Use of Delphian lymph node metastasis to predict central and lateral involvement in papillary thyroid carcinoma: A systematic review and meta-analysis

Meta-analysis of the effect and clinical significance of Delphian lymph node metastasis in papillary thyroid cancer

Objective

To investigate the effect and clinical significance of Delphian lymph nodes (DLN) on the factors influencing papillary thyroid cancer (PTC) to provide individualized guidance for the surgical treatment of thyroid cancer.

Methods

Relevant studies from PubMed, Web of Science, the Cochrane Library, Embase, and China National Knowledge Infrastructure databases were searched until February 13, 2023. Stringent selection parameters were used to obtain included data and homogeneous articles. Analyses were performed using Revman 5.4 and SPSS software. A P-value of < 0.05 was considered statistically significant.

Results

Five studies were finally included in this study. The results revealed a higher risk of DLN metastasis (DLNM) in patients with tumor size >1cm, multifocality, and extrathyroidal extension (ETE) of the thyroid. The risk of central lymph node metastasis (CLNM) was 11.25 times higher in DLN-positive patients with PTC than in DLN-negative (OR = 11.25, 95% CI: 8.64-14.64, P < 0.05) patients. The risk of LLNM was 5.57 times higher in DLN-positive patients with PTC than in DLN-negative (OR = 5.57, 95% CI: 4.57-6.78, P < 0.001) patients. The risk of postoperative recurrence in DLN-positive patients with PTC was 3.49 times higher (OR = 3.49, 95% CI: 1.91-6.38, P < 0.001) than in DLN-negative patients with PTC.

Conclusion

Patients with tumor size >1 cm in diameter, multifocality, and ETE have an increased risk for DLN development. DLN-positive patients with central and lateral cervical lymph node metastasis and postoperative recurrence are at higher risk than DLN-negative patients.

Relationship between pretracheal and/or prelaryngeal lymph node metastasis and paratracheal and lateral lymph node metastasis of papillary thyroid carcinoma: A meta-analysis

Objective

We conducted a meta-analysis to study the relationship between pretracheal and/or prelaryngeal lymph node metastasis and paratracheal and lateral lymph node metastasis in papillary thyroid carcinoma.

Method

A systematic literature search was conducted using PubMed, Embase, and the Cochrane Library electronic databases for studies published up to February 2022. The reference lists of retrieved articles were also reviewed. Two authors independently assessed the methodological quality and extracted the data. A random-effects model was used to calculate the overall pooled relative risk. Publication bias in these studies was evaluated using Egger’s test and Begg’s test.

Results

Twenty-five independent studies involving 10,525 patients were included in the meta-analysis. The pooled relative risk for ipsilateral and contralateral paratracheal lymph node metastasis was 3.01 (95% confidence interval [CI]: 1.66, 5.45) and 5.68 (95% CI: 2.50, 12.88), respectively, in patients with pretracheal lymph node metastasis. Among patients with prelaryngeal lymph node metastasis, the pooled relative risk for ipsilateral paratracheal and/or pretracheal contralateral paratracheal, and lateral lymph node metastasis was 2.02 (95% CI: 1.90, 2.14), 2.22 (95% CI: 1.34, 3.67), and 3.85 (95% CI: 2.89, 5.14), respectively.

Conclusion

Pretracheal lymph node metastasis and prelaryngeal lymph node metastasis were significantly associated with an increased likelihood of both ipsilateral lymph node metastasis and contralateral paratracheal lymph node metastasis in papillary thyroid carcinoma. Prelaryngeal lymph node metastasis was positively correlated with the incidence of lateral lymph node metastasis.

Analysis of the Clinical Value of Delphian Lymph Node Metastasis in Papillary Thyroid Carcinoma

Purpose

Delphian lymph node (DLN) is often involved in metastasis of malignant head and neck tumors. This study evaluates the predictive utility of the DLN and the clinicopathological factors related to DLN metastasis in individuals suffering from papillary thyroid carcinoma (PTC). Patients and Methods. A retrospective analysis was made on 969 PTC patients enrolled from 2017 to 2021. Among these patients, 522 PTC patients are DLN positive and 447 are negative. Comparisons of clinicopathological characteristics between the DLN-positive and DLN-negative patients were made.

