Prediction of ipsilateral and contralateral central lymph node metastasis in unilateral papillary thyroid carcinoma: a retrospective study

Prediction of bilateral thyroid carcinoma and lateral cervical lymph node metastasis in PTC patients with suspicious thyroid nodules

PURPOSE

This study aimed to evaluate the factors associated with bilateral papillary thyroid carcinoma (PTC) and lateral cervical lymph node metastasis (LLNM) in patients with suspicious unilateral PTC.

METHODS

This study analyzed patients with suspicious unilateral PTC who were enrolled in a university hospital between 2016 and 2019 in Zhejiang, China. Using logistic regression, the study examined the factors associated with bilateral PTC and LLNM in demographic data, anthropometric measurements, lifestyle factors, medical history, preoperative diagnostic tests, and histopathological factors.

RESULTS

A total of 256 patients, with a mean age of 49 years, were enrolled. Bilateral PTC was associated with multifocality (aOR: 5.069, 95% CI: 2.440-10.529, P < 0.001), and contralateral nodule in the upper (aOR: 9.073, 95% CI: 2.111-38.985, P = 0.003) and middle (aOR: 9.926, 95% CI: 2.683-36.717, P < 0.001). LLNM was positively associated with bilateral PTC (aOR, 4.283, 95% CI: 1.378-13.308, p = 0.012), male (aOR, 3.377, 95% CI: 1.205-9.461, P = 0.021), upper location of carcinoma (aOR, 3.311, 95% CI: 1.091-10.053, p = 0.035), and punctate echogenic foci (aOR, 3.309, 95% CI: 1.165-9.394, P = 0.025). Contralateral maximal nodule in the upper (aOR: 0.098, 95% CI: 0.015-0.628, p = 0.014), middle (aOR: 0.114, 95% CI: 0.033-0.522, p < 0.001), and lower (aOR, 0.028, 95% CI: 0.003-0.276, P = 0.002) location were inversely associated with LLNM.

CONCLUSION

Upper and middle location of contralateral nodule and tumor multifocality predicted the risk bilateral PTC. Bilateral PTC, male, upper tumor location, punctate echogenic foci and contralateral nodule location in the entire lobes were independent predictors for LLNM.

Optimal range of lymph node dissection in patients with unilateral papillary thyroid carcinoma with lateral cervical lymph node metastasis

Background

Whether patients with unilateral papillary thyroid carcinoma (PTC) with lateral cervical lymph node metastasis (LLNM) require prophylactic central regional lymph node dissection (CLND) remains unclear. Herein, we investigated the independent risk factors associated with contralateral central lymph node metastasis (cCLNM) in unilateral PTC with LLNM and analyzed the optimal extent of lymph node dissection by comparing the 5-year recurrence-free survival rates.

Materials and methods

We retrospectively analyzed 695 patients with unilateral papillary thyroid carcinoma and lateral cervical lymph node metastasis. Factors including sex, age, multifocal, location of primary tumor, tumor diameter, capsule invasion, thyroid nodular goiter, Hashimoto thyroiditis, ipsilateral central lymph node metastasis(iCLNM), and lateral cervical lymph node metastasis were analyzed using univariate and multivariate logistic regression analyses to explore the independent risk factors of cCLNM. Propensity scores were matched to compare the 5-year recurrence-free survival rates in patients divided by different lymph node metastases and dissections.

Results

Of all patients who underwent bilateral (b)CLND, 52% (149/286) had cCLNM. Receiver operating characteristic (ROC) curve analysis was performed on 286 patients who underwent bCLND, for which a tumor diameter of 20.5 mm and number of LLNM of 3.5 were used as the thresholds for predicting cCLNM. The 5-year recurrence-free survival (RFS) rates in the cCLN-negative and cCLN-positive groups were 98.6% and 91.2%, with statistically significant differences (P=0.034). The 5-year RFS rates showed no significant difference between the ipsilateral (i)CLND and bCLND groups (P=0.235). Multifactorial regression analysis showed that tumor diameter >2 cm, presence of iCLNM, and number of LLNM >3 were independent risk factors of cCLNM.But male sex, young age (<45 years), multifocality, location of primary tumor, capsule invasion, thyroid nodular goiter, and Hashimoto thyroiditis were not associated with cCLNM.

