases treated at our tertiary medical institution between January 2019 and December 2022. Only patients with indications for total thyroidectomy and cN0 disease were included. CNP has been associated with a higher number of harvested lymph nodes and a lower rate of accidental parathyroid gland (PTG) removal. Patients who used CNP in this study were classified as group 1, while those who denied its use were classified as group 2.

Results

In total, 116 cases were included, with 80 patients in group 1 and 36 in group 2. Most patients were in stage T1, with 68 (85.0 %) patients in group 1 and 31 (86.1 %) in group 2. Postoperative hoarseness occurred in 3 (3.8 %) patients in group 1 and 1 (2.8 %) in group 2, which recovered within two months. In group 2, 250 nodes were harvested, 72 (28.8 %) of which were metastatic; in group 1, 889 nodes were harvested, 316 (35.5 %) of which were metastatic; the difference regarding the rates of metastatic lymph nodes between the 2 groups was statistically significant (P = 0.047). Differences in postoperative blood calcium and parathyroid hormone levels between the two groups were statistically significant (P = 0.035 and P = 0.034, respectively). There were symptoms of hypocalcemia in 6 (16.7 %) patients in group 2 but in only 2 (2.5 %) in group 1, all of which recovered within three months; the difference was statistically significant (p = 0.017).

Conclusion

pCCLND is worth undertaking for cN0 PTC. CNP is beneficial for achieving more thorough dissection and reducing temporary hypoparathyroidism.

Central Neck Lymph Node Size Measured by Ultrasound Significantly Predicts Central Neck Lymph Node Metastasis of Papillary Thyroid Carcinoma

Objective: The aim of this study was to investigate whether Central lymph node (CLN) size as measured by an ultrasound can significantly predict CLN metastasis of papillary thyroid carcinoma (PTC). Materials and methods: This retrospective chart review of patients diagnosed with PTC who underwent ultrasound and central neck dissection (CND). We excluded patients who received previous thyroid surgery or radiation. We analyzed the correlation between CLN size and characteristics by ultrasound and histopathologic findings among positive CLN patients. Results: Of the 48 patients who underwent preoperative ultrasound and CND, 34 patients had positive CLN identified by ultrasound. The positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of ultrasound in this diagnostic setting was 88.0%, 21.0%, 73.2%, 42.9%, and 68.7%, respectively. The risk of CLN metastasis of PTC was 67.7% and 85.7% for lymph node size 3.1 to 4 mm and 4.1 to 5 mm, respectively. The risk increased to 100% when the lymph node size was >5 mm. Positive preoperative ultrasound of lateral neck lymph node was found to be a significant risk factor for CLN metastasis (P = .003). Conclusion: Ultrasound was found to be an effective preoperative evaluation in patients with PTC to determine the likelihood of CLN metastasis and whether CND is indicated, especially in the ultrasound-positive central lymph node. A high risk of metastasis was found in CLN size >3 mm by ultrasound, and the risk dramatically increased in CLN size >5 mm. We also found positive lateral neck node from preoperative ultrasound to be a significant risk factor for CLN metastasis.

Development and validation of nomograms for predicting the risk of central lymph node metastasis of solitary papillary thyroid carcinoma of the isthmus

BACKGROUND

This study was conducted to develop nomograms and validate them by assessing risk factors for the development of central lymph node metastasis (CLNM) in patients with solitary papillary thyroid carcinoma of the isthmus (PTCI) for predicting the probability of CLNM.

METHODS

Demographic and clinicopathological variables of patients with solitary papillary thyroid carcinoma (PTC) from May 2018 to May 2023 at the First Hospital of Shanxi Medical University were retrospectively analyzed, and the lobar group and the isthmus group were divided according to tumor location. Patients with the same sex, age difference of less than 3 years, and equal gross tumor diameter were selected from the lobar group and compared with the paraisthmic tumor group. Independent risk factors were determined using univariate and multivariate logistic regression analysis. On this basis, clinical predictive nomograms were developed and validated.

RESULTS

Clinical data from 326 patients with solitary PTCI and 660 cases of solitary lobar PTC were used for analysis in our study. The incidence of solitary tumors CLNM located in the median isthmus, paracentral isthmus, and lobes was 69.8%, 40.9%, and 33.6%, respectively. Statistical analysis revealed that gender, age, isthmus location, maximum nodal diameter, the presence of possible CLNM in advance on preoperative ultrasound, chronic lymphocytic thyroiditis, and the lymphocyte/monocyte ratio were independent risk factors for preoperative CLNM in patients with solitary PTCI. Age, isthmus location, chronic lymphocytic thyroiditis, gross tumor diameter, presence of intraoperative extrathyroidal extension, and presence of metastasis in the Delphian lymph node on frozen section were independent risk factors for intraoperative CLNM. The concordance indices of nomograms for preoperative and intraoperative are 0.871 and 0.894 in the training set and 0.796 and 0.851 in the validation set, calibration curve and decision curve analysis also demonstrated the strong reliability and clinical applicability of this clinical prediction model.

CONCLUSION

In this study, we concluded that solitary PTCI is more aggressive compared to solitary lobar PTC, and we constructed nomograms and risk stratification to accurately identify patients with solitary PTCI who are at high risk of developing CLNM, which will help clinicians in personalized decision making.

Prevalence of Occult Central Lymph Node Metastasis by Tumor Size in Papillary Thyroid Carcinoma: A Systematic Review and Meta-Analysis

BACKGROUND

While papillary thyroid carcinoma (PTC) is associated with high occult central neck metastasis (CNM) rates, prophylactic central neck dissection (pCND) is controversial. This meta-analysis aims to look at the occult CNM rate according to tumor size.

METHODS

A literature search was conducted in PubMed from inception to April 2023. Inclusion criteria were primary studies that determined occult CNM rates in cN0 PTC by tumor size. Heterogeneity, influential case diagnostics, and proportion data were evaluated with Cochran's Q-test, Baujat plots and Forest plots, respectively.

RESULTS

Fifty-two studies were included in this meta-analysis. The findings demonstrated an occult CNM rate of 30.3% for tumors ≤ 5 mm, 32.7% for tumors ≤ 1 cm, 46.0% for tumors between 1 and 2 cm, 43.1% for tumors between 2 and 4 cm, and 61.2% for tumors > 4 cm. The heterogeneity of each study group was high, though no publication bias was noted. While there was a trend towards increased occult CNM rates with larger tumors, comparisons between different size cutoffs varied in significance.

CONCLUSION

This comprehensive review affirms that occult CNM is high and that an ipsilateral pCND can be justified in all PTC patients for accurate differentiation between Stage I and Stage II disease and its clinical implications.

Prophylactic central neck dissection for cN0 papillary thyroid carcinoma: is there any difference between western countries and China? A systematic review and meta-analysis

Background

Recommendations for the performance of prophylactic central neck dissection (pCND) in patients with clinically node-uninvolved (cN0) papillary thyroid carcinoma (PTC) are not the same. This meta-analysis set out to compare the effectiveness of pCND with total thyroidectomy (TT) in different countries and regions, mainly between western countries and China.

Methods

The electronic databases PubMed, EMBASE, and Cochrane Library were searched for studies published until August 2022. The incidence rate of cervical lymph node metastases (LNMs), locoregional recurrences (LRRs), and postoperative complications were pooled by a random-effects model. Subgroup analyses based on different countries and regions were performed.

Results

Eighteen studies involving 5,346 patients were analyzed. In the subgroup of western countries, patients undergoing pCND with TT had a significantly lower LRR rate [69/1,804, 3.82% vs. 139/2,541, 5.47%; odds ratio (OR) = 0.56; 95% CI 0.37-0.85] and a higher rate of temporary hypoparathyroidism (HPT) (316/1,279, 24.71% vs. 194/1,467, 13.22%; OR = 2.23; 95% CI 1.61-3.08) than that of the TT alone group, while no statistically significant difference was found in the rate of permanent HPT and temporary and permanent recurrent laryngeal nerve (RLN) injury. In the Chinese subgroup, the pCND with TT group had a significantly higher incidence rate of both temporary HPT (87/374, 23.26% vs. 36/324, 11.11%; OR = 2.24; 95% CI 1.32-3.81) and permanent HPT (21/374, 5.61% vs. 4/324, 1.23%; OR = 3.58; 95% CI = 1.24-10.37) than that of the TT alone group, while no significant difference was detected in the rate of LRR and temporary and permanent RLN injury.

