The fallacy of the conventional radical neck dissection for papillary carcinoma of the thyroid

Interobserver Variability in the Histopathologic Assessment of Extrathyroidal Extension of Well Differentiated Thyroid Carcinoma Supports the New American Joint Committee on Cancer Eighth Edition Criteria for Tumor Staging

Background: Extrathyroidal extension (ETE) by papillary and follicular thyroid carcinoma can be associated with increased risk of tumor recurrence and mortality. In the seventh edition of its Cancer Staging Manual, the American Joint Committee on Cancer (AJCC) defined minimal ETE as the involvement of skeletal muscle (i.e., strap muscles) or perithyroidal soft tissue. The eighth edition of the AJCC Cancer Staging Manual has changed the criteria so that only grossly evident (macroscopic) ETE involving strap muscles (not microscopic ETE involving perithyroidal soft tissue) affects tumor staging. Summary: Concordance of identifying microscopic ETE (as well as extranodal extension by carcinoma metastatic to lymph nodes) was previously evaluated among 11 expert endocrine pathologists. The overall agreement rate was slight when rendering a diagnosis of ETE. Concordance was highest when pathologists assessed the spatial relationship of carcinoma to skeletal muscle. This article discusses the significance of these findings. It also reviews relevant anatomic and developmental considerations related to the boundaries of the thyroid. Conclusions: The results of the concordance study provide additional rationale supporting stringent criteria for diagnosing ETE, as proposed by the eighth edition of the AJCC Cancer Staging Manual. It is expected that these rigid morphologic criteria will potentially reduce interobserver variability and enhance consistency in the diagnosis and staging of thyroid carcinoma.

Anatomical study of accessory nerve innervation relating to functional neck dissection

PURPOSE

The present study sought to clarify correlations of accessory nerve innervation in the neck region and innervation of the sternocleidomastoid and trapezius muscles with postoperative dysfunction after functional neck dissection by macroscopic observation.

MATERIALS AND METHODS

The materials used in this study were 35 cadavers provided for anatomical practice to the Department of Anatomy, Tokyo Dental College. The accessory nerve was identified at the anterior margin of the trapezius muscle, and its innervation in the posterior triangle of the neck was examined in detail.

RESULTS

The superficial cervical vein vascularizes the anterior margin of the trapezius muscle near an area where the main trunk of the accessory nerve innervates the trapezius muscle. The results showed 3 types of accessory nerve innervation of the sternocleidomastoid muscle: Type A, the not penetrating type; Type B, the partially penetrating type; and Type C, the completely penetrating type. In addition, 5 types of innervation of the trapezius muscle by the main trunk and branches of the accessory nerve were apparent, with the number of branches innervating the muscle ranging from 0 to 4.

CONCLUSIONS

Dysfunction after functional neck dissection can thus be avoided by paying attention to not only the main trunk of the accessory nerve, but also the branches. Moreover, when identifying accessory nerve innervation of the trapezius muscle, the superficial cervical vein may offer a useful surgical landmark.

A study of sternocleidomastoid muscular atrophy after modified neck dissection

To elucidate the conditions of atrophy in the sternocleidomastoid muscle (SCM) after modified neck dissection (MND), we tried to scrutinize the atrophic regions in the SCM and determine the cause of atrophy, by electromyography in 40 patients with SCM atrophy following MND. We also examined the detailed anatomy of the SCM in 40 cadavers. Atrophy was observed in the caudal portion in the SCM in 90% of the patients. Electromyographic examination revealed neurogenic atrophy in 24 patients, ischemic atrophy in 11, and a mixing of both types in 5. The SCM was found to be innervated by the spinal accessory nerve (SAN) and the SCM branch of the cervical nerve. The main artery feeding the cranial half of the SCM was a branch of the occipital artery (Oc) or the external carotid artery (Ex), and the auxiliary artery was a branch of the posterior auricular artery (Ap). The main artery feeding the caudal half of the SCM was a branch of the superior thyroidal artery (St), and the auxiliary artery was a branch of the subclavian artery (Sc). Postoperative SCM atrophy is attributed to damage of the feeding artery in the SCM caudal portion and local damage in the nerve fibers running through the SCM. To prevent this type of atrophy, it is important to carefully handle this muscle itself and protect the nerve fibers running through it, as well as to conserve the SCM branches of the St and Sc.