Conclusion

Not all unilateral PTC with LLNM require prophylactic cCLND; however, prophylactic cCLND is necessary in cases which display high-risk factors for cCLNM, including primary diameter >2 cm, iCLNM, and number of LLNM >3.

Prelaryngeal and/or pretracheal lymph node metastasis could help to identify papillary thyroid carcinoma with intermediate risk from unilateral lobe cT1-2N0 papillary thyroid carcinoma

Objective

The study aims to explore the possibility of prelaryngeal and/or pretracheal lymph node metastasis in identifying papillary thyroid carcinoma with more than 5 metastatic central lymph nodes from unilateral lobe cT1-2N0 papillary thyroid carcinoma.

Methods

A retrospective analysis was conducted on patients who underwent the initial thyroid surgery for unilateral lobe cT1-2N0 PTC in a single tertiary center between July 2018 to December 2022. Multivariable binary logistic regression analysis was used to identify risk factors for unilateral lobe cT1-2N0 papillary thyroid carcinoma with more than 5 metastatic central lymph nodes.

Results

A total of 737 patients were included in the study and 399 patients were confirmed to suffer from occult central lymph node metastasis. The larger size of the largest diameter of tumor (> 1cm; OR = 3.3, 95%CI 1.6 - 6.83; p = 0.001), pretracheal lymph node metastasis (OR = 5.91, 95%CI 2.73 - 12.77; p < 0.001), prelaryngeal lymph node metastasis (OR = 3.74, 95%CI 1.73 - 8.1; p = 0.001), ipsilateral paratracheal lymph node metastasis (OR = 12.22, 95%CI 3.43 - 43.48; p < 0.001), and contralateral paratracheal lymph node metastasis (OR = 7.68, 95%CI 3.86 - 15.3; p < 0.001) were confirmed to be risk factors for unilateral lobe cT1-2N0 PTC with more than 5 metastatic central lymph nodes. When more than two metastatic prelaryngeal and/or pretracheal lymph nodes occurred, the incidence of more than 5 metastatic central lymph nodes was 71.2%.

Conclusion

Prelaryngeal and/or pretracheal lymph node metastasis could help to identify papillary thyroid carcinoma with more than 5 metastatic central lymph nodes from unilateral lobe cT1-2N0 papillary thyroid carcinoma. When more than two metastatic pretracheal and/or prelaryngeal lymph nodes occurred, total thyroidectomy and ipsilateral central lymph node dissection should be performed and contralateral paratracheal lymph node dissection might be also necessary.

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

Objective

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

Method

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

Results

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

Conclusion

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

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

Purpose

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

Results

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

Conclusions

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

Prophylactic bilateral central neck dissection should be evaluated based on prospective randomized study of 581 PTC patients

BACKGROUND

Prophylactic central lymph node dissection (PCND) was a basic consensus for patients with papillary thyroid carcinoma (PTC) in China. However, unilateral or bilateral central lymph node dissection (CND) was still controversial. This study aimed at investigating the safety and long-term benefit for the patients undergone with bilateral central lymph node dissection (BCCD).

METHODS

581 patients were enrolled and divided randomly into the test and control groups according to range of CND. 285 patients were prospectively assigned to undergo thyroid lobectomy plus BCND in the test group, other 296 patients were assigned to undergo thyroid lobectomy plus ipsilateral central lymph node dissection (ICND) in the control group.

RESULTS

We found that the numbers of total LN and pN1a in the test group were more than that of the control group (p = 0.002,0.004), but there was no difference in the number of metastasized lymph nodes (p = 0.857) and tumor recurrence (p = 0.308). Additionally, in the aspect of postoperative complication (1 day after surgery), the serum levels of parathyroid hormone in the BCND group were lower than that in the ICND group (P = 0.010), and the numbers of transient laryngeal nerve palsy were more than that(p = 0.033). Meanwhile, we further found that pathological tumor size larger than 1 cm and tumor side lymph node metastasis were independent risk factors for contralateral central lymph node metastasis(p = 0.002,0.001).

CONCLUSION

BCND may be an alternative for patients with tumor sizes larger than 1 cm, but it would significantly increase the rate of transient vocal cord palsy, parathyroid auto transplantation and decreased PTH, but the risk of permanent complications was similar to the ICND group.

