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Park JO, Kim JH, Joo YH, Kim SY, Kim GJ, Kim HB, Lee DH, Hong HJ, Park YM, Chung EJ, Ji YB, Oh KH, Lee HS, Lee DK, Park KN, Ban MJ, Kim BH, Kim DH, Cho JK, Ahn DB, Kim MS, Seok JG, Jang JY, Choi HG, Kim HJ, Park SJ, Jung EK, Kim YS, Hong YT, Lee YC, Won HR, Shin SC, Baek SK, Kwon SY. Guideline for the Surgical Management of Locally Invasive Differentiated Thyroid Cancer From the Korean Society of Head and Neck Surgery. Clin Exp Otorhinolaryngol 2023; 16:1-19. [PMID: 36634669 PMCID: PMC9985989 DOI: 10.21053/ceo.2022.01732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/11/2023] [Indexed: 01/12/2023] Open
Abstract
The aim of this study was to develop evidence-based recommendations for determining the surgical extent in patients with locally invasive differentiated thyroid cancer (DTC). Locally invasive DTC with gross extrathyroidal extension invading surrounding anatomical structures may lead to several functional deficits and poor oncological outcomes. At present, the optimal extent of surgery in locally invasive DTC remains a matter of debate, and there are no adequate guidelines. On October 8, 2021, four experts searched the PubMed, Embase, and Cochrane Library databases; the identified papers were reviewed by 39 experts in thyroid and head and neck surgery. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of evidence, and to develop and report recommendations. The strength of a recommendation reflects the confidence of a guideline panel that the desirable effects of an intervention outweigh any undesirable effects, across all patients for whom the recommendation is applicable. After completing the draft guidelines, Delphi questionnaires were completed by members of the Korean Society of Head and Neck Surgery. Twenty-seven evidence-based recommendations were made for several factors, including the preoperative workup; surgical extent of thyroidectomy; surgery for cancer invading the strap muscles, recurrent laryngeal nerve, laryngeal framework, trachea, or esophagus; and surgery for patients with central and lateral cervical lymph node involvement. Evidence-based guidelines were devised to help clinicians make safer and more efficient clinical decisions for the optimal surgical treatment of patients with locally invasive DTC.
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Affiliation(s)
- Jun-Ook Park
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joo Hyun Kim
- Department of Otolaryngology-Head and Neck Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Young Hoon Joo
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang-Yeon Kim
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Geun-Jeon Kim
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Bum Kim
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Hyun Lee
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Jun Hong
- Department of Otolaryngology-Head and Neck Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Young Min Park
- Department of Otolaryngology-Head and Neck Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Eun-Jae Chung
- Department of Otolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Bae Ji
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Kyoung Ho Oh
- Department of Otolaryngology-Head and Neck Surgery, Korea University College of Medicine, Seoul, Korea
| | - Hyoung Shin Lee
- Department of Otolaryngology-Head and Neck Surgery, Kosin University College of Medicine, Busan, Korea
| | - Dong Kun Lee
- Department of Otolaryngology-Head and Neck Surgery, Dong-A University College of Medicine, Busan, Korea
| | - Ki Nam Park
- Department of Otolaryngology-Head and Neck Surgery, Soonchunhyang University College of Medicine, Asan, Korea
| | - Myung Jin Ban
- Department of Otolaryngology-Head and Neck Surgery, Soonchunhyang University College of Medicine, Asan, Korea
| | - Bo Hae Kim
- Department of Otolaryngology-Head and Neck Surgery, Dongguk University College of Medicine, Goyang, Korea
| | - Do Hun Kim
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Inje University, Busan, Korea
| | - Jae-Keun Cho
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Inje University, Busan, Korea
| | - Dong Bin Ahn
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Min-Su Kim
- Department of Otolaryngology-Head and Neck Surgery, CHA University School of Medicine, Seongnam, Korea
| | - Jun Girl Seok
- Department of Otolaryngology-Head and Neck Surgery, National Cancer Center, Goyang, Korea
| | - Jeon Yeob Jang
- Department of Otolaryngology-Head and Neck Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Hyo Geun Choi
- Department of Otolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Hee Jin Kim
- Department of Otolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Sung Joon Park
- Department of Otolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Eun Kyung Jung
- Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Medical School, Kwangju, Korea
| | - Yeon Soo Kim
- Department of Otolaryngology-Head and Neck Surgery, Konyang University College of Medicine, Daejeon, Korea
| | - Yong Tae Hong
- Department of Otolaryngology-Head and Neck Surgery, Jeonbuk National University Medical School, Jeonju, Korea
| | - Young Chan Lee
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Ho-Ryun Won
- Department of Otolaryngology-Head and Neck Surgery, Chungnam National University College of Medicine, Daejeon, Korea
| | - Sung-Chan Shin
- Department of Otolaryngology-Head and Neck Surgery, Pusan National University School of Medicine, Yangsan, Korea
| | - Seung-Kuk Baek
- Department of Otolaryngology-Head and Neck Surgery, Korea University College of Medicine, Seoul, Korea
| | - Soon Young Kwon
- Department of Otolaryngology-Head and Neck Surgery, Korea University College of Medicine, Seoul, Korea
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Das R, Rahman T, Das AK, Das K, Das A, Kakati K, Das R. Pattern of Nodal Metastasis in Relation to Size of the Primary Tumour in Well-Differentiated Thyroid Carcinoma. Indian J Otolaryngol Head Neck Surg 2022; 74:2435-2439. [PMID: 36452724 PMCID: PMC9702493 DOI: 10.1007/s12070-020-02167-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 09/21/2020] [Indexed: 11/25/2022] Open
Abstract
This study was conducted to see the pattern of neck node metastasis in relation to the size of primary tumour in Well-differentiated thyroid cancer. A prospective study on 50 patients was carried out in the Department of Head and Neck Surgery, Dr B. Borooah Cancer Institute from 1st August, 2018 to 31st July, 2019. All new cases who had not previously received treatment were included which were histopathogically proven. Residual and recurrent cases were not taken into account. Most common age-group affected was 21-30 years (24%). It was more common in females (84%). Papillary thyroid cancer has been found to be the most common histological type of WDTC (88%), out of which the classical variant of PTC constitute 72%. 46% of them had tumour size > 4 cm 88% cases had cervical neck node metastases, out of which 72% were unilateral and 16% were bilateral. The commonest level involved was level VI. There is a definite correlation (clinical and histological) between increased involvement of positivity of lymph node in relation to size of the primary tumour in well-differentiated thyroid carcinoma.