Conclusion

Compared with the TT alone for cN0 PTC patients, pCND with TT had a significantly lower LRR rate while having a higher temporary HPT rate in Europe, America, and Australia; however, it showed no significant difference in decreasing LRR rate while having a significantly raised rate of temporary and permanent HPT in China. More population-based results are required to advocate precision medicine in PTC.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022358546.

Development and validation of a dynamic nomogram based on conventional ultrasound and contrast-enhanced ultrasound for stratifying the risk of central lymph node metastasis in papillary thyroid carcinoma preoperatively

Purpose

The aim of this study was to develop and validate a dynamic nomogram by combining conventional ultrasound (US) and contrast-enhanced US (CEUS) to preoperatively evaluate the probability of central lymph node metastases (CLNMs) for patients with papillary thyroid carcinoma (PTC).

Methods

A total of 216 patients with PTC confirmed pathologically were included in this retrospective and prospective study, and they were divided into the training and validation cohorts, respectively. Each cohort was divided into the CLNM (+) and CLNM (-) groups. The least absolute shrinkage and selection operator (LASSO) regression method was applied to select the most useful predictive features for CLNM in the training cohort, and these features were incorporated into a multivariate logistic regression analysis to develop the nomogram. The nomogram's discrimination, calibration, and clinical usefulness were assessed in the training and validation cohorts.

Results

In the training and validation cohorts, the dynamic nomogram (https://clnmpredictionmodel.shinyapps.io/PTCCLNM/) had an area under the receiver operator characteristic curve (AUC) of 0.844 (95% CI, 0.755-0.905) and 0.827 (95% CI, 0.747-0.906), respectively. The Hosmer-Lemeshow test and calibration curve showed that the nomogram had good calibration (p = 0.385, p = 0.285). Decision curve analysis (DCA) showed that the nomogram has more predictive value of CLNM than US or CEUS features alone in a wide range of high-risk threshold. A Nomo-score of 0.428 as the cutoff value had a good performance to stratify high-risk and low-risk groups.

Conclusion

A dynamic nomogram combining US and CEUS features can be applied to risk stratification of CLNM in patients with PTC in clinical practice.

Nomogram prediction for cervical lymph node metastasis in multifocal papillary thyroid microcarcinoma

Aim

Accurate preoperative prediction of cervical lymph node metastasis (LNM) in patients with mPTMC provides a basis for surgical decision making and the extent of tumor resection. This study aimed to develop and validate an ultrasound radiomics nomogram for the preoperative assessment of LN status.

Methods

A total of 450 patients pathologically diagnosed with mPTMC were enrolled, including 348 patients in the modeling group and 102 patients in the validation group. Univariate and multivariate logistic regression analyses were performed on the basic information, ultrasound characteristics, and American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) scores of the patients in the modeling group to identify independent risk factors for LNM in mPTMC and to construct a logistic regression equation and nomogram to predict the risk of LNM. The validation group data were used to evaluate the predictive performance of the nomogram.

Results

Male sex, age <40 years, a single lesion with a maximum diameter >0.5 cm, capsular invasion, a maximum ACR score >9 points, and a total ACR score >19 points were independent risk factors for the development of cervical LNM in mPTMC. Both the area under the curve (AUC) and concordance index (C-index) of the prediction model constructed from the above six factors were 0.838. The calibration curve of the nomogram was close to the ideal diagonal line. Furthermore, decision curve analysis (DCA) demonstrated a significantly greater net benefit of the model. The external validation demonstrated the reliability of the prediction nomogram.

Conclusions

The presented radiomics nomogram, which is based on ACR TI-RADS scores, shows favorable predictive value for the preoperative assessment of LNs in patients with mPTMC. These findings may provide a basis for surgical decision making and the extent of tumor resection.

Scope of prophylactic lymph node dissection in the surgical treatment of differentiated thyroid cancer. Recommendations of the AFCE (Association francophone de chirurgie endocrinienne) with the SFE (Société française d'endocrinologie) and the SFMN (Société française de médecine nucléaire)

Prophylactic lymph node dissection is considered only for papillary cancers. It is not indicated for vesicular cancers or oncocytic cancers, nor should it entail a secondary surgical intervention in the event of an incidental discovery of papillary cancer on a thyroidectomy specimen. Prophylactic lymph node dissection means a cervical lymph node dissection in the absence of any pre- or intraoperative evidence (biological, cytological, histological, clinical or ultrasound) of lymph node metastases. There is currently no evidence in the literature that prophylactic central dissection improves overall survival, which is similar for N0 and NX patients. Yet although prophylactic lymph node dissection is not justified by overall survival, it does seem to reduce the risk of locoregional recurrence in the case of micro-N1, and it allows occult metastases to be detected and a tumour to be reclassified. This enables patients at risk of recurrence to be more surely identified and therapeutic strategy and follow-up adapted accordingly. Prophylactic homolateral central lymph node dissection is warranted for papillary cancers with largest ultrasound diameter 4cm and above and/or with intraoperative macroscopic evidence of perithyroid tissue invasion. The benefits and risks of lymph node dissection must be assessed and discussed on a case-by-case basis. Only a central lymph node dissection homolateral to the tumour is recommended, except for bilateral or isthmic cancers, for which a prophylactic bilateral central lymph node dissection may be considered. This bilateral lymph node dissection incurs an increased risk of complications (parathyroids, recurrent laryngeal nerve). Prophylactic lateral lymph node dissection is not recommended.

Prognostic value of lymphovascular space invasion in stage IA to IIB cervical cancer: A meta-analysis

BACKGROUND

Lymphovascular space invasion (LVSI) is a prognostic factor in the existing TNM classification system. The present meta-analysis assessed the role of LVSI in predicting the prognosis of stage IA to IIB cervical cancer (CC).

MATERIALS AND METHODS

PubMed, EMBASE, and Cochrane Library electronic databases were searched to determine relevant articles published in the English language. Our search deadline was May 2022. Critical Appraisal of Prognostic Studies was used to assess the quality for each article. Pooled hazard ratios (HRs) were used to evaluate the performance of LVSI in prognosis prediction.

RESULTS

We enrolled 8 studies involving 25,352 patients published after 2010. Thus, high LVSI was an unfavorable factor in predicting overall survival (HR, 2.08; 95% confidence interval, 1.63-2.66; P = .006) and disease-free survival (HR, 2.20; 95% confidence interval, 1.79-2.70; P = .000) for patients with CC. However, the disease-free survival and overall survival were significantly different on univariate analysis based on the subgroup analysis stratified by analysis method, but no obvious heterogeneity was found across diverse articles.

CONCLUSIONS

The present study showed that LVSI predicts the poor prognostic outcome of stage IA to IIB CC. However, well-designed clinical articles should further assess the independent prognosis prediction performance of LVSI in CC.

A Nod to the Nodes: An Overview of the Role of Central Neck Dissection in the Management of Papillary Thyroid Carcinoma

Lymph node metastasis in thyroid cancer is common and associated with an increased risk of locoregional recurrence (LRR). Although therapeutic central neck dissection is well established, prophylactic central node dissection (pCND) for microscopic occult nodal involvement is controversial and recommendations are based on low-level evidence. The potential benefits of pCND such as reducing LRR and re-operation, refining staging, and improving surveillance are enthusiastically debated and the decision to perform pCND must be weighed up against the increased risks of complications.

Incidental Node Metastasis as an Independent Factor of Worse Disease-Free Survival in Patients with Papillary Thyroid Carcinoma

INTRODUCTION

Papillary thyroid carcinoma (PTC) have high node metastasis rates. Occasionally after thyroidectomy, the pathological report reveals node metastasis unintentionally resected. The present study aimed to evaluate the prognosis of these patients.

