Skip lateral lymph node metastasis leaping over the central neck compartment in papillary thyroid carcinoma

Risk factors analysis of lateral cervical lymph node metastasis in papillary thyroid carcinoma: a retrospective study of 830 patients

OBJECTIVE

The aim of this study is to investigate the risk factors for lateral cervical lymph node metastasis in papillary thyroid carcinoma (PTC).

METHODS

Clinicopathological data (age, gender, Hashimoto's thyroiditis, preoperative circulating tumor cells (CTCs), multifocal, maximum lesion diameter, invaded capsule, T stage, and lymph node metastasis) of 830 PTC patients diagnosed and treated in Meizhou People's Hospital from June 2021 to April 2023 were collected. The related factors of lateral cervical lymph node metastasis were analyzed.

RESULTS

There were 334 (40.2%), and 103 (12.4%) PTC patients with central lymph node metastasis, and lateral cervical lymph node metastasis, respectively. Compared with patients without lateral cervical lymph node metastasis, PTC patients with lateral cervical lymph node metastasis had a higher proportion of multifocal, maximum lesion diameter > 1 cm, invaded capsule, T3-T4 stage. Regression logistic analysis showed that male (odds ratio (OR): 2.196, 95% confidence interval (CI): 1.279-3.769, p = 0.004), age < 55 years old (OR: 2.057, 95% CI: 1.062-3.988, p = 0.033), multifocal (OR: 2.759, 95% CI: 1.708-4.458, p < 0.001), maximum lesion diameter > 1 cm (OR: 5.408, 95% CI: 3.233-9.046, p < 0.001), T3-T4 stage (OR: 2.396, 95% CI: 1.241-4.626, p = 0.009), and invaded capsule (OR: 2.051, 95% CI: 1.208-3.480, p = 0.008) were associated with lateral cervical lymph node metastasis.

CONCLUSIONS

Male, age < 55 years old, multifocal, maximum lesion diameter > 1 cm, T3-T4 stage, and invaded capsule were independent risk factors for lateral cervical lymph node metastasis in PTC.

Combining Clinicopathologic and Ultrasonic Features for Predicting Skip Metastasis of Lateral Lymph Nodes in Papillary Thyroid Carcinoma

Background

Skip metastasis, regarded as lateral lymph node metastasis (LLNM) without involving the central lymph node metastasis (CLNM), in papillary thyroid carcinoma (PTC) patients is commonly unpredictable. The purpose of the present research was to investigate the independent risk factors of skip metastasis in patients with PTC.

Methods and Materials

In the present research, 228 consecutive PTC patients who experienced total thyroidectomy coupled with central and lateral lymph node dissection from May 2020 to September 2022 at the Affiliated hospital of Jiangsu University were included in our research. Univariate and multivariate analysis were then applied to investigate the risk factors of skip metastasis in patients with PTC. Furthermore, a predictive model of skip metastasis was then constructed based on risk factors.

Results

The skip metastasis rate was 11.8% (27/228) in the current research. After the univariate and multivariate analysis, tumor size ≤ 10 mm, unilaterality, microcalcification, and upper tumor location were determined to be predictive factors of skip metastasis. The risk score of skip metastasis was calculated: risk score = 1.229 × (if tumor nodule ≤ 10mm) + 1.518 × (if unilaterality nodule) + 1.074 × (if microcalcification in nodule) + 2.332 × (if nodule in upper location).

Conclusion

Tumor size ≤ 10 mm, unilaterality, microcalcification, and upper tumor location can increase the occurrence of skip metastasis in patients with PTC, which is expected to provide useful information to guide the suitable intraoperative window.

Risk factors associated with preferential lateral lymph node metastasis in papillary thyroid carcinoma

BACKGROUND

Lateral lymph node metastasis (LLNM) is common in patients with papillary thyroid cancer (PTC), usually occurring after central lymph node metastasis (CLNM). However, some patients experience LLNM without first developing CLNM. This study aimed to identify the risk factors for developing LLNM without CLNM.

METHODS

We retrospectively reviewed 421 patients diagnosed with PTC who underwent lobectomy or total thyroidectomy with central and ipsilateral lateral lymph node dissection. We collected clinicopathological data and used univariate and multivariate logistic regression analyses to determine the risk factors associated with LLNM without CLNM.

RESULTS

The LLNM without CLNM frequency was 18.3% (77/421). Univariate analyses demonstrated that age over 55 years, primary tumor in the upper portion of the thyroid, the number of central lymph node (CLN) and LLNM, primary tumor size, and the summed size of multi-foci tumors smaller than 1 cm were significantly associated with LLNM without CLNM (p < 0.05). Multivariate analysis revealed that LLNM without CLNM was more likely to occur in patients aged ≥55 years (odds ratio [OR], 2.309; 95% confidence interval [CI], 1.133-4.704; p = 0.021), and primary tumor in the upper portion of the thyroid (OR, 0.524; 95% CI, 0.295-0.934; p = 0.028).

CONCLUSION

The lymph node metastasis pattern in patients with PTC is not constant. Therefore, surgeons should evaluate the lateral lymph nodes, especially in patients older than 55 years or when the primary tumor is in the upper portion of the thyroid.

Clinical analysis of cervical lymph node metastasis patterns and multivariate factors in differentiated thyroid carcinoma

The incidence rate of thyroid cancer is rising rapidly in numerous parts of the world, but the mortality rate is relatively stable or even declining. The aim of the present study was to analyze the risk factors of cervical lymph node metastasis (LNM) in differentiated thyroid carcinoma (DTC). The clinical data of 846 patients with DTC were collected from the Department of General Surgery of Chifeng Municipal Hospital of Inner Mongolia Medical University (Chifeng, China) from June 2018 to June 2022. The relationship between central LNM (CLNM) and lateral LNM (LLNM) was explored in terms of sex, age, tumor diameter, multifocality, capsular invasion and Hashimoto's thyroiditis. It was revealed that male sex, age <35 years, tumor size >1 cm, multifocality and capsular invasion were associated with CLNM and LLNM (P<0.001), while there was no relationship between Hashimoto's thyroiditis, CLNM and LLNM (P>0.05). The number of positive lymph nodes in CLNM dissection, accounting for ≥50% of the total number of lymph nodes dissected, was significantly associated with LLNM (P<0.0001). In conclusion, there was no correlation between Hashimoto's thyroiditis and CLNM and LLNM. The present study revealed that patients with the characteristics of sex, age <35 years, tumor size >1 cm, multifocality and capsular invasion were associated with cervical LNM. The proportion of the number of central lymph node metastases to the total number of lymph nodes cleared during surgery is more than or equal to 50%, indicating a susceptibility to external cervical lymph node metastasis. The results of multivariate logistic analysis showed that male sex, multifocality, capsular invasion and CLNM were risk factors for LLNM, and age was a protective factor for LLNM in DTC.

Comprehensive analysis of clinicopathologic and sonographic features in thyroid cancer with skip lymph node metastasis: establish and assessment of a prediction nomogram

Lateral Lymph Node Metastasis (LLNM) is common in Papillary Thyroid Carcinoma (PTC) and is associated with a poor prognosis. LLNM without central lymph node metastasis as skip metastasis is not common. We aimed to investigate clinicopathologic and sonographic risk factors for skip metastasis in PTC patients, and to establish a nomogram for predicting the possibility of skip metastasis in order to determine the therapeutic strategy. We retrospectively reviewed the data of 1037 PTC patients who underwent surgery from 2016 to 2020 at a single institution. Univariate and multivariate analyses were used to identify the clinicopathologic and preoperative sonographic risk factors of skip metastasis. A nomogram including the risk factors for predicting skip metastasis was further developed and validated. The incidence of skip metastasis was 10.7%. The univariate and multivariate analyses suggested that gender (p= 0.001), tumor location (p= 0.000), extrathyroidal extension (p= 0.000), and calcification (p= 0.000) were independent risk factors. For papillary thyroid microcarcinoma, tumor location (p= 0.000) and calcification (p= 0.001) were independent risk factors. A nomogram according to the clinicopathologic and sonographic predictors was developed. The receiver operating characteristic curve indicated that AUC was 0.824 and had an excellent consistency. The calibration plot analysis showed a good performance and clinical utility of the model. Decision curve analysis revealed it was clinically useful. A nomogram for predicting the probability of skip metastasis was developed, which exhibited a favorable predictive value and consistency. For the female PTC patient, tumor located at the upper pole is more likely to have skip metastasis. Surgeons and sonographers should pay close attention to the patients who have the risk factors. Evidence level: This article's evidence level is 3. Level 3 evidence is derived from non-randomized, controlled clinical trials. In this study, patients who receive an intervention are compared to a control group. Authors may detect a statistically significant and clinically relevant outcome.