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Affiliation(s)
- Rajjyoti Das
- Department of Head and Neck Surgery, B Borooah Cancer Institute, House No 10, Gopal Phukan Path, Ajanta Path, Beltola, Guwahati, Assam 781028 India
| | - Tashnin Rahman
- Department of Head and Neck Surgery, B Borooah Cancer Institute, House No 10, Gopal Phukan Path, Ajanta Path, Beltola, Guwahati, Assam 781028 India
| | - Ashok Kumar Das
- Department of Head and Neck Surgery, B Borooah Cancer Institute, House No 10, Gopal Phukan Path, Ajanta Path, Beltola, Guwahati, Assam 781028 India
| | - Kishore Das
- Department of Head and Neck Surgery, B Borooah Cancer Institute, House No 10, Gopal Phukan Path, Ajanta Path, Beltola, Guwahati, Assam 781028 India
| | - Anupam Das
- Department of Head and Neck Surgery, B Borooah Cancer Institute, House No 10, Gopal Phukan Path, Ajanta Path, Beltola, Guwahati, Assam 781028 India
| | - Kaberi Kakati
- Department of Head and Neck Surgery, B Borooah Cancer Institute, House No 10, Gopal Phukan Path, Ajanta Path, Beltola, Guwahati, Assam 781028 India
| | - Rupjyoti Das
- Department of Head and Neck Surgery, B Borooah Cancer Institute, House No 10, Gopal Phukan Path, Ajanta Path, Beltola, Guwahati, Assam 781028 India
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Khafif A, Yosef LM. Para-tracheal neck dissection - is dissection of the upper part of level Ⅵ necessary? World J Otorhinolaryngol Head Neck Surg 2020; 6:171-175. [PMID: 33073212 PMCID: PMC7548385 DOI: 10.1016/j.wjorl.2020.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 02/16/2020] [Indexed: 01/06/2023] Open
Abstract
Papillary thyroid carcinoma (PTC) has a high propensity for regional metastases, however, the impact of such metastases on the outcome of the patients is minimal. The central compartment of the neck is considered the first and the most common echelon of metastases from thyroid carcinoma. Physical examination along with ultrasonography are the gold standard pre-operative evaluation of patients with PTC. Ultrasonography is highly sensitive in evaluating lateral neck nodes, however, its value in evaluating the central compartment is limited, resulting in a relatively high rate of occult metastases in this compartment. The main potential complications of para-tracheal neck dissection (PTND) are recurrent laryngeal nerve paralysis and hypocalcemia and these may be higher in patients undergoing PTND compared to thyroidectomy alone. New histological data is available showing no evidence of lymph nodes in the central compartment above a level parallel to the inferior border of the cricoid cartilage. These findings support withholding dissection of the upper para-tracheal region routinely as a part of PTND in patients with well-differentiated thyroid cancer. By doing that, the complications may be lower and identical to thyroidectomy alone, thus may abolish arguments against more common use of elective PTND in patients with thyroid carcinoma.