METHODS

A retrospective cohort of patients submitted to thyroidectomy with or without central compartment neck dissection (CCND) due to PTC with a minimum follow-up of five years.

RESULTS

A total of 698 patients were included: 320 Nx, 264 pN0-incidental, 37 pN1a-incidental, 32 pN0-CCND and 45 pN1a-CCND. Patients with node metastasis were younger, had larger tumors, higher rates of microscopic extra-thyroidal extension, and angiolymphatic invasion and most received radioiodine therapy. Treatment failure was higher in patients pN1a-incidental and pN1a-CCND (32% and 16%, respectively; p < 0.001-Chi-square test). Disease-free survival (DFS) was lower in patients pN1a-incidental compared to patients Nx and pN0-incidental (p < 0.001 vs. Nx and pN0-incidental and p = 0.005 vs. pN0-CCND) but similar when compared to patients pN1a-CCND (p = 0.091)-Log-Rank test. Multivariate analysis demonstrated as independent risk factors: pT4a (HR = 5.524; 95%CI: 1.380-22.113; p = 0.016), pN1a-incidental (HR = 3.691; 95%CI: 1.556-8.755; p = 0.003), microscopic extra-thyroidal extension (HR = 2.560; 95%CI: 1.303-5.030; p = 0.006) and angiolymphatic invasion (HR = 2.240; 95%CI: 1.077-4.510; p = 0.030).

CONCLUSION

Patients that were pN1a-incidental were independently associated with lower DFS.

Prelaryngeal and/or pretracheal lymph node metastasis could help to identify papillary thyroid carcinoma with intermediate risk from unilateral lobe cT1-2N0 papillary thyroid carcinoma

Objective

The study aims to explore the possibility of prelaryngeal and/or pretracheal lymph node metastasis in identifying papillary thyroid carcinoma with more than 5 metastatic central lymph nodes from unilateral lobe cT1-2N0 papillary thyroid carcinoma.

Methods

A retrospective analysis was conducted on patients who underwent the initial thyroid surgery for unilateral lobe cT1-2N0 PTC in a single tertiary center between July 2018 to December 2022. Multivariable binary logistic regression analysis was used to identify risk factors for unilateral lobe cT1-2N0 papillary thyroid carcinoma with more than 5 metastatic central lymph nodes.

Results

A total of 737 patients were included in the study and 399 patients were confirmed to suffer from occult central lymph node metastasis. The larger size of the largest diameter of tumor (> 1cm; OR = 3.3, 95%CI 1.6 - 6.83; p = 0.001), pretracheal lymph node metastasis (OR = 5.91, 95%CI 2.73 - 12.77; p < 0.001), prelaryngeal lymph node metastasis (OR = 3.74, 95%CI 1.73 - 8.1; p = 0.001), ipsilateral paratracheal lymph node metastasis (OR = 12.22, 95%CI 3.43 - 43.48; p < 0.001), and contralateral paratracheal lymph node metastasis (OR = 7.68, 95%CI 3.86 - 15.3; p < 0.001) were confirmed to be risk factors for unilateral lobe cT1-2N0 PTC with more than 5 metastatic central lymph nodes. When more than two metastatic prelaryngeal and/or pretracheal lymph nodes occurred, the incidence of more than 5 metastatic central lymph nodes was 71.2%.

Conclusion

Prelaryngeal and/or pretracheal lymph node metastasis could help to identify papillary thyroid carcinoma with more than 5 metastatic central lymph nodes from unilateral lobe cT1-2N0 papillary thyroid carcinoma. When more than two metastatic pretracheal and/or prelaryngeal lymph nodes occurred, total thyroidectomy and ipsilateral central lymph node dissection should be performed and contralateral paratracheal lymph node dissection might be also necessary.

Evaluation of the role of prophylactic bilateral central neck lymph node dissection in patients with papillary thyroid carcinoma: a case controlled study

Thyroid cancer is the most common malignancy in the endocrine system. Papillary thyroid carcinoma (PTC) is the most common differentiated thyroid cancer. There are considerable discrepancies regarding the role and extent of prophylactic central lymph node dissection (PCLND) for patients with PTC. Our primary goal was the evaluation of CLN involvement based on the tumor features and staging on the eight version of the American Joint Committee on Cancer and also the TNM method. Our secondary aim was to evaluate the features of the CLNs with tumoral features and also features associated with the development of transient hypoparathyroidism. This prospective case-controlled study was performed among PTC patients. Total thyroidectomy and bilateral dissection of the CLNs of the central compartment of the neck was performed, and samples were sent for pathological evaluation. CLN involvement, tumoral features and transient hypoparathyroidism were cross-evaluated and analyzed with SPSS version 26.0. In this study, out of 61 patients, 11 (18%) were male, the average age was 37.3 ± 13.7 years, based on AJCC staging, 53 (86.9%) were stage I and 8 (13.1%) were stage II, and based on TNM staging, 39 patients (66.1%) were T1, including 13 (22.0%) T1a and 26 (44.1%) T1b, 15 patients (25.4%) were T2, and five patients (8.5%) were T3. Based on permanent pathology evaluation, the majority of patients (n = 48; 78.7%) had CLN involvement. None of the preoperative and tumor features had a significant association with CLN involvement. 75% of stage I and 100% of stage two cases, while 76.9% of T1, 86.7% of T2, and 80.0% of T3 cases had CLN involvement. There was no significant association between the involvement of CLN and the AJCC staging (P = 0.184) or TNM staging (P = 0.875). The involved to dissected CLN ratio was significantly higher in stage II patients compared to stage I (72.5 vs. 34.8%; P = 0.006), and also with higher T staging (0.009). There was a statistically significant association between the larger CLN size and older patients' age, higher postoperative thyroglobulin levels, and smaller tumor size. Higher postoperative thyroglobulin level was significantly associated with larger tumors size and thyroid capsule invasion. Also, 26 (44.8%) of patients developed transient hypoparathyroidism, which was significantly associated with vascular invasion (P = 0.048), bilateral location of tumor (P = 0.048) or on the right side (0.005), and larger size of the tumor (P = 0.016). Tumor features and staging were not associated with CLN involvement features. Therefore, full extent PCLND should be carried out to avoid reoperation or metastasis in PTC patients.

Near-infrared fluorescent imaging techniques for the detection and preservation of parathyroid glands during endocrine surgery

Objectives

In over 30% of all thyroid surgeries, complications arise from transient and definitive hypoparathyroidism, underscoring the need for real-time identification and preservation of parathyroid glands (PGs). Here, we evaluate the promising intraoperative optical technologies available for the identification, preservation, and functional assessment of PGs to enhance endocrine surgery.

Methods

We performed a review of the literature to identify published studies on fluorescence imaging in thyroid and parathyroid surgery.

Results

Fluorescence imaging is a well-demonstrated approach for both in vivo and in vitro localization of specific cells or tissues, and is gaining popularity as a technique to detect PGs during endocrine surgery. Autofluorescence (AF) imaging and indocyanine green (ICG) angiography are two emerging optical techniques to improve outcomes in thyroid and parathyroid surgeries. Near-infrared-guided technology has significantly contributed to the localization of PGs, through the detection of glandular AF. Perfusion through the PGs can be visualized with ICG, which can also reveal the blood supply after dissection.

Conclusions

Near infrared AF and ICG angiography, providing a valuable spatial and anatomical information, can decrease the incidence of complications in thyroid surgery.

