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Wang Z, Qu L, Chen Q, Zhou Y, Duan H, Li B, Weng Y, Su J, Yi W. Deep learning-based multifeature integration robustly predicts central lymph node metastasis in papillary thyroid cancer. BMC Cancer 2023; 23:128. [PMID: 36750791 PMCID: PMC9906958 DOI: 10.1186/s12885-023-10598-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 02/01/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Few highly accurate tests can diagnose central lymph node metastasis (CLNM) of papillary thyroid cancer (PTC). Genetic sequencing of tumor tissue has allowed the targeting of certain genetic variants for personalized cancer therapy development. METHODS This study included 488 patients diagnosed with PTC by ultrasound-guided fine-needle aspiration biopsy, collected clinicopathological data, analyzed the correlation between CLNM and clinicopathological features using univariate analysis and binary logistic regression, and constructed prediction models. RESULTS Binary logistic regression analysis showed that age, maximum diameter of thyroid nodules, capsular invasion, and BRAF V600E gene mutation were independent risk factors for CLNM, and statistically significant indicators were included to construct a nomogram prediction model, which had an area under the curve (AUC) of 0.778. A convolutional neural network (CNN) prediction model built with an artificial intelligence (AI) deep learning algorithm achieved AUCs of 0.89 in the training set and 0.78 in the test set, which indicated a high prediction efficacy for CLNM. In addition, the prediction models were validated in the subclinical metastasis and clinical metastasis groups with high sensitivity and specificity, suggesting the broad applicability of the models. Furthermore, CNN prediction models were constructed for patients with nodule diameters less than 1 cm. The AUCs in the training set and test set were 0.87 and 0.76, respectively, indicating high prediction efficacy. CONCLUSIONS The deep learning-based multifeature integration prediction model provides a reference for the clinical diagnosis and treatment of PTC.
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Affiliation(s)
- Zhongzhi Wang
- grid.216417.70000 0001 0379 7164Department of General Surgery, the Affiliated Zhuzhou Hospital Xiangya Medical College, Central South University, Zhuzhou, Hunan China
| | - Limeng Qu
- grid.452708.c0000 0004 1803 0208Department of General Surgery, The Second Xiangya Hospital of Central South University, No. 139, Renmin Central Road, Changsha, 410011 P.R. China
| | - Qitong Chen
- grid.452708.c0000 0004 1803 0208Department of General Surgery, The Second Xiangya Hospital of Central South University, No. 139, Renmin Central Road, Changsha, 410011 P.R. China
| | - Yong Zhou
- grid.216417.70000 0001 0379 7164Department of General Surgery, the Affiliated Zhuzhou Hospital Xiangya Medical College, Central South University, Zhuzhou, Hunan China
| | - Hongtao Duan
- grid.216417.70000 0001 0379 7164Department of Ultrasound Diagnosis, the Affiliated Zhuzhou Hospital Xiangya Medical College, Central South University, Zhuzhou, Hunan China
| | - Baifeng Li
- grid.216417.70000 0001 0379 7164Department of General Surgery, the Affiliated Zhuzhou Hospital Xiangya Medical College, Central South University, Zhuzhou, Hunan China
| | - Yao Weng
- grid.216417.70000 0001 0379 7164Department of Metabolic Endocrinology, the Affiliated Zhuzhou Hospital Xiangya Medical College, Central South University, Zhuzhou, Hunan China
| | - Juan Su
- Department of Medical Administration, the Affiliated Zhuzhou Hospital Xiangya Medical College, Central South University, No.116, Changjiang South Road, Zhuzhou, 412007, P.R. China.
| | - Wenjun Yi
- Department of General Surgery, The Second Xiangya Hospital of Central South University, No. 139, Renmin Central Road, Changsha, 410011, P.R. China.