Cystic metastases of the neck from occult thyroid adenocarcinoma

In 9 of 118 patients with differentiated thyroid carcinomas, a solitary cystic lateral cervical mass simulating a branchial cleft anomaly was the sole presenting sign of the disease. These masses were nodal metastases of occult papillary adenocarcinoma of the thyroid that underwent liquefaction necrosis. Sonographically, the masses presented a complex pattern. Accordingly, it is suggested that, in patients presenting with an asymptomatic solitary lateral cystic cervical mass, the possibility of metastasis from an occult thyroid malignancy should be considered, and consent for definitive surgery should be obtained. The ultrasonic pattern of the cystic mass is of importance in the differentiation of a cavitated lymph node from a branchial cleft cyst.

The clinical outcome of prospective screening for multiple endocrine neoplasia type 2a. An 18-year experience

An important question facing physicians who care for families with multiple endocrine neoplasia type 2a is whether prospective screening to detect early abnormalities of the thyroid, parathyroid, or adrenal glands favorably influences the ultimate course of the disease. An 18-year study of a large family has allowed us to examine the effect of early treatment on the clinical course of the disease. Of 22 patients who underwent thyroidectomy for early C-cell abnormalities, 19 remained free of detectable medullary thyroid carcinoma according to all criteria, at a mean of 11 years after thyroidectomy. None of the 22 patients had evidence of parathyroid disease either at the time of surgery or after a mean follow-up of 10 years. Prospective screening for adrenal medullary abnormalities by means of measurement of 24-hour urinary epinephrine excretion and the ratio of urinary epinephrine to norepinephrine was predictive of pheochromocytoma in 10 of 11 patients (with a false negative result in one patient) but was not useful in diagnosing adrenal medullary hyperplasia. We conclude that regular, prospective screening and early treatment of the manifestations of multiple endocrine neoplasia can prevent metastasis of medullary thyroid carcinoma and the morbidity and mortality caused by pheochromocytoma.

Modified neck dissection in treatment of thyroid cancer: a safe procedure

Differentiated carcinoma of the thyroid metastasizes early and frequently to cervical lymph nodes. Radical neck dissection performed electively or therapeutically results in high cure rates. Modified neck dissection consisting of a single transverse incision, resection of the jugular chain of nodes and those in the posterior triangle of the neck with preservation of the sternomastoid muscle, the spinal accessory nerve and the submandibular salivary gland provides a cosmetic, functional result with minimal morbidity. In a series of 313 neck dissections for thyroid carcinoma, only three patients with papillary or follicular carcinoma, which was resectable, treated by thyroidectomy and modified neck dissection died of disease.

Differentiated thyroid cancer: a stage adapted approach to the treatment of regional lymph node metastases

The controversy in the management of regional lymph nodes in patients with differentiated thyroid cancer is discussed on the basis of a review of the literature. Since no prospective studies have yet compared limited dissections ('node picking') with more extensive dissections [(modified) radical neck dissection], a retrospective analysis was performed using two patient groups in which patients were managed differently with regard to the preoperative diagnosis and treatment of regional lymph node metastases. Only patients with proven lymph node metastases were included in the study. Because of selection methods necessary to create comparable patient groups, only 83 patients could be included in the analysis. There was no difference in survival or recurrence rate in either group, although recurrences occurred less frequently in the explored side of the neck after MRND (3.9% vs. 6.3%). More postoperative morbidity was found in the patients who had been subjected to a more extensive search for and treatment of lymph node metastases. Because of the relatively small number of patients only the difference in occurrence of accessory nerve palsies reached statistical significance (P = 0.05). It is advocated that only in the case of papillary carcinoma with limited lymph node involvement node picking is the procedure of choice. In all other cases a modified radical neck dissection should be standard treatment.

