Sonographically-Directed Neck Dissection for Recurrent Thyroid Carcinoma:

Recurrent Papillary Thyroid Carcinoma to the Cervical Lymph Nodes: Outcomes of Compartment-Oriented Lymph Node Resection

INTRODUCTION

Recurrence of papillary thyroid carcinoma after initial treatment is challenging. Surgical reintervention is recommended, but cure after surgery in uncertain and surgical morbidity may be high. This study evaluates the effect of compartment-oriented lymph node dissection (LND) on clinical and biochemical cure rate as well as the related complications.

PATIENTS AND METHODS

All patients who underwent LND for recurrent papillary thyroid carcinoma between 2000 and 2015 were included. Demography, the extent of the initial surgery, usage of ¹³¹I, the pattern of recurrence, diagnosis, details of the surgical reintervention, histological findings, surgical morbidity, and clinical and biochemical outcomes were analyzed.

RESULTS

There were 11 (12.7%) males and 75 (87.2%) females with a mean age of 42.8 ± 14.6 years. Seventy-seven patients had undergone total thyroidectomy and in 67 (77.9%) some type of LN resection. In 76 (88.3%), ¹³¹I was administered after the initial surgery. We localized suspicious lymph nodes by US in all patients, and metastases were documented before surgery by FNA in 63. Seven (8.13%) patients underwent central LND, 63 (73.2%) lateral LND and 16 (18.6%) both, central and lateral LND. Major complications occurred in 6 patients (6.9%). Sixty-two (72.0%) patients received ¹³¹I after surgery. A second surgical re-exploration was performed in 30 (34.8%) patients, and 7 patients required 3 or more additional LND. In a mean follow-up of 59.4 ± 39 months, 51 (59.3%) patients are clinically, radiologically and biochemically free of disease.

CONCLUSIONS

In this series, compartment-oriented lymph node resection of recurrent papillary thyroid carcinoma leads to a final clinical and biochemical disease-free status of 59.3% with 6.9% of major complications.

Radioguided occult lesion localization in patients with recurrent thyroid cancer

PURPOSE

Well planned re-surgery is critical for recurrent/persistent thyroid cancer (TC). We aimed to investigate the clinical outcome of radioguided-occult lesion localization (ROLL) guided surgery in patients with recurrent/persistent TC.

METHODS

This study includes 29 patients [F/M: 22/7, median age 43 ± 12 years (18-58)] with a diagnosis of TC (22 papillary, 2 follicular and 5 medullary). Before surgery, all patients underwent ultrasonography (USG) guided mapping and intra-lesional radioactivity injection. Surgery was performed based on the excision of radioactivity injected lesions by a gamma probe and non-injected tumor foci via USG-neck map. Researchers determined surgical success by post-operative tumor markers and neck-USG.

RESULTS

Among 29 patients, 60 metastatic lesions were identified by USG [median size 10 ± 6.3 mm (range 5-30)]. Neck-USG performed after surgery provided no evidence of disease (NED) in %97 (28/29) of TC patients. In the follow-up, stimulated thyroglobulin (Tg) levels were less than 1 ng/ml in 79%(19/24) of DTC patients and suppressed Tg < 0.2 ng/ml was noted in 92% (22/24).In patients with DTC with an incomplete structural response, we dramatically changed the American Thyroid Association (ATA) response category and achieved an excellent response in 92% (22/24) of patients. Among patients with MTC, 5/5 patients had normal USG and calcitonin levels were reduced by 60-80% in 4/5 and > 80% in1/5 patients.

CONCLUSIONS

In this study we have shown that, ROLL-guided surgery yielded NED rate of %97 (28/29) and increased excellent response rates according to ATA guidelines. Further studies with larger patient groups and longer follow-up should be performed to confirm the efficacy of this surgery.

Comprehensive Lateral Neck Dissection in Papillary Thyroid Carcinoma may Reduce Lateral Neck Recurrence Rates

OBJECTIVE

To Identify predictors of recurrent disease following lateral neck dissection (LND) for papillary thyroid carcinoma (PTC).

METHODS

A retrospective review of patients who underwent first-time LND for PTC at our institution (2000-2015) was performed. Medical records were examined for biopsy or pathologically proven lateral neck recurrence. Differences between the groups with and without recurrence were compared. All LNDs were then classified in to two groups: "comprehensive" (CND), involving levels IIa-Vb at minimum, or "selective", labelling less extensive dissection (SND).