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Altiner S, Kozan R, Cihangir Emral A, Taneri F, Karamercan A. Effects of Patient and Tumor Characteristics on Central Lymph Node Metastasis in Papillary Thyroid Cancer: A Guide for Selective Node Dissection. ARCHIVES OF IRANIAN MEDICINE 2022; 25:730-736. [PMID: 37543897 PMCID: PMC10685851 DOI: 10.34172/aim.2022.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 10/10/2021] [Indexed: 08/08/2023]
Abstract
BACKGROUND Prophylactic central lymph node dissection (CLND) in papillary thyroid carcinoma (PTC) is still controversial. This study aimed to analyze the factors related to the patient and tumor characteristics affecting central lymph node metastasis (CLNM) in PTC patients and to evaluate the contribution of the results to shaping the surgical treatment algorithm. METHODS Two hundred and fifty-five PTC patients who underwent total thyroidectomy and CLND were evaluated retrospectively. Histopathology reports were examined to reveal tumor characteristics. The CLNM ratio and the relationship between CLNM with clinicopathological and demographic characteristics were analyzed. RESULTS The incidence of CLNM was 54.9% (95 CI%: 49-60.8). Male gender (P=0.027), age<45 years (P=0.016), tumor size≥9.5 mm (P<0.001), lymphovascular invasion (P<0001) and extracapsular invasion (P=0.007) were factors that increased the risk of metastasis. The follicular variant decreased the risk (P=0.010). There was no relationship between CLNM and focality (P=0.054). A low-to-moderate correlation was found between tumor diameter and the metastatic lymph node (MLN) number/total lymph node number ratio (r=0.396, P<0.001). CONCLUSION A selective prophylactic CLND strategy can be applied in cN0 patients. As the tumor diameter increases in PTC, both the risk of CLNM and the number of MLN increase. Lymphovascular and extracapsular invasion are other factors that increase the risk. The follicular variant is associated with a lower risk of CLNM. Male patients who are under the age of 45 and have a tumor diameter of 9.5 mm or more are definite candidates for prophylactic CLND.
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Affiliation(s)
- Saygin Altiner
- Department of General Surgery, University of Health Sciences, Ankara Training and Research Hospital, Ankara, Turkey
| | - Ramazan Kozan
- Department of General Surgery, Faculty of Medicine, Gazi University, Ankara, Turkey
| | | | - Ferit Taneri
- Department of General Surgery, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ahmet Karamercan
- Department of General Surgery, Faculty of Medicine, Gazi University, Ankara, Turkey
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Liu W, Wang S, Xia X. Risk Factor Analysis for Central Lymph Node Metastasis in Papillary Thyroid Microcarcinoma. Int J Gen Med 2021; 14:9923-9929. [PMID: 34949939 PMCID: PMC8688831 DOI: 10.2147/ijgm.s346143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/07/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Although the prognosis of papillary thyroid microcarcinoma (PTMC) is excellent, cervical lymph node metastasis (CLNM) is commonly observed in PTMC. This study aimed to investigate the incidence and risk factors for CLNM in PTMC. Patients and Methods Altogether, 687 patients with PTMC who initially underwent unilateral thyroidectomy with unilateral central lymph node dissection or bilateral thyroidectomy with bilateral central lymph node dissection between January 2014 and June 2018 at our hospital were included. The patients were divided into two groups: PTMC with CLNM and PTMC with no CLNM. The clinicopathologic characteristics and ultrasound features were compared between the groups. Univariate and multivariate logistic regression analyses were used to identify the risk factors for CLNM. Results CLNM was observed in 121/687 (17.6%) patients with PTMC. PTMC patients aged <55 years exhibited a greater incidence of CLNM (87.6% vs 12.4%) than those aged ≥55 years. PTMC patients with CLNM were more likely to have capsular extension (24.0% vs 15.4%) and extension to the adjacent structures (9.9% vs 4.2%). Patients with microcalcification on ultrasound images were more likely to have CLNM (66.1% vs 47.9%). Multivariate logistic regression analysis revealed that microcalcification (odds ratio [OR]: 2.066, 95% confidence interval [CI]: 1.361-3.135, P<0.001), age <55 years (OR: 2.341, 95% CI: 1.309-4.187, P=0.004), capsular invasion (OR: 1.772, 95% CI: 1.082-2.879, P=0.023), and invasion of the adjacent tissues (OR: 2.872, 95% CI: 1.355-4.187, P=0.004) were significant risk factors for CLNM. Conclusion Microcalcification, age <55 years, capsular invasion, and invasion of the adjacent tissues were significant risk factors for CLNM in PTMC.