Radical neck dissection

This article discusses how the spread of tumor occurs and reviews surgical treatment, including classic and functional radical neck dissection, as well as complications.

Thyroid carcinoma: criteria in selection of patients for total and subtotal thyroidectomy

Surgical management of patients with thyroid carcinoma continues to be a controversial subject among surgeons throughout the nation. The authors have recently treated patients with differentiated thyroid carcinoma using a selective surgical approach based on criteria classifying patients into high- and low-risk subgroups. Categorization is based on patient age, size and invasiveness of the tumor, and the presence or absence of distant metastatic disease. Women older than 50 and men over the age of 40 were classified as "high-risk" patients. Other criteria qualifying patients for high-risk categorization included lesion size greater than 3 cm and/or the presence of distant metastases. For patients with follicular tumors, histologic evidence of significant vascular invasion also constituted a high-risk criterion. Patients with high-risk criteria are associated with a significantly poorer prognosis. The records of 136 patients treated from 1958 to 1978 were reviewed. The findings and research from the literature suggest that these high-risk patients, when treated by total thyroidectomy, have an overall increased rate of survival when compared with those under-going lesser surgical procedures.

The solitary thyroid nodule: diagnosis and management of malignant disease

While few solitary thyroid nodules are carcinomatous, it is essential to identify and preferentially select those that are for surgery. Clinical, biochemical, serologic, radiographic, scintigraphic, sonographic, biopsy, and even therapeutic evaluation may be necessary to choose those patients with the greatest probability of malignancy. The benefits and limitations of each diagnostic modality are discussed, and the importance of fine-needle aspiration is stressed. After the operative confirmation of malignancy, the prognosis in any given case depends on 1) the histologic type of the neoplasm, 2) its size and extent, 3) the presence of angioinvasiveness, 4) the tendency toward multicentricity of the lesion, 5) the age and sex of the patient, and 6) whether distant metastases are present. These factors influence the extent of surgery required for well-differentiated carcinomas. Meticulous dissection and preservation of the recurrent laryngeal nerves and the parathyroid glands along with their blood supply are important if total thyroidectomy for papillary carcinoma is to be employed with an acceptable operative morbidity to optimize survival. The value of the adjunctive use of thyroid hormone and radioactive iodine is also discussed. Finally, the clinical behaviors and treatments of undifferentiated carcinomas, sarcomas, lymphomas, and neoplasms metastatic to the thyroid gland are reviewed.

Thyroid cancer in Kuwait: review of 117 cases

One hundred and seventeen patients with thyroid cancer were seen at the Radiotherapy and Isotope Centre, Al-Sabah Hospital, Kuwait, between 1963 and 1974. Thyroid cancer constituted 4.7 per cent of all cancer cases among females and 2.4 per cent among males. Of these carcinomas, 58 per cent were papillary, 25 per cent follicular, 11 per cent anaplastic and 1.7 per cent medullary. Four cases (3.4 per cent) were of malignant lymphoma. The 10-year survival was 74, 96 and 21 per cent for papillary, follicular and anaplastic tumours respectively. The present series confirms the prognostic value of age, sex and histology and shows that node metastasis does not prejudice survival. The study does not show any correlation between the type of operation and survival.

Natural history of familial medullary thyroid carcinoma: effect of a program for early diagnosis

To detect familial medullary thyroid carcinoma in a premetastatic stage, we administered tests provocative of calcitonin secretion (infusion of calcium or pentagastrin or both) each year for seven years to members of a pedigree now numbering 107. Since 1970, 21 patients converted from normal to abnormal secretory responses (two separate tests in which calcitonin levels exceeded 0.58 ng per milliliter). Twenty of 21 glands removed showed C-cell hyperplasia, and eight of the 20 also showed foci of carcinoma. As compared to the 12 patients with tumors detected during the first year of screening, all of whom had bilateral carcinoma (seven of 12 with local metastases), later carcinomas were smaller (mean diameter of 0.2 vs. 0.8 cm), were unilateral (in all but two cases) and occurred in younger patients (mean age of 14.9 vs. 36.4 years), and none had detectable metastases.