Predicting skip metastasis in lateral lymph nodes of papillary thyroid carcinoma based on clinical and ultrasound features

Background

Skip metastasis in papillary thyroid cancer (PTC), defined as lateral lymph node metastasis (LLNM) without the involvement of central lymph node metastasis (CLNM), is generally unpredictable. Our study aimed to develop a model to predict skip metastasis by using clinicopathological and ultrasound factors of PTC.

Methods

We retrospectively reviewed the medical records of patients who underwent total thyroidectomy and central lymph node dissection (CLND) plus lateral lymph node dissection (LLND) between January 2019 and December 2021 at the First Affiliated Hospital of Soochow University. Furthermore, univariate and multivariate analyses assessed the clinical and ultrasound risk factors. Receiver operating characteristic (ROC) curves were used to find the optimal cut-off values for age and dominant nodule diameter. Multivariate logistic regression analysis results were used to construct a nomogram and were validated internally.

Results

In all patients, the skip metastasis rate was 15.4% (41/267). Skip metastasis was more frequently found in patients with a tumour size ≤10 mm (OR 0.439; P = 0.033), upper tumour location (OR 3.050; P=0.006) and fewer CLNDs (OR 0.870; P = 0.005). After analysing the clinical and ultrasound characteristics of the tumour, five factors were ultimately associated with lateral lymph node skip metastasis and were used to construct the model. These factors were an age >40 years, tumour diameter <9.1 mm, upper tumour location, non-smooth margin and extrathyroidal extension. The internally evaluated calibration curves indicated an excellent correlation between the projected and actual skip metastasis probability. The nomogram performed well in discrimination, with a concordance index of 0.797 (95% CI, 0.726 to 0.867).

Conclusions

This study screened for predictors of skip metastasis in PTC and established a nomogram that effectively predicted the risk of potential skip metastasis in patients preoperatively. The method can predict and distinguish skip metastases in PTC in a simple and inexpensive manner, and it may have future therapeutic utility.

Case report: Lymph node metastases of breast cancer and thyroid cancer encountered in axilla

Occurrences of breast cancer and thyroid cancer metachronously or synchronously are common for women, but axillary lymph node metastasis from both cancers is rarely seen. We report a patient who had two metastatic lymph nodes from papillary thyroid carcinoma after axillary lymph node dissection with mastectomy. Papillary thyroid carcinoma diagnosis was ensured after thyroidectomy. A literature review revealed that even the co-occurrence of breast cancer and thyroid cancer is not rare, but the etiology behind this phenomenon is not elucidated well. Genetic disorders, thyroid dysfunction, and hormone receptors may be relevant. Considering the rareness of axillary lymph node metastasis of thyroid cancer, adjuvant therapy and surgery treatment for this kind of case should be considered elaborately.

The Application of Carbon Nanomaterials in Sensing, Imaging, Drug Delivery and Therapy for Gynecologic Cancers: An Overview

Gynecologic cancers are one of the main health concerns of women throughout the world, and the early diagnosis and effective therapy of gynecologic cancers will be particularly important for the survival of female patients. As a current hotspot, carbon nanomaterials have attracted tremendous interest in tumor theranostics, and their application in gynecologic cancers has also been developed rapidly with great achievements in recent years. This Overview Article summarizes the latest progress in the application of diverse carbon nanomaterials (e.g., graphenes, carbon nanotubes, mesoporous carbon, carbon dots, etc.) and their derivatives in the sensing, imaging, drug delivery, and therapy of different gynecologic cancers. Important research contributions are highlighted in terms of the relationships among the fabrication strategies, architectural features, and action mechanisms for the diagnosis and therapy of gynecologic cancers. The current challenges and future strategies are discussed from the viewpoint of the real clinical application of carbon-based nanomedicines in gynecologic cancers. It is anticipated that this review will attract more attention toward the development and application of carbon nanomaterials for the theranostics of gynecologic cancers.

Effect of skip metastasis to lateral neck lymph nodes on outcome of patients with papillary thyroid carcinoma

CONTEXT

Lymph node metastasis (N1) is a prognostic factor for disease recurrence in papillary thyroid carcinoma (PTC) patients. Skip metastasis is defined as only lateral N1 with negative central lymph nodes (LNs).

OBJECTIVE

The aim of this study was to explore the outcome of PTC patients with skip N1.

PATIENTS AND DESIGN

All patients who underwent a total thyroidectomy with ipsilateral central and lateral LN dissection for PTC from 1999 to 2019 in a high-volume endocrine surgery centre were included in this study.

MAIN OUTCOME MEASURE

Demographic and outcomes-recurrence and disease-specific survival (DSS)-were compared between three groups: N1a (central N1 only), N1b-CL (central and lateral N1), and N1b-Skip (lateral N1 without central LN involvement).

RESULTS

During the study period, 3046 patients had surgery for PTC, including 1138 with N1 (37%, 860 women, mean age: 44.8 years) comprising 474 N1a (42%), 513 N1b-CL (45%), and 151 N1b-Skip (13%). The median follow-up was 74 months (range 12-216 months). The recurrence rate in the N1b-Skip group was 13% (20/151) and 10% (47/474) in the N1a group. This was significantly lower than that in the N1b-CL group (27%, 140/513) (p < 0.0001). DSS at 10 years was 99% for group N1a, 98% for the N1b-CL, and 99% in the N1b-Skip group.

CONCLUSION

The recurrence rate of N1b-Skip patients was lower than that of N1b-CL patients and similar to that of N1a patients. This result could be used as an indication for the modality of radioiodine therapy, and for the pattern of follow-up procedures.

[Risk factors of skip lateral cervical lymph node metastasis in papillary thyroid carcinoma]

Objective:To investigate the incidence and risk factors of skip lateral cervical lymph node metastasis in patients with papillary thyroid carcinoma（PTC）. Methods:The clinical and pathological data of 85 patients with PTC who underwent total thyroidectomy plus central and lateral neck dissection in the Department of Otolaryngology Head and Neck Surgery, the First Affiliated Hospital of Hebei North University from January 2018 to January 2022 were analyzed retrospectively. SPSS 26.0 software was used to process the data, and univariate and multivariate analysis were performed to assess the relationships between skip lateral cervical lymph node metastasis and clinicopathological characteristics. Results:There were 31 cases（36.5%） of skipped lateral cervical lymph node metastasis. Univariate analysis showed that the largest tumor diameter ≤5 mm（P=0.006） and the tumor located in the upper pole of the thyroid（P=0.002） were associated with the occurrence of skip lateral cervical lymph node metastasis in patients with PTC. Most of the skip metastases involved a single area（18/31, 58.1%）, of which area Ⅲ was most likely to be involved（10/31, 32.3%）, followed by area Ⅱ（5/31, 16.1%）. The results of binary logistic analysis showed that tumor diameter less than 5 mm（OR 7.800, 95%CI 1.710-21.394, P=0.005） and tumor at the upper pole of the gland（OR 4.060, 95%CI 1.468-11.235, P=0.007） were independent risk factors of skip lateral cervical lymph node metastasis in PTC patients. Conclusion:PTC patients with tumor diameter ≤5 mm and tumor located in the upper pole of the gland are more prone to skip lateral cervical lymph node metastasis. When the diameter of the tumor is less than 5 mm and the tumor is located at the upper pole of the gland, careful evaluation should be made before operation, even in the absence of central lymph node metastasis, attention should be paid to the possibility of lateral cervical lymph node metastasis.

The Prognosis of Skip Metastasis in Papillary Thyroid Microcarcinoma Is Better Than That of Continuous Metastasis

CONTEXT

A few papillary thyroid microcarcinomas (PTMCs) may have skip metastasis (SLNM), but the risk factors remain controversial and the prognosis is unclear.

OBJECTIVES

To investigate the incidence, lymph node metastasis (LNM) patterns, risk factors, and prognosis of SLNM in PTMCs.

METHODS

We reviewed the medical records of PTMC patients who underwent thyroid surgery in our institution. Analyses of risk factors were performed for SLNM. Recurrence-free survival (RFS) of SLNM, central lymph node metastasis (CLNM), and continuous metastasis (CLNM and lateral lymph node metastasis [CLNM + LLNM]) were compared after propensity score matching (PSM).