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Affiliation(s)
- Wenfei Liu
- Department of Thyroid, Parathyroid, Breast and Hernia Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, People's Republic of China
| | - Shoufei Wang
- Department of Thyroid, Parathyroid, Breast and Hernia Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, People's Republic of China
| | - Xiaotian Xia
- Department of Thyroid, Parathyroid, Breast and Hernia Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, People's Republic of China
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Yang JR, Song Y, Chang SJ, Shi LL. Prediction of central compartment nodal metastases in papillary thyroid cancer using TI-RADS score, blood flow, and multifocality. Acta Radiol 2021; 63:1374-1380. [PMID: 34842479 DOI: 10.1177/02841851211041811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The relationship between the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) and the risk of lymph node metastases in papillary thyroid cancer (PTC) could improve the detection rate of lymph node metastases in thyroid cancer and provide a scientific basis for clinical diagnosis. PURPOSE To evaluate the risk of lymph node metastases of PTC associated with the score from ACR TI-RADS adjusted for other correlative factors. MATERIAL AND METHODS A total of 560 patients with pathologically confirmed PTC were included in the study and classified into a metastases group and a non-metastases group. Clinical and pathological manifestations of the patients were collected. RESULTS The median TI-RADS score was 13 (p25-p75 = 11-14) among the patients with lymph node metastases, higher than those without metastases 9 (8-10) (P < 0.001). Multiple logistic regression indicated that TI-RADS score (odds ratio [OR] = 2.204), male sex (OR = 2.376), multifocality (OR = 4.170), and rich blood flow (OR = 3.656) were risk factors for lymph node metastases in patients with thyroid carcinoma. Some related factors such as TI-RADS score, age(<45years old), male, multifocality and rich blood flow were related to lymph node metastases in the central area of the neck which could provide therapeutic strategy for further treatment. CONCLUSION it is not just the TI-RADS score but also multifocality, blood flow, and sex that influence the prediction of the risk of PTC central lymph node metastases.
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Affiliation(s)
- Jin-Ru Yang
- Department of Ultrasonics, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, PR China
| | - Yan Song
- Department of Ultrasonics, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, PR China
| | - Shu-Juan Chang
- Department of Ultrasonics, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, PR China
| | - Li-Li Shi
- Department of Ultrasonics, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, PR China
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Li X, Zhou W, Zhan W. Clinical and ultrasonographic features of medullary thyroid microcarcinomas compared with papillary thyroid microcarcinomas: a retrospective analysis. BMC Med Imaging 2020; 20:49. [PMID: 32410587 PMCID: PMC7227110 DOI: 10.1186/s12880-020-00444-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 04/21/2020] [Indexed: 11/27/2022] Open
Abstract
Background To identify the sonographic features that help to differentiate medullary thyroid microcarcinomas (MTMCs) from papillary thyroid microcarcinomas (PTMCs). Methods A total of 46 MTMCs in 41 patients and 136 PTMCs in 104 patients that were proven by surgery and pathology were included in the study. Patient age and nodule size were analyzed by independent sample t-tests, and sex, multiplicity and cervical lymph node metastases were analyzed by χ2 or Fisher’s exact tests. Univariate analysis and multivariate logistic regression analysis were performed on the sonographic features of thyroid nodules, including location, shape, boundary, margin, peripheral halo ring, echogenicity, composition, calcifications and vascularization. Results Compared with the corresponding number of patients with PTMCs, more MTMC patients had cervical lymph node metastases (P = 0.040). There were no significant differences in age, sex, nodule size, multiplicity, location, boundary, margin, peripheral halo ring, echogenicity or microcalcifications between MTMCs and PTMCs (P > 0.05 for all). However, significant differences were found in shape (P = 0.000), composition (P = 0.032), macrocalcifications (P = 0.004) and vascularity (P = 0.000) between the two groups. Conclusions There were some overlapping sonographic features between MTMCs and PTMCs. However, MTMCs tended to have a > 50% solid composition, be ovoid to round nodules with macrocalcifications and be hypervascular. Cervical lymph node metastases were more common in MTMC patients.
