Number of lymph nodes removed during modified radical neck dissection for papillary thyroid cancer does not influence lateral neck recurrence

Papillary thyroid cancer: the value of bilateral diagnostic lymphadenectomy

Purpose

Papillary thyroid carcinoma (PTC) spreads early to lymph nodes (LN). However, prophylactic central (CND) and lateral neck dissection (LND) is controversially discussed in patients with clinically negative nodes (cN0). The preoperative prediction of LN metastasis is desirable as re-operation is associated with higher morbidity and poor prognosis. The study aims to analyse possible benefits of a systemic bilateral diagnostic lateral lymphadenectomy (DLL) for intraoperative LN staging.

Methods

Preoperative prediction of LN metastasis by conventional ultrasound (US) was correlated with the results of DLL and intra-/postoperative complications in 118 consecutive patients with PTC (cN0) undergoing initial thyroidectomy and bilateral CND and DLL.

Results

Lateral LNs (pN1b) were positive in 43/118 (36.4%) patients, including skip lesions (n = 6; 14.0%). Preoperative US and intraoperative DLL suspected lateral LN metastasis in 19/236 (TP: 8.1%) and 54/236 (TP: 22.9%) sides at risk, which were confirmed by histology. Sixty-seven out of 236 (FN: 28.4%) and 32/236 (FN: 13.6%) sides at risk with negative preoperative US and intraoperative DLL lateral LN metastasis were documented. DLL was significantly superior compared to US regarding sensitivity (62.8% vs 22.1%; p < 0.002), positive predictive value (100% vs 76.0%), negative predictive value (82.4% vs 68.2%), and accuracy (86.4% vs 69.1%), but not specificity (100% vs 96.0%; p = 0.039). DLL-related complications (haematoma) occurred in 6/236 [2.5%] sides at risk, including chylous fistula in 2/118 [1.7%] patients.

Conclusion

DLL can be recommended for LN staging during initial surgery in patients with PTC to detect occult lateral LN metastasis not suspected by US in order to plan lateral LN dissection.

Neck recurrence in papillary thyroid carcinoma

INTRODUCTION

papillary thyroid carcinoma is a tumor with good prognosis. However, some patients treated present neck recurrence.

OBJECTIVE

to evaluate the risk factors for neck recurrence.

METHODS

a retrospective study enrolled 89 patients (68 women and 21 men) diagnosed with papillary carcinoma who underwent total thyroidectomy. In 21 patients, neck dissection was performed and 62 patients underwent radioiodinetherapy. Twelve patients relapsed with metastasis in this period with an average of 3.6 years.

RESULTS

out of 89 patients, 76.4% were female. Relapse occurred in nine (13.23%) women and three (14.28%) men. The average age of the patients was 44 years in the control group and in patients with relapsed. Eighteen patients (23.37%) in the control group and eight (64.28%) who relapsed had positive lymph nodes at initial diagnosis. The tumor size was significantly larger in the group of patients with cervical recurrence (3.3cm vs. 1.6cm - p=0.008, Student t test), whereas the presence of metastatic lymph nodes at the moment of the first operation was also significant (p=0.004 -Fisher exact test). The tumor size was an independent risk factor for recurrence at the multivariate anaylsis (OR=2.4, IC95%:1.3-4.6 - p=0,007, logistic regression).

CONCLUSION

there is an increase in the risk of lymph node recurrence during the follow up of 2.4 folds for each increase of 1cm in the longer nodule diameter.

The influence of cervical lymph node number of neck dissection on the prognosis of the early oral cancer patients

Background/purpose

The status of neck lymph nodes (LNs) plays an important role in survival of oral cavity cancer. Early stage oral cancer patients are still at a risk for locoregional metastasis. We aimed to determine the number of LNs that needs to be retrieved for adequate diagnosis and treatment of the neck tumor.

Materials and methods

We conducted a retrospective study of 126 oral cavity cancer patients who underwent wide excision and 3 types of neck dissection at MacKay Memorial Hospital, Taiwan. Data from the operative and pathology reports were collected and analyzed. The significant difference was defined as p < 0.05 by SPSS 21.0 and Prizm 5 software.

Results

There was a significant difference between the total retrieved LNs and tumor differentiation and nerve invasion on multivariate analysis. Receiveroperating characteristic (ROC) curve showed significant difference in the total number of neck LNs between the survival and expired groups. The cut-off point was 36.5 nodes. However, there was no difference in survival between supraomohyoid and modified radical neck dissection.