Results

The DLN was detected in 53.9% (522/969) cases, and DLN metastasis occurred in 20.3% (106/522) cases. The independent predictors of DLN metastasis (DLNM) include tumor size >1 cm, tumor located in the upper third thyroid or isthmus, central lymph node metastasis (CLNM), and lateral lymph node metastasis (LLNM). DLN-positive individuals exhibited a higher incidence and the number of CLNM, contralateral CLNM (CCLNM), and LLNM as compared to DLN-negative patients. Whether it is cN0 or cN+, the CLNM incidence was increased among DLN-positive patients as compared to that of DLN-negative patients.

Conclusions

Positive DLN indicated an increased rate and number of metastases in the cervical lymph nodes. Intraoperative rapid freezing is recommended to assess the status of the DLN, and careful assessment of cervical lymph nodes is warranted when the DLN is involved to implement an appropriate surgical approach.

CDK9 is up-regulated and associated with prognosis in patients with papillary thyroid carcinoma

ABSTRACT

Papillary thyroid carcinoma (PTC) is the most common type of thyroid malignancy but shows excellent prognosis. We investigated the clinical significance of cyclin-dependent kinase 9 (CDK9) in patients with PTC.This prospective observational study included 192 patients with PTC, who visited our hospital between August 2018 and February 2020. We obtained 93 tissue samples from patients with benign thyroid disease during the same period as controls. Immunohistochemical evaluation and reverse transcription-quantitative polymerase chain reaction assay were performed to evaluate CDK9 expression. Patients' demographic and clinical characteristics were analyzed.Delphian lymph node (DLN) metastasis in patients with PTC was associated with clinicopathological characteristics. CDK9 expression was up-regulated in patients with PTC, and those with DLN metastasis showed higher CDK9 expression. We also observed that tumor size, capsule invasion, tumor-node-metastasis classification (TNM) stage, and multifocality were the risk factors for DLN metastasis in patients with PTC. Additionally, CDK9 expression was strongly associated with tumor size, capsule invasion, TNM stage, and multifocality and weakly associated with the number of metastatic DLN.CDK9 is up-regulated in patients with PTC and associated with prognosis in these patients.

Nomograms Combining Ultrasonic Features With Clinical and Pathological Features for Estimation of Delphian Lymph Node Metastasis Risk in Papillary Thyroid Carcinoma

Background

This work explores the clinical significance of Delphian lymph nodes (DLN) in thyroid papillary carcinoma (PTC). At the same time, a nomogram is constructed based on clinical, pathological, and ultrasonic (US) features to evaluate the possibility of DLN metastasis (DLNM) in PTC patients. This is the first study to predict DLNM using US characteristics.

Methods

A total of 485 patients, surgically diagnosed with PTC between February 2017 and June 2021, all of whom underwent thyroidectomy, were included in the study. Using the clinical, pathological, and US information of patients, the related factors of DLNM were retrospectively analyzed. The risk factors associated with DLNM were identified through univariate and multivariate analyses. According to clinical + pathology, clinical + US, and clinical + US + pathology, the predictive nomogram for DLNM was established and validated.

Results

Of the 485 patients with DLN, 98 (20.2%) exhibited DLNM. The DLNM positive group had higher positive rates of central lymph node metastasis (CLNM), lateral lymph node metastasis (LLNM), and T3b–T4b thyroid tumors than the negative rates. The number of CLNM and LLNM lymph nodes in the DLNM+ group was higher as compared to that in the DLNM- group. Multivariate analysis demonstrated that the common independent risk factors of the three prediction models were male, bilaterality, and located in the isthmus. Age ≥45 years, located in the lower pole, and nodural goiter were protective factors. In addition, the independent risk factors were classified as follows: (I) P-extrathyroidal extension (ETE) and CLNM based on clinical + pathological characteristics; (II) US-ETE and US-CLNM based on clinical + US characteristics; and (III) US-ETE and CLNM based on clinical +US + pathological features. Better diagnostic efficacy was reported with clinical + pathology + US diagnostic model than that of clinical + pathology diagnostic model (AUC 0.872 vs. 0.821, p = 0.039). However, there was no significant difference between clinical + pathology + US diagnostic model and clinical + US diagnostic model (AUC 0.872 vs. 0.821, p = 0.724).