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Affiliation(s)
- Xiaoyu Li
- Ultrasound Department, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Rd, Shanghai, 200025, China
| | - Wei Zhou
- Ultrasound Department, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Rd, Shanghai, 200025, China
| | - Weiwei Zhan
- Ultrasound Department, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Rd, Shanghai, 200025, China.
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Wu X, Li BL, Zheng CJ, He XD. Predictive factors for central lymph node metastases in papillary thyroid microcarcinoma. World J Clin Cases 2020; 8:1350-1360. [PMID: 32368529 PMCID: PMC7190943 DOI: 10.12998/wjcc.v8.i8.1350] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 03/04/2020] [Accepted: 04/04/2020] [Indexed: 02/05/2023] Open
Abstract
Papillary thyroid microcarcinoma (PTMC) measures 1 cm or less in its longest dimension. The incidence of PTMC is increasing worldwide. Surgery is the primary treatment; however, prophylactic central lymph node dissection is controversial, and discrepancies between different guidelines have been noted. Routine prophylactic central lymph node dissection may result in hypoparathyroidism and recurrent laryngeal nerve injury in some patients without lymph node metastasis, while simple thyroidectomy may leave metastatic lymph nodes in high-risk patients. To selectively perform prophylactic lymph node dissections in high-risk patients, it is important to identify predictive factors for lymph node metastases in patients with PTMC. Several studies have reported on this, but their conclusions are not entirely consistent. Several clinicopathologic characteristics have been identified as risk factors for central lymph node metastases, and the most commonly reported factors include age, gender, tumor size and location, multifocality, bilaterality, extrathyroidal extension, and abnormal lymph node found using ultrasound. Here, we provide an overview of previous studies along with a favorable opinion on or against these factors, with the aim of increasing the understanding of this topic among the medical community. In addition, current opinions about prophylactic central lymph node dissection are reviewed and discussed.
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Affiliation(s)
- Xin Wu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Bing-Lu Li
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Chao-Ji Zheng
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xiao-Dong He
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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Liu Z, Liu Y, Fan Y, Wang X, Lu X. Level IIb lymph node metastasis characteristics and predictive factors for patients with cN1b papillary thyroid carcinoma. Surgery 2020; 167:962-968. [PMID: 32178864 DOI: 10.1016/j.surg.2020.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 02/01/2020] [Accepted: 02/04/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND The aim of the present study was to examine the frequency, characteristics, and risk factors of level IIb lymph node metastases in papillary thyroid carcinoma. METHODS We reviewed and collected clinical and pathological records for 954 papillary thyroid carcinoma patients with clinically positive lateral neck node metastasis. Univariate and multivariate analyses were performed to detect risk factors for level IIb lymph node metastasis; a predictive model was built based on multivariate analysis and tested in a validation group. RESULTS Level IIb lymph node metastasis was observed in 137 of 954 patients (14.4%). Univariate and multivariate analyses using the training group indicated that gross extrathyroidal extension of the primary tumor, tumor location in the upper pole, and preoperative distant metastasis were 3 independent risk factors for level IIb lymph node metastasis. This model was built and tested in a validation group, and the area under the curve was 0.840 (P < .001). The cutoff of the IIb score was 12, which was tested in the validation group; the sensitivity was 82.1% and the specificity was 95.6%. CONCLUSION Level IIb dissection should be performed in select patients with IIb scores ≥12.