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Affiliation(s)
- Avi Khafif
- The Head and Neck Surgery and Oncology Unit, A.R.M Center for Otolaryngology Head and Neck Surgery, Assuta Medical Center, Affiliated with Ben Gurion University of the Negev, Tel Aviv, Israel
| | - Liron Malka Yosef
- The Head and Neck Surgery and Oncology Unit, A.R.M Center for Otolaryngology Head and Neck Surgery, Assuta Medical Center, Affiliated with Ben Gurion University of the Negev, Tel Aviv, Israel.,Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Affiliated with the Hebrew University of Jerusalem, Rehovot, Israel
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Clinical features and therapeutic outcomes of patients with papillary thyroid microcarcinomas and larger tumors. Nucl Med Commun 2019; 40:477-483. [PMID: 30973839 DOI: 10.1097/mnm.0000000000000991] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The aim of this study was to identify clinical features and therapeutic outcomes of patients with papillary thyroid cancer (PTC) according to tumor diameter and evaluate the correlation of neck lymph node (LN) involvement of papillary thyroid microcarcinoma (PTMC) according to patients' age. PATIENTS AND METHODS We divided 467 patients into two groups according to tumor diameter: PTMC group (≤1 cm) and non-PTMC group (>1 cm). The clinical data were analyzed retrospectively. Thereafter, we divided the PTMC patients into three subgroups according to age: young subgroup (<45 years), middle subgroup (45-54 years), and old subgroup (≥55 years). A further study about clinical features, especially the neck LN involvement in three subgroups, was analyzed. RESULTS All patients received radioiodine ablation at least once. There were more patients with a single cancer lesion and cancer in the unilateral lobe, less number of neck LN involvement, fewer patients with neck lymph node metastasis (LNM), and more patients with Hashimoto's thyroiditis in PTMC group than in non-PTMC group. At the further evaluation, 58.03% patients maintained clinical remission, which was more in the PTMC group than in non-PTMC group. There was no significant difference in recurrence, but the disease-free survival rate of patients in the PTMC group was higher than in the non-PTMC group. In the PTMC group, the radioactive iodine curative ratio in younger patients is lower than that in the other two subgroups. Both the LNM and central LNM (CLNM) rates were significantly higher in young patients compared with older patients. In addition, the LNM-positive group had more male patients, larger tumor size, and higher thyroglobulin antibody level. Both LNM and the CLNM rates were significantly higher in the young subgroup than in the older subgroup. Young and middle age and extrathyroid extension were independent risk factors for neck LNM. Unlike LNM, young age, extrathyroid extension, and male sex were independent risk factors for CLNM. CONCLUSION Some PTMCs were less aggressive and the therapeutic outcomes of them were better than non-PTMC. Moreover, PTMCs in young patients were more aggressive, especially in LNM. Hence, clinicians should consider an individualized treatment according to tumor characteristics and age to achieve better therapeutic efficacy.
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Liu C, Wang S, Zeng W, Guo Y, Liu Z, Huang T. Total tumour diameter is superior to unifocal diameter as a predictor of papillary thyroid microcarcinoma prognosis. Sci Rep 2017; 7:1846. [PMID: 28500312 PMCID: PMC5431972 DOI: 10.1038/s41598-017-02165-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 04/07/2017] [Indexed: 01/05/2023] Open
Abstract
The current American Joint Committee (AJCC) on Cancer TNM classification does not describe the treatment of multifocal papillary thyroid microcarcinomas (PTMCs) with a total tumour diameter (TTD) >1 cm. Herein, we investigated this PTMC subgroup in terms of extrathyroidal extension (ETE), local infiltration, central lymph node metastasis (LNM), and prognosis. Consecutive patients (n = 1102) were identified and the proportions of LNM, ETE, and local infiltration were similar between PTCs with a unifocal tumour diameter >1 cm and ≤2 cm and PTMCs with a multifocal TTD >1 cm and ≤2 cm. The proportions of LNM, ETE, and local infiltration were also similar between PTMCs with a unifocal diameter ≤1 cm vs. multifocal TTD ≤1 cm. However, when comparing PTMCs with a unifocal diameter ≤1 cm vs. multifocal TTD >1 cm, significant differences were observed. In the Kaplan-Meier analysis, significant differences were observed between PTMCs with a unifocal diameter ≤1 cm vs. multifocal TTD >1 cm and multifocal TTD ≤1 cm vs. multifocal TTD >1 cm. Accordingly, TTD may represent a more accurate criterion for tumour size of PTCs and should be considered in the revised AJCC staging system.
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Affiliation(s)
- Chunping Liu
- Department of Breast and Thyroid Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Shuntao Wang
- Department of Breast and Thyroid Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Wen Zeng
- Department of Ophthalmology, Zhongnan Hospital, Wuhan University, Wuhan, Hubei, China
| | - Yawen Guo
- Department of Breast and Thyroid Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Zeming Liu
- Department of Breast and Thyroid Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China.
| | - Tao Huang
- Department of Breast and Thyroid Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China.
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Kruijff S, Petersen JF, Chen P, Aniss AM, Clifton-Bligh RJ, Sidhu SB, Delbridge LW, Gill AJ, Learoyd D, Sywak MS. Patterns of structural recurrence in papillary thyroid cancer. World J Surg 2014; 38:653-9. [PMID: 24149717 DOI: 10.1007/s00268-013-2286-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Papillary thyroid carcinoma (PTC) is uncommonly associated with tumor-related mortality, although local recurrence can be a frequent and difficult problem. This study was conducted to clarify the pattern of structural locoregional recurrence in PTC. MATERIAL AND METHOD A retrospective cohort study of patients undergoing surgical intervention for PTC was undertaken. Data were collected from a comprehensive thyroid cancer database maintained within a single tertiary referral center. The primary outcome measure was cancer recurrence requiring surgical intervention. Secondary outcome measures were site of recurrence, time to recurrence, and risk factors for recurrence. RESULTS In the period 1980-2013, 1,183 patients with PTC were included in the study. The overall rate of structural recurrence requiring reoperative surgery was 7.9 %. The median time to reoperation was 31 months. Younger age, male gender, large primary tumor diameter, and number of positive lymph nodes at initial presentation were all significantly associated with disease recurrence. The lateral compartments (levels I, II, III, IV, V) were involved almost twice as frequently as the central compartment (level VI) (67 vs 32 %, P < 0.01). The distribution of recurrences was level I (1 %), level II (12 %), level III (18 %), level IV (18 %), level V (17 %), level VI (32 %), level VII (2 %). CONCLUSIONS In a center with a liberal approach to central compartment lymph node dissection for PTC, the lateral neck compartment is the most common site of structural recurrence requiring reoperative surgery.
