The Importance of Central Compartment Elective Lymph Node Excision in the Staging and Treatment of Papillary Thyroid Cancer

Shindo, Maisie L.; Wu, James; Park, Eunice E.; Tanzella, Frances

doi:10.1001/archotol.132.6.650

Cited by 159 publications

(118 citation statements)

References 21 publications

(32 reference statements)

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“…In a similar type of comparison study, Hughes et al [6] found no difference in TG, but they noted an upstaging of almost one third of their cN0 patients older than 45 to Stage III disease based on pathologically positive central nodes (pN1a), which subsequently affected the dose of postoperative radioactive iodine (150 mCi for pN1 vs. 30 mCi for pN0). Similar upstaging of patients had previously been noted by Shindo et al [7]. Studies have yet to clarify whether this upstaging translates into identification of truly higher risk patients who may benefit from more aggressive RAI dosing, or whether these upstaged patients are overtreated.…”

supporting

confidence: 67%

Prophylactic central lymph node dissection in differentiated thyroid cancer

Goddard

Steward

2013

Endocrine

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Conzo et al. [1] describe their experience of treating differentiated thyroid carcinoma in patients who lack clinically evident nodal disease (cN0) with total thyroidectomy, without prophylactic central lymph node dissection, followed by radioactive iodine (RAI). 93.8 % of their 221 patients had AJCC Stage I or II papillary thyroid carcinoma. They report a low locoregional recurrence rate of 3.16 % after almost 10 years as well as low complication rates (0.91 % for both permanent hypoparathyroidism and permanent vocal fold paralysis). The merits of prophylactic lymph node dissection are debated in these patients with early-stage disease, and the authors' discussion highlights this debate. They note that the current literature lacks conclusive evidence of survival or recurrence benefit, but has established an increase in complication rates (specifically, transient hypocalcemia) associated with prophylactic central nodal dissection compared with total thyroidectomy alone. Based on their results and their scrutiny of this literature, those authors have come to conclude that their treatment paradigm is acceptable and that prophylactic central neck dissection can be avoided [1].Multiple staging systems for papillary thyroid carcinoma have been developed, many of which do not include cervical nodal metastasis as a factor. However, TNM staging is utilized by the American Thyroid Association in its most recently published guidelines for differentiated thyroid carcinoma. As with other cancers, this system includes clinical staging as well as pathologic staging for nodal metastases. Patients who do not have suspicious cervical lymph nodes by preoperative palpation, preoperative ultrasound, or intraoperative inspection are designated clinically node negative, or cN0. If there are lymph nodes with suspicious characteristics by these evaluations, then patients are considered clinically node positive, or cN1. Pathologic staging is based on microscopic evaluation of nodes in a surgical specimen. Patients without pathologic evidence of nodal disease are staged pN0 and those with disease are designated pN1.The importance of clinical nodal evaluation is evident in the article by Conzo et al. Patients are appropriately classified as cN0 versus cN1, as evidenced by the exclusion of 211 patients who had clinically suspicious lymph node findings by preoperative ultrasound or intraoperative inspection. These cN1 patients underwent therapeutic central nodal dissection rather than prophylactic, and this is a critical distinction. Benefit of central compartment dissection in the setting of clinically positive nodes is widely agreed upon. However, definitive evidence regarding oncologic benefit from dissecting clinically negative nodal basins has yet to be established, and the significance of microscopic nodal disease is widely questioned. A closer look at nodal metastases was recently provided the ATA [2]. In this publication, Randolph et al. note the differences in recurrence risk in node-positive patients based on nodal characteristics...

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supporting

confidence: 67%

Prophylactic central lymph node dissection in differentiated thyroid cancer

Goddard

Steward

2013

Endocrine

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“…Extrathyroidal invasion (16), multifocality (17) and bilateral thyroid tumors of PTMC (18) are the important risk factors in lymph node metastasis that represent biological characteristics of progress. Although the study by McCarthy et al (19) reported that multifocality is highly homologous within the gland and is not associated with tumor invasion, Shindo et al (17) and Chow et al (20) found that neck lymph node metastasis and tumor multifocality remain significantly correlated, which is the major reason for lymph node metastasis.…”