Characteristics of Malignant Thyroid Tumors: A Retrospective Study on 320 Patients

Papillary thyroid cancer accounts for 80-85% of diagnosed thyroid cancers, while follicular, medullary, and anaplastic cancers are diagnosed significantly less frequently. This study aimed to show the characteristics of malignant thyroid tumors. In this retrospective study, we analyzed data from 320 patients who underwent thyroid surgery from January 2018 to December 2019. We recorded and statistically analyzed basic demographic data, data of the cytological and pathohistological findings, and tumor characteristics (size, multifocality, extrathyroidal and lymphovascular invasion). Thyroid cancer was diagnosed in 95 patients. The incidence of thyroid cancer was higher in women than in men, but without a significant difference (p=0.46). There was a significant difference between preoperative cytological findings and definitive pathohistological diagnosis (p=0.001). There was no significant difference between genders in tumor size, extrathyroidal and lymphovascular invasion, and multifocality. There were significantly more thyroid cancers with a lymphovascular invasion that were less than 2 cm in size (p=0.04). In our opinion, it is important to emphasize the value of early diagnostics and analysis of the malignant tumor characteristics that are major prognostic factors for survival in patients with thyroid cancer.

Risk Factors for Lymph Node Metastasis in Papillary Thyroid Carcinoma: A Systematic Review and Meta-Analysis

Purpose: To explore the risk factors that may predict the lymph node metastasis potential of these lesions and new prevention strategies in papillary thyroid carcinoma patients. Materials and Methods: In total, 9,369 papillary thyroid carcinoma patients with 37.17% lymph node metastasis were analyzed (Revman 5.3 software) in this study. The PubMed and Embase databases were used for searching works systematically that were published through to January 22, 2020. Results: Several factors were related to the increased risk of lymph node metastasis in patients with papillary thyroid carcinoma: age <45 years (pooled OR = 1.52, 95% CI = 1.14-2.01, p <0.00001); gender = male (pooled OR = 1.68, 95% CI = 1.51-1.87, p <0.00001); multifocality (pooled OR = 2.05, 95% CI = 1.45-2.89, p <0.0001); tumor size ≥1.0 cm (pooled OR = 3.53, 95% CI = 2.62-4.76, p <0.00001); tumor location at the upper pole 1/3 (pooled OR =1.46, 95% CI = 1.04-2.04, p = 0.03); capsular invasion + (pooled OR = 3.48, 95% CI = 1.69-7.54, p = 0.002); and extrathyroidal extension + (pooled OR = 2.03, 95% CI= 1.78-2.31, p <0.00001). However, tumor bilaterality (pooled OR = 0.85, 95% CI = 0.54-1.34, p = 0.49) and Hashimoto's thyroditis (pooled OR = 1.08, 95% CI = 0.79-1.49, p = 0.62) showed no correlation with lymph node metastasis in papillary thyroid carcinoma patients. Conclusion: The systematic review and meta-analysis defined several significant risk factors of lymph node metastasis in papillary thyroid cancer patients: age (<45 years), gender (male), multifocality, tumor size (>1 cm), tumor location (1/3 upper), capsular invasion, and extra thyroidal extension. Bilateral tumors and Hashimoto's thyroiditis were unrelated to lymph node metastasis in patients with papillary thyroid cancer.

Meta-analysis of risk factors for CCLNM in patients with unilateral cN0 PTC

BACKGROUND

In patients with papillary thyroid cancer (PTC) with clinical negative central lymph nodes (cN0), the use of prophylactic central lymph node dissection remains controversial. Contralateral central lymph node metastasis (CCLNM) occurs in 3.88–30.63% of patients with cN0 PTC. Therefore, the present meta-analysis aimed to obtain evidence for CCLNM risk factors in unilateral cN0 PTC.

MATERIALS AND METHODS

Relevant studies were identified in the PubMed, SCIE, and Wanfang databases up to Oct 31, 2019. The included patients had undergone lobectomy or total thyroidectomy with bilateral central lymph node dissection and were diagnosed pathologically with PTC. Revman 5.3 software was applied for statistical analysis.

RESULTS

Thirteen studies comprising 2449 patients were included. The factors associated with increased CCLNM risk in patients with cN0 disease were: age <45 years (odds ratio (OR) = 1.89, 95% CI = 1.43–2.49, P < 0.00001), male sex (OR = 1.67, 95% CI = 1.24–2.24, P = 0.0007), extrathyroidal extension (OR = 1.63; 95% CI = 1.17–2.28; P = 0.004), tumor size ≥1 cm (OR = 2.63, 95% CI 1.85–3.74, P < 0.00001), lymphovascular invasion (OR = 4.27, 95% CI = 2.47–7.37, P < 0.00001), and ipsilateral central lymph node metastasis (OR = 11.42, 95% CI = 5.25–24.86, P < 0.00001). However, no association was found for capsular invasion, multifocality, or Hashimoto thyroiditis.