RESULTS

SLNM was detected in 1.7% (50/3923) and frequently involved level III (66.7%). Compared with CLNM + LLNM, SLNM had more LNM at a single level (P < 0.01) and less LNM at 2 levels (P < 0.05). A tumor size of 0.5 to 1 cm (odds ratio [OR], 2.26; 95% CI, 1.27-4.00) and location in the upper pole (OR, 3.30; 95% CI, 2.02-5.40) were independent risk factors for SLNM. A total of 910 (23.2%) PTMCs with LNM were included in the prognostic analysis. At a median follow-up of 60 months, the RFS of SLNM did not differ from that of CLNM (P = 0.10) but was significantly higher than that of CLNM + LLNM (P < 0.01) after using PSM.

CONCLUSIONS

When the tumor size is 0.5 to 1 cm or its location is in the upper pole, we must remain vigilant to SLNM in PTMC. Because its prognosis is comparable to that of only CLNM and better than that of CLNM + LLNM, less intensive treatment should be considered.

Role and Extent of Neck Dissection for Neck Lymph Node Metastases in Differentiated Thyroid Cancers

Differentiated thyroid cancers (DTC) consist of 95% of thyroid tumors and include papillary thyroid cancer (PTC), follicular thyroid cancer (FTC), and Hurthle cell thyroid cancer (HTC). Rates of lymph node metastases are different depending on histologic subtypes and <5% in FTC and between 5% and 13% in HTC. Lymph node metastasis is more frequent in PTC and while rate of clinical metastasis can be seen approximately 30% rate of routine micrometastasis can be seen up to 80%. Lymph node metastasis of DTC mostly develops first in the Level VI lymph nodes at the central compartment starting from the ipsilateral paratracheal lymph nodes and then spreading to the contralateral paratracheal lymph nodes. Spread to the Level VII is mostly after Level VI invasion. Subsequent spread is to the lateral neck compartments of Levels IV, III, IIA, and VB and sometimes to the Levels IIB and VA. Occasionally skip metastasis to the lateral neck compartments develop without spreading to the central compartments and this situation is more frequent in upper pole tumors. Although application of prophylactic central neck dissection (pCND) in DTC increases the rate of complication, due to its unclear effects on oncologic results and quality of life, the interest to the pCND is decreasing and debate on its surgical extent is increasing. pCND is not essential in DTC and characteristics of patient and tumor and experience of surgeon should be considered when deciding for pCND. Due to lower complication rate of one sided pCND compared to bilateral central neck dissection (CND), low possibility of contralateral central neck metastasis and low risk of recurrence, application of one-sided CND is logical. Although therapeutic CND (tCND) is the standart treatment when there is a clinically involved lymph node, extent of dissection is a matter of debate. A case-based decision for the extent of tCND can be made by considering patient and tumor characteristics and experience of the surgeon. Due to the higher complication risk of bilateral CND, unilateral tCND can be performed if there is no suspicious lymph node on the contralateral side and bilateral tCND can be applied when there is a suspicion for metastasis only on the contralateral side or there are features for risk of metastasis to the contralateral side. In patients with clinical central metastasis owing to intra-operative pathology results by frozen section procedure are compatible with post-operative pathology results, when there is a suspicion for contralateral metastasis, a decision for one- or two-sided dissection can be made using frozen section procedure. In DTC, it can be stated that there is a consensus in the literature about not performing prophylactic lateral neck dissection (LND), but performing therapeutic LND (tLND). In addition, there is a debate on the extent of tLND. In a meta-analysis about lateral metastasis, the rates of metastasis to the Levels IIA, IIB, III, IV, VA, and VB were 53.1%, 15.5%, 70.5%, 66.3%, 7.9%, and 21.5%, respectively. Ultrasonography (USG) is an effective procedure for detection of cervical nodal metastasis on lateral compartment. Pre-operative imaging with USG and/or combination with the fine needle aspiration biopsy (cytology/molecular test/Thyroglobulin test) can allow pre-operative detection and verification of lateral lymph node metastasis. Extent of tLND can be determined to minimize morbidity considering pre-operative USG findings, pre-operative tumor and clinical features of lateral metastasis. Especially in the presence of limited lateral metastases, limited selective LND such as Levels III, IV or Levels IIA, III, IV can be applied according to the patient. Levels IIB and VB should be added to the dissection in the presence of metastases in these regions. In cases that increase the risk of Level IIB involvement, such as presence of metastasis at Level IIA, extranodal tumor involvement, presence of multifocal tumor, and in cases that increase the risk of Level VB involvement such as macroscopic extranodal spread, and simultaneous metastases at Levels II, III, IV; Levels IIB and VB can be added to dissection material. Levels I and VA should be added to the dissection in the presence of clinically detected metastases.

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.

A multi-institutional study of association of sonographic characteristics with cervical lymph node metastasis in unifocal papillary thyroid carcinoma

OBJECTIVE

Papillary thyroid carcinoma (PTC) is the most common pathological type of thyroid carcinoma, and is prone to cervical lymph node metastases (CLNM). We aim to evaluate the association between sonographic characteristics of PTC and CLNM before the initial surgery.

METHODS

Clinical information as well as ultrasonographic measurements and characteristics for 2376 patients from three hospitals were acquired in this retrospective cohort study. Univariate and multivariate logistic analysis were performed to predict CLNM in unifocal PTC patients. Receiver operating characteristic (ROC) curve was created to evaluate diagnostic performance.

RESULTS

Univariate analysis showed that gender, age, maximum tumor diameter and volume, cross-sectional and longitudinal aspect ratio, location, echogenicity, margin, and echogenic foci were independently associated with CLNM metastatic status (P < 0.05). Multivariate logistic analysis showed that gender, age, maximum tumor diameter and volume, cross-sectional aspect ratio (CSAR), location, echogenicity, margin, and echogenic foci were independent correlative factors; CSAR showed a significant difference for PTC2 to predict CLNM. The area under the curve (AUC) of the maximum tumor diameter, tumor volume, margin, and echogenic foci was 0.70, 0.69, 0.65, and 0.70, respectively. The multiple-variable linear regression model was constructed with an AUC of 0.77, a specificity of 73.4%, and a sensitivity of 72.3%. Kruskal-Wallis analysis for positive subgroups, maximum tumor diameter and volume, cross-sectional and longitudinal aspect ratio, margin, and echogenic foci showed statistical significance (P < 0.05).

CONCLUSIONS

Younger age (< 55 years), male, larger tumor, and echogenic foci were high risk factors for CLNM in patients with unifocal PTC. CSAR had a more effective predictive value for CLNM in patients with larger thyroid tumors. A larger tumor with irregular and punctate echogenic foci was also more prone to the lateral neck, and both central and lateral neck metastasis.

A Novel and Effective Model to Predict Skip Metastasis in Papillary Thyroid Carcinoma Based on a Support Vector Machine

INTRODUCTION

Skip metastasis, referred to as lymph node metastases to the lateral neck compartment without involvement of the central compartment, is generally unpredictable in papillary thyroid carcinoma (PTC). This study aims to establish an effective predictive model for skip metastasis in PTC.

METERIALS AND METHODS

Retrospective analysis was performed of clinical samples from 18192 patients diagnosed with thyroid cancer between 2016 to 2020. The First Affiliated Hospital of Wenzhou Medical University. The lateral lymph node metastasis was occureed in the training set (630 PTC patients) and validation set (189 PTC patients). The univariate and multivariate analyses were performed to detect the predictors of skip metastasis and the support vector machine (SVM) was used to establish a model to predict skip metastasis.

RESULTS

The rate of skip metastasis was 13.3% (84/631). Tumor size (≤10 mm), upper location, Hashimoto's thyroiditis, extrathyroidal extension, absence of BRAFV600E mutation, and less number of central lymph node dissection were considered as independent predictors of skip metastasis in PTC. For the training set, these predictors performed with 91.7% accuracy, 86.4% sensitivity, 92.2% specificity, 45.2% positive predictive value (PPV), and 98.9% negative predictive value (NPV) in the model. Meanwhile, these predictors showed 91.5% accuracy,71.4% sensitivity, 93.1% specificity, 45.5% PPV, and 97.6% NPV in validation set.

CONCLUSION

This study screened the predictors of the skip lateral lymph node metastasis and to establish an effective and economic predictive model for skip metastasis in PTC. The model can accurately distinguish the skip metastasis in PTC using a simple and affordable method, which may have potential for daily clinical application in the future.