Section: Discussionmentioning

confidence: 99%

Outcome of papillary thyroid microcarcinoma: Study of 1,990 cases

Zhang

Wei

et al. 2015

Molecular and Clinical Oncology

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Abstract. The present study examines the requirement of prophylactic neck node dissection in papillary thyroid microcarcinoma (PTMC) patients by analyzing high-risk factors of neck lymph node metastasis in PTMC. The clinical pathological data was a review of 1,990 patients diagnosed between January 2013 and January 2014. The data included information on patient gender, age, tumor size, multifocal, tumor pathological staging, bilateral thyroid cancer, the subtypes, BRAF V600E mutation, human telomerase reverse transcriptase (hTERT), extrathyroidal invasion and neck lymph node metastasis. The univariate analysis (χ 2 test) showed that a number of factors were significantly associated with neck lymph node metastasis in PTMC (P<0.05): Male gender, aged <45 years, extrathyroidal invasion, bilateral thyroid cancer, various subtypes (package type, follicular variant, diffuse sclerosing variant, eosinophils, tall cell and column variant), BRAF V600E mutation-positive, hTERT mutation-positive, pt3/4 and multifocality. The multivariate analysis (regression binary logistic) showed that the male gender, <45 years, tumor size >5 mm, extrathyroidal invasion, bilateral thyroid tumors, multifocality, BRAF V600E mutation-positive, hTERT mutation-positive and pt3/4 are associated with the neck lymph node metastasis in PTMC (P<0.05). These paired analysis results show that the subtypes of PTMC with tumor size >5 mm is more common than the specific types of PTMC in which the tumor is ≤5 mm in neck lymph node metastasis. The neck lymph node metastasis incidence of the >45 years age group patients without high-risk factors in PTMC is 8.13 and 6.80%, respectively. In conclusion, PTMC patients with high-risk factors only are recommended to undergo a prophylactic lymph node dissection.

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“…Preferimos avaliar presença de linfonodos no compartimento central e lateral pela ultrassonografia pré-operatória. Observamos no intraoperatório toda região e cadeias júgulo-carotídeas, realizamos exame de congelação em eventuais linfonodos encontrados e, se confirmada metástase, preferimos o esvaziamento de todo compartimento central e não apenas "Picking procedure", afinal tal procedimento é incompleto e está associado a maior freqüência de recorrência (26,27). A reabordagem do compartimento central, já manipulado, devido à recorrência, certamente eleva o percentual do hipoparatireodismo e principalmente o de lesão do nervo recorrente (28 foi comprovado que linfadenopatia metastática com rotura capsular apresenta pior prognóstico (29).…”

Section: Discussionunclassified

Microcarcinoma da tireóide: experiência e conduta em clínica privada

Friguglietti

Kulcsar

2007

Arq Bras Endocrinol Metab

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RESUMO), e 313 a iodoterapia (94,27%). Tivemos metástase a distância em 5 pacientes (1,5%). Após 1 ano, de 170 pacientes submetidos à PCI, temos 141 considerados livres de doença, 21 com anti-tireoglobulina positivo, 6 com tireoglobulina superior a 2 ng/ml, sendo 1 com metástase pulmonar e outro com recidiva linfonodal (0,3%). Conclusão: Recomendamos que seja realizada a tireoidectomia total, esvaziamento cervical de necessidade e iodoterapia ablativa na presença de fatores clínicos e anátomo-patológicos de risco. Objective: The study of papillary microcarcinoma observed during the thyroidectomies in our private clinic. Material and methods: We reviewed clinical and histopathological results of 1,930 consecutive patients submitted for thyroidectomies in the period from 2002 to 2006, 606 had thyroid carcinomas but only 332 were papillary microcarcinoma. We studied gender, age, histologic type, size, multifocality, frequency of neck dissection, and results of Whole Body Scan and thyroglobulin. Results: Overall, we found 48 males and 146 older than 45 years old. Therapy included total thyroidectomy for all, therapeutic neck dissection in 19 (5.72%), and radioiodine for 313 (94.27%). We found 5 patients with distant metastases (1.5%). After 1 year, from 170 submitted to WBS, we consider 141 free of disease, 21 have positive thyroglobulin antibody, 6 have thyroglobulin level above 2 ng/ml, being 1 with lung metastases and other with lymph node recurrence (0.3%). Conclusion: We recommend total thyroidectomy, therapeutic neck dissection and radioiodine ablation when present clinical and pathological risk factors.

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The Importance of Central Compartment Elective Lymph Node Excision in the Staging and Treatment of Papillary Thyroid Cancer

Cited by 159 publications

References 21 publications

Prophylactic central lymph node dissection in differentiated thyroid cancer

Prophylactic central lymph node dissection in differentiated thyroid cancer

Outcome of papillary thyroid microcarcinoma: Study of 1,990 cases

Microcarcinoma da tireóide: experiência e conduta em clínica privada

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