CARCINOMA OF THE THYROID

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

Background

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

Methods

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

Results

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

Conclusions

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

Experience with the modified hockey stick incision for block dissection of neck

BACKGROUND

The modified hockey stick incision was originally described by Lahey in 1940. This allows elevation of a superiorly based cervical skin flap, with additional exposure of the parotid as necessary.

METHODS

The longitudinal portion of the incision runs from the mastoid process downward, behind the anterior border of the trapezius muscle, and curves gently at the junction of the lateral one-third and medial two-thirds of the clavicle. The transverse component extends medially, approximately 2 cm below the clavicle. When parotidectomy is required, incision is extended in front of the ear and a forward cut is made for additional exposure.

RESULTS

We present our experience with a series of 16 patients, undergoing a total of 17 neck dissections for various pathologies. The majority (11 patients) received postoperative radiotherapy. There were two episodes of minor skin necrosis which were not related to radiotherapy, but to patient co-morbidity, and settled with conservative management. All patients had a satisfactory cosmetic result.

CONCLUSION

We find the modified hockey stick incision to be cosmetically superior and provide excellent exposure of the neck, with protection of the carotid vessels.

Metastatic minimally invasive (encapsulated) follicular and Hurthle cell thyroid carcinoma: a study of 34 patients

Most studies that have examined minimally invasive, encapsulated, follicular carcinoma (FC) or Hurthle cell carcinomas (HCs) have contained only a few metastatic neoplasms. We studied 34 patients with a single, minimally invasive, metastatic FC or HC and compared them with 38 patients with similar, nonmetastatic FCs or HCs. The numbers of incomplete capsular penetration (neoplasm into but not through the capsule), complete capsular penetration (neoplasm through the capsule), and vascular invasion foci were quantified. The median number (three), range, and distribution of complete capsular penetration and vascular invasion foci were similar in the nonmetastatic and metastatic carcinomas. All of the metastatic FCs and HCs had at least one vascular invasion or complete capsular penetration focus. Sixty-two percent of the metastatic carcinomas had two to four complete capsular penetration foci, and 60% had two to four vascular invasion foci. Two metastatic neoplasms had incomplete capsular penetration but had one and two vascular invasion foci, respectively. One tumor had no vascular invasion but had four complete capsular penetration foci. No metastatic neoplasms had incomplete capsular penetration only. There were no differences in the number of vascular invasion or complete capsular penetration foci between metastatic and nonmetastatic FCs and HCs and between metastatic FCs and HCs. Most metastatic neoplasms had vascular space invasion and complete capsular penetration. The number of complete capsular penetration or vascular invasion foci was not associated with the initial site of metastasis or the interval between the surgery and the metastasis.

The relationship between the nodular goitre and carcinoma of the thyroid

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The unilateral hockey-stick incision for neck dissection in oral carcinoma. Technical note

In 42 patients, a hockey-stick incision was used as standard approach in unilateral neck dissection. This approach permits a good overview of all structures in the neck and allows en bloc resection with intraoral tumor removal. The incision does not interfere with simultaneous reconstruction by pedicled or free flaps, and results in a scar which is barely visible and easily covered.

Frequency and degree of aneuploidy in benign and malignant thyroid neoplasms

The frequency and degree of aneuploidy in 44 benign and 124 malignant thyroid neoplasms were analyzed by DNA flow cytometry. Single aneuploid cell populations were found in 72% of the undifferentiated carcinomas, 64% of the follicular carcinomas, 24% of the papillary carcinomas and in 24% of the follicular adenomas. Multiple aneuploid cell populations were detected in 4% of the papillary and in 36% of the follicular carcinomas but not in undifferentiated carcinomas. A low degree of aneuploidy was found in well differentiated papillary carcinomas (mean DNA index of aneuploid populations: DI = 1.17; SD +/- 0.09). Significantly higher values were found for aneuploid moderately differentiated papillary carcinomas (DI = 1.46; SD +/- 0.29), well and moderately differentiated follicular carcinomas (DI = 1.61; SD +/- 0.33 and DI = 1.60; SD +/- 0.30, respectively) and undifferentiated carcinomas (DI = 1.72; SD +/- 0.19). High DNA indices were also found in several follicular adenomas (DI = 1.49; SD +/- 0.22). Comparison of the 10-year survival rates of patients with moderately versus well differentiated papillary carcinoma (79 vs. 98 months, respectively) indicates that loss of differentiation and progression of aneuploidy in this tumour type is associated with more aggressive clinical behaviour. Similarly, the high frequency and degree of aneuploidy in undifferentiated carcinomas is in agreement with the very poor survival rate (0% at 10 years) in this group of patients. However, the occurrence of highly aneuploid adenomas and (near)-diploid undifferentiated carcinomas does not point to a direct causal relationship between DNA-ploidy changes and clinical behaviour of these thyroid tumours.

Scar contracture after neck dissection. Causes, prevention, and treatment

Every effort should be made to employ neck incisions that allow for the accomplishment of surgical extirpative goals and at the same time provide maximal functional and aesthetic rehabilitation. Incisions parallel to the normal skin tension lines best fulfill these criteria. When vertical incisions are used, they should be anteriorly directed so as to cross the skin crease lines at an acute angle rather than a perpendicular angle. Such incisions perpendicular to the normal skin crease lines usually result in the greatest degree of scar contracture. Significant improvement in both major and minor scar contractures can be achieved with conventional Z-plasty technics to redistribute the skin tension. A wide resection of the subcutaneous cicatrix in such cases is imperative for a successful result.

Carcinoma of the thyroid; a re-evaluation

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The early stages of thyroid carcinoma

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Carcinoma of the thyroid gland

Sixty-three cases of cancer of the thyroid gland were studied. In 16 cases the cancer arose in an adenoma-without clinical evidence of carcinoma in any instance.Hoarseness, dyspnea and dysphagia, fixation and hardness, and slow enlargement of the lateral lymph nodes were the most common diagnostic signs and symptoms. The most common avenue of spread is the lymphatic system. In two-thirds of the cases in which metastasis occurred, the cervical nodes were involved. Prognosis is related to the histologic type of the lesion. Of 35 patients observed for five years after treatment, ten had no evidence of disease at the end of that time. Twenty were followed for ten years and four of them apparently were free of cancer. The trend in treatment is toward more extensive surgical dissection. In inoperable cases, irradiation has been used with some benefit.

Carcinoma of the Thyroid

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