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Affiliation(s)
- Schelto Kruijff
- University of Sydney Endocrine Surgery Unit, Royal North Shore Hospital, Suite 202, 69 Christie St., St. Leonards, Sydney, NSW, 2065, Australia,
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Lang BHH, Ng SH, Lau LLH, Cowling BJ, Wong KP, Wan KY. A systematic review and meta-analysis of prophylactic central neck dissection on short-term locoregional recurrence in papillary thyroid carcinoma after total thyroidectomy. Thyroid 2013; 23:1087-98. [PMID: 23402640 DOI: 10.1089/thy.2012.0608] [Citation(s) in RCA: 149] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Prophylactic central neck dissection (pCND) at the time of total thyroidectomy (TT) remains controversial in clinically node-negative (cN0) papillary thyroid carcinoma (PTC). Despite occult central lymph node metastases being common, it is unclear if removing these metastases initially would reduce future locoregional recurrence (LRR). This systematic review and meta-analysis aimed at comparing the short-term LRR between patients who underwent TT with pCND and those who underwent TT alone. METHODS A systematic review of the literature was performed to identify studies comparing LRR between patients with PTC who underwent TT + pCND (group A) and those who underwent TT alone (group B). Inclusion criteria were cN0 patients, with each comparative group containing > 10 patients, and with the number of LRR and mean follow-up duration available. The pooled incidence rate ratio (IRR) was used for calculating the LRR rate between the two groups. Other parameters evaluated included postoperative radioiodine (RAI) ablation, surgically related complications, and overall morbidity. Meta-analysis was performed using a fixed-effects model. RESULTS Fourteen studies matched the selection criteria. Of the 3331 patients, 1592 (47.8%) belonged to group A, while 1739 (52.2%) belonged to group B. Relative to group B, group A was significantly more likely to have postoperative RAI ablation (71.7% vs. 53.1%; odds ratio [OR] = 2.60 [95% confidence interval (CI) = 2.12-3.18]), temporary hypocalcemia (26.0% vs. 10.8%; OR = 2.56 [CI = 2.04-3.21]), and overall morbidity (33.2% vs. 17.7%; OR = 2.12 [CI = 1.75-2.57]). When temporary hypocalcemia was excluded, overall morbidity was similar between the two groups (7.3% vs. 6.8%; OR = 1.07 [CI = 0.78-1.47]). Group A had a significantly lower risk of LRR than group B (4.7% vs. 8.6%; IRR = 0.65 [CI = 0.48-0.86]). CONCLUSIONS Group A was more likely to have postoperative RAI ablation, temporary hypocalcemia, and overall morbidity than group B. Temporary hypocalcemia was the major surgical morbidity in pCND and, when excluded, the overall morbidity appeared similar between the two groups. Although our meta-analysis would suggest that those who undergo TT + pCND may have a 35% reduction in risk of LRR than those who undergo TT alone in the short term (< 5 years), it remains unclear how much of this risk reduction is related to increased use of RAI ablation and potential selection bias in some of the studies examined.
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Ito Y, Fukushima M, Higashiyama T, Kihara M, Takamura Y, Kobayashi K, Miya A, Miyauchi A. Tumor size is the strongest predictor of microscopic lymph node metastasis and lymph node recurrence of N0 papillary thyroid carcinoma. Endocr J 2013; 60:113-7. [PMID: 22972223 DOI: 10.1507/endocrj.ej12-0311] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
It is well-known that papillary thyroid carcinoma (PTC) frequently metastasizes to the regional (central and lateral) lymph nodes, even though it is diagnosed as node-negative on preoperative imaging studies. In this study, we investigated predictors of microscopic node metastasis and lymph node recurrence of PTC without node metastasis detected preoperatively (N0). Of the clinicopathological features that can be evaluated pre- and intraoperatively, tumor size (> 2 cm) was the strongest predictor of microscopic central and lateral node metastasis on multivariate logistic analysis. Also, the tumor size most markedly affected lymph node recurrence, but not distant recurrence. Lymph node recurrence may not be immediately life-threatening, but it can be a stressor both for physicians and patients. Therefore, careful lymph node dissection is recommended for PTC with a large size, even though it is prophylactic.
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Affiliation(s)
- Yasuhiro Ito
- Department of Surgery, Kuma Hospital, Kobe 650-0011, Japan.