Significance of lymph node metastasis in differentiated thyroid cancer

In age-matched patients with differentiated carcinoma of the thyroid, the tumor recurred in 32 per cent of those with lymph node metastases and in 14 per cent of those without lymph node metastases. Twenty-four per cent of patients with nodal involvement at the initial examination died of thyroid cancer, whereas only 8 per cent of those without nodal involvement died of thyroid cancer. In patients less than forty years old, there were no deaths in those without nodal metastases bu there were three deaths (11 per cent) in patients with nodal metastases. In patients more than forty years old, nine (41 per cent) iwth nodal metastases died of tumor, and four (15 per cent) without nodal metastases died of tumor. In the presence of positive nodes the death rate was substantially greater in the older than in the younger patients. Nodal involvement has an adverse effect on prognosis, but appears to be less important than the age of the patient.

Surgical treatment for thyroid cancer

Thyroid cancer, although a rare disease, may cause significant disability and even death. Its proper surgical management is based on an understanding of the different biolgoic behavior of the four subtypes. Papillary and follicular cancers are best managed by total lobectomy on the side of the lesion and subtotal lobectomy on the contralateral side, unless there is gross disease bilaterally or distant metastasis (in which circumstances total thyroidectomy is performed). Cervical lymph node metastasis, when present, is handled satisfactorily by modified neck dissection. Because of its high incidence of multicentricity and its more serious prognosis, medullary thyroid carcinoma is managed by total thyroidectomy and--usually--radical neck dissection for involved nodes. For anaplastic carcinoma, there is no effective treatment at present. Postoperatively, all patients should be given suppressive doses of thyroid hormone to prevent myxedema and to prevent cancer from recurring. Radioiodine therapy may be of value in suppressing metastasis of some papillary and follicular cancers that exhibit a high degree of follicular differentiation.

Treatment of thyroid cancer in 293 patients

Two hundred and ninety-three patients with thyroid cancer were treated at The Royal Marsden Hospital, London, between 1931 and 1963. Thirty-six per cent of the tumours were papillary, 21 per cent follicular, 1 per cent medullary and 42 per cent anaplastic. Surgery combined with radiotherapy formed the commonest treatment regime. Thirty-six per cent of the patients with papillary carcinoma survived for 20 years, 20 per cent with follicular tumour and 4 per cent with anaplastic carcinoma. The present series indicates that treatment influences the survival time, confirms the prognostic value of histology and age and shows that papillary node metastases do not prejudice survival.

Primary malignant tumours of the thyroid: the relationship between histological classification and clinical behaviour

One hundred and seventy-nine primary malignant tumours of the thyroid seen at The London Hospital between 1945 and 1972 were classified by the system of Woolner et al. (1961) and Hazard (1964). The distinct pathological and clinical features of the differentiated primary carcinomas and the similarities and differences between malignant lymphoma and anaplastic carcinoma were confirmed. This study showed the 'benign' behaviour of more than half the 'differentiated' papillary and follicular carcinomas when treated by thyroid lobectomy and the very malignant nature of anaplastic carcinomas and lymphomas whatever their treatment. The behaviour of medullary carcinoma was closer to that of the other differentiated tumours than to the undifferentiated varieties. Our patients were not thought to have been exposed to known goitrogens or previous thyroid irradiation.

Anaplastic carcinoma of the thyroid

Images

Thyroid cancer in young patients in Great Britain

Recent collective experience with thyroid cancer in children in Britain is reported. Fifteen out of 16 patients with papillary carcinoma treated in the years 1962–7 are still living at least 5–10 years later; the sixteenth patient died of an unrelated cause. Two patients with follicular carcinoma also survived. Seven deaths between 1957 and 1970 were due to anaplastic or medullary carcinomas and 1 death was caused by a papillary carcinoma.

These data emphasize that in the treatment of papillary carcinoma we should take account of its prolonged natural history. Radical operations which have serious associated morbidity do not appear to be indicated.