CONCLUSION

The meta-analysis identified that age <45 years, tumor ≥1 cm, male sex, lymphovascular invasion, extrathyroidal extension, and ipsilateral central lymph node metastasis are related to CCLNM in patients with unilateral CN0 PTC. These factors should influence the use of prophylactic central lymph node dissection in this group of patients.

CUNR scoring system for the prediction of lateral lymph node metastasis in papillary thyroid carcinoma

Objective

Our present study aimed to evaluate and compare the number and rate of central lymph node metastases (LNMs) for the prediction of lateral LNM (LLNM) in papillary thyroid carcinoma (PTC) and to develop a scoring system.

Results

Capsule invasion, tumor location in the upper portion of the thyroid, an ipsilateral central compartment LNM number ≥3, and an ipsilateral central compartment LNM rate of ≥56% were identified as significant independent predictors of ipsilateral lateral LNM in PTC. The predictive ability of an ipsilateral central compartment LNM rate ≥56% (area under the curve (AUC) = 0.802) was better than that of an ipsilateral central compartment LNM number ≥3 (AUC = 0.755). The ROC curves identified the best index point (CUNR) to distinguish the presence or absence of ipsilateral LLNM as 11, which has a high sensitivity (0.860) and a low false-negative rate (0.100, 1-Specificity). These findings were supported by the validation cohort.

Conclusions

Patients with a CUNR index point equal to or greater than 11 and ipsilateral lateral lymph node dissection should be considered for a diagnosis of LLNM.

Patients and Methods

A total of 1,281 PTC patients were included and divided into two groups: those with a presence of LLNM (n = 222) and those with an absence of LLNM (n = 1059). Univariate and multivariate analyses were performed to detect the risk factors for LLNM, and receiver operating characteristic (ROC) curves were used to detect the best cutoff values of these predictors. Additionally, a scoring system for the odds ratio (OR) of independent factors was developed and validated in an independent cohort of PTC patients (n = 560).

Patterns and clinical significance of cervical lymph node metastasis in papillary thyroid cancer patients with Delphian lymph node metastasis

Although the roles of Delphian lymph node (DLN) metastasis in papillary thyroid cancer (PTC) have been previously reported, there are still limited data on correlations of clinicopathologic factors with DLN metastasis and unique patterns of cervical node subsite metastasis in PTC patients with DLN metastasis. We retrospectively reviewed medical records of 320 patients with a diagnosis of PTC who underwent primary surgery. Clinicopathologic features and DLN metastasis patterns were analyzed for predicting extensive cervical lymph node metastasis. Both univariate and multivariate Cox regression analyses were used to identify independent factors for cervical lymph node metastasis. DLN metastasis was significantly associated with multifocality, tumor size > 1 cm, extrathyroid extension, BRAF^V600E mutation, central neck node metastasis (CNNM), and lateral neck nodes metastases. Patients with DLN metastasis had more lymph node metastases in the central compartment. CNNM number and tumor size > 1 cm were independent risk factors for DLN metastasis. DLN metastasis was highly predictive of lateral lymph node metastasis with moderate sensitivity and high specificity. DLN metastasis is associated with several poor prognostic factors, including extensive cervical lymph node metastasis, and can serve as a predictor of advanced PTC. The presence of DLN metastasis should prompt surgeons to perform an aggressive surgery approach.