RESULTS

Four hundred nine patients underwent 467 LNDs. Surveillance data were available for 317 patients who underwent 362 LNDs (mean age 45 ± 16; range 18-88). The median follow-up was 64 ± 48 months (range 3-197). Recurrence was detected in 71 lateral necks (20%). The total number of lymph nodes was greater in the group without recurrence compared to those with recurrence (23 vs. 19, p = 0.02). Among patient demographics, radioactive iodine treatment, primary tumor characteristics and characteristics of nodal metastases, only an older patient age (mean 50 vs. 43 years) was associated with lateral neck recurrence (p < .01). CND was performed in 102 lateral necks and SND in 143 necks. There were 12 recurrences recorded in the CND group (12%) vs. 31 in the SND group (22%, p = .04). The majority of recurrences (70%) involved levels included in the original dissection.

CONCLUSIONS

Younger patients, more extensive dissection and a higher total number of lymph nodes removed are associated with a lower incidence of lateral neck recurrence after LND for papillary thyroid carcinoma.

Treatment of lateral neck papillary thyroid carcinoma recurrence after selective lateral neck dissection

BACKGROUND

There is a paucity of data regarding optimal treatment options and outcomes for recurrent disease after lateral neck dissection in patients with papillary thyroid carcinoma.

METHODS

Retrospective review of patients who underwent either percutaneous ethanol injection or surgery for first-time ipsilateral recurrences after ipsilateral lateral neck dissection for papillary thyroid carcinoma was performed.

RESULTS

Follow-up data were available for 54 patients with recurrences in 57 lateral necks treated by either percutaneous ethanol injection (n = 32) or surgery (n = 25). Tumor burden at the time of lateral neck recurrence differed between the groups including the largest lymph node diameter (mean: 13 mm vs 18 mm, P < .01) and the mean number of metastatic lymph nodes identified on ultrasound (1.3 vs 1.9, P = .04). Each modality alone achieved similar estimated rates of disease control at 36 months (75% for percutaneous ethanol injection and 74% for surgery, P = .8) with similar number of reinterventions (1.8 for percutaneous ethanol injection, 1.6 for surgery, P = .6).

CONCLUSIONS

Both ethanol ablation and surgery can achieve disease control in the majority of patients with recurrences after ipsilateral lateral neck dissection for papillary thyroid carcinoma. Ethanol ablation, when used for treatment of a single small lymph node, can result in outcomes that are similar to reoperative surgery for larger and multiple lymph nodes.

Contemporary Management of Recurrent Nodal Disease in Differentiated Thyroid Carcinoma

Differentiated thyroid carcinoma (DTC) comprises over 90% of thyroid tumors and includes papillary and follicular carcinomas. Patients with DTC have an excellent prognosis, with a 10-year survival rate of over 90%. However, the risk of recurrent tumor ranges between 5% and 30% within 10 years of the initial diagnosis. Cervical lymph node disease accounts for the majority of recurrences and in most cases is detected during follow-up by ultrasound or elevated levels of serum thyroglobulin. Recurrent disease is accompanied by increased morbidity. The mainstay of treatment of nodal recurrence is surgical management. We provide an overview of the literature addressing surgical management of recurrent or persistent lymph node disease in patients with DTC.

2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer

BACKGROUND

Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association's (ATA's) guidelines for the management of these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer.

METHODS

The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations for therapeutic interventions. We developed a similarly formatted system to appraise the quality of such studies and resultant recommendations. The guideline panel had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members.

RESULTS

The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, use of molecular markers, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to screening for thyroid cancer, staging and risk assessment, surgical management, radioiodine remnant ablation and therapy, and thyrotropin suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using imaging and serum thyroglobulin, thyroid hormone therapy, management of recurrent and metastatic disease, consideration for clinical trials and targeted therapy, as well as directions for future research.

CONCLUSIONS

We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.

Management of recurrent/persistent nodal disease in patients with differentiated thyroid cancer: a critical review of the risks and benefits of surgical intervention versus active surveillance

BACKGROUND

The primary goals of this interdisciplinary consensus statement are to define the eligibility criteria for management of recurrent and persistent cervical nodal disease in patients with differentiated thyroid cancer (DTC) and to review the risks and benefits of surgical intervention versus active surveillance.

METHODS

A writing group was convened by the Surgical Affairs Committee of the American Thyroid Association and was tasked with identifying the important clinical elements to consider when managing recurrent/persistent nodal disease in patients with DTC based on the available evidence in the literature and the group's collective experience.

SUMMARY

The decision on how best to manage individual patients with suspected recurrent/persistent nodal disease is challenging and requires the consideration of a significant number of variables outlined by the members of the interdisciplinary team. Here we report on the consensus opinions that were reached by the writing group regarding the technical and clinical issues encountered in this patient population.