Conclusions

This study found that DLNM may be a sign that PTC is more invasive and has extensive lymph node metastasis. By exploring the clinical, pathology, and US characteristics of PTC progression to DLNM, three prediction nomograms, established according to different combinations of features, can be used in different situations to evaluate the transfer risk of DLN.

Application of the laboratory risk indicator for necrotizing fasciitis score to the head and neck: a systematic review and meta-analysis

BACKGROUND

Recent studies have attempted to verify the predictive capability of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) for cervical necrotizing fasciitis (CNF).

METHODS

The two authors independently reviewed six databases (PubMed, Cochrane, Embase, Web of Science, SCOPUS and Google Scholar databases were searched). Seven cohort studies were included in the analysis. Sensitivity and specificity were determined by extracting items from binary classification from each paper. The diagnostic accuracy of the included studies was evaluated using QUADAS ver. 2.

RESULTS

The diagnostic odds ratio (OR) of LRINEC for CNF with the cutoff value of 6 was 13.9952 (95% CI, 3.8537; 50.8255, I²  = 76.7%). The area under the SROC curve was 0.842, suggesting acceptable diagnostic accuracy. The correlation between sensitivity and false positive rate was 0.055, indicating that it was not heterogeneous. The sensitivity, specificity, and negative predictive values were 0.7503 ([0.4637; 0.9126], I²  = 79.1%), 0.8455 ([0.7084; 0.9250], I²  = 96.0%) and 0.9829 ([0.9089; 0.9970], I²  = 93.7%), respectively. In the comparison of subgroups according to a LRINEC score (6-8, and), the cutoff value of 6 showed moderate sensitivity (75%) and high specificity (85%) and greater diagnostic power than other cutoff values.

CONCLUSIONS

LRINEC is a useful adjunctive tool for predicting CNF in patients with a soft tissue infection. In addition, a more accurate diagnosis is possible by using the LRINEC score with a cutoff value of 6.

Predictive value of ipsilateral central lymph node metastasis for contralateral central lymph node metastasis in patients with thyroid cancer: Systematic review and meta-analysis

Careful consideration of prophylactic central compartment dissection is required to ensure that its benefits outweigh its risks in the thyroid cancer. Sixteen prospective or retrospective studies were included. True positive, true negative, false positive, and false negative were extracted from each study. The diagnostic odds ratio of ipsilateral central lymph node metastasis (iCLNM) for predicting contralateral central lymph node metastasis (cCLNM) was 12.9237 (95% confidence interval [CI], 8.1595-20.4695). The area under the summary receiver operating characteristic curve was 0.854. The sensitivity, specificity, and negative predictive value were 0.8925 [0.8232-0.9368], 0.6884 [0.6311-0.7404], and 0.9802 [0.9631-0.9894], respectively. There were strong correlations between cCLNM and clinicopathologic characteristics. Ipsilateral central lymph node pathology is useful for predicting contralateral central compartment invasion in patients with thyroid cancer. In addition, clinicopathologic characteristics were associated with cCLNM in patients with unilateral thyroid cancer.

Carbon nanoparticle-guided intraoperative lymph node biopsy predicts the status of lymph nodes posterior to right recurrent laryngeal nerve in cN0 papillary thyroid carcinoma

BACKGROUND

The lymph nodes in the right central compartment can be divided into 2 parts by the right recurrent laryngeal nerve (RLN), and there is a lack of an accurate and convenient method for assessing metastases in the lymph node posterior to the right recurrent laryngeal nerve (LN-prRLN) in cN0 thyroid papillary carcinoma patients.