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Rajeev P, Ahmed S, Ezzat TM, Sadler GP, Mihai R. The number of positive lymph nodes in the central compartment has prognostic impact in papillary thyroid cancer. Langenbecks Arch Surg 2012; 398:377-82. [DOI: 10.1007/s00423-012-1041-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 12/11/2012] [Indexed: 01/08/2023]
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Moreno MA, Edeiken-Monroe BS, Siegel ER, Sherman SI, Clayman GL. In papillary thyroid cancer, preoperative central neck ultrasound detects only macroscopic surgical disease, but negative findings predict excellent long-term regional control and survival. Thyroid 2012; 22:347-55. [PMID: 22280230 PMCID: PMC3968956 DOI: 10.1089/thy.2011.0121] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Ultrasound (US) of the central neck compartment (CNC) is considered of limited sensitivity for nodal spread in papillary thyroid cancer (PTC); elective neck dissection is commonly advocated even in the absence of sonographic abnormalities. We hypothesized that US is an accurate predictor for long-term disease-free survival, regardless of the use of elective central neck dissection in patients with PTC. METHODS A retrospective chart review of 331 consecutive PTC patients treated with total thyroidectomy at M.D. Anderson Cancer Center between 1996 and 2003 was performed. Information retrieved included preoperative sonographic status of the CNC, surgical treatment of the neck, demographics, cancer staging, histopathological variables and use of adjuvant treatment. The endpoints for the study were nodal recurrence and survival. RESULTS There were 112 males and 219 females with a median age of 44 years (range 11-87). The median follow-up time for the series was 71.5 months (range 12.7-148.7). There were 151 (45.6%) patients with a T1, 58 (17.5%) with a T2, 70 (21.1%) with a T3, and 52 (15.7%) with a T4. Preoperative sonographic abnormalities were present in the CNC in 79 (23.9%) patients. During the surveillance period, 11 (3.2%) patients recurred in the central neck, with an average time for recurrence of 22.8 months. Advanced T stage (T3/T4) and abnormal US were independent prognostic factors for recurrence in the central neck (p=0.013 and p=0.005 respectively). There were 119 (35%) patients with a sonographically negative central compartment who underwent elective central neck dissection; 85 of them (71.4%) were found to be histopathologically N(+) while 34 (28.6%) were pN0. There were no differences in overall survival (p=0.32), disease specific survival (DSS; p=0.49), and recurrence-free survival (p=0.32) between these two groups. Preoperative US of the CNC was an age-independent predictor for overall survival (p<0.001), DSS (p=0.0097), and disease-free survival (p=0.0005) on bivariate Cox regression. CONCLUSIONS US of the central compartment is an age-independent predictor for survival and CNC recurrence-free survival in PTC. Prophylactic neck dissection of the central compartment does not improve long-term disease control, regardless of the histopathological status of the lymph nodes retrieved. Our findings emphasize the ability of US to clinically detect relevant nodal disease and support conservative management of the CNC in the absence of abnormal findings.
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Affiliation(s)
- Mauricio A. Moreno
- Department of Otolaryngology/Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Beth S. Edeiken-Monroe
- Department of Diagnostic Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Eric R. Siegel
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Steven I. Sherman
- Department of Endocrine Neoplasia, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Gary L. Clayman
- Department of Head and Neck Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
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Creach KM, Siegel BA, Nussenbaum B, Grigsby PW. Radioactive iodine therapy decreases recurrence in thyroid papillary microcarcinoma. ISRN ENDOCRINOLOGY 2012; 2012:816386. [PMID: 22462017 PMCID: PMC3313572 DOI: 10.5402/2012/816386] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Accepted: 11/24/2011] [Indexed: 11/23/2022]
Abstract
Background. The most appropriate therapy for papillary microcarcinoma (PMC) is controversial. Methods. We reviewed the therapy and outcome of 407 patients with PMC. Results. Three hundred-eighty patients underwent total thyroidectomy, and 349 patients received I-131 therapy. The median followup was 5.3 years. Forty patients developed recurrent disease. On univariate analysis, development of disease recurrence was correlated with histological tumor size > 0.8 cm (P = 0.0104), age < 45 years (P = 0.043), and no I-131 therapy (P < 0.0001). On multivariate analysis, histological tumor size > 0.8 cm, positive lymph nodes, and no I-131 therapy were significant. The 5-year RFS for patients treated with I-131 was 95.0% versus 78.6% (P < 0.0001) for patients not treated with I-131. Patients with lymph node metastasis who did not receive I-131 had a 5-year RFS of 42.9% versus 93.2% (P < 0.0001) for patients who received I-131. Conclusions. Recommend I-131 remnant ablation for patients with PMC, particularly patients with lymph node metastasis.
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Affiliation(s)
- Kimberly M Creach
- Department of Radiation Oncology, Washington University School of Medicine, 4921 Parkview Place, Mailstop no. 90-38-635, St. Louis, MO 63110, USA
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Mulla M, Schulte KM. Central cervical lymph node metastases in papillary thyroid cancer: a systematic review of imaging-guided and prophylactic removal of the central compartment. Clin Endocrinol (Oxf) 2012; 76:131-6. [PMID: 21722150 DOI: 10.1111/j.1365-2265.2011.04162.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Papillary thyroid cancer (PTC) is a common endocrine cancer and commonly presents with lymph node (LN) metastases. The role of surgical removal of the central cervical LN compartment is poorly defined. There are no prospective randomized controlled trials addressing the relevance to the extent of the initial surgical approach. DESIGN AND METHODS A systematic review of studies of patients with PTC undergoing either prophylactic or therapeutic lymphadenectomy of the central LNs was carried out. Studies involving imaging modalities in the detection of LNs in PTC were also analysed. RESULTS Twenty-one studies contained data on 4188 patients undergoing prophylactic or imaging-guided removal of the central compartment. Imaging-guided surgery retrieved cancerous central LNs in 346 or 30% of eligible patients, whilst prophylactic central neck dissection yielded histopathological proof of cancer in 898 or 26·2% of patients. Five imaging studies revealed data on the use of ultrasound (US) and/or computerized tomography (CT). The sensitivity of US and CT was poor, ranging from 50% to 70% when accurately calculated. CONCLUSION Metastatic central LNs are found in nearly half of all patients with PTC when prophylactic central lymph node dissection (CLND) is performed. With unreliable imaging modalities, prophylactic CLND should be performed on all patients with PTC.