Clinical Value of Ultrasonography and Serum Markers in Preoperative N Staging of Thyroid Cancer

We aimed to determine factors influencing lymph node metastasis (LNM) and develop a more effective method to assess preoperative N staging. Overall, data of 2130 patients who underwent thyroidectomy for thyroid cancer between 2018 and 2021 were retrospectively analysed. Patients were divided into groups according to pN0, pN1a, and pN1b stages. Pathology was used to analyse the correlation between preoperative serum marker indicators and LNM. Receiver operating characteristic curves were used to compare the diagnostic value of ultrasound (US) examination alone, serum thyroglobulin, age, and combined method for LNM. A significant moderate agreement was observed between preoperative US and postoperative pathology for N staging. Between the pN0 and pN1 (pN1a + pN1b) groups, the differences in free triiodothyronine, anti-thyroid peroxidase antibody, and serum thyroglobulin levels were statistically significant. Among the indicators, serum thyroglobulin was an independent predictor of LNM. The area under the receiver operating characteristic curve was 0.610 for serum thyroglobulin level for predicting LNM, 0.689 for US alone, and 0.742 for the combined method. Both preoperative US and serum thyroglobulin level provide a specific value when evaluating the N staging of thyroid cancer, and the combined method is more valuable in the diagnosis of LNM than US alone.

Impact of Lymph Node Dissection on Postoperative Complications of Total Thyroidectomy in Patients with Thyroid Carcinoma

Background: Lymph node dissection (LND) in primary treatment of differentiated thyroid carcinoma is controversial. The aim of our retrospective study was to analyse the risk factors of post-thyroidectomy complications and to assess the morbidity of lymph node dissection, especially in the central neck compartment, since prophylactic central lymph node dissection has not been proven to bring an overall survival benefit. Methods: We performed a retrospective analysis of postoperative complications from 1547 consecutive patients with differentiated thyroid carcinoma in an academic department of endocrine surgery over a period of 10 years. Results: A total of 535 patients underwent lymph node dissection, whereas the other 1012 did not. The rate of postoperative hypoparathyroidism was higher in patients with LND (17.6% vs. 11.4%, p = 0.001). No significant difference in the rate of permanent hypoparathyroidism (2.4% vs. 1.3%, p = 0.096) was observed between these two groups. A multivariate analysis was performed. Female gender, ipsilateral and bilateral central LND (CLND), parathyroid autotransplantation, and the presence of the parathyroid gland on the resected thyroid were associated with transient hypoparathyroidism. Bilateral CLND and the presence of the parathyroid gland on specimen were associated with permanent hypoparathyroidism. The rate of transient recurrent laryngeal nerve (RLN) injury (15.3% vs. 5.4%, p < 0.001) and permanent RLN injury (6.5% vs. 0.9%, p < 0.001) were higher in the LND group. In multivariate analysis, ipsilateral and bilateral lateral LND (LLND) were the main predictive factors of transient and permanent RLN injury. Bilateral RLN injury (2.6% vs. 0.4%, p < 0.001), chyle leakage (2.4% vs. 0%, p < 0.001), other nerve injuries (2.2% vs. 0%, p < 0.001), and abscess (2.4% vs. 0.5%, p = 0.001) were higher in the patients with LND. Conclusions: The surgical technique and the extent of lymph node dissection during surgery for thyroid carcinoma increase postoperative morbidity. A wider knowledge of lymph-node-dissection-related complications associated with thyroid surgery could help surgeons to carefully evaluate the surgical and medical therapeutic options.

Effect of prophylactic central neck dissection following total thyroidectomy on surgical site wound infection, hematoma, and haemorrhage in subjects with clinically node-negative papillary thyroid carcinoma: A meta-analysis

We performed a meta-analysis to evaluate the effect of prophylactic central neck dissection following total thyroidectomy on surgical site wound infection, hematoma, and haemorrhage in subjects with clinically node-negative papillary thyroid carcinoma. A systematic literature search up to April 2022 was performed and 3517 subjects with clinically node-negative papillary thyroid carcinoma at the baseline of the studies; 1503 of them were treated with prophylactic central neck dissection following total thyroidectomy, and 2014 were using total thyroidectomy. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the effect of prophylactic central neck dissection following total thyroidectomy on surgical site wound infection, hematoma, and haemorrhage in subjects with clinically node-negative papillary thyroid carcinoma using the dichotomous method with a random or fixed-effect model. The prophylactic central neck dissection following total thyroidectomy subjects had a significantly lower surgical site wound infection (OR, 0.40; 95% CI, 0.20-0.78, P = .007) in subjects with clinically node-negative papillary thyroid carcinoma compared with total thyroidectomy. However, prophylactic central neck dissection following total thyroidectomy did not show any significant difference in hematoma (OR, 0.08; 95% CI, 0.43-2.71, P = .87), and haemorrhage (OR, 0.72; 95% CI, 0.26-1.97, P = .52) compared with total thyroidectomy in subjects with clinically node-negative papillary thyroid carcinoma. The prophylactic central neck dissection following total thyroidectomy subjects had a significantly higher surgical site wound infection, and no significant difference in hematoma, and haemorrhage compared with total thyroidectomy in subjects with clinically node-negative papillary thyroid carcinoma. The analysis of outcomes should be with caution because of the low number of studies in certain comparisons.

Risk Factors for Central Lymph Node Metastases and Benefit of Prophylactic Central Lymph Node Dissection in Middle Eastern Patients With cN0 Papillary Thyroid Carcinoma

Background

Prophylactic central lymph node dissection (PCLND) for adult patients with papillary thyroid carcinoma (PTC) is still a matter of debate. Data on incidence, risk and benefits of PCLND in Middle Eastern patients is lacking. Therefore, we aimed to identify the incidence and predictive clinico-pathological and molecular marker of PCLND in adult patients with clinically node negative (cN0) Middle Eastern PTC.

Methods

This retrospective study included 942 adult Middle Eastern patients with cN0 PTC who underwent total thyroidectomy (TT) or TT+PCLND. Clinico-pathological associations of central lymph node metastasis (CLNM) were assessed. Multivariate analysis was performed using logistic regression and Cox proportional hazards model.

Results

213 patients underwent PCLND and 38.0% (81/213) had positive CLNM. Multivariate analysis demonstrated age ≤55 years (Odds Ratio (OR) = 7.38; 95% Confidence Interval (CI) = 1.59 – 34.31; p = 0.0108), tumor bilaterality (OR = 3.01; 95% CI = 1.01 – 9.21; p = 0.0483), lymphovascular invasion (OR = 2.92; 95% CI = 1.18 – 7.23; p = 0.0206) and BRAF mutation (OR = 3.24; 95% CI = 1.41 – 7.49; p = 0.0058) were independent predictors of CLNM in adult PTC. Furthermore, patients who underwent PCLND showed significant association with improved recurrence-free survival (RFS; p = 0.0379). Multivariate analysis demonstrated that PCLND was an independent predictor of improved recurrence-free survival.

Conclusions

cN0 Middle Eastern PTC patients treated with PCLND showed a significantly better prognosis. PCLND was effective in improving RFS in Middle Eastern PTC patients and should be encouraged for patients with potential risk factors for CLNM.

Real-World Evidence on the Sensitivity of Preoperative Ultrasound in Evaluating Central Lymph Node Metastasis of Papillary Thyroid Carcinoma

INTRODUCTION

Guidelines for prophylactic dissection in clinical central negative node (cN0) of papillary thyroid carcinoma vary among different countries due to the uncertainty on the benefit of dissection. The Chinese guidelines recommend prophylactic central compartment lymph node dissection (pCLND) under professional technology. Preoperative ultrasound (US) evaluation of central lymph node determines the surgical strategy used. Sensitivity differs significantly when US is conducted by different physicians even in diverse hospitals. In this study, the aim was to explore why the Chinese guidelines were different from the America Thyroid Association (ATA) guidelines through the real-world evidence on the preoperative diagnosis of cN0.

METHODS

Preoperative US and surgical pathology data for 1,015 patients with PTC attending 13 Grade-A tertiary hospitals in 2017 were collected. A retrospective analysis using US assessment of CLNM was the conducted to explore the benefits of this approach in China. US physicians in our hospital were trained on scanning the thyroid gland and its regional lymph nodes in normalization. Data of 1,776 patients were collected under the same condition from 2012 to 2017, whose ultrasonography was performed by diverse physicians and doctors. Further, data of 339 patients evaluated by the same sonographer and operated by the same surgical team was collected between 2015 and 2017. In this set of data, US combined CT versus US alone was compared. Patients were grouped into metastasis group and non-metastasis group based on postoperative pathological diagnosis of CLNM. Diagnostic efficacy of US was evaluated.