CONCLUSIONS

Identification of recurrent/persistent disease requires a team decision-making process that includes the patient and physicians as to what, if any, intervention should be performed to best control the disease while minimizing morbidity. Several management principles and variables involved in the decision making for surgery versus active surveillance were developed that should be taken into account when deciding how best to manage a patient with DTC and suspected recurrent or persistent cervical nodal disease.

Update in utility of secondary node dissection for papillary thyroid cancer

BACKGROUND

Detection of recurrent/persistent thyroid cancer has improved significantly in the past decade. Disease is detected earlier in recently treated patients and localized in patients long out from initial treatment. This update reviews recent literature regarding the utility of secondary node dissection for papillary thyroid carcinoma. Outcomes include disease-free status measured biochemically and clinically.

RESULTS

The utility of secondary node dissection as measured by clinically detectable disease exceeds 70% for all series and 90% for most. The utility as measured biochemically is more modest, with rates of biochemical cure ranging from 27-81% depending upon strictness of definition and patient selection. In predominately radioiodine scan-negative patients, using the strictest definition of biochemical cure, undetectable stimulated thyroglobulin (Tg) of less than 0.5 ng/ml, a rate of 27% is reported. Biochemical cure rates are reportedly 30-51% for stimulated Tg of less than 2 ng/ml and 56-71% for basal Tg of less than 2 ng/ml, with higher preoperative Tg levels less likely to achieve biochemical cure. Radioiodine-avid disease appears more amenable to cure, with 81% of patients achieving negative stimulated Tg after repeat I131 treatment and radio-assisted surgery. Complication rates of secondary nodal surgery appear similar to initial surgery in experienced hands; however, bilateral reoperative central neck dissection is associated with significantly higher complication rates than unilateral.

SUMMARY

Surgical resolution of clinically detectable disease is likely. Biochemical cure rates are more modest, with the greatest likelihood of biochemical cure occurring in patients with radioiodine-avid disease. In radioiodine-negative patients, there may be a higher likelihood of biochemical cure for those with lower preoperative detectable Tg levels.

American Thyroid Association consensus review and statement regarding the anatomy, terminology, and rationale for lateral neck dissection in differentiated thyroid cancer

BACKGROUND

Cervical lymph node metastases from differentiated thyroid cancer (DTC) are common. Thirty to eighty percent of patients with papillary thyroid cancer harbor lymph node metastases, with the central neck being the most common compartment involved. The goals of this study were to: (1) identify appropriate methods for determining metastatic DTC in the lateral neck and (2) address the extent of lymph node dissection for the lateral neck necessary to control nodal disease balanced against known risks of surgery.

METHODS

A literature review followed by formulation of a consensus statement was performed.

RESULTS

Four proposals regarding management of the lateral neck are made for consideration by organizations developing management guidelines for patients with thyroid nodules and DTC including the next iteration of management guidelines developed by the American Thyroid Association (ATA). Metastases to lateral neck nodes must be considered in the evaluation of the newly diagnosed thyroid cancer patient and for surveillance of the previously treated DTC patient.

CONCLUSIONS

Lateral neck lymph nodes are a significant consideration in the surgical management of patients with DTC. When current guidelines formulated by the ATA and by other international medical societies are followed, initial evaluation of the DTC patient with ultrasound (or other modalities when indicated) will help to identify lateral neck lymph nodes of concern. These findings should be addressed using fine-needle aspiration biopsy. A comprehensive neck dissection of at least nodal levels IIa, III, IV, and Vb should be performed when indicated to optimize disease control.

Level V in therapeutic neck dissections for papillary thyroid carcinoma

Neck dissection for papillary thyroid carcinoma (PTC) is the standard of care for patients with clinical evidence of regional metastases. However, the extent of neck dissection is debatable. The purpose of the current study was to develop evidence-based recommendations for when to include level V, or 1 of its sublevels, among patients with PTC undergoing neck dissection. A literature review of all studies evaluating the occurrence of metastases in level V in patients with regional metastases from PTC undergoing neck dissection was performed. Occurrence of metastases at level V is low in most series (5% to 10%), although a wide range was noticed. In cases in which metastases were found at level V, they occurred almost exclusively at sublevel VB. Sublevel VA was rarely, if ever, involved with metastatic lymph nodes. However, only recently have investigators begun to specify which sublevels of level V are at risk. Therapeutic dissection of level V is indicated when there is clinical evidence of disease involving this zone. Elective dissection of sublevel VB is indicated when there is involvement of level IV, or possibly multiple nodes at levels II and III. Under these circumstances, dissection of sublevel VB is indicated but sublevel VA may be spared.