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Affiliation(s)
- Zheng Liu
- Department of Thyroid Surgery, The First Affiliated Hospital of Zhengzhou University, China
| | - Yang Liu
- Department of Thyroid Surgery, The First Affiliated Hospital of Zhengzhou University, China
| | - Yuxia Fan
- Department of Thyroid Surgery, The First Affiliated Hospital of Zhengzhou University, China
| | - Xiaoming Wang
- Department of Thyroid Surgery, The First Affiliated Hospital of Zhengzhou University, China
| | - Xiubo Lu
- Department of Thyroid Surgery, The First Affiliated Hospital of Zhengzhou University, China.
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Zheng X, Peng C, Gao M, Zhi J, Hou X, Zhao J, Wei X, Chi J, Li D, Qian B. Risk factors for cervical lymph node metastasis in papillary thyroid microcarcinoma: a study of 1,587 patients. Cancer Biol Med 2019; 16:121-130. [PMID: 31119052 PMCID: PMC6528461 DOI: 10.20892/j.issn.2095-3941.2018.0125] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objective The purposes of this study were to identify risk factors for cervical lymph node metastasis and to examine the association between BRAFV600E status and clinical features in papillary thyroid microcarcinoma (PTMC).
Methods A total of 1,587 patients with PTMC, treated in Tianjin Medical University Cancer Institute and Hospital from January 2011 to March 2013, underwent retrospective analysis. We reviewed and analyzed factors including clinical results, pathology records, ultrasound results, and BRAFV600E status.
Results Multivariate logistic regression analyses demonstrated that gender (male) [odds ratio (OR) = 1.845, P = 0.000], age (< 45 years)(OR = 1.606,P = 0.000), tumor size (> 6 mm) (OR = 2.137,P = 0.000), bilateralism (OR = 2.011, P = 0.000) and extrathyroidal extension (OR = 1.555, P = 0.001) served as independent predictors of central lymph node metastasis (CLNM). Moreover, CLNM (OR = 29.354, P = 0.000) served as an independent predictor of lateral lymph node metastasis (LLNM). Among patients with a solitary primary tumor, those with tumor location in the lower third of the thyroid lobe or the isthmus were more likely to experience CLNM (P < 0.05). Univariate analyses indicated that CLNM, LLNM, extrathyroidal extension, and multifocality were not significantly associated with BRAFV600E mutation.
Conclusions The present study suggested that prophylactic neck dissection of the central compartment should be considered in patients with PTMC, particularly in men with tumor size greater than 6 mm, age less than 45 years, extrathyroidal extension, and tumor bilaterality. Among patients with PTMC, BRAFV600E mutation is not significantly associated with prognostic factors. For a better understanding of surgical management of PTMC and the risk factors, we recommend multicenter research and long-term follow-up.
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Affiliation(s)
- Xiangqian Zheng
- Department of Head and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Chen Peng
- Department of Head and Neck, Shanxi Cancer Hospital, Taiyuan 030013, China
| | - Ming Gao
- Department of Head and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Jingtai Zhi
- Department of Head and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Xiukun Hou
- Department of Head and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Jingzhu Zhao
- Department of Head and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Xi Wei
- Department of Ultrasound, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Jiadong Chi
- Department of Head and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Dapeng Li
- Department of Head and Neck Tumor, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Biyun Qian
- Department of Epidemiology, School of Public Health, Shanghai Jiao Tong University, Shanghai 200240, China
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Correction to: Influence of tumor extent on central lymph node metastasis in solitary papillary thyroid microcarcinomas: a retrospective study of 1092 patients. World J Surg Oncol 2017; 15:187. [PMID: 29061158 PMCID: PMC5654044 DOI: 10.1186/s12957-017-1234-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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