RESULTS

A total of 925 patients who underwent preoperative ultrasonography in central lymph node, including 825 cases who underwent thyroidectomy and central lymph node dissection were included in this study. The sensitivity of ultrasonography in detecting CLNM was 23.18%, with occult metastasis rate of 40.8%. Data for 1,776 patients comprising paired ultrasonic report and pathological report were collected in our hospital, whose physicians underwent standardized training. The sensitivity was 37.58%. Furthermore, specialized evaluation showed high sensitivity in US/CT (84.58%) than US (58.21%) alone.

CONCLUSION

Although the sensitivity of US could be enhanced by standardized training and combination with CT, the prevalence of low sensitivity of US in real-world multicenter data and the high occult metastasis rate indicated that the Chinese guidelines were based on the current conditions.

Prophylactic central neck dissection for well-differentiated thyroid carcinoma: results and methodological assessment of systematic reviews

OBJECTIVE

The aim was to assess the methodological quality of systematic reviews evaluating the effectivness of prophylactic central neck dissection plus thyroidectomy to decrease locoregional recurrence in patients with thyroid carcinoma.

INTRODUCTION

Many systematic reviews have been published concerning prophylactic central neck dissection in well-differentiated thyroid carcinoma, finding inconsistent results regarding the risk of locoregional recurrence. Because systematic reviews are considered the best source on which to base clinical decisions, the assessment of methodological quality is important.

INCLUSION CRITERIA

This paper included studies that mentioned that a systematic review was performed in adult patients with confirmed diagnosis of well-differentiated thyroid carcinoma without evidence of nodal metastatic disease who underwent total thyroidectomy. Reviews evaluated prophylactic central neck dissection compared with no neck diessection for decreasing locoregional recurrence.

METHODS

A systematic search was performed using MEDLINE, Embase, the Cochrane Database of Systematic Reviews, LILACS, Web of Science, CNKI, and Google Scholar. PROSPERO was searched for unpublished studies and gray literature. Data regarding the study characteristics, patient types, numbers of patients, and locoregional recurrence by group were extracted. Methodological characteristics, type of statistical analysis and summary estimator, heterogeneity, and publication bias were recorded. The methodological quality was measured using the AMSTAR 2 tool.

RESULTS

The search identified 12 systematic reviews. Only four systematic reviews reported adherence to methodological guidelines. The AMSTAR 2 critical criteria classified all the studies as critically low quality. The pooled risk difference for locoregional recurrence varied among studies from -5% to 0%. Most of the studies were published in high-impact journals.

CONCLUSIONS

The published systematic reviews that assessed prophylactic central neck dissection as an intervention to decrease the rate of locoregional recurrence have a critically low methodological quality. The results and recommendations based on these studies should be used with caution. The evaluation of methodological quality by peer reviewers must be improved.

A prospective randomized controlled trial to assess the efficacy and safety of prophylactic central compartment lymph node dissection in papillary thyroid carcinoma

BACKGROUND

The efficacy of prophylactic central compartment lymph node dissection for papillary thyroid carcinoma remains controversial. We performed a randomized controlled trial to evaluate the efficacy and safety of prophylactic central compartment lymph node dissection in patients with papillary thyroid carcinoma.

METHODS

In this parallel-group randomized controlled trial, we assessed 101 patients aged 20 to 70 years with small/noninvasive papillary thyroid carcinoma and no clinical metastases or history of cervical surgery/radiation exposure. Randomization ran from April 2015 to November 2017. Data were collected between April 2015 and October 2020. Of the 101 enrolled patients, 50 underwent total thyroidectomy (TTx group) and 51 underwent total thyroidectomy as well as prophylactic central compartment lymph node dissection (TTx+pCND group). Surgical completeness, local recurrence, successful ablation, postoperative complication, and papillary thyroid carcinoma upstaging were compared between the 2 groups.

RESULTS

No patient showed structural recurrence after 46.6 ± 9.1 months of follow-up. Both groups had similar rates of surgical completeness and successful ablation. There was no difference in the incidence of complications. More patients were upstaged to pN1a in the TTx+pCND group compared to those in the TTx group (P < .05).

CONCLUSIONS

Prophylactic central compartment lymph node dissection detected more lymph node metastases but did not affect recurrence. The 2 groups showed similar outcomes with regard to surgical completeness, successful ablation, and complications. In conclusion, for small/noninvasive papillary thyroid carcinoma without clinical evidence of lymph node metastases, prophylactic central compartment lymph node dissection may not be required if total thyroidectomy is planned.

Central lymph node dissection and permanent hypoparathyroidism after total thyroidectomy for papillary thyroid cancer: population-based study

BACKGROUND

Papillary thyroid cancer is treated with total/near-total thyroidectomy (TT) with or without central lymph node dissection (CLND), depending on risk factors and tumour size. Balancing the risk of disease recurrence and surgical morbidity remains a challenge. A population-based nationwide study was undertaken to evaluate the risk of permanent hypoparathyroidism associated with CLND.

METHOD

Data on patients with stage pT1-3 papillary thyroid cancer, who underwent TT with or without CLND between 1 July 2004 and 30 June 2014 were retrieved from the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery. Drug use was ascertained by cross-linking with the Swedish Prescribed Drug Register. Permanent hypoparathyroidism was defined as treatment with active D vitamin or oral calcium drugs for more than 6 months after surgery. Data were analysed separately for all patients and those who underwent TT + CLND. Univariable and multivariable logistic regression analyses were done, yielding odds ratios (ORs) with 95 per cent confidence intervals.

RESULTS

A total of 722 patients were included in the study. Permanent hypoparathyroidism was more common in the TT + CLND group than the TT group: 30 of 265 patients (6·6 per cent) versus six of 457 (2·3 per cent) (P = 0·011). In multivariable logistic regression analysis, CLND was a risk factor for permanent hypoparathyroidism (OR 3·74, 95 per cent c.i. 1·46 to 9·59, based on use of combined therapy 6 months after surgery). In patients who had TT + CLND, node negativity was associated with a risk of permanent hypoparathyroidism (OR 3·08, 1·31 to 7·25).

CONCLUSION

CLND is an independent risk factor for permanent hypoparathyroidism. Node negativity is associated with a higher risk of permanent hypoparathyroidism.

Impacto del fenómeno de migración de estadio ganglionar en la supervivencia y la recurrencia de pacientes con cáncer papilar de tiroides sometidos a vaciamiento ganglionar profiláctico

Introducción. Dado que un ensayo clínico aleatorio es irrealizable, el rol del vaciamiento ganglionar profiláctico en pacientes con cáncer papilar de tiroides sin comprobación clínica de compromiso ganglionar metastásico (cN0) es controversial. El vaciamiento ganglionar profiláctico acarrea un proceso de reclasificación de pacientes, al hacer evidente la positividad ganglionar micrometastásica antes ignorada, lo que genera una aparente pero falsa mejoría en los desenlaces de los grupos de estadificación, mientras el pronóstico individual y total de la población no cambia, fenómeno conocido como migración de estadio o fenómeno de Will Rogers. Métodos. Se ejecutaron simulaciones de poblaciones con cáncer papilar de tiroides con compromiso ganglionar metastásico clínicamente evidente (cN+) y cN0, para determinar el impacto del fenómeno de migración de estadio en los pacientes sometidos a vaciamiento ganglionar profiláctico. Resultados. Con la simulación de las poblaciones y sus estadios ganglionares, se observa cómo la migración de estadio ganglionar genera una aparente mejoría en los desenlaces de recurrencia loco regional y supervivencia, sin cambiar los desenlaces de la población total ni individuales. Discusión. El fenómeno de migración de estadio es uno de los sesgos más importantes que limitan el uso de grupos históricos de control en ensayos de tratamiento experimental. De acuerdo con nuestros resultados, este fenómeno podría explicar los beneficios observados con el vaciamiento ganglionar profiláctico en algunos de los estudios agregativos publicados hasta el momento, hallazgos que no han sido documentados para el cáncer papilar de tiroides.