METHODS

Patients diagnosed with cN0 thyroid papillary carcinoma and underwent intraoperative carbon nanoparticle-guided lymph node biopsy from January 2017 to November 2020 at the Center for Thyroid and Breast Surgery of Xuanwu Hospital were retrospectively analyzed. The intraoperative frozen section examination and postoperative LN-prRLN status should have been comprehensively recorded. The participants were divided into the LN-prRLN positive group and LN-prRLN negative group according to their recorded LN-prRLN status.

RESULTS

In total, 189 cases (LN-prRLN positive group, n=30; LN-prRLN negative group, n=159) were included in the analysis. The univariate and multivariate regression analyses revealed that the number of metastatic lymph nodes during intraoperative lymph node biopsy was the potential predictor for LN-prRLN metastasis [odds ratio (OR): 1.320, 95% confidence interval (CI): 1.057 to 1.649, P=0.014]. The receiver operating characteristic (ROC) curve showed that the area under the curve (AUC) reached 0.7 upon a combined analysis of multiple lymph node statuses located at pre-laryngeal (Delphian), pre-tracheal, and para-tracheal lymph nodes ipsilateral to the tumor in predicting the metastasis of LN-prRLN, and the cut-off value was 0.5.

CONCLUSIONS

Number of metastatic lymph nodes in intraoperative biopsy was an indicator of LN-prRLN metastasis in cN0 thyroid carcinoma patients. Patients staging in cN0 with negative intraoperative lymph node status might be considered not to require LN-prRLN dissection during central lymph nodes dissection.

Diagnostic Model Incorporating Clinicopathological Characteristics of Delphian Lymph Node Metastasis Risk Profiles in Papillary Thyroid Cancer

The Delphian lymph node (DLN), also known as the prelaryngeal node, is one component of the central lymph node. The DLN has been well studied in laryngeal cancer, although its significance in papillary thyroid cancer (PTC) remains unclear. We retrospectively analyzed 936 patients with PTC who underwent thyroidectomy by a single surgeon in Tianjin Cancer Hospital from 2017 to 2019. Moreover, 250 PTC patients who underwent thyroidectomy by another surgeon in Tianjin Cancer Hospital from January 2019 to April 2019 were used as a validation cohort. Among the 936 patients with PTC, 581 patients (62.1%) had DLNs, of which 177 samples with metastasis (177/581, 30.5%) were verified. DLN metastasis was significantly correlated with sex, age, tumor size, bilateral cancer, multifocality, extrathyroidal extension, lymphovascular invasion and central and lateral neck lymph node metastasis. Multivariate analysis revealed that independent risk factors for DLN metastasis included age, gender, tumor size, extrathyroid extension, lymphovascular invasion and central lymph node metastasis, which determined the nomogram. In particular, tumor size was proven to be one of the most predominant single predictors. The diagnostic model had an area under the curve (AUC) of 0.829 (95% confidence interval, 0.804-0.854). The internal and external validations of the nomogram were 0.819 and 0.745, respectively. Our results demonstrate that DLN metastasis appears to be a critical parameter for predicting metastatic disease of the central compartments. Furthermore, this study provides a precise criterion for assessing DLN metastasis and has great clinical significance for treating PTC.

Delphian lymph node metastasis is a novel indicator of tumor aggressiveness and poor prognosis in papillary thyroid cancer

BACKGROUND AND OBJECTIVES

Although the significance of Delphian lymph nodes (DLNs) in patients with papillary thyroid carcinoma (PTC) has been reported, all studies have been based on a small sample size and lack a direct statement concerning prognosis.

METHODS

A total of 904 consecutive patients were enrolled in the current study, and all patients were divided into two groups (DLN-positive and DLN-negative) according to the presence of DLN metastasis.