Capsular extension at ultrasound is associated with lateral lymph node metastasis in patients with papillary thyroid carcinoma: a retrospective study

BACKGROUND

In patients with papillary thyroid cancer (PTC), cervical lymph node metastasis (LNM) must be carefully assessed to determine the extent of lymph node dissection required and patient prognosis. Few studies attempted to determine whether the ultrasound (US) appearance of the primary thyroid tumor could be used to predict cervical lymph node involvement. This study aimed to identify the US features of the tumor that could predict cervical LNM in patients with PTC.

METHODS

This was a retrospective study of patients with pathologically confirmed PTC. We evaluated the following US characteristics: lobe, isthmus, and tumor size; tumor position; parenchymal echogenicity; the number of lesions (i.e., tumor multifocality); parenchymal and lesional vascularity; tumor margins and shape; calcifications; capsular extension; tumor consistency; and the lymph nodes along the carotid vessels. The patients were grouped as no LNM (NLNM), central LNM (CLNM) alone, and lateral LNM (LLNM) with/without CLNM, according to the postoperative pathological examination.

RESULTS

Totally, 247 patients, there were 67 men and 180 women. Tumor size of > 10 mm was significantly more common in the CLNM (70.2%) and LLNM groups (89.6%) than in the NLNM group (45.4%). At US, capsular extension > 50% was most common in the LLNM group (35.4%). The multivariable analysis revealed that age (OR = 0.203, 95%CI: 0.095-0.431, P < 0.001) and tumor size (OR = 2.657, 95%CI: 1.144-6.168, P = 0.023) were independently associated with CLNM compared with NLNM. In addition, age (OR = 0.277, 95%CI: 0.127-0.603, P = 0.001), tumor size (OR = 6.069, 95%CI: 2.075-17.75, P = 0.001), and capsular extension (OR = 2.09, 95%CI: 1.326-3.294, P = 0.001) were independently associated with LLNM compared with NLNM.

CONCLUSION

Percentage of capsular extension at ultrasound is associated with LLNM. US-guided puncture cytology and eluent thyroglobulin examination could be performed as appropriate to minimize the missed diagnosis of LNM.

Diagnostic Accuracy of Ultrasound for the Evaluation of Lateral Compartment Lymph Nodes in Papillary Thyroid Carcinoma

AIMS

To evaluate the diagnostic accuracy of ultrasound (US) assessing the lateral compartment lymph node metastasis in patients with primary papillary thyroid carcinoma (PTC), and to demonstrate the incidence and patterns of the lateral lymph node metastasis.

METHODS

We retrospectively reviewed 198 patients with primary PTC who underwent thyroidectomy in addition to modified lateral neck dissections (MLND) involving level II to level V due to clinically positive lateral neck disease. A skilled and experienced single operator performed all US examinations. Surgical pathology results were accepted as the reference method and sensitivity, specificity, and diagnostic accuracy of US in detecting metastatic lymph nodes established using level-by-level analysis.

RESULTS

In the study cohort, 10.1% of the patients had lateral compartment lymph node metastases without any central compartment involvement. For the lateral compartment, 48.5% had level II, 74.7% had level III, 64.6% had level IV, and 29.3% of the patients had level V metastasis. None of the patients had isolated level V metastasis. The sensitivity, specificity, and diagnostic accuracy of US in identifying lateral lymph compartment metastasis ranged from 87% to 91.4%, 92% to 98.6% 92.4% to 96%, respectively. However, the sensitivity (74.7%) and diagnostic accuracy (76.2%) of US significantly decreased for the central compartment while specificity (90%) remained similar.

CONCLUSION

US performed by a skilled operator has an excellent diagnostic accuracy for the evaluation of lateral cervical lymph nodes in primary PTC; thus, might enable precise tailoring of the management strategies. Moreover, the high incidence of level V involvement favors MLND over selective approaches.

Lymph node metastasis between the sternocleidomastoid and sternohyoid muscle in papillary thyroid carcinoma patients: A prospective study at multiple centers

BACKGROUND

The lymph nodes between the sternocleidomastoid and sternohyoid muscle (LNSS) are not explicitly mentioned in the 2015 American Thyroid Association and 2008 American Head and Neck Society (AHNS) guidelines, but they are easily overlooked in papillary thyroid carcinoma (PTC). We prospectively evaluated the clinical significance of the LNSS in papillary thyroid carcinoma (PTC) patients.

METHOD

In five medical centers, two hundred and thirty-four PTC patients with lateral neck metastasis who underwent 264 neck dissection were enrolled in this study. LNSS was resected and used as a specimen to investigate the relationship of LNSS with several clinicopathological parameters.

RESULT

Of the 264 lateral neck dissections, the average lymph node metastasis rate of LNSS was 23.48%, significantly second only to that in level III (p<0.05). Univariate and multivariate analyses showed that a patient age over 45 years (OR 2.155, 95% CI 1.191 to 3.898, p = 0.011), with a tumor located in the inferior lobe of the thyroid (OR 1.517, 95% CI 1.113 to 2.068, p = 0.008), and LN metastasis at levels IIb (OR 2.298, 95% CI 1.121 to 4.712, p = 0.020) and level III (OR 2.408, 95% CI 1.222 to 4.745, p = 0.011) were independent risk factors for LNSS lymphatic metastasis.

CONCLUSION

The LNSS has a high metastatic rate and is easily overlooked. Additional attention should be paid to LNSS, especially in patients over 45 years old and with PTC located in the thyroid's inferior lobe.

Risk Factors for and Prediction Model of Skip Metastasis to Lateral Lymph Nodes in Papillary Thyroid Carcinoma

BACKGROUND

Cervical lymph node metastasis is a prognostic factor of papillary thyroid carcinoma (PTC). Skip metastasis (central lymph node negative and lateral lymph node positive) of PTC is not uncommon. This study aimed to retrospectively investigate the risk factors for skip metastasis in PTC and develop a prediction model for skip metastasis.

METHODS

A total of 745 PTC patients underwent total thyroidectomy and central plus lateral lymph node dissection at the First Affiliated Hospital of Chongqing Medical University from January 2012 to December 2017. Clinicopathological characteristics were collected and analyzed. Univariate and multivariate analyses were performed to detect the risk factors for skip metastasis. A prediction model was established based on the results of multivariate analyses.

RESULTS

The skip metastasis rate was 9.7% (72/745). Age > 55 years (OR 2.63, 95% CI 1.34-5.04, p = 0.004), tumor located in the upper portion (OR 4.15, 95% CI 2.30-7.63, p = 0.001), and unilaterality (OR 2.76, 95% CI 1.14-8.23, p = 0.040) were independent risk factors for skip metastasis. Clinically lymph node-negative (cN0) patients with tumor in the upper portion (24.6%, 43/175) had higher possibility of skip metastasis than those of clinically lateral lymph node-positive (cN1b) patients (5.9%, 10/169) (p = 0.001). The area under the receiver operating characteristic curve of prediction model was 0.734 and 0.740 in derivation group and validation group, respectively. However, skip metastasis was not associated with tumor-free survival rate of PTC patients (p = 0.274).

CONCLUSION

Age > 55 years, tumor located in the upper portion, and unilaterality may increase the risk of skip metastasis. We developed the first prediction model for skip metastasis based on clinicopathological parameters in PTC patients.

A Specific Predicting Model for Screening Skip Metastasis From Patients With Negative Central Lymph Nodes Metastasis in Papillary Thyroid Cancer

Skip metastasis is a specific type of papillary thyroid cancer lymph node metastasis (LNM). The present study aimed to clarify the typical clinical characteristics of skip metastasis and optimize the prediction model, so as to provide a more individual treatment mode for skip metastasis. We retrospectively analyzed 1075 PTC patients with different lymph node metastasis statuses from two clinical centers. Comparisons have been made between patients with skip metastasis and other types of LNM. Univariate and multivariate analyses were performed to detect the risk factors for skip metastasis with negative LNM, and a nomogram for predicting skip metastasis was established. The rate of skip metastasis was 3.4% (37/1075). Compared with other types of LNM, significant differences showed in tumor size, upper portion location, thyroid capsular invasion, and ipsilateral nodular goiter with the central lymph node metastasis (CLNM) group, and in age and gender with the lateral lymph node metastasis (LLNM) group. Four variables were found to be significantly associated with skip metastasis and were used to construct the model: thyroid capsular invasion, multifocality, tumor size > 1 cm, and upper portion. The nomogram had good discrimination with a concordance index of 0.886 (95% confidence interval [CI], 0.823 to 0.948). In conclusion, the significant differences between skip metastasis and other types of LNM indicated that the lymph node drainage pathway of skip metastasis is different from either CLNM or LLNM. Furthermore, we established a nomogram for predicting risk of skip metastasis, which was able to effectively predict the potential risk of skip metastasis in patients without preoperative LNM clue.