Microscopic positive surgical margins in thyroid carcinoma: a proposal for thyroid oncology teams

PURPOSE

In the case of well-differentiated thyroid cancer, the importance of microscopic margin status remains controversial. We discuss the relevance of the effect of microscopic positive surgical margins in the early stages of differentiated thyroid cancer.

METHODS

A comprehensive literature search and review of available evidence in English literature was undertaken.

RESULTS

A previous meta-analysis did not find an association between microscopic positive surgical margins and local recurrence. Heterogeneity of definitions and differences between microscopic surgical margins and extrathyroid extension are discussed. Impact on clinical decision-making is explored.

CONCLUSION

The finding of microscopic positive surgical margins in a patient with a thyroid tumor without intraoperative evidence of macroscopic invasion to adjacent structures, with complete resection made by the surgeon and without pathological report of extrathyroid extension, does not have a worse prognostic effect. We present a classification of surgical margins that may help thyroid oncology teams to tailor further management in patients with thyroid cancer.

Management of the Neck in Well-Differentiated Thyroid Cancer

PURPOSE OF REVIEW

In this narrative review, we discuss the indications for elective and therapeutic neck dissections and the postoperative surveillance and treatment options for recurrent nodal disease in patients with well-differentiated thyroid cancer.

RECENT FINDINGS

Increased availability of advanced imaging modalities has led to an increased detection rate of previously occult nodal disease in thyroid cancer. Nodal metastases are more common in young patients, large primary tumors, specific genotypes, and certain histological types. While clinically evident nodal disease in the lateral neck compartments has a significant oncological impact, particularly in the older age group, microscopic metastases to the central or the lateral neck in well-differentiated thyroid cancer do not significantly affect outcome. As patients with clinically evident nodal disease are associated with worse outcomes, they should be treated surgically in order to reduce rates of regional recurrence and improve survival. The benefit of elective neck dissection remains unverified as the impact of microscopic disease on outcomes is not significant.

Preoperative Prediction of Cervical Lymph Node Metastasis in Papillary Thyroid Carcinoma via Conventional and Contrast-Enhanced Ultrasound

OBJECTIVES

To investigate the independent risk factors for cervical lymph node metastasis (CLNM) in patients with papillary thyroid carcinoma (PTC) and establish a prediction model via conventional ultrasound (US) and contrast-enhanced ultrasound (CEUS).

METHODS

A total of 275 patients with single PTC, who were admitted to our hospital from January 2016 to December 2018, were enrolled in this study. The clinical characteristics and features of the tumor on conventional US and CEUS were retrospectively analyzed. A binary logistic regression model was established, and the diagnostic efficacy of conventional US and CEUS was compared.

RESULTS

The binary logistic regression analysis showed that age younger than 38 years, size of 10.0 mm or greater, solid composition, peak of the nodule interior of 28.3750 or greater, and area under the curve (AUC) of the peripheral ring of less than 3.2500 were independent risk factors of CLNM (P < .05, for all). Prediction model: Logit (p) = -4.135 + 1.040 (age) + 1.920 (size) + 1.769 (composition) + 1.230 (peak of nodule interior) + 0.812 (AUC of peripheral ring). The model positively predicted CLNM at a value of L > -0.199. The AUC, sensitivity, and negative predictive value of the receiver operating characteristic curve for the model were 0.727, 71.7%, and 75.2%, respectively, which were significantly higher than those of conventional US (Z = -2.403; P = .016; Z = -5.330; P < .001; and Z = -2.390; P = .017). The specificity of the model was 73.7%, which was lower than that of conventional US (Z = 3.508; P < .001).

CONCLUSIONS

The preoperative prediction model established via conventional US and CEUS may be helpful to evaluate CLNM in patients with PTC and determine the appropriate treatment options.

A miRNA-clinicopathological nomogram for the prediction of central lymph node metastasis in papillary thyroid carcinoma-analysis from TCGA database

It is of significance to evaluate central lymph node status in patients with papillary thyroid carcinoma (PTC), because it can decrease postoperative complications resulting from unnecessary prophylactic central lymph node dissection (CLND). Due to the low sensitivity and specificity of neck ultrasonography in the evaluation of central lymph node metastasis (CLNM), it is urgently required to find alternative biomarkers to predict CLNM in PTC patients, which is the main purpose of this study.RNA-sequencing datasets and clinical data of 506 patients with thyroid carcinoma from the Cancer Genome Atlas (TCGA) database were downloaded and analyzed to identify differentially expressed miRNAs (DEMs), which can independently predict CLNM in PTC. A nomogram predictive of CLNM was developed based on clinical characteristics and the identified miRNAs. Receiver operating characteristics curves were drawn to evaluate the predictive performance of the nomogram. Bioinformatics analyses, including target genes identification, functional enrichment analysis, and protein-protein interaction network, were performed to explore the potential roles of the identified DEMs related to CLNM in PTC.A total of 316 PTC patients were included to identify DEMs. Two hundred thirty-seven (75%) PTC patients were randomly selected from the 316 patients as a training set, while the remaining 79 (25%) patients were regarded as a testing set for validation. Two DEMs, miRNA-146b-3p (HR: 1.327, 95% CI = 1.135-1.551, P = .000) and miRNA-363-3p (HR: 0.714, 95% CI = 0.528-0.966, P = .029), were significantly associated with CLNM. A risk score based on these 2 DEMs and calculating from multivariate logistic regression analysis, was significantly lower in N0 group over N1a group in both training (N0 vs N1a: 2.04 ± 1.01 vs 2.73 ± 0.61, P = .000) and testing (N0 vs N1a: 2.20 ± 0.93 vs 2.79 ± 0.68, P = .003) sets. The nomogram including risk score, age, and extrathyroidal extension (ETE) was constructed in the training set and was then validated in the testing set, which showed better prediction value than the other three predictors (risk score, age, and ETE) in terms of CLNM identification. Bioinformatics analyses revealed that 5 hub genes, SLC6A1, SYT1, COL19A1, RIMS2, and COL1A2, might involve in pathways including extracellular matrix organization, ion transmembrane transporter activity, axon guidance, and ABC transporters.On the basis of this study, the nomogram including risk score, age, and ETE showed good prediction of CLNM in PTC, which has a potential to facilitate individualized decision for surgical plans.

Prophylactic lymph node dissection in clinically N0 differentiated thyroid carcinoma: example of personalized treatment

Considering the 'differentiated thyroid carcinoma (DTC) epidemic', the indolent nature of DTC imposes a treatment paradigm shift toward elimination of recurrence. Lymph node metastases in cervical compartments, encountered in 20-90% of DTC, are the main culprit of recurrent disease, affecting 5-30% of patients. Personalized risk-stratified cervical prophylactic lymph node dissection (PLND) at initial thyroidectomy in DTC with no clinical, sonographic or intraoperative evidence of lymph node metastases (clinically N0) has been advocated, though not unanimously. The present review dissects the controversy over PLND. Weighing the benefit yielded from PLND up against the PLND-related morbidity is so far hampered by the inconsistent profit yielded by PLND and the challenging patient selection. Advances in tailoring PLND are anticipated to empower optimal patient care.