RESULTS

DLN was detected in 687 patients (76.0%), and 123 (17.9%) had DLN metastasis. Compared to those in the DLN-negative group, the proportion of other central lymph node (CLN) metastases, mean number of metastatic CLNs, and mean metastatic CLN ratio were higher in the DLN-positive group (86.2 vs. 50.2%, 6.70 ± 5.19 vs. 1.60 ± 2.37, and 0.54 ± 0.25 vs. 0.18 ± 0.26, respectively; p < .001). The same phenomena were observed in the metastatic lateral lymph nodes (LLNs) between the DLN-positive and DLN-negative groups (52.0 vs. 15.4%, 7.28 ± 6.08 vs. 3.38 ± 3.73, and 0.23 ± 0.15 vs. 0.13 ± 0.12, respectively; p < .001). Patients in the DLN-positive group had shorter LLN metastasis-free survival and distant metastasis-free survival than patients in the DLN-negative group (93.5% vs. 98.6% and 95.9% vs. 98.8%, respectively, p < .05).

CONCLUSIONS

DLN metastasis in PTC is associated with tumor aggressiveness and a poor prognosis.

Predictive Value of Delphian Lymph Node Metastasis in the Thyroid Cancer

OBJECTIVE/HYPOTHESIS

To evaluate the diagnostic accuracy of Delphian lymph node (DLN) metastasis for the prediction of central lymph node (CLN) metastasis and lateral lymph node (LLN) metastasis.

METHODS

Two authors independently reviewed the six databases (Cochrane database, Embase, Google Scholar, PubMed, SCOPUS, and Web of Science). Four parameters were extracted from each study: true positive, true negative, false positive, and false negative. The quality of the methodology was evaluated using the Quality Assessment of Diagnostic Accuracy Studies ver. 2 tool.

RESULTS

The diagnostic odds ratio of DLN in CLN metastasis was 8.859 (95% confidence interval [CI], 4.419; 16.578). The area under the summary receiver operating characteristic curve was 0.748. The diagnostic odds ratio of DLN in LLN metastasis was 7.61 (95% CI, 4.48; 12.94). The area under the summary receiver operating characteristic curve was 0.837. DLN metastasis was moderately predictive of CLN metastasis (sensitivity = 32%, specificity = 95%), LLN metastasis (sensitivity = 52%, specificity = 89%), and contralateral CLN metastasis (sensitivity = 46%, specificity = 85%). DLN metastasis had statistically significant correlation with specific clinicopathological characteristics, including younger age (< 45 years old), bilaterality, capsule invasion, extrathyroidal extension, lymphovascular invasion, male sex, multifocality, and tumor size (> 1 cm).

CONCLUSIONS

The higher specificities of DLN pathology may help predict central and lateral compartment involvement in patients with thyroid cancer.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:1990-1996, 2021.

Clinical implications of Delphian lymph node metastasis in papillary thyroid carcinoma

Background

As is known, identifying risk factors precisely for lymph node metastasis (LNM) plays a vital role in initial treatment for papillary thyroid carcinoma (PTC). Nonetheless, whether Delphian lymph node (DLN) metastasis has value in predicting LNM remains an open question. This study covered a sample of 1,575 patients, which is the largest sample group so far, aiming to assess the predictive validity of DLN metastasis in PTC.

Methods

This retrospective cohort study was conducted with 1,575 eligible PTC patients who underwent thyroid operation between July 2013 and December 2018 and clinicopathologic parameters of patients with DLN metastasis were compared with those without DLN metastasis.

Results

The incidence of DLN metastasis, according to our research samples, is 24.4% (384/1,575 patients). And results show that DLN positivity was closely associated with adverse prognostic factors including younger age, larger tumor size, extrathyroid extension, tumor location in the isthmus or upper lobe of the thyroid, number of LNM >5, higher recurrence. After carefully adjusting important confounding factors, we find that in multivariate logistic regression analyses, DLN metastasis is an independent predictor for both central LNM (CLNM, adjusted OR =7.81, P<0.001) and lateral LNM (LLNM, adjusted OR =3.40, P<0.001). Moreover, the stratified analyses also show convincing evidence of a positive correlation between DLN metastasis and LNM in levels II-IV in the vast majority of subgroups.

Conclusions

The present study suggests that DLN metastasis is an independent risk factor for CLNM and LLNM of levels II-IV. The cervical lymph nodes should be meticulously evaluated to guide tailored treatment during operation in patients with DLN involvement.