Completion Total Thyroidectomy Is Not Necessary for Papillary Thyroid Microcarcinoma with Occult Central Lymph Node Metastasis: A Long-Term Serial Follow-Up

Simple Summary

The necessity of completion total thyroidectomy is unclear in patients with papillary thyroid microcarcinoma (PTMC) with only pathological central lymph node metastasis (pCLNM). The aim of our study was to determine the necessity of completion total thyroidectomy after an initial surgery by comparing the prognosis according to the presence of pCLNM during a long-term follow-up. We retrospectively compared the pathological central lymph node (pCLN)-positive group of 165 patients who underwent thyroid lobectomy with the pCLN-negative group of 711 patients and found no difference between the two groups in the recurrence rate and disease-free survival rates. Therefore, PTMC patients who underwent thyroid lobectomy with prophylactic central compartment neck dissection and were diagnosed with pCLNM after surgery do not require completion total thyroidectomy.

Abstract

The necessity of completion total thyroidectomy in patients with papillary thyroid microcarcinoma (PTMC) and pathological central lymph node metastasis (pCLNM) who underwent thyroid lobectomy with central compartment neck dissection (CCND) is unclear. We determined the necessity of completion total thyroidectomy by retrospectively comparing the prognosis according to the presence of pCLNM during a long-term follow-up. We enrolled 876 patients with PTMC who underwent thyroid lobectomy with prophylactic CCND from January 1986 to December 2009. Patients were divided according to central lymph node (CLN) metastasis: 165 (18.8%) and 711 (81.2%) in the CLN-positive and CLN-negative groups, respectively. Medical records were reviewed retrospectively, and clinicopathologic characteristics and recurrence rates were analyzed. The CLN-positive group was associated with male sex (p = 0.001), larger tumor size (p < 0.001), and more microscopic capsular invasion (p < 0.001) compared with the CLN-negative group. There was no significant difference between the two groups’ recurrence (p = 0.133) or disease-free (p = 0.065) survival rates. Univariate and multivariate analyses showed no factors associated with tumor recurrence except male sex (hazard ratio = 3.043, confidence interval 1.117–8.288, p = 0.030). Patients who were diagnosed with pCLNM after undergoing thyroid lobectomy with prophylactic CCND do not require completion total thyroidectomy; however, frequent follow-up is necessary for patients with PTMC and pCLNM.

PTC located in the upper pole is more prone to lateral lymph node metastasis and skip metastasis

Background

Lateral lymph node metastasis (LLNM) is very common in papillary thyroid carcinoma (PTC). The influence of tumour location on LLNM remains controversial. The purpose of this study was to reveal the association between PTC tumours located in the upper pole and LLNM.

Methods

We reviewed a total of 1773 PTC patients who underwent total thyroidectomy with central and lateral lymph node dissection between 2013 and 2018. Patients were divided into two groups according to tumour location. Univariate and multivariate analyses were performed to identify risk factors associated with LLNM and “skip metastasis”.

Results

In the upper pole group, LLNM and skip metastasis were significantly likely to occur. Multivariate analysis showed that tumours located in the upper pole, male sex, extrathyroidal extension (ETE), central lymph node metastasis (CLNM) and tumour size were independent risk factors for LLNM, with odds ratios ([ORs], 95% confidence intervals [CIs]) of 2.136 (1.707–2.672), 1.486 (1.184–1.867), 1.332 (1.031–1.72), 4.172 (3.279–5.308) and 2.496 (1.844–3.380), respectively. Skip metastasis was significantly associated with the primary tumour location in the upper pole and age > 55 years, with ORs of 4.295 (2.885–6.395) and 2.354 (1.522–3.640), respectively.

Conclusions

In our opinion, papillary thyroid tumours located in the upper pole may have an exclusive drainage pathway to the lateral lymph nodes. When the tumour is located in the upper pole, lateral neck dissection should be evaluated meticulously.

A nomogram to predict skip metastasis in papillary thyroid cancer

Background

Skip metastases are defined as lateral lymph node metastasis (LNM) without the involvement of central LNM in papillary thyroid cancer (PTC), and it is difficult to predict in clinical practice. Our study aimed to investigate the risk factors of skip metastasis and establish a nomogram for predicting the probability of skip metastasis in PTC patients.

Patients and methods

A total of 378 consecutive PTC patients with clinically suspected LNM who underwent modified radical neck dissection (MRND) from March 2018 to July 2019 in our hospital were enrolled. Univariate and multivariate analyses were used to examine risk factors of skip metastasis, and a nomogram prediction model was established and internally validated.

Results

The incidence of skip metastases was 11.6% (44/378). Primary tumor size of ≤ 1 cm (OR = 2.703; 95% CI, 1.342–5.464; P = 0.005), age (OR = 1.051; 95% CI, 1.017–1.805; P = 0.005), and primary tumor location in the upper portion (OR = 6.799; 95% CI, 2.710–17.060; P < 0.001) were found to be independent risk factors for skip metastasis in PTC patients. A nomogram based upon these predictors performed well. The area under the curve (AUC) was 0.806 (95% CI, 0.736–0.876), and the P value of the Hosmer-Lemeshow goodness of fit test was 0.66. Decision curve analysis revealed that the nomogram was clinically useful.

Conclusion

Based on the risk factors of skip metastasis, a high-performance nomogram was established, which can provide an individual risk assessment and can guide treatment decisions for patients.

Risk factors of skip lateral lymph node metastasis in papillary thyroid carcinoma

PURPOSE

Cervical lymph node metastasis is a prognostic factor of papillary thyroid carcinoma (PTC). This study aimed to investigate clinicopathological features and risk factors of skip lateral lymph node metastasis in PTC patients.

METHODS

We retrospectively reviewed medical records of patients who underwent simultaneous total thyroidectomy with therapeutic central compartment lymph node dissection (LND) and lateral LND for primary PTC from 2014 to 2019. Univariate and multivariate logistic regression analyses were performed to identify clinicopathologic risk factors for skip metastasis. Receiver-operating characteristic (ROC) curves were constructed using the results of the multiple logistic regression analysis to identify data points with the highest sensitivity and lowest false-negative rate.

RESULTS

The frequency of skip metastasis was approximately 12.8% (50/390). Multivariate logistic regression analysis showed that age (odds ratio [OR], 1.033; 95% confidence interval [CI], 1.008-1.059; P = 0.010), tumor size (OR 0.251; 95% CI 0.129-0.490; P < 0.001) and tumor located in the upper portion (OR 0.378; 95% CI 0.200-0.715; P = 0.003) were independent risk factors of skip metastasis (all P < 0.05). The ROC curves showed that the cut-off value of age for predicting skip metastasis was 44.5 years old (sensitivity = 0.620, specificity = 0.618, area under the curve [AUC] = 0.627, P = 0.004); the cut-off value of the tumor diameter for predicting skip metastasis was 1.05 cm (sensitivity = 0.503, specificity = 0.760, AUC = 0.682, P < 0.001).

CONCLUSIONS

Skip metastasis was common in PTC. The PTC patients with age > 44.5 years, tumor diameter < 1.05 cm and tumor located in the upper portion should be carefully evaluated for skip metastasis.

Prophylactic lymph node dissection in clinically N0 differentiated thyroid carcinoma: example of personalized treatment

Considering the 'differentiated thyroid carcinoma (DTC) epidemic', the indolent nature of DTC imposes a treatment paradigm shift toward elimination of recurrence. Lymph node metastases in cervical compartments, encountered in 20-90% of DTC, are the main culprit of recurrent disease, affecting 5-30% of patients. Personalized risk-stratified cervical prophylactic lymph node dissection (PLND) at initial thyroidectomy in DTC with no clinical, sonographic or intraoperative evidence of lymph node metastases (clinically N0) has been advocated, though not unanimously. The present review dissects the controversy over PLND. Weighing the benefit yielded from PLND up against the PLND-related morbidity is so far hampered by the inconsistent profit yielded by PLND and the challenging patient selection. Advances in tailoring PLND are anticipated to empower optimal patient care.