Conclusion

Retrieval of adequate LNs can improve oral cancer survival rates. If total number of neck nodes examined is <37 with poor differentiation and/or nerve invasion, early oral cancer patients with neck dissection have a lower survival rate and are candidates for adjuvant therapy.

Patterns of Lymph Node Metastasis in Differentiated Thyroid Cancer; Clinical Implications with Particular Emphasis on the Emerging Role of Compartment-Oriented Lymph Node Dissection

Recent advances in modern imaging allow an accurate identification of involved or suspicious lymph nodes within the nodal compartments of the neck. Careful ultrasonographic lymphatic mapping of the neck by an experienced radiologist allows a targeted, compartment-oriented (or selective) lymph node dissection to be performed instead of the more extensive modified radical lymph node dissection. Compartment-oriented lymph node dissection necessitates the close cooperation of an experienced radiologist with a particular interest in thyroid and neck ultrasonography. There is emerging evidence that this more conservative strategy allows local control of the disease while at the same time morbidity is minimized and a better cosmetic result is achieved. Further investigation is needed to establish the precise role of this interesting surgical approach.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Persistent and recurrent disease in patients with papillary thyroid carcinoma with clinically apparent (cN1), but not extensive, lymph node involvement and without other factors for poor prognosis

OBJECTIVE

Lymph node metastases (LNM) are frequent in patients with papillary thyroid cancer (PTC). The risk of persistent disease (PD) and tumor recurrence (TR) is increased when factors for poor prognosis other than LNM exist, when LNM are numerous, large, detected by preoperative ultrasonography (US), or exhibit extranodal extension. This study evaluated the risk of PD and TR in patients with LNM not exhibiting these characteristics.

SUBJECTS AND METHODS

Eighty-six patients with 5 or fewer LNM detected during intraoperative inspection, but not by preoperative US, who had no other factors for poor prognosis [tumors > 4 cm, extensive extrathyroid invasion, vascular invasion, aggressive histological subtype, distant metastases, incomplete tumor resection], were studied. All patients underwent total thyroidectomy followed by radioiodine ablation. PD was defined as metastases on initial post-therapy whole-body scans (RxWBS) or detected by imaging methods up to 12 months after ablation. TR was defined as structural disease diagnosed more than one year after ablation in patients without PD.

RESULTS

PD was diagnosed in 3/86 patients (3.5%). TR was observed in 2/83 patients (2.5%) after 62 months of follow-up. There was no case of death due to the disease. A correlation was observed between pre-ablation Tg and PD or TR [1/48 (2%) with Tg ≤ 2 ng/mL versus 2/22 (9%) with Tg > 2 ≤ 10 ng/mL versus 2/7 (28.5%) with Tg ≥ 10 ng/ml)]. It is noteworthy that 38 patients had up to 3 positive LN and pre-ablation Tg ≤ 2 ng/ml, and none of them had PD or TR.

CONCLUSIONS

The frequency of PD and TR was low in patients with PTC with 5 or fewer LNM and without other factors for poor prognosis. Low postoperative stimulated Tg was predictive of the absence of PD and TR in these patients.

Risk factors for recurrence in patients with papillary thyroid carcinoma undergoing modified radical neck dissection

BACKGROUND

This study evaluated the impact of lymph node-related factors on the risk of and site of recurrence in patients who had papillary thyroid carcinoma with lymph node metastasis in the lateral compartment (classified as pN1b).

METHODS

Patients underwent total thyroidectomy with unilateral modified radical neck dissection for classical papillary thyroid carcinoma. Risk factors for recurrence were evaluated according to the pattern of recurrence.

RESULTS

A total of 324 patients were included in the study. The median follow-up was 63 (range 14-181) months. Recurrence was detected in 47 patients (14·5 per cent). In the multivariable analysis, a maximum diameter of metastatic lymph nodes larger than 2·0 cm (hazard ratio (HR) 1·15, 95 per cent c.i. 1·06 to 1·25; P = 0·033) and a central compartment metastatic lymph node ratio of more than 0·42 (HR 3·35, 1·65 to 6·79; P < 0·001) were identified as independent risk factors for locoregional recurrence. Age 45 years or older (HR 5·69, 1·24 to 26·12; P = 0·025) and extranodal extension of metastasis (HR 12·71, 1·64 to 98·25; P = 0·015) were risk factors for distant metastasis. In subgroup analysis of locoregional recurrence, several lymph node-related factors affected the risk of recurrence according to the specific site of metastasis.