Use of ultrasound in the management of thyroid cancer

The use of ultrasound for thyroid cancer has evolved dramatically over the last few decades. Since the late 1960s, ultrasound has become essential in the examination of the thyroid gland with the increased availability of high-frequency linear array transducers and computer-enhanced imaging capabilities of modern day portable ultrasound equipment in a clinic- or office-based setting. As a noninvasive, rapid, and easily reproducible imaging study, ultrasound has been demonstrated to have a broadened utility beyond the simple confirmation of thyroid nodules and their sizes. Recently, office-based ultrasound has become an integral part of clinical practice, where it has demonstrated overwhelming benefits to patients being evaluated and treated for thyroid cancer. Ultrasound has become useful in the qualitative characterization of thyroid nodules based on benign or malignant features. On the basis of such classifications and the relative risk for thyroid malignancy, the need for ultrasound-guided fine-needle aspiration, preoperative and intraoperative staging, lymph node mapping, and the extent of surgery can subsequently be determined. Furthermore, ultrasound has additional value in the surveillance of patients treated for thyroid cancer.

Developments in the use of ultrasound for thyroid cancer

PURPOSE OF REVIEW

This article reviews the recent developments in neck ultrasound for thyroid cancer published in the last 18 months, with emphasis on the emerging role of surgeon-performed ultrasound in clinical endocrine practice.

RECENT FINDINGS

Ultrasound has evolved beyond the simple differentiation of solid and cystic thyroid nodules and their measurement. Although no single ultrasound feature has the highest accuracy in distinguishing between benign and malignant thyroid lesions, the combination of several ultrasound characteristics (e.g. hypoechogenicity, irregular borders and microcalcifications) within such thyroid nodules may have a stronger correlation for thyroid cancer. Based on these ultrasound features and risk for thyroid malignancy, the need for ultrasound-guided fine needle aspiration, preoperative staging, lymph node mapping and extent of surgery can subsequently be determined and performed. Furthermore, ultrasound has an additional value intraoperatively and in the postoperative surveillance of patients treated for thyroid cancer. Surgeon-performed ultrasound has recently become indispensible in clinical practice where endocrine surgeons have integrated this versatile imaging modality in the evaluation and treatment of patients with thyroid cancer.

SUMMARY

Ultrasound is an essential modality in the evaluation of thyroid malignancy. Surgeon-performed ultrasound has proved invaluable in the preoperative, intraoperative and postoperative setting. Future developments in ultrasound may lead to further improvement in the diagnostic accuracy of this modality.

Clinical risk factors associated with cervical lymph node recurrence in papillary thyroid carcinoma

BACKGROUND

Recurrence of regional cervical lymph nodes in patients with papillary thyroid carcinoma (PTC) is not uncommon, and is an important factor affecting the quality of life. The aims of this study are to investigate the risk factors that are associated with regional lymph node recurrence by comparing a group of patients with regional lymph node recurrence with a group without lymph node recurrence, and to analyze the clinical characteristics of recurrent regional lymph nodes in PTC.

METHODS

A retrospective analysis was performed on 189 patients who underwent surgery for PTC. By comparing a group with recurrent cervical lymph nodes (n = 33) with a group without recurrent cervical lymph nodes (n = 156), the risk factors for cervical lymph node recurrence were investigated and the clinical characteristics of recurrent cervical lymph nodes were analyzed.

RESULTS

Tumor size >2 cm, presence of extrathyroid tumor spread, high T stage, and presence of lymph node metastasis were associated with regional lymph node recurrence in univariate analysis (p < 0.05). Among them, only the N stage was significantly associated with regional recurrence in multivariate analysis (p < 0.05). The disease-free survival period was shorter in the lymph node metastasis-positive group, and the 10-year disease-free survival rate was 77.8% in the lymph node metastasis-negative group and 57.9% in the lymph node metastasis-positive group (p < 0.05). Among 130 patients without lymph node metastasis, regional recurrence occurred in 13 patients (10%), and the frequent levels of regional recurrence were levels II-IV of ipsilateral neck. In the patients with lymph node metastasis, the frequent levels were levels IV-VI of ipsilateral side and level II of the contralateral side.

CONCLUSION

Considering the low incidence of regional lymph node recurrence and the levels with frequent regional recurrence in patients without lymph node metastasis, elective neck dissection in all cases of total thyroidectomy may be immoderate. However, if any risk factors for regional recurrence, including large tumor size, presence of extrathyroid spread, high T stage, and presence of lymph node metastasis, are detected by preoperative and intraoperative evaluation, a systematic compartment-oriented lymphadenectomy should be considered because of the high possibility of regional recurrence.