A Diagnostic Dilemma: Skip Metastasis in Papillary Thyroid Cancer

The frequency, pattern, and predictive factors for skip LN metastasis in patients with papillary thyroid carcinoma (PTC) remain controversial. In this study, we evaluated predictive factors of skip LN metastasis in these patients. We reviewed the medical records of 68 PTC patients who underwent total thyroidectomy, central neck dissection, and lateral neck dissection at the initial operation. The relationships between skip LN metastasis and clinicopathologic factors were analyzed. After careful examination of electronic medical records of patients, 19 patients were excluded from the study. Of the remaining 49 patients, 9 (18.4%) had skip LN metastasis. Multivariate analysis showed that tumor size <1 cm was an independent risk factor for the presence of skip metastasis ( P = 0.035, odds ratio: 3.78, 95% confidence interval: 1.09–13.15). The rate of positive LN was relatively higher in micro-PTC patients than PTC patients. This finding is clinically significant and should be considered in routine clinical practice.

Cystic Lateral Lymph Node Metastases From Papillary Thyroid Cancer Patients

OBJECTIVES/HYPOTHESIS

Papillary thyroid carcinoma (PTC) tends to metastasize rather early to local lymph nodes (LNs). Incidences of cystic LN metastases is relatively rare compared with that of solid LN metastases. Few studies have attempted to assess the characteristics in these patients. This study aimed to compare the clinicopathologic characteristics and surgical outcomes between patients with cystic LN metastases and those with solid LN metastases.

STUDY DESIGN

Retrospective cohort study.

METHODS

We retrospectively reviewed the data of 1,028 patients with N1b PTC who underwent bilateral total thyroidectomy with central compartment neck dissection and modified radical neck dissection between January 2005 and September 2011. Of these, 136 (13.2%) had cystic LN metastases and 892 (86.8%) had solid LN metastases. Clinicopathologic characteristics and surgical outcomes were compared between these two patient groups.

RESULTS

The proportion of patients with thyroid tumor multifocality was relatively higher in the cystic node cohort (19.9% vs. 12.7%, P = .048). The number of total metastatic LNs and positive lateral LNs was slightly higher in the cystic node cohort (11.3 ± 8.9 vs. 9.7 ± 7.5, P = .029 and 6.9 ± 6.3 vs. 5.5 ± 4.6, P = .018, respectively). The proportion of patients with recurrence was higher in the cystic node cohort (14.0% vs. 3.0%, P < .001). Multivariate analysis indicated that cystic nodes were a significant risk factor for recurrence (hazard ratio: 5.265, 95% confidence interval: 2.898-9.563).

CONCLUSIONS

This study demonstrates that cystic lateral LN metastases are associated with aggressive tumor behavior in PTC patients. and that their presence is a significant independent prognostic factor for disease-free survival.

LEVEL OF EVIDENCE

2b Laryngoscope, 2020.

Development and validation of web-based nomograms for predicting lateral lymph node metastasis in patients with papillary thyroid carcinoma

Background

The purpose of this study was to evaluate the factors associated with lateral lymph node metastasis (LLNM) in patients with papillary thyroid carcinoma (PTC), and to develop two web-based nomograms that predict the probability of level-II and level-III/IV LLNM in these patients.

Methods

The records of 653 patients with PTC were retrospectively reviewed. Univariate and multivariate analyses were performed to identify risk factors associated with LLNM in 460 patients ("derivation group"). Two models [including and excluding the subregions of central lymph node metastasis (CLNM)] were used to predict the probability of level-II LLNM; the same two models were also used for level-III/IV LLNM. Model performance was assessed using receiver operating characteristic (ROC) analysis and decision curve analysis (DCA) in 193 patients ("validation group"). Two web-based nomograms were established.

Results

Increased tumor size, a tumor in the upper lobe, and prelaryngeal and ipsilateral paratracheal lymph node metastasis (LNM) were significantly associated with level-II LNM (P<0.05). Increased tumor size, a tumor in the upper lobe, and certain subregions of CLNM were associated with level-III/IV LNM (P<0.05). Use of ROC analysis of each model indicated that including subgroups of CLNM led to better model performance than excluding these subgroups. We quantified the benefit of each model by using DCA analysis in the validation group.

Conclusions

Our web-based nomograms provide quantification of risk for LLNM in patients with PTC before and during surgery.

Predictive Factors for Lateral Lymph Node Metastasis and Skip Metastasis in Papillary Thyroid Carcinoma

In papillary thyroid cancer (PTC) patients, cervical lymph node metastases are common, which disseminate sequentially from the central neck to the lateral neck. However, there is also a chaotic pattern of lymph node metastasis occasionally. In this study, we summarized 653 PTC patients who underwent thyroidectomy and central lymph node dissection with or without lateral lymph node dissection from two hospitals to investigate the pattern and risk factors of lateral lymph node metastasis (LLNM) and skip metastasis. LLNM was significantly associated tumor size > 1 cm, presence of extrathyroidal extension, tumors in the upper-lateral pole, and the number of metastatic lymph nodes in the central compartment. The frequency of skip metastasis was 22.5% (20 of 89 patients). Multivariate analyses showed tumor size ≤ 1 cm, and tumors in the upper-lateral pole were separately and independently associated with the risk of skip metastasis. Presence of LLNM affected the recurrence-free survival (RFS). RFS did not show the significantly difference between patients with LLNM and skip metastasis. Despite the low incidence of skip metastasis, attention should be paid to the possibility of LLNM even in the absence of central lymph node metastases. Besides, for patients with risk factors of LLNM or skip metastasis, detailed preoperative examination for the lateral compartment, especially the level III, is essential.

Preoperative serum thyroglobulin is a risk factor of skip metastasis in papillary thyroid carcinoma

BACKGROUND

Lymph node metastasis of papillary thyroid carcinoma (PTC) was a significant risk factor of local recurrence and distant metastasis, and our study aimed to identify predictive factors of skip metastasis in PTC, helping surgeons to build a strategy when facing patients in N1b stage with clinical central lymph node-negative.

METHODS

A total of 304 patients who underwent total thyroidectomy with central and lateral lymph node dissection and were diagnosed PTC with lateral lymph node metastasis (LLNM) in the Department of General Surgery at Guangdong Provincial People's Hospital were enrolled. We collected clinicopathological characteristics and analyzed their correlation with skip metastasis by univariate and multivariate analysis.

RESULTS

The incidence of skip metastasis in PTC was 14.8%. Univariate analysis showed that age, tumor diameter, primary tumor location, and preoperative serum thyroglobulin (Tg) were risk factors. Age (P=0.049, OR =3.418), primary tumor location (P<0.001, OR =7.279), and Tg (P=0.038, OR =9.412) were independent predictors in PTC by multivariate analysis.

CONCLUSIONS

Skip metastasis of PTC was significantly associated with preoperative serum Tg ≤77 ng/mL, tumor diameter ≤10 mm, age ≥55, and tumor located in the upper lobe. It is the first time to demonstrate that Tg is associated with skip metastasis of PTC.

Prevalence, Risk Factors And Location Of Skip Metastasis In Papillary Thyroid Carcinoma: A Systematic Review And Meta-Analysis

Background

Skip metastasis is a special type in cervical lymph node metastasis (LNM) of patients diagnosed with papillary thyroid carcinoma (PTC) which induced poor prognosis. There are few studies about skip metastasis and conclusions remained uncertain. Therefore, this study aims to explore the frequency and to investigate risk factors of skip metastasis in PTC.

Methods

Through searching the keyword by PubMed and Embase databases which articles published up to 1^st August 2018 about skip metastasis in papillary thyroid carcinoma, we extract data in order to assure whether those materials meet the criteria.

Results

The prevalence of skip metastasis is 12.02% in light of our meta-analysis of 18 studies with 2165 patients. The upper pole location (RR = 3.35, 95% CI =1.65-6.79, P = 0.0008) and tumors size ≤1 cm (RR = 2.65, 95% CI =1.50-4.70, P = 0.0008) are significantly associated with skip metastasis, whereas lymphovascular invasion (RR = 0.33, 95% CI =0.15-0.75, P = 0.0083) exists lower rate of skip metastasis. Multifocality, gender, age, bilaterality, thyroiditis and Extrathyroidal extension (ETE) are insignificantly associated with skip metastasis. Level II and level III are the most frequently affected areas.

Conclusion

The lateral compartment should be carefully examined especially for those PTC patients who present primary tumors in the upper lobe with a primary tumor size ≤10 mm which could be detected with skip metastasis.

The prognostic value of the lymphocyte-to-monocyte ratio for high-risk papillary thyroid carcinoma

Background and Aims

The prognosis of papillary thyroid carcinoma (PTC) is highly variable, even for high-risk cases. The predictive and prognostic role of the lymphocyte-to-monocyte ratio (LMR) has been reported in other cancers. The aim of our present study was to explore the value of LMR prognostic prediction in high-risk PTC patients.