Prophylactic Central Lymph Node Dissection Improves Disease-Free Survival in Patients with Intermediate and High Risk Differentiated Thyroid Carcinoma: A Retrospective Analysis on 399 Patients

The role of prophylactic central lymph node dissection (pCLND) in the treatment of differentiated thyroid cancer (DTC) is controversial and still a matter of debate. The primary outcome of our study was to assess whether pCLND is effective in reducing the incidence of recurrent disease, and the secondary goal was to estimate the incidence of postoperative complications in patients who underwent pCLND and to evaluate the prognostic value of occult node metastases. In this retrospective study, we included patients with preoperative diagnosis of DTC and clinically uninvolved lymph nodes (cN0). The patients were divided into two groups, depending on the surgical approach: total thyroidectomy alone (TT group) or total thyroidectomy and pCLND (pCLND group). Three hundred and ninety-nine patients were included in this study, 320 (80.2%) in the TT group and 79 (19.8%) in the pCLND group. There were no significant differences in morbidity among the two groups. Histopathological evaluation demonstrated a similar distribution of aggressive features, especially regarding multicentricity, extrathyroidal extension, and angioinvasivity between the two groups. Occult lymph node metastases were found in 20 (25.3%) patients in the pCLND group. Prophylactic CLND was effective in improving disease-free survival in patients with intermediate and high risk of disease recurrence (p = 0.0392); occult lymph node metastases resulted as a significant negative prognostic factor (p < 0.001).

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.

The Effect of Prophylactic Central Neck Dissection During Hemithyroidectomy on Locoregional Recurrence in Patients With Papillary Thyroid Carcinoma: A Meta-Analysis

Objectives.

Hemithyroidectomy is commonly performed in patients with low- to intermediate-risk papillary thyroid carcinoma. The purpose of this meta-analysis was to evaluate the effect of prophylactic central neck dissection on locoregional recurrence in patients undergoing hemithyroidectomy.

Methods.

A meta-analysis was performed of full-text publications published in English retrieved from the Embase database.

Results.

The rate of regional recurrence in the central compartment after hemithyroidectomy, with or without prophylactic central neck dissection, was 0.17% and 1.78%, respectively. This difference was statistically significant. Recurrence in the lateral compartment or contralateral thyroid was not affected by prophylactic central neck dissection; the overall rate of recurrence was 1.3% and 5.4%, respectively.

Conclusion.

Prophylactic central neck dissection significantly reduced the risk of recurrence in the central compartment in patients undergoing hemithyroidectomy.

Effect of prophylactic central neck dissection on the surgical outcomes in papillary thyroid cancer: experience in a single center

PURPOSE

Morbidity due to papillary thyroid carcinoma (PTC) is increased mostly due to lymph node (LN) metastases, which lead to reoperations and complications associated with these operations. The aim is to compare the outcomes of PTC having total thyroidectomy and prophylactic central lymph node dissection (TT + PCND) with patients having total thyroidectomy (TT) alone.

METHODS

This study is a retrospective cohort analysis of 358 PTC patients that were operated by a single surgeon in a single center. Data about the patients were extracted from the medical records.

RESULTS

Of the patient cohort, 258 patients had TT + PCND (42.5 ± 11.3 years) and 100 patients (41.2 ± 11.9 years) had only TT. Total number of LN extracted in the TT + PCND group was 8.1 ± 6.9. The mean number of metastatic LN were 2.2 ± 1.9. Percentage of patients that had RAI were less in the TT + PCND group compared to the TT group. Seven patients (2.7%) in the TT + PCND group and 19 (19.0%) in TT group had recurrent disease (p < 0.0001). Of the complications, only transient hypoparathyroidism was increased in TT + PCND group compared to TT group (26.7% vs 10%, p < 0.0001).

CONCLUSION

TT + PCND performed by an experienced surgeon seems to decrease the number of LN recurrences, and the need for reoperations.

Impact of BMI on Complications and Satisfaction in Patients With Papillary Thyroid Cancer and Lateral Neck Metastasis

BACKGROUND

This study investigates the effect of body mass index (BMI) on complications and satisfaction in patients who underwent thyroidectomy and lateral neck dissection.

METHODS

We retrospectively reviewed 386 patients with papillary thyroid cancer who underwent total thyroidectomy and lateral neck dissection between January 2013 and December 2016. We compared variables including population characteristics, subjective satisfaction, and complications in nonobese (BMI < 28.0 kg/m²) and obese (BMI ≥ 28.0 kg/m²) patients.

RESULTS

Obesity was associated with an increased risk of postoperative hemorrhage (POH) (P = .014), accessory nerve injury (P < .001), operative time (P < .001) and infection (P = .013). However, obese patients had higher subjective satisfaction and Vancouver Scar Scale (VSS) scores (P < .05).

CONCLUSIONS

Obesity was associated with increased risk of POH, injury of the SAN, and infection. Interestingly, we found that obese patients had higher subjective satisfaction and VSS scores.

The role of prophylactic central compartment lymph node dissection in elderly patients with differentiated thyroid cancer: a multicentric study

BACKGROUND

Prophylactic central neck lymph-nodes dissection is still a topic of major debate in Literature. There is a lack of randomized controlled trials proving advantages in its application in terms of overall survival and local recurrence. Due to the recent rapid increase of elderly population, differentiated tumor carcinoma diagnosis increased in patients over 65 years old. The aim of this study was to compare recurrence rate, complications rate and histological features of tumors in elderly population.

METHODS

A retrospective study was carried out collecting data from 371 patients with differentiated thyroid cancer without clinical evidence of lymph-nodes involvement in three Italian referral centers from 2005 to 2015. All patients were aged ≥ 65 years and were divided in two groups based on the performed surgery (total thyroidectomy alone or associated with central lymph-nodes dissection). Moreover, patients were stratified according to the age between 65 and 74 years old and over 75 years old.

RESULTS

Total thyroidectomy alone was performed in 184 patients (group A) and total thyroidectomy with prophylactic central neck dissection was performed in 187 cases (group B). There was a statistically significant difference in complications between the groups in terms of neck hematoma (0.5% group A vs 3.7% group B), temporary hypoparathyroidism (11.4% group A vs 21.4% group B), and temporary unilateral recurrent nerve injury (1.5% group A vs 6.4% group B). Lymph nodes recurrence rate was 9.2% in group A and 8.5% in group B, with no statistically significant difference. There was a statistically significant difference in patients over 75 years old in terms of temporary hypoparathyroidism (24% group A vs 11% group B), permanent hypoparathyroidism (2,7% group A vs 0,3% group B) and recurrent nerve injury (9,5% group A vs 2% group B).

CONCLUSIONS

The role of prophylactic central neck dissection is still controversial, especially in elderly patients, and an aggressive surgical approach should be carefully evaluated. The Authors reported a similar low recurrence rate between total thyroidectomy and total thyroidectomy associated with prophylactic central neck dissection, with increased postoperative complications in the lymphadenectomy group and in patients over 75 years old, advocating a tailored surgical approach in elderly population.

Robotic transoral thyroidectomy: Total thyroidectomy and ipsilateral central neck dissection with da Vinci Xi Surgical System

BACKGROUND

Transoral approach for thyroidectomy draws attention recently among the thyroid surgeons, with the merits of cosmetic outcomes and minimal flap dissection. The aim of this study is to demonstrate the details and the steps of transoral robotic thyroidectomy.

METHODS

We made three incisions in the gingival-buccal sulcus for three 8-mm intraoral ports: one inverted U-shaped 1-cm midline incision approximately 2 cm above the frenulum, and two 0.5-cm lateral incisions near the commissure of lips. An additional 8-mm axilla port was inserted for countertraction and later drain insertion.

RESULTS

Right thyroid lobectomy, ipsilateral central neck dissection, and left thyroid lobectomy were performed with preserving recurrent laryngeal nerves and parathyroid glands. There was no development of transient or permanent hypoparathyroidism, vocal cord palsy, postoperative bleeding, or surgical site infection.

CONCLUSION

Transoral robotic total thyroidectomy and ipsilateral central neck dissection using the da Vinci Xi Surgical System are feasible and safe.