CONCLUSION

Lymph node-related factors are of importance for the risk of recurrence in patients with classical papillary thyroid carcinoma classified as pN1b.

Recurrence of papillary thyroid carcinoma with lateral cervical node metastases: Predictive factors and operative management

BACKGROUND

Lateral neck lymph node (LN) metastases (N1b) have been identified as independent risk factors of recurrence in patients with papillary thyroid carcinoma (PTC).

OBJECTIVE

This study aimed to determine the predictive factors of recurrence in N1b PTC patients and to clarify the postoperative event patterns.

METHODS

All patients who underwent operation for N1b PTC between 1978 and 2012 were reviewed. The median follow-up period was 6.5 years.

RESULTS

In total, 344 N1b patients were included. Twenty-four patients (7%) were lost to long-term follow-up. Among the remaining 320 patients, the mean (± SD) follow-up time was 8.9 ± 8.8 years (median, 6.5; range, 2-36.4). Eighty-two patients (26%) presented with lymph node recurrence (LR). Multivariate analyses showed that LN metastases with extracapsular extension and the LN ratio (ratio between the number of N1 and number of resected LN) in the lateral compartment were independent predictors of recurrent disease. The median time to reoperation was 19 months (range, 3-173), with 79% of reoperations occurring within 2 years after the initial thyroidectomy. Reoperations for LR (75 patients) were performed in 76% of the patients with a focused minimal access approach or selective LN dissection. After curative reoperative surgery for recurrence, complications occurred in 6 patients (8%), including a 1% permanent complication rate.

CONCLUSION

Extranodal extension of LN metastases and the LN ratio in the lateral compartment are prognostic factors for recurrence. In most cases, reoperation for LR can be performed with a focused minimal access approach, with a low morbidity rate.

Ultrasonographic findings relating to lymph node metastasis in single micropapillary thyroid cancer

Background

In thyroid cancer, preoperative ultrasonography (US) is performed to detect the primary tumor and lymph node metastasis (LNM), which are related to prognosis. This study examined the relationships between specific US findings and LNM in micropapillary thyroid cancer (MPTC).

Methods

Data on 220 patients with solitary MPTC who underwent total thyroidectomy and neck dissection between 2008 and 2009 were evaluated retrospectively. We classified the US findings according to the nature, shape, echogenicity, extent, margin, and calcification of the primary tumor and evaluated the correlations between these findings and those of LNM.

Results

Hypoechogenicity (odds ratio = 2.331, P = 0.025) and marked hypoechogenicity (OR = 4.032, P = 0.016) of MPTC were risk factors for central LNM. All of the patients with lateral cervical LNM showed hypoechogenicity or marked hypoechogenicity. Hypoechogenicity (odds ratio = 5.349, P = 0.047) and other types of calcification (odds ratio = 2.495, P = 0.010) were significant risk factors for lateral cervical LNM.

Conclusions

Specific sonographic findings (hypoechogenicity or marked hypoechogenicity, and calcification) suggest LNM.

Risk factors for recurrence after therapeutic lateral neck dissection for primary papillary thyroid cancer

BACKGROUND

Lateral lymph node metastasis is an important prognostic factor and is predictive of tumor recurrence and cause-specific survival in patients with papillary thyroid cancer (PTC). However, the factors predicting recurrence and clinical outcomes after therapeutic lateral neck dissection are not well established. The aims of this study were to evaluate the incidence, pattern, and factors predictive of PTC recurrence after therapeutic lateral neck dissection.

MATERIALS AND METHODS

The records of 126 consecutive patients who underwent total thyroidectomy with therapeutic lateral neck dissection for primary PTC at the National Cancer Center were retrospectively reviewed. The factors predictive of recurrence were determined using both univariate and multivariate analyses considering several clinicopathologic variables.

RESULTS

The median follow-up period was 61.2 months, during which 22 patients (17.5 %) experienced recurrence with 1 death (0.8 %) due to disease. Locoregional recurrence and distant metastasis were found in 20 cases (15.9 %) and 2 cases (1.6 %), respectively. Male gender, aggressive histology, number of lymph node metastases, initial level of T4-off Tg per ng/mL, and ATA risk categories (high risk) were independent risk factors for recurrence. Of note, initial T4-off Tg levels greater than 4.2 ng/mL showed highest sensitivity and specificity in predicting recurrence.

CONCLUSIONS

These results provide useful information regarding the clinical outcomes after therapeutic lateral neck dissection for primary PTC and can be used to identify at-risk patients who need aggressive treatment and intensive surveillance for postoperative recurrence.