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Affiliation(s)
- Mubashir Mulla
- Department of Endocrine Surgery, King's College Hospital, Denmark Hill, London, UK.
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Central compartment dissection for well differentiated thyroid cancer … and the band plays on. Curr Opin Otolaryngol Head Neck Surg 2011; 19:106-12. [PMID: 21252666 DOI: 10.1097/moo.0b013e328343af58] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The role of central compartment dissection in the surgical management of well differentiated thyroid cancer is controversial. Lack of high-quality prospective studies results in management decisions being based on expert opinions and weaker levels of evidence. The American Thyroid Association has recently revised its management guidelines with particular emphasis on this topic, and a separate working group has set out to define the surgical anatomy that encompasses this procedure. RECENT FINDINGS Central compartment dissection comprises the removal of nodal tissue from the prelaryngeal, pretracheal and paratracheal compartments, with no role for berry-picking procedures. There is universal agreement that therapeutic nodal dissection should be performed in patients with metastatic disease detected either through preoperative imaging or during intraoperative evaluation of the central compartment, with either visual inspection or frozen-section pathology. In contrast, there may be limited benefit from routine prophylactic central compartment dissection, for either disease recurrence or survival outcomes. As such, it should be performed only in patients deemed high risk: larger tumors, extra-thyroidal extension or aggressive histologic subtypes. SUMMARY Future studies should focus on identifying the subpopulation of patients who would most benefit from these procedures and spare low-risk patients from the unwanted complications.
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Pattern and risk factors of central compartment lymph node metastasis in papillary thyroid cancer: a prospective study from an endocrine surgery centre. J Thyroid Res 2011; 2012:436243. [PMID: 21977331 PMCID: PMC3184406 DOI: 10.1155/2012/436243] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 08/04/2011] [Accepted: 08/04/2011] [Indexed: 01/09/2023] Open
Abstract
Lymphatic metastasis in papillary thyroid cancer (PTC) is eminent; however, the extent of central compartment lymph nodes dissection (CCD) is controversial and requires the knowledge of pattern and risk factors for central compartment lymph nodes metastasis (CCM). We did a prospective study of 47 cases with PTC who underwent total thyroidectomy (TT) with CCD with/without lateral lymph nodes dissection (LND). Clinicopathological profile including CCM as ipsilateral and contralateral was documented. On histopathology, the mean tumour size was 3.57 ± 2.42 cm 59.6% had CCM, which was bilateral in the majority (60.72%). The tumour-size was the most important predictor for lymph nodes metastasis-(P=0.018) whereas multicentricity-(P=0.002) and ipsilateral CCM-(P=0.001) were the predictors for contralateral CCM. The long-term morbidity of CCD done in primary setting is comparable with TT-alone. Bilateral CCD should be done with thyroidectomy in PTC, otherwise the risk of residual diseases and subsequent recurrence is high. The long-term morbidity is comparable in experienced hands.
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The role of prophylactic central neck dissection in differentiated thyroid carcinoma: issues and controversies. JOURNAL OF ONCOLOGY 2011; 2011:127929. [PMID: 21977029 PMCID: PMC3184411 DOI: 10.1155/2011/127929] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Accepted: 07/18/2011] [Indexed: 11/17/2022]
Abstract
Prophylactic central neck dissection (pCND) in differentiated thyroid carcinoma (DTC) is one of the most controversial surgical subjects in recent times. To date, there is little evidence to support the practice of pCND in patients with DTC undergoing total thyroidectomy. Although the recently revised American Thyroid Association (ATA) guideline has clarified many inconsistencies regarding pCND and has recommended pCND in “high-risk” patients, many issues and controversies surrounding the subject of pCND in DTC remain. The recent literature has revealed an insignificant trend toward lower recurrence rate in patients with DTC who undergo total thyroidectomy and pCND than those who undergo total thyroidectomy alone. However, this was subjected to biases, and there are concerns whether pCND should be performed by all surgeons who manage DTC because of increased surgical morbodity. Performing a unilateral pCND may be better than a bilateral pCND given its lower surgical morbidity. Further studies in this controversial subject are much needed.
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Well-differentiated thyroid carcinomas: management of the central lymph node compartment and emerging biochemical markers. JOURNAL OF ONCOLOGY 2011; 2011:705305. [PMID: 21969828 PMCID: PMC3182563 DOI: 10.1155/2011/705305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 08/07/2011] [Indexed: 01/21/2023]
Abstract
Well-differentiated thyroid cancers (WDTCs) are generally indolent cancers that are associated with a low mortality. Although the incidence of these tumors is increasing, there has not been an associated increase in the mortality rates. As we gain a greater understanding and more experience with these good prognosis cancers, the way in which we treat these tumors is evolving. The definition of persistent or recurrent disease has seen a shift from being a clinical and/or radiological diagnosis to now one based on a biochemical blood marker, thyroglobulin. Central lymph node metastases are a very common problem in WDTC, being present in up to 90% of patients. The optimal surgical management of the central lymph node compartment remains a hotly debated topic. This paper identifies these controversies and presents available data surrounding these issues. Biochemical tumor markers are gaining wider use in practice and in time hopefully provide more specific information with which surgical decision-making can be based. A summary of the clinically available markers is presented.