Efficacy of Central Neck Dissection for Clinically Node-Negative Papillary Thyroid Carcinoma: Propensity Scoring Matching

Objectives: The utility of prophylactic central neck dissection (pCND) for papillary thyroid carcinoma (PTC) is still controversial. Although the procedure may reduce locoregional recurrence, it is associated with a high rate of postoperative complications. The aim of this study was to evaluate the role of pCND in patients with PTC. Materials and Methods: From January 1995 to April 2011, the records of 477 patients who underwent total thyroidectomy with or without pCND for clinically node-negative PTC measuring < 4 cm were retrospectively reviewed. Of these, 341 patients had undergone pCND with total thyroidectomy and 136 patients did not undergo pCND. The clinicopathologic characteristics, surgical outcomes, complications, recurrence, and survival were analyzed using propensity score matching, using age, sex, tumor size, extrathyroidal extension, and radioactive iodine ablation as covariates to minimize selection bias. Results: At baseline, there was no significant difference in sex, age, and multiplicity and bilaterality of the cancer between the two groups. However, extrathyroidal extension was more common and tumor size larger in patients who underwent pCND. For the propensity score-matched analysis, two matched groups, each comprising 135 patients, were generated. After propensity score matching, the significant differences observed at baseline between the two groups disappeared. The postoperative complication rate did not differ between the two groups. Recurrence occurred in 4 patients (2.96%) who had undergone pCND and in 2 patients (1.48%) who did not undergo pCND (P = 0.684). The recurrence-free survival curves did not differ between the two groups. Conclusion: The efficacy of pCND in total thyroidectomy for clinically node-negative PTC is limited, and pCND is not recommended for these patients.

Determine the Optimal Extent of Thyroidectomy and Lymphadenectomy for Patients With Papillary Thyroid Microcarcinoma

Background: The optimal extent of surgery, including lymph node dissection, remains controversial in papillary thyroid microcarcinoma (PTMC). Determining risk factors of central lymph node metastasis (CLNM) and recurrence-free survival (RFS) may help surgeons determine individualized surgery. Methods: A total of 353 patients with PTMC were retrospectively analyzed, including 263 with overt PTMC and 90 with incidental PTMC. The recurrence rates between different extents of thyroidectomy were compared. The relationship between CLNM and clinicopathologic factors was analyzed. The Cox regression model was used to determine the risk factors for RFS. Results: Lobectomy/total thyroidectomy (TT) with central neck dissection (CND) was performed in 263 overt PTMC patients, and lobectomy/partial thyroidectomy was performed in 90 incidental PTMC patients. In 263 overt PTMC patients, 93 (26.3%) had CLNM only and 13 (3.7%) had both CLNM and lateral lymph node metastases (LLNM). Multifocal PTMC patients who underwent lobectomy had a higher rate of thyroid bed and lymph node recurrence than patients who underwent TT (P < 0.05). Independent predictors for CLNM were age <45 years, tumor size >5 mm and presence of extrathyroidal extension (ETE). Tumor size >5 mm, multifocality, presence of ETE, presence of CLNM, and presence of LLNM were the significant factors related to the RFS. Conclusion: Fine-needle aspiration biopsy is advised to distinguish incidental PTMC from the benign nodules. For multifocal PTMC patients, TT should be performed to reduce recurrence. Routine prophylactic CND can be recommended in PTMC patients with independent risk factors of CLNM. Aggressive surgery and close follow-up are essential for patients with risk factors of RFS.

Parathyroid gland management using optical technologies during thyroidectomy or parathyroidectomy: A systematic review

New optical technologies enhancing localization or assessing viability of parathyroid glands (PG) during endocrine surgery have been reported in clinical studies. These technologies could become complementary to the surgeon's eyes and may improve surgical outcomes in thyroidectomy and parathyroidectomy. Here, we conducted a systematic review focusing on PG identification and functional assessment using optical methods to enhance surgery. A systematic literature review was performed using MEDLINE and Embase database. Two authors selected studies and extracted data; qualitative analysis was performed to summarize the characteristics of reported optical tools for thyroidectomy or parathyroidectomy. Identification and vascularisation of PG during surgery were evaluated. Clinical and biochemical outcomes were appraised when reported. Studies relating to parathyroidectomy or thyroidectomy combined with autofluorescence, fluorescent methylene blue, 5-aminolevulinic acid, indocyanine green (ICG), optical coherence tomography, laser speckle contrast imaging, dynamic optical contrast imaging and Raman spectroscopy were identified with MEDLINE and Embase. We included a total of 47 relevant articles with a total of 1615 patients enrolled. Each optical technique is described and appreciated related to its surgical purpose. Autofluorescence and ICG imaging of PG are the most widely reported optical technologies for identification and assessment of vascularisation of PG. Results are mainly based on observational studies and argue for the feasibility of both techniques in endocrine surgery but prospective randomized studies have not been performed. In vivo applications are still limited for the other methods and further investigations correlating these techniques with post-operative parathormone measurements are still needed before considering these technologies in clinical practice.

The learning curve of endoscopic thyroid surgery for papillary thyroid microcarcinoma: CUSUM analysis of a single surgeon's experience

Background

With the development of surgical technics, endoscopic thyroid surgery has been gradually accepted and utilized in thyroid disease treatment, including thyroid carcinoma. This study aimed to evaluate the learning curve for endoscopic hemithyroidectomy (EHT) with ipsilateral central neck dissection (CND) and investigate how many cases must be performed before a surgeon becomes competent and proficient in this approach.

Methods

Ninety-nine consecutive patients who underwent EHT with ipsilateral CND for papillary thyroid microcarcinoma by a single surgeon between June 2015 and October 2017 were analyzed. Multidimensional cumulative summation (CUSUM) analysis was performed to evaluate the learning curve.

Results

The CUSUM graph showed the learning curve ascended in the first 31 cases and declined in the following cases. The number of lymph nodes removed in phase 2 (the following 68 cases) was significantly more than that in phase 1 (the first 31 cases) (5.06 ± 1.44 vs. 4.19 ± 1.51, P = 0.001). The operation time in phase 2 was shorter than that in phase 1 (123.38 ± 12.71 min vs. 132.90 ± 13.95 min, P = 0.008) and the rate of accidental removal of parathyroid gland decreased from 35.5% in phase 1 to 16.2% in phase 2 (P = 0.040). There was a declining trend but no significant difference in the rate of postoperative complications (9.7% in phase 2 vs. 4.4% in phase 1, P = 0.309).

Conclusion

EHT with ipsilateral CND performed by surgeons was mastered after 31 cases, and the safety and feasibility of this endoscopic approach can also be demonstrated.

Central Lymph Node Status has Significant Prognostic Value in the Clinically Node-Negative Tall-Cell Variant of Papillary Thyroid Cancer Regardless of T-Staging and Radioactive Iodine Administration: First Evidence From a Population-Based Study

BACKGROUND

The prognostic value of central lymph node (CLN) status in papillary thyroid cancer (PTC) remains controversial. This study aimed to provide the first evidence on this issue for the aggressive tall-cell variant (TCV) subtype.

METHODS

The study identified TCV patients from the Surveillance, Epidemiology, and End Results database. The Kaplan-Meier method, log-rank test, and multivariate Cox regression models were used for analysis.

RESULTS

Of the 744 patients included, 404 were recorded as N0, which were pathologically or only clinically confirmed. Overall survival (OS) and cancer-specific survival (CSS) did not differ significantly between the N0 and pN1a patients (p > 0.05). To investigate the reason, the N0 patients were subdivided according to the number of examined lymph nodes (ELN). The patients with a N0 diagnosis confirmed by two or more ELNs (N0-e2+) showed significantly better outcomes than the pN1a patients and their N0 counterparts without ELN (N0-e0) (p < 0.05), whereas the N0-e0 and pN1a groups demonstrated comparable outcomes in both the log-rank and multivariate analyses (p > 0.05). Moreover, the subgroup analyses showed that even among the patients with early T-staging (T1-T2) or receipt of radioactive iodine (RAI) therapy, the N0-e0 patients still demonstrated compromised OS compared with the N0-e2+ group (p < 0.05).

CONCLUSION

The cN0 patients without ELN (N0-e0) had outcomes similar to those of the pN1a patients, but showed a poorer OS than the N0-e2+ group regardless of T-staging and RAI administration, suggesting that occult CLN metastases might act as a negative prognosticator in cN0 TCV. Therefore, prophylactic central neck dissection might be considered for biopsy-proven cN0 TCV patients. Prospective studies are expected to further validate our conclusions.