Patients and Methods

Two hundred and twenty-four PTC high-risk cases at West China Hospital were randomized into a training set (112 cases) and testing set (112 cases), while 48 cases in Shang Jin Nan Fu Hospital were included as the external validation set.

Results

A lower preoperative LMR correlated with larger tumor size, advanced N and M stages, and an increased number of multiple PTC cases in the training, testing, and validation sets (all P<0.05 in the three sets). Patients with a high LMR exhibited significantly improved overall and PTC-free survival compared with those of patients with a low LMR in the training, testing, validation, and combined sets (all P<0.05 in the individual and combined sets). Moreover, multivariate analyses identified the LMR as an independent prognostic factor for overall and PTC-free survival. The nomograms for predicting the 5-year mortality and PTC recurrence were developed based on the risk factors in the training set and validated in the independent testing and validation sets.

Conclusion

The preoperative LMR was identified as an independent prognostic factor that could be incorporated into the two nomograms with other risk factors to predict overall survival and PTC-free survival for individual patients.

Risk factor analysis for predicting cervical lymph node metastasis in papillary thyroid carcinoma: a study of 966 patients

Backgrounds

The aim of this study is to investigate the risk factors for the cervical lymph node metastasis in papillary thyroid carcinoma (PTC).

Methods

The clinicopathological data from the 966 PTC patients who underwent thyroid operation between January 2013 and December 2015 in the general surgery department of Shengjing Hospital of China Medical University were collected. The risk factors of predicting cervical lymph node metastasis were analyzed.

Results

Male, age ≤ 45 years old, tumor size> 1.0 cm, extrathyroidal extension (ETE), US features as microcalcification, were independent risk factors for central lymph node metastasis (CLNM) (P < 0.05). Only CLNM was independent risk factors for lateral lymph node metastasis (LLNM) (P < 0.05). The ROC curve showed that the cutoff value of the number of CLNM for predicting lateral lymph node metastasis was defined as 2.5 (Sensitivity = 0.535, Specificity = 0.722, AUC = 0.669, P < 0.05). When the number of CLNM > 3, OR value was significantly higher, suggesting that the risk of LLNM increased significantly. The incidence of LLNM in level III (66.8%) and level IV (67.3%) were significantly higher than level II (42.2%) and level V (21.3%) (P < 0.05). The incidence of LLNM and skip metastasis in tumor located in the upper 1/3 of the lobe was the highest (P < 0.05).

Conclusions

Prophylactic central lymph node dissection should be performed in patients with risk factors as male, age ≤ 45 years old, tumor size> 1.0 cm, ETE and US features as microcalcification. Lateral lymph node dissection (LLND) should be more actively performed in patients with the number of CLNM> 3. Extent of LLND should include levels II, III, IV and V. Tumor located in the upper 1/3 of the lobe was vulnerable for LLNM and skip metastasis, so lymph node in lateral compartment should be noticed when lymph node status was preoperatively evaluated by imaging examination.

Skip metastases to lateral cervical lymph nodes in differentiated thyroid cancer: a systematic review

Papillary thyroid carcinoma is a slow-growing cancer with a generally good prognosis that sometimes have an aggressive behaviour. Metastases to neck lymph nodes is the first step of the diffusion. The central neck compartment is involved most commonly. The ipsilateral lateral neck compartments are usually involved afterwards, and the involvement of the contralateral one is considered a quite rare occurrence. In more rare cases, metastases to lateral neck compartment without central lymph node metastasis (so called “skip metastases”) could be observed. Aim of this literature review study is to analyse the average incidence, pattern and risk factors of this occurrence.

This study was performed according to PRISMA criteria. A final selection of 13 articles published in English language from 1997 to 2017 was performed. Any research article, review or meta-analysis was taken into consideration. Research was expanded considering the related references of articles.

The incidence of skip metastases ranged from 1.6 to 21.8%. Risk factors such as age > 45 years, size < 5 mm and tumor located in the upper pole or isthmus of thyroid gland were found.

Due to the frequency of skip metastases in thyroid cancer, a careful preoperative examination of lateral lymph nodes should be necessary.

Risk factors for skip metastasis and lateral lymph node metastasis of papillary thyroid cancer

BACKGROUND

Lymph node metastases from papillary thyroid cancer is believed to disseminate sequentially, first to the central neck and later to the lateral neck. Skip metastases of papillary thyroid cancer, however, are defined as lateral lymph node metastasis without central lymph node metastasis. The aim of this study was to investigate the risk factors for skip metastases and lateral lymph node metastasis of papillary thyroid cancer.

METHODS

We reviewed 721 papillary thyroid cancer patients undergoing total thyroidectomy with central lymph node dissection and lateral lymph node dissection during 2013 to 2018. Multivariate logistic regression analysis was performed to identify clinicopathologic risk factors for skip metastasis and lateral lymph node metastasis of papillary thyroid cancer.

RESULTS

The rate of skip metastases was 7.4% (42 of 567 patients). Multivariate analysis showed that female sex and papillary thyroid microcarcinoma (≤ 1 cm) were independent risk factors for skip metastases, with odds ratios ([OR], 95% confidence interval [CI]) of 2.29 (1.02-5.16) and 2.84 (1.46-5.16), respectively. Intrathyroidal spread of papillary thyroid cancer and an increased number of central lymph nodes dissected were inversely associated with skip metastases with ORs (95% CI) of 0.13 (0.02-0.99) and 0.88 (0.83-0.94), respectively. In contrast, a greater tumor size, central lymph node metastasis, an increased number of central lymph nodes dissected, and an increased number of lateral lymph nodes dissected were associated with a lateral lymph node metastasis risk of papillary thyroid cancer, with ORs (95% CI) as follow: 1.67 (1.08-2.59), 3.07 (1.71-5.52), 1.25 (1.14-1.37), and 1.07 (1.04-1.10), respectively, by multivariate analysis.

CONCLUSION

Greater tumor size, central lymph node metastasis, and an increased number of both central lymph nodes and lateral lymph nodes dissected were predictors for lateral lymph node metastasis of papillary thyroid cancer. In addition, papillary thyroid microcarcinoma was an independent risk factor for skip metastases. A complete and comprehensive central compartment dissection may decrease the false-positive detection of skip metastases of papillary thyroid cancer.

Standards and Definitions in Neck Dissections of Differentiated Thyroid Cancer

Papillary and follicular thyroid carcinomas arising from the follicular epithelial cells and forming differentiated thyroid cancer (DTC) consist of >95% of thyroid cancers. Lymph node metastasis to the neck is common in DTC, especially in papillary thyroid cancer. The removal of only the metastatic lymph nodes (berry picking) does not help to achieve a potential positive contribution to the survival and recurrence of lymph node dissection in the DTC. Thus, systematic dissection of the cervical lymph nodes is needed. Today, according to the widely accepted and commonly used definitions and lymph node staging, the deep lymph nodes of the lateral side of the neck are divided into five regions. Based on the fact that some groups have biologically independent regions, Groups I, II, and V are divided into the A and B subgroups. The central region lymph nodes contain VI and VII region lymph nodes, which consist of the prelaryngeal, pretracheal, and right and left paratracheal lymph node groups. Radical neck dissection (RND) is accepted as the standard basic procedure in defining neck dissections. In this method, in addition to all the regions of the Groups I-V lymph nodes at one side, the ipsilateral spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle are removed. Sparing of one or more of the routinely removed non-lymphatic structures in the RND is called modified RND (MRND), whereas the preservation of one or more of the routinely removed lymph node groups in the RND is termed as selective neck dissection (SND). In difference, the procedure with an addition of a lymph node and/or non-lymphatic structures to routinely removed neck structures in RND is called extended RND. Generally, involving one or more regions of SND are applied for DTC. The removal of the paratracheal, prelaryngeal, and pretracheal lymph node groups at one side is termed as ipsilateral central dissection, whereas the removal of the bilateral paratracheal lymph node groups, in other words, the excision of four lymph node groups in the central region (Groups VI and VII), is defined as bilateral central dissection. In conclusion, bilateral central neck dissection (CND) is the SND in which the regions of VI and VII are removed. In the DTC, CND is prophylactically and therapeutically applied, whereas lateral neck dissection is performed only therapeutically in the presence of clinical metastasis (N1b) in the lateral neck region. Debates on the extent of SNDs to be made in the central and lateral neck regions are still ongoing. Central dissection should be made at least unilaterally. In the lateral side of the neck, SNDs can be applied in different combinations in which at least one region from Groups I to V is removed. The main variables that determine the extent of SND in the central and lateral regions in DTC are the complication rates, the effect of the procedure, and its effect on prognosis and recurrence.