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Bozec A, Dassonville O, Chamorey E, Poissonnet G, Sudaka A, Peyrottes I, Ettore F, Haudebourg J, Bussière F, Benisvy D, Marcy PY, Sadoul JL, Hofman P, Lassale S, Vallicioni J, Demard F, Santini J. Clinical impact of cervical lymph node involvement and central neck dissection in patients with papillary thyroid carcinoma: a retrospective analysis of 368 cases. Eur Arch Otorhinolaryngol 2011; 268:1205-1212. [PMID: 21607578 DOI: 10.1007/s00405-011-1639-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Accepted: 05/10/2011] [Indexed: 11/25/2022]
Abstract
The impact of cervical lymph node metastases and the optimal surgical management of the neck in patients with papillary thyroid carcinoma (PTC) remain controversial. The objectives of this retrospective study were to determine, in patients with PTC, the predictive factors and the impact on tumor recurrence rate of cervical lymph node involvement, and to evaluate the oncologic results and the morbidity of central neck dissection (CND). We reviewed the records of patients who had undergone surgical treatment for PTC at our institution between 1990 and 2000. A total of 368 patients (86 men and 282 women) were included in this study. Young age (p = 0.02), tumor size (p = 0.001) and extrathyroidal tumor extension (p = 0.003) were significant predictive factors of cervical lymph node metastatic involvement (multivariate analysis). Initial metastatic cervical lymph node involvement was identified as an independent risk factor of tumor recurrence (multivariate analysis, p = 0.01). Metastatic lymph node(s) were found in prophylactic CND specimens in 31% of the patients. CND increased the risk of postoperative hypocalcemia (p = 0.008) and of permanent hypoparathyroidism (p = 0.002). In conclusion, cervical lymph node metastatic involvement at the time of initial surgery is an independent risk factor of tumor recurrence. CND provided an up-staging of more than 30% of patients with a clinically N0 neck, but was associated with significant morbidity regarding parathyroid function.
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Affiliation(s)
- Alexandre Bozec
- Département de Chirurgie, Institut Universitaire de la Face et du Cou, Centre Antoine Lacassagne, 33 avenue de Valombrose, 06189, Nice, France.
| | - Olivier Dassonville
- Département de Chirurgie, Institut Universitaire de la Face et du Cou, Centre Antoine Lacassagne, 33 avenue de Valombrose, 06189, Nice, France
| | - Emmanuel Chamorey
- Département de Statistiques Médicales, Centre Antoine Lacassagne, 33 avenue de Valombrose, 06189, Nice, France
| | - Gilles Poissonnet
- Département de Chirurgie, Institut Universitaire de la Face et du Cou, Centre Antoine Lacassagne, 33 avenue de Valombrose, 06189, Nice, France
| | - Anne Sudaka
- Département d'Anatomie Pathologique, Centre Antoine Lacassagne, 33 avenue de Valombrose, 06189, Nice, France
| | - Isabelle Peyrottes
- Département d'Anatomie Pathologique, Centre Antoine Lacassagne, 33 avenue de Valombrose, 06189, Nice, France
| | - Francette Ettore
- Département d'Anatomie Pathologique, Centre Antoine Lacassagne, 33 avenue de Valombrose, 06189, Nice, France
| | - Juliette Haudebourg
- Département d'Anatomie Pathologique, Centre Antoine Lacassagne, 33 avenue de Valombrose, 06189, Nice, France
| | - Françoise Bussière
- Département de Médecine nucléaire, Centre Antoine Lacassagne, 33 avenue de Valombrose, 06189, Nice, France
| | - Danielle Benisvy
- Département de Médecine nucléaire, Centre Antoine Lacassagne, 33 avenue de Valombrose, 06189, Nice, France
| | - Pierre-Yves Marcy
- Département d'imagerie médicale, Centre Antoine Lacassagne, 33 avenue de Valombrose, 06189, Nice, France
| | - Jean Louis Sadoul
- Service d'endocrinologie et métabolisme, Centre Hospitalier Universitaire de Nice, Hôpital Pasteur, 30 av de la voie romaine, 06002, Nice, France
| | - Paul Hofman
- Service d'anatomie pathologique clinique et expérimentale, Centre Hospitalier Universitaire de Nice, Hôpital Pasteur, 30 av de la voie romaine, 06002, Nice, France
| | - Sandra Lassale
- Service d'anatomie pathologique clinique et expérimentale, Centre Hospitalier Universitaire de Nice, Hôpital Pasteur, 30 av de la voie romaine, 06002, Nice, France
| | - Jacques Vallicioni
- Département de Chirurgie, Institut Universitaire de la Face et du Cou, Centre Antoine Lacassagne, 33 avenue de Valombrose, 06189, Nice, France
| | - François Demard
- Département de Chirurgie, Institut Universitaire de la Face et du Cou, Centre Antoine Lacassagne, 33 avenue de Valombrose, 06189, Nice, France
| | - José Santini
- Département de Chirurgie, Institut Universitaire de la Face et du Cou, Centre Antoine Lacassagne, 33 avenue de Valombrose, 06189, Nice, France
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Roh JL, Kim JM, Park CI. Central lymph node metastasis of unilateral papillary thyroid carcinoma: patterns and factors predictive of nodal metastasis, morbidity, and recurrence. Ann Surg Oncol 2011; 18:2245-50. [PMID: 21327454 DOI: 10.1245/s10434-011-1600-z] [Citation(s) in RCA: 148] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Indexed: 12/25/2022]
Abstract