Role of prophylactic central neck dissection in clinically node-negative differentiated thyroid cancer: assessment of the risk of regional recurrence

Prophylactic central neck dissection in clinically node-negative patients remains controversial. The aim of this multicenter retrospective study was to determine the rate of metastases in the central neck in clinically node-negative differentiated thyroid cancer patients, to examine the morbidity, and to assess the risk of regional recurrence in patients treated with total thyroidectomy with concomitant bilateral or ipsilateral central neck dissection compared with those undergoing total thyroidectomy alone. 258 consecutive clinically node-negative patients were divided into three groups according to the procedures performed: total thyroidectomy only (group A), total thyroidectomy with concomitant ipsilateral central neck dissection (group B), and total thyroidectomy combined with bilateral central neck dissection (group C). Mean operative time and postoperative stay were shorter in Group A (p < 0.01). The incidence of postoperative transient hypoparathyroidism was lower in Group A (p = 0.03), whereas no differences in the incidence of permanent hypoparathyroidism and nerve palsy were present. Postoperative radioactive iodine administration was higher in group B and particularly C (p = 0.03) compared with group A. There were no statistically significant differences in terms of regional recurrence. Differentiated thyroid cancer has a high rate of central lymph node metastasis even in clinically node-negative patients; in the present study there was no statistically significant difference in the rates of locoregional recurrence between the three modalities of treatment. Total thyroidectomy appears to be an adequate treatment for clinically node-negative differentiated thyroid cancer. Prophylactic central neck dissection might be considered for differentiated thyroid cancer patients with large tumor size or extrathyroidal extension.

Level I lymph node involvement in patients with N1b papillary thyroid carcinoma: a prospective study

Most of the studies on the incidence, pattern, and predictive factors of lymph node (LN) metastasis with papillary thyroid carcinoma (PTC) have been performed retrospectively and no common consensus has been reached regarding the predictors for the involvement of level I LNs. This study was conducted prospectively to determine the incidence and the possible predictors of level I involvement in N1b PTC patients. The study included 30 consecutive patients with N1b stage of PTC. All the patients underwent neck dissection (ND) including level I. The relation between involvement of level I LNs and various clinicopathological variables was studied. Unilateral neck dissection was performed in 24 patients and bilateral neck dissection in six patients leading to 36 NDs. Level I was excised in all patients, with five specimens (14%) positive for metastasis. Levels II, III, IV, V, VI, and VII were positive in 52.8, 58.3, 58.3, 33.3, 63, and 22.2%, respectively. Level I involvement was significantly related to the number of lymph node levels affected (p = 0.003) and macroscopic extranodal invasion (p = 0.04). It was not related to the involvement of other individual levels, gender, age, size of the largest thyroid nodule, size of the largest LN involved, or histo-pathological variant of the tumor. This study suggests that including level I in therapeutic neck dissection for N1b PTC patients might be recommended in selected cases of multiple level involvement and macroscopic extranodal invasion requiring sacrifice of internal jugular vein, spinal accessory nerve, or sternomastoid muscle.

Clinicopathological features for predicting central and lateral lymph node metastasis in papillary thyroid microcarcinoma: Analysis of 66 cases that underwent central and lateral lymph node dissection

Currently the surgical approach for papillary thyroid microcarcinoma (PTMC), particularly the range of lymph node dissection, remains controversial. The present study aims to evaluate the risk factors for central and lateral lymph node metastasis (CLNM and LLNM) for appropriate clinical decision of neck lymph node dissection in PTMC. A total of 66 cases of PTMC that underwent unilateral or bilateral lobectomy plus prophylactic cervical lymph node dissection were collected for clinicopathological evaluation, including age, gender, tumor size, subtypes, extrathyroidal invasion, multifocality, calcifications, loss of cellular polarity/cohesiveness (LOP/C) in the invasive front, CLNM and LLNM, and retrospectively analysis. Univariate analysis revealed that LOP/C was significantly associated with CLNM (P=0.001) and LLNM (P<0.0001). The male gender was a risk factor of CLNM (P=0.04), while the age <45 years, tumor size >0.5 cm and multifocality were high-risk factors of LLNM (P=0.022, 0.044 and 0.005, respectively). Multivariable analysis revealed that LOP/C was significantly associated with CLNM [P=0.007, odds ratio (OR)=7.765, 95% confidence interval (CI)=1.773–33.996] and LLNM [P=0.029, OR=5.717, 95% CI=1.190–27.470]. Both multivariable analysis and χ² test revealed that CLNM was another important high-risk factor of LLNM (P=0.021, OR=5.444, 95% CI=1.290–22.969, χ²=17.867, P<0.001). The present study revealed that prophylactic central lymph node dissection is essential for PTMC surgery and that prophylactic lateral lymph node dissection is recommend for patients with LOP/C and CLNM, which can be performed by intraoperative frozen section pathological examination. This must be considered discreetly in the case of patients with age <45 years, tumor size >0.5 cm and multifocal lesions.