Conventional Ultrasound, Immunohistochemical Factors and BRAFV600E Mutation in Predicting Central Cervical Lymph Node Metastasis of Papillary Thyroid Carcinoma

The study was aimed at evaluating the correlation between central cervical lymph node metastasis (CLNM) in papillary thyroid carcinoma (PTC) patients and ultrasound (US) features, immunohistochemical factors and BRAF^V600E mutation. A total of 225 consecutive patients (225 PTCs) who had undergone surgery were included. All PTCs were pre-operatively analysed by US with respect to size, components, echogenicity, shape, margins, microcalcification, multiple cancers or not, internal vascularity and capsule contact or involvement. The presence of four immunohistochemical factors, including cytokeratin 19, human bone marrow endothelial cell 1, galectin-3 and thyroid peroxidase, and BRAF^V600E mutation was also evaluated. Univariate and multivariate analyses were performed to identify the risk factors for central CLNM, and a risk model was established. Pathologically, 44% (99/225) of the PTCs had central CLNMs. Multivariate analysis revealed that size ≤10mm, microcalcification, internal vascularity, capsule contact or involvement and BRAF^V600E mutation were independent risk factors for central CLNM. The risk score for central CLNM was calculated as follows: risk score = 1.5 × (if lesion size ≤10 mm) + 1.9 × (if microcalcification) + 0.8 × (if internal flow) + 3.0 × (if capsule contact or involvement) + 1.5 × (if BRAF^V600E mutation). The rating result was divided into six stages, and the relevant risk rates of central CLNM were 0% (0/1), 0% (0/22), 7.4% (4/54), 48.6% (34/70), 71.2% (42/59) and 100% (19/19), respectively. In conclusion, PTC ≤10mm, microcalcification, internal vascularity, capsule contact or involvement and BRAF^V600E mutation are risk factors for central CLNM. The risk model may be useful in treatment planning and management of patients with PTCs.

Predictive factors of lateral lymph node metastasis in solitary papillary thyroid microcarcinoma without gross extrathyroidal extension

BACKGROUND

Solitary papillary thyroid microcarcinoma (PTMC) without gross extrathyroidal extension (ETE) were the main candidates for active surveillance (AS). Predictive factors of lateral lymph node metastasis (LLNM) in solitary PTMC without gross ETE were essential but still unknown.

METHODS

Altogether, 171 patients of solitary PTMC without gross ETE were enrolled in our study and divided into two groups. Group A: 123 patients without lateral lymph node dissection (LLND) were considered to be LLNM negative because there was no lateral recurrence by at least 8-year follow up for all patients. Group B: 48 patients with LLND were considered to be LLNM positive which confirmed by postoperative pathology.

RESULTS

Multivariate logistic regression showed male gender, upper location of tumor and diameter of tumor ≥7 mm to be predictive factors (odds ratio = 4.237 [confidence interval (CI) 1.365-13.149, p = 0.012; odds ratio = 2.933 [CI 1.117-7.700, p = 0.029; odds ratio = 4.557 [CI 1383-15.016, p = 0.013) for LLNM in solitary PTMC patients without gross ETE. Multiple level metastasis happened in 29 (60.42%) cases while single level metastasis in 19 (39.58%). Within the lateral cervical lymph node chain, level Ⅲ nodes were consistently the most frequently involved (38/48, 79%), following by level Ⅳ (27/48, 56%), level Ⅱ (25/48, 52%) and level V (5/48, 10%). Most interesting, there are 12 (12/48, 25%) skip metastatic (positive in lateral neck and negative in central neck) patients among LLNM positive group.

CONCLUSIONS

Male gender, upper location of tumor and diameter of tumor ≥0.7 cm to be predictive factors of LLNM in solitary PTMC without gross ETE.

Predictive Factors of Skip Metastasis in Papillary Thyroid Cancer

Background

Skip metastasis is defined as metastasis incident to the lateral compartment without involvement of the central compartment, and is generally unpredictable in papillary thyroid cancer (PTC). The present study aimed to investigate the frequency and predictor value of skip metastasis in PTC patients.

Material/Methods

A total of 355 patients diagnosed with thyroid cancer who had received a prior complete thyroidectomy with bilateral central neck and ipsilateral lateral neck lymph node dissection were enrolled in this study. The clinicopathological and ultrasound features were analyzed. A univariate and multivariate analysis were performed to identify the risk factors of skip metastasis.

Results

The frequency of skip metastasis was 12.4% (44/355). The PTC patients with skip metastasis exhibited fewer lymph node metastasis, which was more commonly detected in tumor size ≤1 cm (OR 9.354; p=0.001; 95% confidence interval (CI) 1.865–26.735), tumors located in upper pole (OR 3.822; p<0.001; 95% CI 1.935–7.549), without a well-defined margin (OR 2.528; p=0.016; CI 1.191–5.367), and extrathyroidal extension (OR 2.406; p=0.013; CI 1.691–4.367).

Conclusions

Skip metastasis was common in PTC. The PTC patients with a tumor size ≤1.0 cm, located in the upper pole, without a well-defined margin and extrathyroidal extension should be carefully evaluated for skip metastasis.

Using a nomogram based on preoperative serum fibrinogen levels to predict recurrence of papillary thyroid carcinoma

Background

Hyperfibrinogenemia is increasingly being recognized as an important risk factor related to cancer stage, development and outcomes. We evaluated whether preoperative serum fibrinogen levels predict recurrence of papillary thyroid carcinoma (PTC).

Methods

We retrospectively collected data for 1023 PTC patients who underwent surgery at our institution from Aug 2014 to Aug 2016. In total, 414 patients (from Aug 2014 to Dec 2015) were used as the training set to build the model, and 609 patients (from Jan 2016 to Aug 2016) were used as the testing set to validate the model.

Results

In the training set, PTC cases with high serum fibrinogen levels were more likely to have multiple PTCs (P = 0.001) and to exhibit surrounding tissue or organ invasion (both P < 0.01). Moreover, PTC patients with higher serum fibrinogen levels were also more likely to have an advanced tumor stage (T, P = 0.001) and distance metastasis (P < 0.001), and these patients had a significantly higher rate of postoperative PTC recurrence (P = 0.002). All of these findings were validated in the testing set. The results of univariate and multivariate analyses indicated that hyperfibrinogenemia was a risk factor for PTC recurrence. The identified risk factors were incorporated into a nomogram and validated using the testing set (C-index = 0.811, 95% CI: 0.762–0.871).

Conclusion

PTC cases with hyperfibrinogenemia are more likely to have an advanced TNM stage and have a higher rate of PTC recurrence. Our nomogram could be used to objectively and accurately predict PTC recurrence in a clinical setting.

A Nomogram Based on the Characteristics of Metastatic Lymph Nodes to Predict Papillary Thyroid Carcinoma Recurrence

BACKGROUND

The extent of metastatic lymph node (LN) invasion was not considered in the postoperative stratification of the recurrence risk of papillary thyroid carcinoma (PTC) in the 2015 American Thyroid Association (ATA) guidelines, and the recommended risk stratification cannot be applied to individuals. A nomogram based on these risk factors was developed based on the risk factors to predict individual recurrence risk.

METHODS

Data from 1788 PTC patients at the West China Hospital and 306 cases from the Shang Jin Nan Fu Hospital between August 2013 and July 2015 were included in this study. The 1788 cases were randomized into two groups-the training set (896 cases) and the testing set (896 cases)-and 306 cases were used as the external evaluation set.

RESULTS

Univariate and multivariate analyses identified the following independent prognostic factors associated with recurrence in the three independent sets and the combined set (p < 0.01): LN invasion in the capsule or organ, more than five metastatic LNs, and a largest metastatic LN diameter >3 cm. Importantly, PTC patients showed significantly different recurrence rates depending on the extent of LN invasion in the three sets and in the combined set (p < 0.001). The nomogram was developed based on the risk factors in the training set and was validated in the independent testing and validation sets.

CONCLUSION

The largest LN metastasis diameter, number of metastatic LNs, and the extent of extranodal invasion had significant prognostic value for predicting the risk of recurrence. Based on the characteristics of the thyroidal PTC lesion and metastatic LNs, the nomogram showed good prediction of recurrence in individual PTC patients.