BACKGROUND Although subclinical cervical lymph node (LN) metastases in papillary thyroid carcinoma (PTC) are common, the efficacy of prophylactic central LN dissection (CLND) is unclear. Few prospective studies have assessed the relationships between complete pathologic information regarding tumors and metastatic nodes in the central compartment. We therefore investigated the pattern and predictive indicators of central LN metastasis, morbidity, and recurrence in patients who underwent total thyroidectomy and prophylactic CLND for unilateral PTC and clinically node-negative neck (cN0) disease. METHODS This prospective study involved 184 patients with previously untreated unilateral PTC and cN0 who underwent total thyroidectomy and bilateral CLND. Nodal samples were divided into the prelaryngeal/pretracheal and ipsilateral and contralateral paratracheal regions, with each assessed for clinicopathologic predictors of central metastases. Postoperative morbidity and recurrence were assessed. RESULTS Rates of metastasis to ipsilateral and contralateral central compartments were 42.9 and 9.8%, respectively. Multivariate analysis showed that tumor size >1 cm and extrathyroidal extension were independent predictors of ipsilateral metastasis, and ipsilateral metastases independently predicted contralateral metastases (P < 0.05 each). Permanent hypoparathyroidism and incidental recurrent nerve paralysis were found in 1.6 and 0% of patients, respectively. After a mean follow-up of 46 months, none of these patients had recurrence in the central compartment. CONCLUSIONS Subclinical metastases are highly prevalent in the ipsilateral central neck of patients with PTC >1 cm. Contralateral central metastases, although uncommon, are associated with ipsilateral central metastases. These findings may guide the necessity and extent of prophylactic bilateral or unilateral CLND.
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Affiliation(s)
- Jong-Lyel Roh
- Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Manrique Franco K, Domínguez Fernández R, Lara Capellán JI, Renedo Pascual G, Rovira Loscos A. [Diffuse sclerosing variant of papillary thyroid carcinoma]. ACTA ACUST UNITED AC 2010; 57:500-2. [PMID: 20843752 DOI: 10.1016/j.endonu.2010.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Revised: 06/11/2010] [Accepted: 06/14/2010] [Indexed: 11/15/2022]
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Asari R, Niederle BE, Scheuba C, Riss P, Koperek O, Kaserer K, Niederle B. Indeterminate thyroid nodules: a challenge for the surgical strategy. Surgery 2010; 148:516-25. [PMID: 20338609 DOI: 10.1016/j.surg.2010.01.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 01/21/2010] [Indexed: 01/08/2023]
Abstract
BACKGROUND Because no clinical parameter can establish the final status of a cytologically indeterminate thyroid nodule (ITN) or nodal-metastases in case of malignancy, the initial surgical strategy should define an oncologically adequate procedure with low morbidity. METHODS The prognostic relevance of sex, age, tumor sizes, multifocality, thyroid function, and recurrence was analyzed in 156 consecutive patients according to the presence of malignancy and nodal metastases. The accuracy of frozen sections to reveal malignancy was determined. Clinical parameters were compared with regard to their ability to identify malignancy and nodal metastases in an ITN to determine an appropriate initial operative strategy. RESULTS One hundred and eighteen (75.6%) patients underwent (total) thyroidectomy, 37 (23.7%) patients underwent hemithyroidectomy, and 1 patient underwent isthmus resection. Fifty-five (35.3%) patients showed malignancy. First step lymphadenectomy (lymph node dissection along the recurrent laryngeal nerve before removing the thyroid lobe) was performed in 142 patients documenting 10 nodal metastases. Comparing benign and malignant ITN, no association was found for sex (P = .17), age (P = 1.0), tumor sizes (P = .33, P = .12, P = .19 for < or =30 mm, < or =40 mm, and < or =50 mm, respectively), or thyroid function (P = .26). The determination of malignancy by frozen section showed a sensitivity of 30.9% and a specificity of 100%. No permanent hypoparathyroidism or recurrent laryngeal nerve palsy was observed postoperatively. CONCLUSION Because of the failure of available clinical parameters to predict malignancy in cytologically ITN, hemithyroidectomy in unilateral goiter and thyroidectomy in bilateral goiter is recommended. Ipsilateral "first step central neck dissection" on the side of ITN offers the advantages of oncologically adequate resection and staging with a low morbidity, as well as avoids reoperation.
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Affiliation(s)
- Reza Asari
- Section of Endocrine Surgery, Division of General Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria.
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Shaha AR. Prophylactic central compartment dissection in thyroid cancer: a new avenue of debate. Surgery 2009; 146:1224-7. [PMID: 19958952 DOI: 10.1016/j.surg.2009.10.020] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 10/05/2009] [Indexed: 01/05/2023]
Affiliation(s)
- Ashok R Shaha
- Cornell University Medical College and the Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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