Papillary thyroid cancer: Surgical management of lymph node metastases

Abstract

Papillary thyroid cancer (PTC), the most common thyroid malignancy, is associated with cervical lymph node metastases in 30% to 90% of patients. While surgery is the primary treatment modality for PTC, radioactive iodine and thyroid hormone suppression often complement the treatment plan. Although thyroid hormone suppression may decrease the incidence of recurrent disease and radioactive iodine may diagnose and treat metastases, lymph node dissection (LND) is the mainstay treatment for clinically evident cervical lymph node metastases. The surgical treatment options published in the literature include the traditional radical LND, the modified radical LND, the selective LND (compartment-based resection based on documented lymph node metastases), and a 'berry picking' resection (in which only the grossly abnormal lymph nodes are excised). At the University of California, San Francisco, we prefer the modified radical LND with preservation of the cervical sensory nerves for the first lymph node dissection with the 'berry picking' procedure limited to surgical treatment of recurrent nodal metastases in previously resected lymph node basins. Some centers are evaluating the potential role of sentinel lymph node biopsies for PTC. While the extent of lymphadenectomy is debated, most physicians treating patients with PTC agree that clinical evidence of lymphatic metastases should be surgically exercised and there is no role for prophylactic LND.

Is Level V Dissection Necessary for Low-risk Patients with Papillary Thyroid Cancer Metastasis in Lateral Neck Levels II, III, and IV

“…Most of node metastasis at level V belong to pN1b, so prophylactic dissection of level V also has only limited clinical importance. levels II, III, and IV were the most frequent with clinically positive lymph node (Caron et al, 2006), our study also have the similar results, Seventeen (36.12%), 36 (76.6%), and 34 (72.34%) patients had positive lymph nodes in levels II, III, and IV, respectively.some studies evaluated the potential predictor factors (Caron et al, 2006), revealed that patients with simultaneous metastases to levels II, III, and IV had greater node metastasis at level V (Caron et al, 2005;Roh et al, 2008), these node metastasis at level V all belong to pN1b, the clinical benefits from level V dessection guided by simultaneous metastases is still controversial. And more patients would not benefit from this dissection while would face postoperative morbidity.…”

“…As the wide use and satisfactory diagnostic efficacy, high resolution ultrasonograpy has been used to detect lateral positive lymph node (Robbins et al, 2002;Caron et al, 2005;Ito et al, 2005;Cooper et al, 2006;Doherty et al, 2009). Nowadays, clinically positive lymph node metastasis includes the nodes detected both by palpation and ultrasonograpy (Caron et al, 2006), and ultrasonograpy is more sensitive than palpation, the proportion of clinically positive lymph node detected by ultrasonograpy becomes greater, we would think that the severity of cN1b detected by ultrasonograpy is less than that by palpation, and would be expected to have lower recurrrence and better survival.…”

Shorter Distance Between the Nodule and Capsule has Greater Risk of Cervical Lymph Node Metastasis in Papillary Thyroid Carcinoma

“…A large number of studies report that the initial lymph node is involved in 30-90% of patients, and it is revealed by pathologic examination that there were high rates of central CLNM (57.9%) and lateral CLNM (25.6%) in patients with PTC (Kupferman et al, 2004;Caron et al, 2005;Roh et al, 2009). Patients with CLNM have an increased chance of recurrence and a low survival rate (Beasley et al, 2002;Mazzaferri et al, 2003;Machens et al, 2003;Lundgren et al, 2006;Ito et al, 2009;Rotstein, 2009).…”

Surgical Techniques for operating on Large Adherent Cervical Nodal Metastases from Thyroid Cancer causing Severe Neck Pain and Compression Effects and encasing Major Vessels

“…3 Selective berry picking of nodes is not recommended as that leads to higher recurrences. 4 By learning fine details of techniques of doing meticulous neck dissections, we can minimize morbidity as well as ensure best cure rates by doing R0 resections 5,6 In patients with thyroid cancer, recurrences happen in 20 to 30% of the patients and most recurrences are due to insufficient initial surgery. 7 Hence, it is very important to understand finer details of doing neck dissections in thyroid cancer to achieve best possible cure rates.…”